RULE-8755
|
If a financial transaction is a non-void, and the PAYEE ID is populated on Cost Sharing Offset segment from the FTX file and the PAYEE ID Type is Capitated plan ID, then the PAYEE ID value reported must be equal to a State Plan Identification Number on a managed care main segment from a MCR file where the managed care contract effective and end dates of the managed care main segment overlap with the coverage period start date on the financial transaction.
|
RULE-8766
|
If a financial transaction is a non-void, and the PAYER ID is populated on Miscellaneous Payment segment from the FTX file and the PAYER ID Type is Capitated plan ID, then the PAYER ID value reported must be equal to a State Plan Identification Number on a managed care main segment from a MCR file where the managed care contract effective and end dates of the managed care main segment overlap with the payment period start date on the financial transaction.
|
RULE-8765
|
If a financial transaction is a non-void, and the PAYER ID is populated on FQHC Wrap Payment segment from the FTX file and the PAYER ID Type is Capitated plan ID, then the PAYER ID value reported must be equal to a State Plan Identification Number on a managed care main segment from a MCR file where the managed care contract effective and end dates of the managed care main segment overlap with the wrap period start date on the financial transaction.
|
RULE-8764
|
If a financial transaction is a non-void, and the PAYER ID is populated on Cost Settlement Payment segment from the FTX file and the PAYER ID Type is Capitated plan ID, then the PAYER ID value reported must be equal to a State Plan Identification Number on a managed care main segment from a MCR file where the managed care contract effective and end dates of the managed care main segment overlap with the cost settlement period start date on the financial transaction.
|
RULE-8763
|
If a financial transaction is a non-void, and the PAYER ID is populated on State Directed Payment Separate Payment Term segment from the FTX file and the PAYER ID Type is Capitated plan ID, then the PAYER ID value reported must be equal to a State Plan Identification Number on a managed care main segment from a MCR file where the managed care contract effective and end dates of the managed care main segment overlap with the payment period start date on the financial transaction.
|
RULE-8762
|
If a financial transaction is a non-void, and the PAYER ID is populated on Value Based Payment segment from the FTX file and the PAYER ID Type is Capitated plan ID, then the PAYER ID value reported must be equal to a State Plan Identification Number on a managed care main segment from a MCR file where the managed care contract effective and end dates of the managed care main segment overlap with the performance period start date on the financial transaction.
|
RULE-8761
|
If a financial transaction is a non-void, and the PAYER ID is populated on Individual Capitation Payment segment from the FTX file and the PAYER ID Type is Capitated plan ID, then the PAYER ID value reported must be equal to a State Plan Identification Number on a managed care main segment from a MCR file where the managed care contract effective and end dates of the managed care main segment overlap with the capitation period start date on the financial transaction.
|
RULE-8760
|
If a financial transaction is a non-void, and the PAYEE ID is populated on Miscellaneous Payment segment from the FTX file and the PAYEE ID Type is Capitated plan ID, then the PAYEE ID value reported must be equal to a State Plan Identification Number on a managed care main segment from a MCR file where the managed care contract effective and end dates of the managed care main segment overlap with the payment period start date on the financial transaction.
|
RULE-8759
|
If a financial transaction is a non-void, and the PAYEE ID is populated on FQHC Wrap Payment segment from the FTX file and the PAYEE ID Type is Capitated plan ID, then the PAYEE ID value reported must be equal to a State Plan Identification Number on a managed care main segment from a MCR file where the managed care contract effective and end dates of the managed care main segment overlap with the wrap period start date on the financial transaction.
|
RULE-8758
|
If a financial transaction is a non-void, and the PAYEE ID is populated on Cost Settlement Payment segment from the FTX file and the PAYEE ID Type is Capitated plan ID, then the PAYEE ID value reported must be equal to a State Plan Identification Number on a managed care main segment from a MCR file where the managed care contract effective and end dates of the managed care main segment overlap with the cost settlement period start date on the financial transaction.
|
RULE-8757
|
If a financial transaction is a non-void, and the PAYEE ID is populated on State Directed Payment Separate Payment Term segment from the FTX file and the PAYEE ID Type is Capitated plan ID, then the PAYEE ID value reported must be equal to a State Plan Identification Number on a managed care main segment from a MCR file where the managed care contract effective and end dates of the managed care main segment overlap with the payment period start date on the financial transaction.
|
RULE-8756
|
If a financial transaction is a non-void, and the PAYEE ID is populated on Value Based Payment segment from the FTX file and the PAYEE ID Type is Capitated plan ID, then the PAYEE ID value reported must be equal to a State Plan Identification Number on a managed care main segment from a MCR file where the managed care contract effective and end dates of the managed care main segment overlap with the performance period start date on the financial transaction.
|
RULE-2382
|
If the managed care plan ID is populated on a managed care participation ELG file segment and the managed care participation managed care plan enrollment end date is greater than the states tmsis cutover date then the effective and end dates on the managed care participation segment must fall within the effective and end dates of one or more continuous managed care main segments.
|
RULE-8754
|
If a financial transaction is a non-void, and the PAYEE ID is populated on Group Insurance Premium Payment segment from the FTX file and the PAYEE ID Type is Capitated plan ID, then the PAYEE ID value reported must be equal to a State Plan Identification Number on a managed care main segment from a MCR file where the managed care contract effective and end dates of the managed care main segment overlap with the premium period start date on the financial transaction.
|
RULE-8753
|
If a financial transaction is a non-void, and the PAYEE ID is populated on Individual Health Insurance Premium Payment segment from the FTX file and the PAYEE ID Type is Capitated plan ID, then the PAYEE ID value reported must be equal to a State Plan Identification Number on a managed care main segment from a MCR file where the managed care contract effective and end dates of the managed care main segment overlap with the premium period start date on the financial transaction.
|
RULE-8752
|
If a financial transaction is a non-void, and the PAYEE ID is populated on Individual Capitation Payment segment from the FTX file and the PAYEE ID Type is Capitated plan ID, then the PAYEE ID value reported must be equal to a State Plan Identification Number on a managed care main segment from a MCR file where the managed care contract effective and end dates of the managed care main segment overlap with the capitation period start date on the financial transaction.
|
RULE-7201
|
If plan ID is populated on a non-denied Medicaid, S-CHIP, or Other encounter from an RX file, then the plan ID must be equal to the plan ID on a managed care main segment from an MCR file where the prescription fill date is within the contract effective and end dates on the managed care main segment.
|
RULE-7200
|
If plan ID is populated on a non-denied Medicaid, S-CHIP, or Other encounter from an OT file, then the plan ID must be equal to the plan ID on a managed care main segment from an MCR file where the beginning date of service on the claim is within the contract effective and end dates on the managed care main segment.
|
RULE-7199
|
If plan ID is populated on a non-denied Medicaid, S-CHIP, or Other encounter from an LT file, then the plan ID must be equal to the plan ID on a managed care main segment from an MCR file where the beginning date of service on the claim is within the contract effective and end dates of the managed care main segment.
|
RULE-7198
|
If plan ID is populated on a non-denied Medicaid, S-CHIP, or Other encounter from an IP file, then the plan ID must be equal to the plan ID on a managed care main segment from an MCR file where the admission date on the claim is within the contract effective and end dates of the managed care main segment.
|
RULE-2990
|
If the affiliated program type is equal to '2' (health plan (state assigned health plan ID)) on a provider affiliated programs PRV file segment and the provider affiliated programs prov affiliated program end date is greater than the states tmsis cutover date then the effective and end dates on the provider affiliated programs segment must fall with the effective and end dates of one or more continuous mangaged care main segments.
|
RULE-2562
|
If a segment is a managed care main segment from an MCR file, then the managed care contract end date value reported must be a valid date of the form CCYYMMDD.
|
RULE-2561
|
If the managed are main segment has a value populated for managed care contract effective date and a value populated for managed care contract end date, then the contract effective date is less than or equal to the contract end date.
|
RULE-2384
|
If the managed care participation plan type is populated on a managed care participation segment and the managed care main plan type is populated on the managed care main file segment and the managed care participation managed care plan enrollment end date is greater than the states tmsis cutover date then managed care participation managed care plan type equals the managed care main managed care plan type and the effective and end dates on the managed care participation segment must fall within the effective and end dates of one or more continuous managed care main segments.
|