RULE-7635

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-HEADER-RECORD-OT.SUBMITTING-STATE • CLAIM-HEADER-RECORD-OT.ICN-ORIG • CLAIM-HEADER-RECORD-OT.ICN-ADJ • CLAIM-HEADER-RECORD-OT.ADJUDICATION-DATE • CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND • CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS • CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY • CLAIM-HEADER-RECORD-OT.CLAIM-DENIED-INDICATOR • CLAIM-HEADER-RECORD-OT.CLAIM-STATUS • CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM
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.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', then for every record of type CLAIM-HEADER-RECORD-OT, there must be a valid record of type CLAIM-LINE-RECORD-OT that matches on the join keys, and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654'
Rule Definition	All non-denied, paid OT claim header records must have a corresponding non-denied claim line record.
Denominator Logic	# of OT claim headers 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.TYPE-OF-CLAIM is not equal to 'Z' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is equal to one of the following: '0', '4' and with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '026', '087', '26', '87', '542', '585', '654'

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-HEADER-RECORD-OT.SUBMITTING-STATE • CLAIM-HEADER-RECORD-OT.ICN-ORIG • CLAIM-HEADER-RECORD-OT.ICN-ADJ • CLAIM-HEADER-RECORD-OT.ADJUDICATION-DATE • CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND • CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS • CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY • CLAIM-HEADER-RECORD-OT.CLAIM-DENIED-INDICATOR • CLAIM-HEADER-RECORD-OT.CLAIM-STATUS • CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM

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.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', then for every record of type CLAIM-HEADER-RECORD-OT, there must be a valid record of type CLAIM-LINE-RECORD-OT that matches on the join keys, and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654'

Rule Definition

All non-denied, paid OT claim header records must have a corresponding non-denied claim line record.

Denominator Logic

# of OT claim headers 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.TYPE-OF-CLAIM is not equal to 'Z' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is equal to one of the following: '0', '4' and with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '026', '087', '26', '87', '542', '585', '654'

Published Date	Data Guide Version	Validation Rule	Action	Field	Before	After
04/01/2022	3.0.0	RULE-7635	ADD	Data Dictionary - Validation Rules	N/A	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 is not equal to 'Z' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '026', '087’,'26', '87', '542', '585', '654', and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '026', '087’,'26', '87', '542', '585', '654', then CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '026', '087’,'26', '87', '542', '585', '654'
05/13/2022	3.0.0	RULE-7635	UPDATE	Data Dictionary - Validation Rules	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 is not equal to 'Z' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '026', '087’,'26', '87', '542', '585', '654', and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '026', '087’,'26', '87', '542', '585', '654', then CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '026', '087’,'26', '87', '542', '585', '654'	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 is not equal to 'Z' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '026', '087’,'26', '87', '542', '585', '654', and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '026', '087’,'26', '87', '542', '585', '654', then for every record of type CLAIM-HEADER-RECORD-OT, there must be a valid record of type CLAIM-LINE-RECORD-OT that matches on join keys and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '026', '087’,'26', '87', '542', '585', '654'