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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-7933

Validation Rule
Last updated

Tier 3.0
Tier Description Relational error
Error Category E3002
Error Category Message Values inconsistently specified (multiple record types, multi file)
Rule Type Three Record Type Rule
File Segment Number CIP00002
Data Element Name PROV-MEDICAID-ENROLLMENT.PROV-MEDICAID-ENROLLMENT-STATUS-CODE
Validation Logic 'if CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-IP.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM does not equal 'Z' and CLAIM-HEADER-RECORD-IP.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-IP.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM is equal to one of the following: '1', 'A' and CLAIM-LINE-RECORD-IP.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-LINE-RECORD-IP has a non-null value for SERVICING-PROV-NUM, then there are greater than 0 PROV-MEDICAID-ENROLLMENT records with matching join keys and the CLAIM-LINE-RECORD-IP.BEGINNING-DATE-OF-SERVICE and CLAIM-LINE-RECORD-IP.ENDING-DATE-OF-SERVICE are overlapping with the PROV-MEDICAID-ENROLLMENT.PROV-MEDICAID-EFF-DATE and PROV-MEDICAID-ENROLLMENT.PROV-MEDICAID-END-DATE, 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 servicing provider number is populated on a non-denied claim from an IP file and the claim is a Medicaid or M-CHIP FFS or Separate CHIP FFS original or adjustment paid claim, the claim line servicing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status where the effective and end dates of the provider medicaid enrollment segment overlap with the beginning date of service and (if populated) ending date of service on the claim line.
Denominator Logic # of IP claim lines with CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY does not equal 'F2' and with CLAIM-HEADER-RECORD-IP.CLAIM-DENIED-INDICATOR does not equal '0' and with CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM does not equal 'Z' and with CLAIM-HEADER-RECORD-IP.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-IP.ADJUSTMENT-IND is equal to '0' or '4' and with CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM is equal to one of the following: '1', 'A' and with CLAIM-LINE-RECORD-IP.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-LINE-RECORD-IP has a non-null value for SERVICING-PROV-NUM