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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-7593

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 COT00002
Data Element Name CLAIM-LINE-RECORD-OT.TYPE-OF-SERVICE
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.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '2', 'B', 'V' and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', then CLAIM-LINE-RECORD-OT has a non-null value for TYPE-OF-SERVICE and CLAIM-LINE-RECORD-OT.TYPE-OF-SERVICE is equal to one of the following: '119', '120', '121', '122', '138', '139', '140', '141', '142', '143', '144''
Rule Definition If a claim is a non-denied, Medicaid/Medicaid expansion CHIP, Separate CHIP or other capitated payment, paid claim from an OT file, then the claim line type of service is non-null and equal to capitated payments for HMOs, HIOs, or PACE plans (119), primary care case management (PCCM) (120), Premium payments for private health insurance (121), capitated payments to prepaid health plans (PHPs) (122), per member per month PMPM payments ('138','139', '140', '141', '142', '143', '144')
Denominator Logic # of OT claim lines with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and with CLAIM-HEADER-RECORD-OT.CLAIM-DENIED-INDICATOR does not equal '0' 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.TYPE-OF-CLAIM is equal to one of the following: '2', 'B', 'V' and with CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654'