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TMSIS Dataguide Medicaid.gov

Version:

3.39.0

RULE-1256

Validation Rule
Last updated

No Updates

Tier 3.0
Tier Description Relational error
Error Category E3002
Error Category Message Values inconsistently specified (multiple record types, multi file)
Rule Type Three Record Type Rule
File Segment Number ELG00003
Data Element Name CLAIM-LINE-RECORD-LT.CATEGORY-FOR-FEDERAL-REIMBURSEMENT
Validation Logic 'if CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-LT.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-LT.CLAIM-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM is not equal to one of the following: 'Z', '3', 'C', 'W' and CLAIM-LINE-RECORD-LT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE is equal to one of the following: '2', '3', then CLAIM-LINE-RECORD-LT.CATEGORY-FOR-FEDERAL-REIMBURSEMENT equals '02''
Rule Definition If a claim is a non-denied claim from an LT file and the variable demographics eligibility chip code is equal to '2' or '3', then the claim line has a category of federal reimbursement equal to '02'.
Denominator Logic # of LT claim lines with CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY not equal to 'F2' and with CLAIM-HEADER-RECORD-LT.CLAIM-DENIED-INDICATOR not equal to '0' and with CLAIM-HEADER-RECORD-LT.CLAIM-STATUS not in: '26', '87', '542', '585', '654' and with CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM not in: 'Z', '3', 'C', 'W' and with CLAIM-LINE-RECORD-LT.CLAIM-LINE-STATUS not in: '26', '87', '542', '585', '654' and with VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE equals: '2', '3'