RULE-7203

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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	CRX00002
Data Element Name	CLAIM-LINE-RECORD-RX.DRUG-UTILIZATION-CODE
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.CLAIM-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM does not equal 'Z', then The substring CLAIM-LINE-RECORD-RX.DRUG-UTILIZATION-CODE(4, 2) must be contained in the set of valid values with id: 'DRUG-UTILIZATION-CODE-E6''
Rule Definition	If the drug utilization code is populated on a non-denied claim from an RX file, then the substring drug utilization code (4,2) value reported must be in the list of valid values for E6 drug utilization codes.
Denominator Logic	# of RX claim lines with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY not equal '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', '87', '542', '585', '654' and with CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS not in: '26', '87', '542', '585', '654' and with CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM not equal to 'Z'

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Published Date	Data Guide Version	Validation Rule	Action	Field	Before	After
08/21/2020	2.4.0	RULE-7203	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-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.CLAIM-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM does not equal 'Z', then The substring CLAIM-LINE-RECORD-RX.DRUG-UTILIZATION-CODE(4, 2) must be contained in the set of valid values with id: 'DRUG-UTILIZATION-CODE-E6''
04/12/2019	2.3.0	RULE-7203	ADD	Data Dictionary - Validation Rules	N/A	'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.CLAIM-STATUS does NOT equal to ('26', '87', '542', '585', '654') and CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM does NOT equal 'Z' and CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS does NOT equal ('26', '87', '542', '585', '654') then If the field is populated and 5th and 6th character value is not null, then 5th and 6th character value must be contained in the set of valid values with id: 'DRUG-UTILIZATION-CODE-E6''