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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-7687

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 CLT00002
Data Element Name CLAIM-HEADER-RECORD-LT.TOT-ALLOWED-AMT • CLAIM-HEADER-RECORD-LT.TOT-MEDICAID-PAID-AMT
Validation Logic 'if CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-LT.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM does not equal 'Z' and CLAIM-HEADER-RECORD-LT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM is equal to one of the following: 'C', '3' and CLAIM-HEADER-RECORD-LT.ADJUSTMENT-IND equals '0' and CLAIM-HEADER-RECORD-LT has a non-null value for TOT-MEDICAID-PAID-AMT and CLAIM-HEADER-RECORD-LT.TOT-ALLOWED-AMT does not equal '0.00' and CLAIM-HEADER-RECORD-LT has a non-null value for TOT-ALLOWED-AMT, then CLAIM-HEADER-RECORD-LT.TOT-MEDICAID-PAID-AMT is less than or equal to CLAIM-HEADER-RECORD-LT.TOT-ALLOWED-AMT'
Rule Definition If a claim is a non-denied claim from an LT file that is an original claim and is a Medicaid or Medicaid-expansion CHIP encounter, separate CHIP encounter claim and the total medicaid paid amount is populated, then the total medicaid paid amount is less than or equal to the total allowed amount.
Denominator Logic # of LT claim headers with CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY does not equal 'F2' and with CLAIM-HEADER-RECORD-LT.CLAIM-DENIED-INDICATOR does not equal '0' and with CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM does not equal 'Z' and with CLAIM-HEADER-RECORD-LT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM is equal to one of the following: 'C', '3' and with CLAIM-HEADER-RECORD-LT.ADJUSTMENT-IND equals '0' and with CLAIM-HEADER-RECORD-LT has a non-null value for TOT-MEDICAID-PAID-AMT and with CLAIM-HEADER-RECORD-LT.TOT-ALLOWED-AMT does not equal '0.00' and with CLAIM-HEADER-RECORD-LT has a non-null value for TOT-ALLOWED-AMT