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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-7773

Validation Rule
Last updated

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.PRESCRIPTION-FILL-DATE • WAIVER-PARTICIPATION.WAIVER-ENROLLMENT-EFF-DATE • WAIVER-PARTICIPATION.WAIVER-ENROLLMENT-END-DATE • CLAIM-HEADER-RECORD-RX.WAIVER-TYPE • WAIVER-PARTICIPATION.WAIVER-TYPE • CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY • CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR • CLAIM-HEADER-RECORD-RX.CLAIM-STATUS • CLAIM-HEADER-RECORD-RX.MSIS-IDENTIFICATION-NUM • CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM
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 has a valid, non-null value for WAIVER-TYPE, then for every record of type CLAIM-HEADER-RECORD-RX, there must be a valid record of type WAIVER-PARTICIPATION that matches on the join keys and CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE must be in (WAIVER-PARTICIPATION.WAIVER-ENROLLMENT-EFF-DATE, WAIVER-PARTICIPATION.WAIVER-ENROLLMENT-END-DATE) and CLAIM-HEADER-RECORD-RX.WAIVER-TYPE equals WAIVER-PARTICIPATION.WAIVER-TYPE
Rule Definition If a claim is a non-denied claim from an RX file, and the waiver type is populated, and the claim prescription fill 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 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 has a non-null value for WAIVER-TYPE