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TMSIS Dataguide Medicaid.gov
Version 3.36.0

RULE-7912

Validation Rule
Last updated

06/02/2023

Tier 1.1
Tier Description Value Error
Error Category E1102
Error Category Message Value does not match specification
Rule Type One Record Type (Single Record)
File Segment Number CRX00002
Data Element Name CLAIM-HEADER-RECORD-RX.BILLING-PROV-NPI-NUM
Validation Logic 'if CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-RX has a valid, non-null value for BILLING-PROV-NPI-NUM and CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is equal to one of the following: '1', 'A', then CLAIM-HEADER-RECORD-RX.BILLING-PROV-NPI-NUM is a valid National Provider Identifier (NPI) number'
Rule Definition If the billing provider NPI number is populated on a non-denied claim from an RX file, and is a Medicaid or Medicaid-expansion CHIP FFS, or separate CHIP FFS claim then the billing provider NPI number value reported must be a valid NPI number.
Denominator Logic # of RX claim headers with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' and with CLAIM-HEADER-RECORD-RX has a valid, non-null value for BILLING-PROV-NPI-NUM and with CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is equal to one of the following: '1', 'A'