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Tier | 1.1 |
---|---|
Tier Description | Missing Value Error |
Error Category | E1105 |
Error Category Message | Data Element Value is Missing |
Rule Type | Two Record Type (1 to 1) |
File Segment Number | CIP00002 |
Data Element Name | CLAIM-LINE-RECORD-IP.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT |
Validation Logic | 'if CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-IP.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM does not equal 'Z' and CLAIM-HEADER-RECORD-IP.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-LINE-RECORD-IP.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-IP.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM is equal to one of the following: '1', 'A' and CLAIM-HEADER-RECORD-IP has a non-null and not invalidly formatted value for TOT-MEDICAID-PAID-AMT and CLAIM-HEADER-RECORD-IP.TOT-MEDICAID-PAID-AMT does not equal '0.00', then CLAIM-LINE-RECORD-IP has a non-null value for CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT' |
Rule Definition | If a claim is a non-denied claim from an IP file, that is a Medicaid or Medicaid-expansion FFS or a Separate CHIP FFS claim and is an original claim or a replacement/resubmission claim payment and total medicaid paid amt is non-null and not zero, then the claim line CMS-64 category for federal reimbursement must be populated. |
Denominator Logic | # of IP claim lines with CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY does not equal 'F2' and with CLAIM-HEADER-RECORD-IP.CLAIM-DENIED-INDICATOR does not equal '0' and with CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM does not equal 'Z' and with CLAIM-HEADER-RECORD-IP.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-LINE-RECORD-IP.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', and with CLAIM-HEADER-RECORD-IP.ADJUSTMENT-IND is equal to '0' or '4' and with CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM is equal to one of the following: '1','A' and with CLAIM-HEADER-RECORD-IP has a non-null and not invalidly formatted value for TOT-MEDICAID-PAID-AMT and with CLAIM-HEADER-RECORD-IP.TOT-MEDICAID-PAID-AMT does not equal '0.00' |