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TMSIS Dataguide Medicaid.gov

Version:

4.0.20

RULE-7511

Validation Rule
Last updated

Tier 1.1
Tier Description Value Error
Error Category E1102
Error Category Message Value does not match specification
Rule Type One Record Type (Single Record)
File Segment Number CRX00002
Data Element Name CLAIM-HEADER-RECORD-RX.PRESCRIBING-PROV-NPI-NUM
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.ADJUSTMENT-IND does not equal '1' and CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', '686' and CLAIM-HEADER-RECORD-RX has a non-null value for PRESCRIBING-PROV-NPI-NUM and CLAIM-HEADER-RECORD-RX.PRESCRIBING-PROV-NPI-NUM is a valid National Provider Identifier (NPI) number that exists in the NPPES NPI data file, then Entity Type Code is equal to '1' in the NPPES NPI data file'
Rule Definition If a claim is a non-denied, non-void claim from an RX file and the prescribing provider NPI is populated and is a valid NPI in the NPPES file, then the 'entity type code' is equal to '1' (individual) in the NPPES NPI data file.
Denominator Logic # of RX claim headers 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.ADJUSTMENT-IND does not equal '1' and with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', '686' and with CLAIM-HEADER-RECORD-RX has a non-null value for PRESCRIBING-PROV-NPI-NUM, and with CLAIM-HEADER-RECORD-RX.PRESCRIBING-PROV-NPI-NUM is a valid National Provider Identifier (NPI) number that exists in the NPPES NPI data file