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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

RULE-1372

Validation Rule
Last updated

No Updates

Tier 1.1
Tier Description Value Error
Error Category E1103
Error Category Message Value not in specified valid value set
Rule Type Valid Value
File Segment Number COT00002
Data Element Name CLAIM-HEADER-RECORD-OT.CLAIM-STATUS
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', '87', '542', '585', '654', '686' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND does not equal '1', then If the CLAIM-STATUS field is populated, the value must be contained in the set of valid values with id: 'CLAIM-STATUS' and (if CLAIM-HEADER-RECORD-OT.ENDING-DATE-OF-SERVICE is non-null then CLAIM-HEADER-RECORD-OT.ENDING-DATE-OF-SERVICE >= Valid Values Effective-Date and CLAIM-HEADER-RECORD-OT.ENDING-DATE-OF-SERVICE <= Valid Values End-Date)'
Rule Definition If a claim is a non-denied, non-void claim from an OT file, and the claim status is populated, then the claim status value reported must be in the list of valid values for claim status.
Denominator Logic #of OT claim headers with 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', '87', '542', '585', '654', '686' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is not equal to '1'