RULE-2758

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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	COT00002
Data Element Name	CLAIM-HEADER-RECORD-OT.DATE-OF-BIRTH • CLAIM-HEADER-RECORD-OT.ENDING-DATE-OF-SERVICE
Validation Logic	'if CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-OT.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND does not equal '1' and CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', '686' and CLAIM-HEADER-RECORD-OT has a valid, non-null value for DATE-OF-BIRTH and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', '686' and the first character of CLAIM-LINE-RECORD-OT.TOOTH-NUM is one of 'A' through 'T', then the difference between dates CLAIM-HEADER-RECORD-OT.DATE-OF-BIRTH and CLAIM-HEADER-RECORD-OT.ENDING-DATE-OF-SERVICE is less than 15 years'
Rule Definition	If a claim is a non-denied, non-void claim from an OT file, and the first value of the claim line tooth number is 'A' through 'T', then difference between the claim date of birth and claim ending date of service is less than 15 years.
Denominator Logic	# of OT claim headers with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and with CLAIM-HEADER-RECORD-OT.CLAIM-DENIED-INDICATOR does not equal '0' and with CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is not equal to '1' and with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', '686' and with CLAIM-HEADER-RECORD-OT has a valid, non-null value for DATE-OF-BIRTH and with CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', '686' and the first character of CLAIM-LINE-RECORD-OT.TOOTH-NUM is one of 'A' through 'T'

Published Date	Data Guide Version	Validation Rule	Action	Field	Before	After
08/21/2020	2.4.0	RULE-2758	UPDATE	Data Dictionary - Validation Rules	Rule only triggered on adjustment claim lines, not on original claims.	Rules will also be triggered on original claim lines and ADJUSTMENT-IND and LINE-ADJUSTMENT-IND will be used to join claim headers and claim lines for the purpose of applying line-level validation rules. 'if CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-HEADER-RECORD-OT has a valid, non-null value for DATE-OF-BIRTH and the first character of CLAIM-LINE-RECORD-OT.TOOTH-NUM is one of 'A' through 'T', then the difference between dates CLAIM-HEADER-RECORD-OT.DATE-OF-BIRTH and CLAIM-HEADER-RECORD-OT.ENDING-DATE-OF-SERVICE is less than 15 years'
05/21/2021	3.0.0	RULE-2758	UPDATE	Data Dictionary - Validation Rules	if CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-HEADER-RECORD-OT has a valid, non-null value for DATE-OF-BIRTH and the first character of CLAIM-LINE-RECORD-OT.TOOTH-NUM is one of 'A' through 'T', then the difference between dates CLAIM-HEADER-RECORD-OT.DATE-OF-BIRTH and CLAIM-HEADER-RECORD-OT.ENDING-DATE-OF-SERVICE is less than 15 years'	if CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-OT.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is not equal to '1' and CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', '686' and CLAIM-HEADER-RECORD-OT has a valid, non-null value for DATE-OF-BIRTH and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', '686' and the first character of CLAIM-LINE-RECORD-OT.TOOTH-NUM is one of 'A' through 'T', then the difference between dates CLAIM-HEADER-RECORD-OT.DATE-OF-BIRTH and CLAIM-HEADER-RECORD-OT.ENDING-DATE-OF-SERVICE is less than 15 years'