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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-7645

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 ELG00021
Data Element Name CLAIM-HEADER-RECORD-RX.SUBMITTING-STATE • CLAIM-HEADER-RECORD-RX.MSIS-IDENTIFICATION-NUM
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 is equal to one of the following: '3', 'C' and CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', '686' and CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND does not equal '1', then for every record of type CLAIM-HEADER-RECORD-RX, there must be a valid record of type ENROLLMENT-TIME-SPAN-SEGMENT that matches on the join keys(ENROLLMENT-TIME-SPAN-SEGMENT[SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM], CLAIM-HEADER-RECORD-RX[SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM])
Rule Definition If a claim is a non-denied, non-void, encounter Medicaid/M-CHIP or S-CHIP claim from an RX file, then the MSIS ID value reported on the claim must be equal to the MSIS ID value on an enrollment time span segment with effective and end date values that overlap with the prescription fill date on the pharmacy claim.
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 is equal to one of the following: '3', 'C' and with CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND is not equal to '1' and with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', '686'