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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 | CRX00002 |
Data Element Name | CLAIM-HEADER-RECORD-RX.SUBMITTING-STATE • CLAIM-HEADER-RECORD-RX.MSIS-IDENTIFICATION-NUM • CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE • ELIGIBILITY-DETERMINANTS.MSIS-IDENTIFICATION-NUM • ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-EFF-DATE • ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-END-DATE • ELIGIBILITY-DETERMINANTS.PRIMARY-ELIGIBILITY-GROUP-IND • ELIGIBILITY-DETERMINANTS.DUAL-ELIGIBLE-CODE • CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY • CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR • CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM • CLAIM-HEADER-RECORD-RX.CLAIM-STATUS • CLAIM-HEADER-RECORD-RX.CROSSOVER-INDICATOR • CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND |
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 does not equal 'Z' and CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM equals '3' and CLAIM-HEADER-RECORD-RX.CROSSOVER-INDICATOR equals '1' and CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-RX has a valid, non-null value for MSIS-IDENTIFICATION-NUM and CLAIM-HEADER-RECORD-RX has a non-null and not invalidly formatted value for PRESCRIPTION-FILL-DATE, then for every record of type CLAIM-HEADER-RECORD-RX, there must be a valid record of type ELIGIBILITY-DETERMINANTS that matches on the join keys and ELIGIBILITY-DETERMINANTS has a valid, non-null value for MSIS-IDENTIFICATION-NUM and ELIGIBILITY-DETERMINANTS has a non-null and not invalidly formatted value for ELIGIBILITY-DETERMINANT-EFF-DATE and ELIGIBILITY-DETERMINANTS has a non-null and not invalidly formatted value for ELIGIBILITY-DETERMINANT-END-DATE and CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE must be in (ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-EFF-DATE, ELIGIBILITY-DETERMINANTS.ELIGIBILITY-DETERMINANT-END-DATE) and ELIGIBILITY-DETERMINANTS.PRIMARY-ELIGIBILITY-GROUP-IND equals '1' and ELIGIBILITY-DETERMINANTS.DUAL-ELIGIBLE-CODE is equal to one of the following: '01', '02', '04', '08' |
Rule Definition | If a claim in a non-denied, original or adjustment Encounter crossover claim from an RX file, and the MSIS ID is populated and the presription fill date is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08' |
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 does not equal 'Z' and with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM equals '3' and with CLAIM-HEADER-RECORD-RX.CROSSOVER-INDICATOR is equal to '1' and CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND is equal to one of the following: '0', '4' and with CLAIM-HEADER-RECORD-RX has a non-null value for MSIS-IDENTIFICATION-NUM and with CLAIM-HEADER-RECORD-RX has a non-null and not invalidly formatted value for PRESCRIPTION-FILL-DATE |