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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 | PRV00007 |
Data Element Name | CLAIM-HEADER-RECORD-RX.SUBMITTING-STATE • CLAIM-HEADER-RECORD-RX.BILLING-PROV-NUM • PROV-MEDICAID-ENROLLMENT.PROV-MEDICAID-ENROLLMENT-STATUS-CODE |
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.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is equal to one of the following: '1', 'A' and CLAIM-HEADER-RECORD-RX has a non-null value for BILLING-PROV-NUM, then for every record of type CLAIM-HEADER-RECORD-RX, there must be a valid record of type PROV-MEDICAID-ENROLLMENT that matches on the join keys(PROV-MEDICAID-ENROLLMENT[SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID], CLAIM-HEADER-RECORD-RX[SUBMITTING-STATE, BILLING-PROV-NUM]), where PROV-MEDICAID-ENROLLMENT.PROV-MEDICAID-ENROLLMENT-STATUS-CODE is equal to one of the following: '01', '02', '03', '04', '05', '06' |
Rule Definition | If the billing provider number is populated on a non-denied claim from an RX file and the claim is a Medicaid or M-CHIP FFS or Separate CHIP FFS original or adjustment paid claim, the billing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the prescription fill date. |
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.ADJUSTMENT-IND is equal to '0' or '4' and with CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is equal to one of the following: '1', 'A' and with CLAIM-HEADER-RECORD-RX has a non-null value for BILLING-PROV-NUM |