An official website of the United States government

Official websites use .gov
A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS
A lock () or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-7285

Validation Rule
Last updated

Tier 2.1
Tier Description Relational error
Error Category E2102
Error Category Message Values inconsistently specified (multi record, single file)
Rule Type Two Record Type (1 to 1)
File Segment Number COT00002
Data Element Name CLAIM-LINE-RECORD-OT.ALLOWED-AMT • 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.PAYMENT-LEVEL-IND equals '2' and CLAIM-LINE-RECORD-OT has a non-null value for MEDICAID-PAID-AMT and CLAIM-LINE-RECORD-OT.ALLOWED-AMT does not equal '0.00' and CLAIM-LINE-RECORD-OT has a non-null value for ALLOWED-AMT, then CLAIM-LINE-RECORD-OT.MEDICAID-PAID-AMT is less than or equal to CLAIM-LINE-RECORD-OT.ALLOWED-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 or Medicaid or Medicaid-expansion CHIP FFS claim and the payment level indicator is equal to 2 and the medicaid paid amount is populated, then the claim line medicaid paid amount is less than or equal to the line total allowed amount.
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.PAYMENT-LEVEL-IND equals '2' and with CLAIM-LINE-RECORD-OT has a non-null value for MEDICAID-PAID-AMT and with CLAIM-LINE-RECORD-OT.ALLOWED-AMT does not equal '0.00' and with CLAIM-LINE-RECORD-OT has a non-null value for ALLOWED-AMT