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TMSIS Dataguide Medicaid.gov
Version 3.27.0

RULE-7959

Validation Rule
Last updated

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 COT00002
Data Element Name CLAIM-LINE-RECORD-OT.XXI-MBESCBES-CATEGORY-OF-SERVICE
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.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '5', 'E' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND does not equal '1' 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' 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-LINE-RECORD-OT has a non-null value for XIX-MBESCBES-CATEGORY-OF-SERVICE, then CLAIM-LINE-RECORD-OT has a null value for XXI-MBESCBES-CATEGORY-OF-SERVICE'
Rule Definition If a claim is a non-denied, Medicaid or M-CHIP supplemental or Separate CHIP supplemental claim from an OT file, and the total medicaid paid amount is a non-null value and does not equal zero, and claim line XIX-MBESCBES category of service is populated, then claim line XXI-MBESCBES category of service must not 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.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '5', 'E' and with CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND does not equal '1' and with CLAIM-HEADER-RECORD-OT has a non-null and not invalidly formatted value for TOT-MEDICAID-PAID-AMT and with CLAIM-HEADER-RECORD-OT.TOT-MEDICAID-PAID-AMT does not equal '0.00' 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-LINE-RECORD-OT has a non-null value for XIX-MBESCBES-CATEGORY-OF-SERVICE