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Tier | 3.0 |
---|---|
Tier Description | Relational error |
Error Category | E3002 |
Error Category Message | Values inconsistently specified (multiple record types, multi file) |
Rule Type | Three Record Type Rule |
File Segment Number | ELG00003 |
Data Element Name | CLAIM-LINE-RECORD-RX.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
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', '686' and CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is not equal to one of the following: 'Z', '3', 'C', 'W' and CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND does not equal '1' and CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', '686' and VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE is equal to one of the following: '2', '3', then CLAIM-LINE-RECORD-RX.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT equals '02'' |
Rule Definition | If the MSIS ID on a non-denied, non-void claim header from an RX file is equal to the MSIS ID reported with a CHIP code for Medicaid-expansion CHIP or separate XXI CHIP on a variable demographic eligibility segment from an ELG file, then the CMS-64 category for federal reimbursement value reported must be for Title XXI Medicaid funding. |
Denominator Logic | # of RX claim headers 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 is not equal to one of the following: '26', '87', '542', '585', '654', '686' and with CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is not equal to one of the following: 'Z', '3', 'C', 'W' and with CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND is not equal to '1' and with CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', '686' and with (CLAIM-HEADER-RECORD-RX.SUBMITTING-STATE and CLAIM-HEADER-RECORD-RX.MSIS-IDENTIFICATION-NUM that match VARIABLE-DEMOGRAPHICS-ELIGIBILITY.SUBMITTING-STATE and VARIABLE-DEMOGRAPHICS-ELIGIBILITY.MSIS-IDENTIFICATION-NUM) and with VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE is equal to one of the following: '2', '3' |