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TMSIS Dataguide Medicaid.gov
Version 3.36.0

RULE-7820

Validation Rule
Last updated

Tier 1.1
Tier Description Missing Value Error
Error Category E1105
Error Category Message Data Element Value is Missing
Rule Type One Record Type (Single Record)
File Segment Number CLT00002
Data Element Name CLAIM-HEADER-RECORD-LT.BILLING-PROV-NPI-NUM
Validation Logic 'if CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-LT.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM does not equal 'Z' and CLAIM-HEADER-RECORD-LT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM is equal to one of the following: '1', 'A' and CLAIM-HEADER-RECORD-LT.ADJUSTMENT-IND is equal to one of the following: '0', '4', then CLAIM-HEADER-RECORD-LT has a non-null value for BILLING-PROV-NPI-NUM'
Rule Definition If a claim is a non-denied claim from an LT file, and is a Medicaid or Medicaid-expansion CHIP Fee-for-service or Separate CHIP Fee-for-service claim and is an original claim or a replacement/resubmission claim payment then the billing provider NPI number must be populated.
Denominator Logic # of LT claim headers with CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY does not equal 'F2' and with CLAIM-HEADER-RECORD-LT.CLAIM-DENIED-INDICATOR does not equal '0' and with CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM does not equal 'Z' and with CLAIM-HEADER-RECORD-LT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM is equal to one of the following: '1', 'A' and with CLAIM-HEADER-RECORD-LT.ADJUSTMENT-IND is equal to one of the following: '0', '4'