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TMSIS Dataguide Medicaid.gov

Version:

4.0.20

RULE-7781

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 CRX00002
Data Element Name CLAIM-HEADER-RECORD-RX.TOT-MEDICARE-COINS-AMT • CLAIM-HEADER-RECORD-RX.TOT-MEDICARE-DEDUCTIBLE-AMT • CLAIM-LINE-RECORD-RX.MEDICARE-PAID-AMT
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.TYPE-OF-CLAIM does not equal 'Z' and CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-RX.CROSSOVER-INDICATOR equals '0' and CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is equal to one of the following: '1', 'A', then (CLAIM-LINE-RECORD-RX has a null value for MEDICARE-PAID-AMT or CLAIM-LINE-RECORD-RX.MEDICARE-PAID-AMT equals '0.00') and (CLAIM-HEADER-RECORD-RX has a null value for TOT-MEDICARE-COINS-AMT or CLAIM-HEADER-RECORD-RX.TOT-MEDICARE-COINS-AMT equals '0.00') and (CLAIM-HEADER-RECORD-RX has a null value for TOT-MEDICARE-DEDUCTIBLE-AMT or CLAIM-HEADER-RECORD-RX.TOT-MEDICARE-DEDUCTIBLE-AMT equals '0.00')'
Rule Definition If a claim is a non-denied, non-crossover Medicaid or M-CHIP or Separate CHIP Fee-for-Service, original or adjustment paid claim from an RX file, then the claim must have a null value or zero value for medicare paid amount, total medicare coinsurance amount and total medicare deductible amount.
Denominator Logic # of RX claim lines 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.TYPE-OF-CLAIM does not equal 'Z' and with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND is equal to one of the following: '0', '4' and with CLAIM-HEADER-RECORD-RX.CROSSOVER-INDICATOR equals '0' and with CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is equal to one of the following: '1', 'A'