RULE-7264

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	COT00002
Data Element Name	CLAIM-LINE-RECORD-OT.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT
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' and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '1', 'A', '2', 'B', then CLAIM-LINE-RECORD-OT has a non-null value for CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT'
Rule Definition	If a claim is a non-denied claim from an OT file, that is a Medicaid or Medicaid-expansion FFS, Separate CHIP FFS, Medicaid or Medicaid-expansion CHIP Capitated or Separate CHIP Capitated claim and is an original claim or a replacement/resubmission claim payment, then CMS-64 category for federal reimbursement must be populated.
Denominator Logic	# of OT claim lines 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.TYPE-OF-CLAIM does not equal 'Z' and with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', and with CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is equal to '0' or '4' and with CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '1', 'A', '2', 'B'

Published Date	Data Guide Version	Validation Rule	Action	Field	Before	After
08/21/2020	2.4.0	RULE-7264	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-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-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '1', 'A', '2', 'B', then CLAIM-LINE-RECORD-OT has a non-null value for CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT'
05/08/2020	2.4.0	RULE-7264	ADD	Data Dictionary - Validation Rules	N/A	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-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is equal to "0" or "4" and TYPE-OF-CLAIM in ("1","A","2","B") then CLAIM-LINE-RECORD-OT has a non-null value for CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT'
10/15/2021	3.0.0	RULE-7264	UPDATE	Data Dictionary - Validation Rules	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-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is equal to "0" or "4"and TYPE-OF-CLAIM in ("1","A","2","B") then CLAIM-LINE-RECORD-OT has a non-null value for CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT'	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' and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is equal to "0" or "4" and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '1', 'A', '2’, 'B’, then CLAIM-LINE-RECORD-OT has a non-null value for CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT'