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TMSIS Dataguide Medicaid.gov

Version:

4.0.20

RULE-1791

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 Many)
File Segment Number CRX00002
Data Element Name CLAIM-HEADER-RECORD-RX.TOT-ALLOWED-AMT
Validation Logic 'if CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-RX.PAYMENT-LEVEL-IND equals '2' and CLAIM-HEADER-RECORD-RX has a valid, non-null value for TOT-ALLOWED-AMT, then CLAIM-HEADER-RECORD-RX.TOT-ALLOWED-AMT is equal to the sum of all CLAIM-LINE-RECORD-RX.ALLOWED-AMT values'
Rule Definition If a non-denied RX claim has a total allowed amount populated and the payment level indicator is for claim detail, then the total allowed amount must equal the sum of all line level allowed amounts.
Denominator Logic # of RX claim headers with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY not equal to 'F2' and with CLAIM-HEADER-RECORD-RX.PAYMENT-LEVEL-IND equal to '2' and with CLAIM-HEADER-RECORD-RX.TOT-ALLOWED-AMT equal to a valid, non-null value