Official websites use .gov
A
.gov website belongs to an official government
organization in the United States.
Secure .gov websites use HTTPS
A
lock () or https:// means you've safely connected to
the .gov website. Share sensitive information only on official,
secure websites.
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.DRUG-UTILIZATION-CODE |
Validation Logic | 'if CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM does not equal 'Z', then The substring CLAIM-LINE-RECORD-RX.DRUG-UTILIZATION-CODE(0, 2) must be contained in the set of valid values with id: 'DRUG-UTILIZATION-CODE-E4'' |
Rule Definition | If the drug utilization code is populated on a non-denied claim from an RX file, then the substring drug utilization code (0,2) value reported must be in the list of valid values for E4 drug utilization codes. |
Denominator Logic | # of RX claim lines with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY not equal to 'F2' and with CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR not equal to '0' and with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS not in: '26', '87', '542', '585', '654' and with CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS not in: '26', '87', '542', '585', '654' and with CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM not equal to 'Z' and with CLAIM-LINE-RECORD-RX.DRUG-UTILIZATION-CODE-E4 equal to a valid, non-null value |