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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-7657

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 One Record Type (Single Record)
File Segment Number CIP00002
Data Element Name CLAIM-HEADER-RECORD-IP.MEDICARE-PAID-AMT • CLAIM-HEADER-RECORD-IP.TOT-MEDICARE-COINS-AMT • CLAIM-HEADER-RECORD-IP.TOT-MEDICARE-DEDUCTIBLE-AMT
Validation Logic 'if CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-IP.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM does not equal 'Z' and CLAIM-HEADER-RECORD-IP.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-IP.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-IP.CROSSOVER-INDICATOR equals '1' and CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM is equal to one of the following: '3', 'C', then (CLAIM-HEADER-RECORD-IP has a non-null and not invalidly formatted value for MEDICARE-PAID-AMT and CLAIM-HEADER-RECORD-IP.MEDICARE-PAID-AMT does not equal '0.00') or (CLAIM-HEADER-RECORD-IP has a non-null and not invalidly formatted value for TOT-MEDICARE-COINS-AMT and CLAIM-HEADER-RECORD-IP.TOT-MEDICARE-COINS-AMT does not equal '0.00') or (CLAIM-HEADER-RECORD-IP has a non-null and not invalidly formatted value for TOT-MEDICARE-DEDUCTIBLE-AMT andCLAIM-HEADER-RECORD-IP.TOT-MEDICARE-DEDUCTIBLE-AMT does not equal '0.00')'
Rule Definition If a claim is a non-denied, crossover Medicaid Encounter, original or adjustment paid claim from an IP file, then the claim must have a non-null value and not zero value for medicare paid amount or total medicare coinsurance amount or total medicare deductible amount.
Denominator Logic # of IP claim headers with CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY does not equal 'F2' and with CLAIM-HEADER-RECORD-IP.CLAIM-DENIED-INDICATOR does not equal '0' and with CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM does not equal 'Z' and with CLAIM-HEADER-RECORD-IP.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-IP.ADJUSTMENT-IND is equal to '0' or '4' and with CLAIM-HEADER-RECORD-IP.CROSSOVER-INDICATOR is equal to '1'and with CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM is equal to one of the following: '3', 'C'