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Tier | 1.1 |
---|---|
Tier Description | Value Error |
Error Category | E1102 |
Error Category Message | Value does not match specification |
Rule Type | One Record Type (Single Record) |
File Segment Number | CIP00002 |
Data Element Name | CLAIM-HEADER-RECORD-IP.BILLING-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-HEADER-RECORD-IP has a non-null value for BILLING-PROV-NPI-NUM and CLAIM-HEADER-RECORD-IP.BILLING-PROV-NPI-NUM is a valid National Provider Identifier (NPI) number that exists in the NPPES NPI data file, then Entity Type Code is equal to '2' in the NPPES NPI data file' |
Rule Definition | If a claim is a non-denied, non-void claim from an IP file and the billing provider NPI is populated and is a valid NPI in the NPPES file, then the 'entity type code' is equal to '2' (organization) in the NPPES NPI data file. |
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.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 with CLAIM-HEADER-RECORD-IP has a non-null value for BILLING-PROV-NPI-NUM, and with CLAIM-HEADER-RECORD-IP.BILLING-PROV-NPI-NUM is a valid National Provider Identifier (NPI) number that exists in the NPPES NPI data file |