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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-689

Validation Rule
Last updated

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 PRV00005
Data Element Name CLAIM-HEADER-RECORD-IP.SUBMITTING-STATE • CLAIM-HEADER-RECORD-IP.BILLING-PROV-NUM
Validation Logic if CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-IP.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-IP.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-IP has a valid, non-null value for BILLING-PROV-NUM, then for every record of type CLAIM-HEADER-RECORD-IP, ((there must be a valid record of type PROV-IDENTIFIERS that matches on the join keys where PROV-IDENTIFIERS.PROV-IDENTIFIER-TYPE equals '1' and CLAIM-HEADER-RECORD-IP has a null value for DISCHARGE-DATE or CLAIM-HEADER-RECORD-IP.DISCHARGE-DATE must be in (PROV-IDENTIFIERS.PROV-IDENTIFIER-EFF-DATE, PROV-IDENTIFIERS.PROV-IDENTIFIER-END-DATE)) OR (there must be a valid record of type PROV-ATTRIBUTES-MAIN that matches on the join keys and CLAIM-HEADER-RECORD-IP has a null value for DISCHARGE-DATE or CLAIM-HEADER-RECORD-IP.DISCHARGE-DATE must be in (PROV-ATTRIBUTES-MAIN.PROV-ATTRIBUTES-EFF-DATE, PROV-ATTRIBUTES-MAIN.PROV-ATTRIBUTES-END-DATE)))
Rule Definition If the billing provider number is populated on a non-denied claim from the IP file, then either the billing provider number value reported must be equal to a provider identifier value reported with a provider identifier type value for state-assigned Medicaid provider identifiers on a provider identifiers segment from a PRV file where the effective and end dates of the provider identifiers segment overlap with the admission and (if populated) discharge date on the claim OR the billing provider number value reported must be equal to a submitting state provider ID on a provider main attributes segment from a PRV file where the effective and end dates of the provider main attributes segment overlap with the admission and (if populated) discharge date on the claim.
Denominator Logic # of IP claim headers with CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY not equal to 'F2' and with CLAIM-HEADER-RECORD-IP.CLAIM-DENIED-INDICATOR not equal to '0' and with CLAIM-HEADER-RECORD-IP.CLAIM-STATUS not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-IP has a valid, non-null value for BILLING-PROV-NUM