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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 | CIP00002 |
Data Element Name | CLAIM-HEADER-RECORD-IP.SUBMITTING-STATE • CLAIM-HEADER-RECORD-IP.ADMISSION-DATE • WAIVER-PARTICIPATION.WAIVER-ENROLLMENT-EFF-DATE • WAIVER-PARTICIPATION.WAIVER-ENROLLMENT-END-DATE • CLAIM-HEADER-RECORD-IP.WAIVER-TYPE • WAIVER-PARTICIPATION.WAIVER-TYPE • CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY • CLAIM-HEADER-RECORD-IP.CLAIM-DENIED-INDICATOR • CLAIM-HEADER-RECORD-IP.CLAIM-STATUS • CLAIM-HEADER-RECORD-IP.MSIS-IDENTIFICATION-NUM • CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM |
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 has a valid, non-null value for WAIVER-TYPE, then for every record of type CLAIM-HEADER-RECORD-IP, there must be a valid record of type WAIVER-PARTICIPATION that matches on the join keys and CLAIM-HEADER-RECORD-IP.ADMISSION-DATE must be in (WAIVER-PARTICIPATION.WAIVER-ENROLLMENT-EFF-DATE, WAIVER-PARTICIPATION.WAIVER-ENROLLMENT-END-DATE) and CLAIM-HEADER-RECORD-IP.WAIVER-TYPE equals WAIVER-PARTICIPATION.WAIVER-TYPE |
Rule Definition | If a claim is a non-denied claim from an IP file, and the waiver type is populated, and the claim admission date is between the waiver enrollment effective and end dates, then the claim waiver type is equal to the waiver participation waiver type. |
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 has a non-null value for WAIVER-TYPE |