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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-RX.SUBMITTING-STATE • CLAIM-HEADER-RECORD-RX.PLAN-ID-NUMBER • MANAGED-CARE-PARTICIPATION.MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE • MANAGED-CARE-PARTICIPATION.MANAGED-CARE-PLAN-ENROLLMENT-END-DATE • CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE • CLAIM-HEADER-RECORD-RX.MSIS-IDENTIFICATION-NUM |
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.TYPE-OF-CLAIM does not equal 'Z' and CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is equal to one of the following: '3', 'C', 'W' and CLAIM-HEADER-RECORD-RX has a valid, non-null value for PLAN-ID-NUMBER, then for every record of type CLAIM-HEADER-RECORD-RX, 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-RX[SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, PLAN-ID-NUMBER]) and CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE 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 Medicaid, S-CHIP, or Other encounter from an RX 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 where the prescription fill date on the claim is within the effective and end dates of the managed care participation segment. |
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 not in: '26', '026', '87', '087', '542', '585', '654' AND with CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM in: '3', 'C', 'W' AND with CLAIM-HEADER-RECORD-RX.PLAN-ID-NUMBER equal to a valid, non-null value |