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TMSIS Dataguide Medicaid.gov
Version 3.36.0

RULE-7892

Validation Rule
Last updated

09/22/2023

Tier 1.1
Tier Description Missing Value Error
Error Category E1105
Error Category Message Data Element Value is Missing
Rule Type Two Record Type (1 to 1)
File Segment Number COT00002
Data Element Name CLAIM-LINE-RECORD-OT.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT
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-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '1', 'A' and CLAIM-HEADER-RECORD-OT has a non-null and not invalidly formatted value for TOT-MEDICAID-PAID-AMT and CLAIM-HEADER-RECORD-OT.TOT-MEDICAID-PAID-AMT does not equal '0.00', then CLAIM-LINE-RECORD-OT has a non-null value for CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT'
Rule Definition If a claim is a non-denied claim that is an original or replacement/ resubmission claim from an OT file, and is a Medicaid or Medicaid-expansion CHIP FFS or Separate CHIP FFS claim and total medicaid paid amt is non-null and not zero, then the claim line CMS-64 category for federal reimbursement must be populated.
Denominator Logic # of OT claim lines 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-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is equal to '0' or '4' and with CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '1', 'A' and with CLAIM-HEADER-RECORD-IP has a non-null and not invalidly formatted value for TOT-MEDICAID-PAID-AMT and with CLAIM-HEADER-RECORD-IP.TOT-MEDICAID-PAID-AMT does not equal '0.00'