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TMSIS Dataguide Medicaid.gov
Version 3.28.0

RULE-7273

Validation Rule
Last updated

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.MEDICAID-PAID-AMT
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.TYPE-OF-CLAIM is equal to one of the following: 'A', '1' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND equals '0' and (CLAIM-HEADER-RECORD-OT.CROSSOVER-INDICATOR equals '0' or CLAIM-HEADER-RECORD-OT has a null value for CROSSOVER-INDICATOR), then CLAIM-LINE-RECORD-OT has a non-null and not invalidly formatted value for MEDICAID-PAID-AMT'
Rule Definition If a claim is a non-denied claim from an OT 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 medicaid paid amount must be populated.
Denominator Logic # of OT claim headers 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.TYPE-OF-CLAIM is equal to one of the following: 'A', '1' and with CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND equals '0' and with  (CLAIM-HEADER-RECORD-OT.CROSSOVER-INDICATOR equals '0' or CLAIM-HEADER-RECORD-OT has a null value for CROSSOVER-INDICATOR)