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Tier | 2.1 |
---|---|
Tier Description | Relational error |
Error Category | E2102 |
Error Category Message | Values inconsistently specified (multi record, single file) |
Rule Type | Two Record Type (1 to 1) |
File Segment Number | CRX00002 |
Data Element Name | CLAIM-LINE-RECORD-RX.XIX-MBESCBES-CATEGORY-OF-SERVICE |
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.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM equals '1' and CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND does not equal '1' and CLAIM-HEADER-RECORD-RX has a non-null and not invalidly formatted value for TOT-MEDICAID-PAID-AMT and CLAIM-HEADER-RECORD-RX.TOT-MEDICAID-PAID-AMT does not equal '0.00' and CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-LINE-RECORD-RX.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT equals '01', then CLAIM-LINE-RECORD-RX has a non-null value for XIX-MBESCBES-CATEGORY-OF-SERVICE' |
Rule Definition | If a claim is a non-denied, Medicaid or M-CHIP fee for service claim from an RX file, and the total medicaid paid amount is a non-null value and the total medicaid paid amount is not equal to zero and CMS 64 category for federal reimbursement is equal to '01', then the XIX-MBESCBES category of service must be populated. |
Denominator Logic | # of RX claim lines 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.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is equal to '1' and with CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND is not equal to '1' and with CLAIM-HEADER-RECORD-RX has a non-null, and not invalidly formatted value for TOT-MEDICAID-PAID-AMT and CLAIM-HEADER-RECORD-RX.TOT-MEDICAID-PAID-AMT is not equal to '0.00' and with CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-LINE-RECORD-RX.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT is equal to '01' |