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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 | One Record Type (Single Record) |
File Segment Number | CRX00002 |
Data Element Name | CLAIM-HEADER-RECORD-RX.TOT-MEDICAID-PAID-AMT |
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.TYPE-OF-CLAIM does not equal 'Z' and CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is equal to one of the following: 'A', '1' and CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND equals '0' and (CLAIM-HEADER-RECORD-RX.CROSSOVER-INDICATOR equals '0' or CLAIM-HEADER-RECORD-RX has a null value for CROSSOVER-INDICATOR), then CLAIM-HEADER-RECORD-RX has a non-null and not invalidly formatted value for TOT-MEDICAID-PAID-AMT' |
Rule Definition | If a claim is a non-denied claim from an RX file that is an original claim and is a separate CHIP FFS, Medicaid or Medicaid-expansion FFS claim, with a crossover indicator equal to 0 or null, then the total medicaid paid amount must be populated. |
Denominator Logic | # of RX claim headers with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' and with CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR does not equal '0' and with CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM does not equal 'Z' and with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is equal to one of the following: 'A', '1' and with CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND equals '0' and with (CLAIM-HEADER-RECORD-RX.CROSSOVER-INDICATOR equals '0' or CLAIM-HEADER-RECORD-RX has a null value for CROSSOVER-INDICATOR) |