RULE-7207

Tier	3.0
Tier Description	Relational error
Error Category	E3002
Error Category Message	Values inconsistently specified (multiple record types, multi file)
Rule Type	Three Record Type Rule
File Segment Number	ELG00003
Data Element Name	CLAIM-LINE-RECORD-LT.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT
Validation Logic	'if CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-LT.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-LT.CLAIM-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-LINE-RECORD-LT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM is not equal to one of the following: 'Z', '3', 'C', 'W' and VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE equals '1', then CLAIM-LINE-RECORD-LT.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT equals '01''
Rule Definition	If a claim is a non-denied claim from an IP file and the variable demographics eligibility chip code is equal to '1', then the claim line has a CMS-64 category for federal reimbursement value equal to '01'.
Denominator Logic	# of LT claim lines with CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY not equal to 'F2' and with CLAIM-HEADER-RECORD-LT.CLAIM-DENIED-INDICATOR not equal to '0' and with CLAIM-HEADER-RECORD-LT.CLAIM-STATUS not in: '26', '87', '542', '585', '654' and with CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM not in: 'Z', '3', 'C', 'W' with CLAIM-LINE-RECORD-LT.CLAIM-LINE-STATUS not in: '26', '87', '542', '585', '654' and with VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE equal to '1'

Published Date	Data Guide Version	Validation Rule	Action	Field	Before	After
08/21/2020	2.4.0	RULE-7207	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-LT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-LT.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-LT.CLAIM-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-LINE-RECORD-LT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM does not equal 'Z' and VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE equals '1', then CLAIM-LINE-RECORD-LT.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT equals '01''
09/11/2020	2.4.0	RULE-7207	UPDATE	Data Dictionary - Validation Rules	if CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-LT.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-LT.CLAIM-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-LINE-RECORD-LT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM does not equal 'Z' and VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE equals '1', then CLAIM-LINE-RECORD-LT.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT equals '01'	if CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-LT.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-LT.CLAIM-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-LINE-RECORD-LT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM not in ('Z','3','C','W') and VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE equals '1', then CLAIM-LINE-RECORD-LT.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT equals '01'
05/10/2019	2.3.0	RULE-7207	ADD	Data Dictionary - Validation Rules	N/A	'If CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY does NOT equal ‘F2’ and CLAIM-HEADER-RECORD-LT.CLAIM-DENIED-INDICATOR does NOT equal ‘0’ and CLAIM-HEADER-RECORD-LT.CLAIM-STATUS does NOT equal to ('26', '87', '542', '585', '654') and CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM does NOT equal 'Z' and CLAIM-LINE-RECORD-LT.CLAIM-LINE-STATUS does NOT equal ('26', '87', '542', '585', '654') and VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE is equal to '1' then CLAIM-LINE-RECORD-LT.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT equals '01'