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TMSIS Dataguide Medicaid.gov
Version 3.28.0

RULE-7203

Validation Rule
Last updated

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'