An official website of the United States government

Official websites use .gov
A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS
A lock () or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-7564

Validation Rule
Last updated

Tier 2.0
Tier Description Relational error
Error Category E2001
Error Category Message Values inconsistently specified (single record type, single record)
Rule Type Two Record Type (1 to 1)
File Segment Number COT00002
Data Element Name CLAIM-HEADER-RECORD-OT.DIAGNOSIS-CODE-1
Validation Logic 'if CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-OT.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM does not equal 'Z' and CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '1', '3', 'A', 'C' and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and substr(CLAIM-LINE-RECORD-OT.PROCEDURE-CODE, 1, 1) is equal to 'D' and CLAIM-HEADER-RECORD-OT has a non-null value for DIAGNOSIS-CODE-FLAG-1, then CLAIM-HEADER-RECORD-OT has a non-null value for DIAGNOSIS-CODE-1'
Rule Definition If a claim is a non-denied claim from an OT file and the adjustment indicator is original or replacement, and the type of claim is Fee for Service Medicaid M-CHIP or S-CHIP or Encounter M-CHIP or S-SHIP, and the procedure code is for dental claims (starts with 'D') and the diagnosis code flag 1 is populated, then the diagnosis code 1 must be populated.
Denominator Logic # of OT claim headers with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-OT.CLAIM-DENIED-INDICATOR does not equal '0' and with CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM does not equal 'Z' and with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is equal to '0' or '4' and with CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '1', '3', 'A', 'C', and with CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with substr(CLAIM-LINE-RECORD-OT.PROCEDURE-CODE, 1, 1) is equal to 'D' and with CLAIM-HEADER-RECORD-OT has a non-null value for DIAGNOSIS-CODE-FLAG-1