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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 | CLT00002 |
Data Element Name | PROV-MEDICAID-ENROLLMENT.PROV-MEDICAID-ENROLLMENT-STATUS-CODE |
Validation Logic | 'if CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-LT.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM does not equal 'Z' and CLAIM-HEADER-RECORD-LT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-LT.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM is equal to one of the following: '1', '3', 'A', 'C' and CLAIM-LINE-RECORD-LT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-LINE-RECORD-LT has a non-null value for SERVICING-PROV-NUM, then there are greater than 0 PROV-MEDICAID-ENROLLMENT records with matching join keys and the CLAIM-LINE-RECORD-LT.BEGINNING-DATE-OF-SERVICE and CLAIM-LINE-RECORD-LT.BEGINNING-DATE-OF-SERVICE are overlapping with the PROV-MEDICAID-ENROLLMENT.PROV-MEDICAID-EFF-DATE and PROV-MEDICAID-ENROLLMENT.PROV-MEDICAID-END-DATE, 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 servicing provider number is populated on a non-denied claim from an LT file and the claim is an Medicaid and S-CHIP FFS and encounter original or adjustment paid claim, the claim line servicing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the beginning date of service. |
Denominator Logic | # of LT claim lines with CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY does not equal 'F2' and with CLAIM-HEADER-RECORD-LT.CLAIM-DENIED-INDICATOR does not equal '0' and with CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM does not equal 'Z' and with CLAIM-HEADER-RECORD-LT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-LT.ADJUSTMENT-IND is equal to '0' or '4' and with CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM is equal to one of the following: '1', '3', 'A', 'C' and with CLAIM-LINE-RECORD-LT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-LINE-RECORD-LT has a non-null value for SERVICING-PROV-NUM |