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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-7196

Validation Rule
Last updated

Tier 3.0
Tier Description Relational error
Error Category E3001
Error Category Message Missing corresponding record (2 record types, multi file) (ex. missing eligibility record for claim header)
Rule Type Two Record Type (1 to 1)
File Segment Number ELG00014
Data Element Name CLAIM-HEADER-RECORD-OT.SUBMITTING-STATE • MANAGED-CARE-PARTICIPATION.MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE • MANAGED-CARE-PARTICIPATION.MANAGED-CARE-PLAN-ENROLLMENT-END-DATE • CLAIM-HEADER-RECORD-OT.PLAN-ID-NUMBER • CLAIM-HEADER-RECORD-OT.MSIS-IDENTIFICATION-NUM • CLAIM-HEADER-RECORD-OT.BEGINNING-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.TYPE-OF-CLAIM does not equal 'Z' 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.ADJUSTMENT-IND does not equal '1' and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '3', 'C', 'W' and CLAIM-HEADER-RECORD-OT has a valid, non-null value for PLAN-ID-NUMBER, then for every record of type CLAIM-HEADER-RECORD-OT, there must be a valid record of type MANAGED-CARE-PARTICIPATION that matches on the join keys(MANAGED-CARE-PARTICIPATION[SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, MANAGED-CARE-PLAN-ID], CLAIM-HEADER-RECORD-OT[SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, PLAN-ID-NUMBER]) and CLAIM-HEADER-RECORD-OT.BEGINNING-DATE-OF-SERVICE must be in (MANAGED-CARE-PARTICIPATION.MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE, MANAGED-CARE-PARTICIPATION.MANAGED-CARE-PLAN-ENROLLMENT-END-DATE)
Rule Definition If plan ID is populated on a non-denied, non-void Medicaid, S-CHIP, or Other encounter from an OT file, then the plan ID must be equal to the plan ID on a managed care participation segment from an ELG file with the same MSIS ID and enrollment effective and end dates that overlap the beginning date of service.
Denominator Logic # of OT claim headers with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY not equal to 'F2' AND with CLAIM-HEADER-RECORD-OT.CLAIM-DENIED-INDICATOR not equal to '0' 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.ADJUSTMENT-IND is not equal to '1' AND with CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '3', 'C', 'W' AND with CLAIM-HEADER-RECORD-OT has a valid, non-null value for PLAN-ID-NUMBER