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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-7200

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 MCR00002
Data Element Name CLAIM-HEADER-RECORD-OT.SUBMITTING-STATE • MANAGED-CARE-MAIN.MANAGED-CARE-CONTRACT-END-DATE • CLAIM-HEADER-RECORD-OT.PLAN-ID-NUMBER • MANAGED-CARE-MAIN.MANAGED-CARE-CONTRACT-EFF-DATE • 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-MAIN that matches on the join keys(MANAGED-CARE-MAIN[SUBMITTING-STATE, STATE-PLAN-ID-NUM], CLAIM-HEADER-RECORD-OT[SUBMITTING-STATE, PLAN-ID-NUMBER]) and CLAIM-HEADER-RECORD-OT.BEGINNING-DATE-OF-SERVICE must be in (MANAGED-CARE-MAIN.MANAGED-CARE-CONTRACT-EFF-DATE, MANAGED-CARE-MAIN.MANAGED-CARE-CONTRACT-END-DATE)
Rule Definition If plan ID is populated on a non-denied 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 main segment from an MCR file where the beginning date of service on the claim is within the contract effective and end dates on the managed care main segment.
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.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