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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-7439

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 PRV00007
Data Element Name CLAIM-HEADER-RECORD-IP.SUBMITTING-STATE • CLAIM-HEADER-RECORD-IP.BILLING-PROV-NUM • PROV-MEDICAID-ENROLLMENT.PROV-MEDICAID-ENROLLMENT-STATUS-CODE
Validation Logic if CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-IP.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM does not equal 'Z' and CLAIM-HEADER-RECORD-IP.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-IP.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM is equal to one of the following: '1', '3', 'A', 'C' and CLAIM-HEADER-RECORD-IP has a non-null value for BILLING-PROV-NUM, then for every record of type CLAIM-HEADER-RECORD-IP, there must be a valid record of type PROV-MEDICAID-ENROLLMENT that matches on the join keys(PROV-MEDICAID-ENROLLMENT[SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID], CLAIM-HEADER-RECORD-IP[SUBMITTING-STATE, BILLING-PROV-NUM]), where PROV-MEDICAID-ENROLLMENT.PROV-MEDICAID-ENROLLMENT-STATUS-CODE is equal to one of the following: '01', '02', '03', '04', '05', '06'
Rule Definition If the billing provider number is populated on a non-denied claim from an IP file and the claim is a Medicaid and S-CHIP FFS and encounter original or adjustment paid claim, the billing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the admission date.
Denominator Logic # of IP claim headers with CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY does not equal 'F2' and with CLAIM-HEADER-RECORD-IP.CLAIM-DENIED-INDICATOR does not equal '0' and with CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM does not equal 'Z' and with CLAIM-HEADER-RECORD-IP.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-IP.ADJUSTMENT-IND is equal to '0' or '4' and with CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM is equal to one of the following: '1', '3', 'A', 'C' and with CLAIM-HEADER-RECORD-IP has a non-null value for BILLING-PROV-NUM