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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 | COT00002 |
Data Element Name | CLAIM-HEADER-RECORD-OT.TOT-ALLOWED-AMT • CLAIM-HEADER-RECORD-OT.TOT-MEDICAID-PAID-AMT |
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' and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '1', 'A' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND equals '0' and CLAIM-HEADER-RECORD-OT has a non-null value for TOT-MEDICAID-PAID-AMT and CLAIM-HEADER-RECORD-OT.TOT-ALLOWED-AMT does not equal '0.00' and CLAIM-HEADER-RECORD-OT has a non-null value for TOT-ALLOWED-AMT, then CLAIM-HEADER-RECORD-OT.TOT-MEDICAID-PAID-AMT is less than or equal to CLAIM-HEADER-RECORD-OT.TOT-ALLOWED-AMT' |
Rule Definition | If a claim is a non-denied claim from an OT file that is an original claim and is a Medicaid or Medicaid-expansion CHIP or Separate CHIP Fee-for-Service 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 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' and with CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '1', 'A' and with CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND equals '0' and with CLAIM-HEADER-RECORD-OT has a non-null value for TOT-MEDICAID-PAID-AMT and with CLAIM-HEADER-RECORD-OT.TOT-ALLOWED-AMT does not equal '0.00' and with CLAIM-HEADER-RECORD-OT has a non-null value for TOT-ALLOWED-AMT |