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RULE-7742
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If a claim in a non-denied, original or adjustment Encounter crossover claim from an RX file, and the MSIS ID is populated and the presription fill date is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
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RULE-7984
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If a claim in a non-denied, original or adjustment FFS crossover claim from an RX file, and the MSIS ID is populated and the presription fill date is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
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RULE-1758
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If a claim is a non-denied, non-void, non-service tracking Medicaid or CHIP claim from an RX file, then the MSIS ID value reported on the claim must be equal to the MSIS ID value on an enrollment time span segment with effective and end date values that overlap with the prescription fill date on the pharmacy claim.
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RULE-6580
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If a claim is a non-denied claim from an RX file, then the MSIS identification number value reported must be compatible with specified T-MSIS picture format: X(20).
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RULE-7197
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If plan ID is populated on a non-denied Medicaid, S-CHIP, or Other encounter from an RX file, then the plan ID must be equal to the plan ID on a managed care participation segment from an ELG file with the same MSIS ID and where the prescription fill date on the claim is within the effective and end dates of the managed care participation segment.
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RULE-7414
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If a claim in a non-denied, original or adjustment FFS or Encounter crossover claim from an RX file, and the MSIS ID is populated and the prescription fill date is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
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RULE-7549
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If the 1115A demonstration indicator is equal to 1 (yes) on a non-denied claim from an RX file, and the prescription fill date is within the 1115A effective and end dates, then the 1115A demonstration indicator value reported on the 1115A demonstration information segment must be populated with a 1 value.
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RULE-7645
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If a claim is a non-denied, non-void, encounter Medicaid/M-CHIP or S-CHIP claim from an RX file, then the MSIS ID value reported on the claim must be equal to the MSIS ID value on an enrollment time span segment with effective and end date values that overlap with the prescription fill date on the pharmacy claim.
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RULE-7773
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If a claim is a non-denied claim from an RX file, and the waiver type is populated, and the claim prescription fill date is between the waiver enrollment effective and end dates, then the claim waiver type is equal to the waiver participation waiver type.
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RULE-7785
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If a claim is a non-denied, non-void, Medicaid/M-CHIP or S-CHIP FFS claim from an RX file, then the MSIS ID value reported on the claim must be equal to the MSIS ID value on an enrollment time span segment with effective and end date values that overlap with the prescription fill date on the pharmacy claim.
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RULE-7900
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If a claim is a non-denied, non-void, supplemental claim from an RX file, then the MSIS ID value reported on the claim must be equal to the MSIS ID value on an enrollment time span segment with effective and end date values that overlap with the prescription fill date on the pharmacy claim.
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