An official website of the United States government

Official websites use .gov
A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS
A lock () or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

TMSIS Dataguide Medicaid.gov

Version:

4.0.20

RULE-7793

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-LINE-RECORD-RX.CLAIM-LINE-STATUS • CLAIM-HEADER-RECORD-RX.TOT-MEDICAID-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-HEADER-RECORD-RX.TYPE-OF-CLAIM is equal to one of the following: '1', 'A' and CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND equals '0' and CLAIM-HEADER-RECORD-RX.PAYMENT-LEVEL-IND equals '2', then CLAIM-HEADER-RECORD-RX.TOT-MEDICAID-PAID-AMT is equal to the sum of all CLAIM-LINE-RECORD-RX.MEDICAID-PAID-AMT values, where CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654''
Rule Definition If a claim is a non-denied claim from an RX file that is an original claim and is a Medicaid or Medicaid-expansion CHIP or Separate CHIP Fee-for-Service claim, and the payment level indicator is for line, then the sum of the claim line medicaid paid amount is equal to the claim header total medicaid paid amount.
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.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-HEADER-RECORD-RX.TYPE-OF-CLAIM is equal to one of the following: '1', 'A' and with CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND equals '0' and with CLAIM-HEADER-RECORD-RX.PAYMENT-LEVEL-IND equals '2'