RULE-7414

Validation Rule

Last updated

Tier	3.0
Tier Description	Relational error
Error Category	E3001
Error Category Message	Missing corresponding record (2 record types, multi file) (ex. missing eligibility record for claim header)
Rule Type	Two Record Type (1 to 1)
File Segment Number	CRX00002
Data Element Name	CLAIM-HEADER-RECORD-RX.SUBMITTING-STATE • CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE • ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-EFF-DATE • ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-END-DATE • ELIGIBILITY-DETERMINANTS.PRIMARY-ELIGIBILITY-GROUP-IND • CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY • CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR • CLAIM-HEADER-RECORD-RX.CLAIM-STATUS • CLAIM-HEADER-RECORD-RX.CROSSOVER-INDICATOR • CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND • CLAIM-HEADER-RECORD-RX.MSIS-IDENTIFICATION-NUM • CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM • ELIGIBILITY-DETERMINANTS.MSIS-IDENTIFICATION-NUM • ELIGIBILITY-DETERMINANTS.DUAL-ELIGIBLE-CODE
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: '1', '3' and CLAIM-HEADER-RECORD-RX.CROSSOVER-INDICATOR equals '1' and CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-RX has a valid, non-null value for MSIS-IDENTIFICATION-NUM and CLAIM-HEADER-RECORD-RX has a non-null and not invalidly formatted value for PRESCRIPTION-FILL-DATE, then for every record of type CLAIM-HEADER-RECORD-RX, there must be a valid record of type ELIGIBILITY-DETERMINANTS that matches on the join keys and ELIGIBILITY-DETERMINANTS has a valid, non-null value for MSIS-IDENTIFICATION-NUM and ELIGIBILITY-DETERMINANTS has a non-null and not invalidly formatted value for ELIGIBILITY-DETERMINANT-EFF-DATE and ELIGIBILITY-DETERMINANTS has a non-null and not invalidly formatted value for ELIGIBILITY-DETERMINANT-END-DATE and CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE must be in (ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-EFF-DATE, ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-END-DATE) and ELIGIBILITY-DETERMINANTS.PRIMARY-ELIGIBILITY-GROUP-IND equals '1' and ELIGIBILITY-DETERMINANTS.DUAL-ELIGIBLE-CODE is equal to one of the following: '01', '02', '04', '08'
Rule Definition	If a claim in a non-denied, original or adjustment FFS or Encounter crossover claim from an RX file, and the MSIS ID is populated and the prescription fill date is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
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: '1', '3' and with CLAIM-HEADER-RECORD-RX.CROSSOVER-INDICATOR equals '1' and with CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND is equal to one of the following: '0', '4' and with CLAIM-HEADER-RECORD-RX has a non-null value for MSIS-IDENTIFICATION-NUM and with CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE has non-null and not invalidly formatted value

Published Date	Data Guide Version	Validation Rule	Action	Field	Before	After
07/14/2023	3.10.0	Rule-7414	UPDATE	Data Dictionary - Validation Rules	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: '1', '3' and CLAIM-HEADER-RECORD-RX.CROSSOVER-INDICATOR equals '1' and CLAIM-HEADER-RECORD-RX has a valid, non-null value for MSIS-IDENTIFICATION-NUM and CLAIM-HEADER-RECORD-RX has a non-null and not invalidly formatted value for PRESCRIPTION-FILL-DATE, then for every record of type CLAIM-HEADER-RECORD-RX, there must be a valid record of type ELIGIBILITY-DETERMINANTS that matches on the join keys and ELIGIBILITY-DETERMINANTS has a valid, non-null value for MSIS-IDENTIFICATION-NUM and ELIGIBILITY-DETERMINANTS has a non-null and not invalidly formatted value for ELIGIBILITY-DETERMINANT-EFF-DATE and ELIGIBILITY-DETERMINANTS has a non-null and not invalidly formatted value for ELIGIBILITY-DETERMINANT-END-DATE and CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE must be in (ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-EFF-DATE, ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-END-DATE) and ELIGIBILITY-DETERMINANTS.PRIMARY-ELIGIBILITY-GROUP-IND equals '1' and ELIGIBILITY-DETERMINANTS.DUAL-ELIGIBLE-CODE is equal to one of the following: '01', '02', '03', '04', '05', '06', '08', '09', '10'	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: '1', '3' and CLAIM-HEADER-RECORD-RX.CROSSOVER-INDICATOR equals '1' and CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-RX has a valid, non-null value for MSIS-IDENTIFICATION-NUM and CLAIM-HEADER-RECORD-RX has a non-null and not invalidly formatted value for PRESCRIPTION-FILL-DATE, then for every record of type CLAIM-HEADER-RECORD-RX, there must be a valid record of type ELIGIBILITY-DETERMINANTS that matches on the join keys and ELIGIBILITY-DETERMINANTS has a valid, non-null value for MSIS-IDENTIFICATION-NUM and ELIGIBILITY-DETERMINANTS has a non-null and not invalidly formatted value for ELIGIBILITY-DETERMINANT-EFF-DATE and ELIGIBILITY-DETERMINANTS has a non-null and not invalidly formatted value for ELIGIBILITY-DETERMINANT-END-DATE and CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE must be in (ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-EFF-DATE, ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-END-DATE) and ELIGIBILITY-DETERMINANTS.PRIMARY-ELIGIBILITY-GROUP-IND equals '1' and ELIGIBILITY-DETERMINANTS.DUAL-ELIGIBLE-CODE is equal to one of the following: ‘01', '02', '04', '08'
10/02/2020	2.4.0	Rule-7414	ADD	Data Dictionary - Validation Rules	N/A	if CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' AND CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR does not equal to '0' AND CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM not equal to "Z" AND CLAIM-HEADER-RECORD-RX.CLAIM-STATUS NOT IN ("26","026","87","087","542","585", "654")) AND CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM IN ("1", "3") AND CLAIM-HEADER-RECORD-RX.CROSSOVER-INDICATOR is equal to "1" AND CLAIM-HEADER-RECORD-RX has a non-null value for MSIS-IDENTIFICATION-NUM' AND CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE has non-null and not invalidly formatted value and ELIGIBILITY-DETERMINANTS has a non-null value for MSIS-IDENTIFICATION-NUM and ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-EFF-DATE has non-null and not invalidly formatted value and ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-END-DATE has non-null and not invalidly formatted value and CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE is greater than or equal to ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-EFF-DATE and CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE is less than or equal to ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-END-DATE AND ELIGIBILITY-DETERMINANTS.PRIMARY-ELIGIBILITY-GROUP-IND is equal to "1" THEN ELIGIBILITY-DETERMINANTS.DUAL-ELIGIBLE-CODE is equal to one of the following: '01','02','03','04','05','06','08','09','10'