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TMSIS Dataguide Medicaid.gov
Version 3.28.0

RULE-986

Validation Rule
Last updated

No Updates

Tier 2.0
Tier Description Relational error
Error Category E2001
Error Category Message Values inconsistently specified (single record type, single record)
Rule Type One Record Type (Single Record)
File Segment Number CLT00002
Data Element Name CLAIM-HEADER-RECORD-LT.TOT-TPL-AMT • CLAIM-HEADER-RECORD-LT.TOT-MEDICARE-COINS-AMT • CLAIM-HEADER-RECORD-LT.TOT-MEDICARE-DEDUCTIBLE-AMT • CLAIM-HEADER-RECORD-LT.TOT-BILLED-AMT
Validation Logic 'if CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-LT has a valid, non-null value for TOT-TPL-AMT and CLAIM-HEADER-RECORD-LT has a valid, non-null value for TOT-BILLED-AMT and CLAIM-HEADER-RECORD-LT has a valid, non-null value for TOT-MEDICARE-COINS-AMT and CLAIM-HEADER-RECORD-LT has a valid, non-null value for TOT-MEDICARE-DEDUCTIBLE-AMT, then the absolute value of CLAIM-HEADER-RECORD-LT.TOT-TPL-AMT is less than or equal to the absolute value of (CLAIM-HEADER-RECORD-LT.TOT-BILLED-AMT - (CLAIM-HEADER-RECORD-LT.TOT-MEDICARE-COINS-AMT + CLAIM-HEADER-RECORD-LT.TOT-MEDICARE-DEDUCTIBLE-AMT))'
Rule Definition If the total TPL amount, total billed amount, Medicare coinsurance amount, and Medicare deductible amount are populated on a non-denied claim from an LT file, then the absolute value of the total TPL amount is less than or equal to the absolute value of (total billed amount - (Medicare coinsurance amount + Medicare deductible amount)).
Denominator Logic # of LT claim headers with CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY not equal to 'F2' AND with CLAIM-HEADER-RECORD.LT.TOT-TPL-AMT equal to a valid, non-null value AND with CLAIM-HEADER-RECORD-LT.TOT-BILLED-AMT equal to a valid, non-null value AND with CLAIM-HEADER-RECORD-LT.TOT-MEDICARE-COINS-AMT equal to a valid, non-null value AND with CLAIM-HEADER-RECORD-LT.TOT-MEDICARE-DEDUCTIBLE-AMT equal to a valid, non-null value