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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-7479

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 CIP00002
Data Element Name CLAIM-LINE-RECORD-IP.OPERATING-PROV-NPI-NUM
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.ADJUSTMENT-IND does not equal '1' and CLAIM-HEADER-RECORD-IP.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', '686' and CLAIM-LINE-RECORD-IP.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', '686' and CLAIM-LINE-RECORD-IP has a non-null value for OPERATING-PROV-NPI-NUM, then CLAIM-LINE-RECORD-IP.OPERATING-PROV-NPI-NUM is a valid National Provider Identifier (NPI) number that exists in the NPPES NPI data file'
Rule Definition If a claim is a non-denied, non-void claim from an IP file and the operating provider NPI num is populated then claim line operating provider NPI num exists in the NPPES NPI data file.
Denominator Logic # of IP claim lines 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.ADJUSTMENT-IND does not equal '1' and with CLAIM-HEADER-RECORD-IP.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', '686' and CLAIM-LINE-RECORD-IP.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', '686' and with CLAIM-LINE-RECORD-IP has a non-null value for OPERATING-PROV-NPI-NUM