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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-7297

Validation Rule
Last updated

Tier 3.0
Tier Description Relational error
Error Category E3002
Error Category Message Values inconsistently specified (multiple record types, multi file)
Rule Type Three Record Type Rule
File Segment Number COT00003
Data Element Name ELIGIBILITY-DETERMINANTS.DUAL-ELIGIBLE-CODE
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', '686' and CLAIM-HEADER-RECORD-OT has a non-null value for MSIS-IDENTIFICATION-NUM and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-LINE-RECORD-OT.TYPE-OF-SERVICE is equal to one of the following: '139', '140', '141', '142' and CLAIM-HEADER-RECORD-OT has a non-null value for BEGINNING-DATE-OF-SERVICE and CLAIM-HEADER-RECORD-OT has a non-null value for ENDING-DATE-OF-SERVICE and ELIGIBILITY-DETERMINANTS has a non-null value for ELIGIBILITY-DETERMINANT-EFF-DATE and ELIGIBILITY-DETERMINANTS has a non-null value for ELIGIBILITY-DETERMINANT-END-DATE and (CLAIM-HEADER-RECORD-OT.BEGINNING-DATE-OF-SERVICE >= ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-EFF-DATE and CLAIM-HEADER-RECORD-OT.ENDING-DATE-OF-SERVICE <= ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-END-DATE), then ELIGIBILITY-DETERMINANTS has a non-null value for DUAL-ELIGIBLE-CODE and ELIGIBILITY-DETERMINANTS.DUAL-ELIGIBLE-CODE does not equal '00''
Rule Definition #N/A
Denominator Logic # of OT claim headers with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY not equal to 'F2' AND with CLAIM-HEADER-RECORD-OT.CLAIM-DENIED-INDICATOR not equal to '0' AND with CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM not equal to 'Z' AND with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS not in ('26','026','87','087','542','585', '654', '686') AND with CLAIM-HEADER-RECORD-OT.MSIS-IDENTIFICATION-NUM having a non-null value AND with CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS not in ('26','87','542','585', '654') AND with CLAIM-LINE-RECORD-OT.TYPE-OF-SERVICE in: '139', '140', '141', '142' AND with the CLAIM-HEADER-RECORD-ID.BEGINNING-DATE-OF-SERVICE having a non-null value AND with the CLAIM-HEADER-RECORD-ID.ENDING-DATE-OF-SERVICE having a non-null value AND with the ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-EFF-DATE having a non-null value AND with the ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-END-DATE having a non-null value AND with the range of CLAIM-HEADER-RECORD-ID.BEGINNING-DATE-OF-SERVICE and CLAIM-HEADER-RECORD-ID.ENDING-DATE-OF-SERVICE inside the range of ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-EFF-DATE and ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-END-DATE