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TMSIS Dataguide Medicaid.gov

Version:

4.0.20

RULE-7963

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 COT00002
Data Element Name CLAIM-LINE-RECORD-OT.XIX-MBESCBES-CATEGORY-OF-SERVICE
Validation Logic 'if CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-OT.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM equals '5' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND does not equal '1' and CLAIM-HEADER-RECORD-OT has a non-null and not invalidly formatted value for TOT-MEDICAID-PAID-AMT and CLAIM-HEADER-RECORD-OT.TOT-MEDICAID-PAID-AMT does not equal '0.00' and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-LINE-RECORD-OT.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT equals '01', then CLAIM-LINE-RECORD-OT has a non-null value for XIX-MBESCBES-CATEGORY-OF-SERVICE'
Rule Definition If a claim is a non-denied, Medicaid or M-CHIP supplemental claim from an OT file, and the total medicaid paid amount is a non-null value and the total medicaid paid amount is not equal to '0.00' and CMS 64 category for federal reimbursement is equal to '01', then the XIX-MBESCBES category of service must be populated.
Denominator Logic # of OT claim lines with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and with CLAIM-HEADER-RECORD-OT.CLAIM-DENIED-INDICATOR does not equal '0' and with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to '5' and with CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is not equal to '1' and with CLAIM-HEADER-RECORD-OT has a non-null, and not invalidly formatted value for TOT-MEDICAID-PAID-AMT and CLAIM-HEADER-RECORD-OT.TOT-MEDICAID-PAID-AMT is not equal to '0.00' and with CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-LINE-RECORD-OT.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT is equal to '01'