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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-1941

Validation Rule
Last updated

Tier 1.1
Tier Description Value Error
Error Category E1103
Error Category Message Value not in specified valid value set
Rule Type Valid Value
File Segment Number CRX00002
Data Element Name CLAIM-LINE-RECORD-RX.HCBS-TAXONOMY
Validation Logic 'if CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', then If the HCBS-TAXONOMY field is populated, the value must be contained in the set of valid values with id: 'HCBS-TAXONOMY' and (if CLAIM-LINE-RECORD-RX.PRESCRIPTION-FILL-DATE is non-null then CLAIM-LINE-RECORD-RX.PRESCRIPTION-FILL-DATE >= Valid Values Effective-Date and CLAIM-LINE-RECORD-RX.PRESCRIPTION-FILL-DATE <= Valid Values End-Date)'
Rule Definition If the HCBS taxonomy is populated on a non-denied claim from an RX file, then the HCBS taxonomy reported must be found in the list of valid values.
Denominator Logic # of RX claim lines with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY not equal to 'F2' and with CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS not in: '26', '87', '542', '585', '654' and with CLAIM-LINE-RECORD-RX.HCBS-SERVICE-CODE equal to a valid, non-null value