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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-7549

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 • 1115A-DEMONSTRATION-INFORMATION.1115A-EFF-DATE • 1115A-DEMONSTRATION-INFORMATION.1115A-END-DATE • 1115A-DEMONSTRATION-INFORMATION.1115A-DEMONSTRATION-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.1115A-DEMONSTRATION-IND • CLAIM-HEADER-RECORD-RX.MSIS-IDENTIFICATION-NUM • CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM
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.1115A-DEMONSTRATION-IND equals '1', then for every record of type CLAIM-HEADER-RECORD-RX, there must be a valid record of type 1115A-DEMONSTRATION-INFORMATION that matches on the join keys and CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE is greater than or equal to 1115A-DEMONSTRATION-INFORMATION.1115A-EFF-DATE and CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE is less than or equal to 1115A-DEMONSTRATION-INFORMATION.1115A-END-DATE and 1115A-DEMONSTRATION-INFORMATION.1115A-DEMONSTRATION-IND equals '1'
Rule Definition If the 1115A demonstration indicator is equal to 1 (yes) on a non-denied claim from an RX file, and the prescription fill date is within the 1115A effective and end dates, then the 1115A demonstration indicator value reported on the 1115A demonstration information segment must be populated with a 1 value.
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.1115A-DEMONSTRATION-IND equals '1'