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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 | ELG00014 |
Data Element Name | CLAIM-HEADER-RECORD-OT.SUBMITTING-STATE • MANAGED-CARE-PARTICIPATION.MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE • MANAGED-CARE-PARTICIPATION.MANAGED-CARE-PLAN-ENROLLMENT-END-DATE • CLAIM-HEADER-RECORD-OT.PLAN-ID-NUMBER • CLAIM-HEADER-RECORD-OT.BEGINNING-DATE-OF-SERVICE • CLAIM-HEADER-RECORD-OT.MSIS-IDENTIFICATION-NUM |
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.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', '686' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND does not equal '1' and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '2', 'B', 'V' and CLAIM-HEADER-RECORD-OT has a valid, non-null value for PLAN-ID-NUMBER, then for every record of type CLAIM-HEADER-RECORD-OT, there must be a valid record of type MANAGED-CARE-PARTICIPATION that matches on the join keys(MANAGED-CARE-PARTICIPATION[SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, MANAGED-CARE-PLAN-ID], CLAIM-HEADER-RECORD-OT[SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, PLAN-ID-NUMBER]) and CLAIM-HEADER-RECORD-OT.BEGINNING-DATE-OF-SERVICE must be in (MANAGED-CARE-PARTICIPATION.MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE, MANAGED-CARE-PARTICIPATION.MANAGED-CARE-PLAN-ENROLLMENT-END-DATE) |
Rule Definition | If plan ID is populated on a non-denied Medicaid, S-CHIP, or Other capitation from an OT file, then the plan ID must be equal to the plan ID on a managed care participation segment from an ELG file with the same MSIS ID and effective and end dates that overlap the beginning date of service. |
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 does not equal 'Z' and with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', '686' and with CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND does not equal '1' and with CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '2', 'B', 'V' and with CLAIM-HEADER-RECORD-OT has a valid, non-null value for PLAN-ID-NUMBER |