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TMSIS Dataguide Medicaid.gov

Version:

3.39.0

RULE-7195

Validation Rule
Last updated

No Updates

Tier 3.0
Tier Description Relational error
Error Category E3001
Error Category Message Missing corresponding record (2 record types, multi file) (ex. missing eligibility record for claim header)
Rule Type Two Record Type (1 to 1)
File Segment Number ELG00014
Data Element Name CLAIM-HEADER-RECORD-LT.SUBMITTING-STATE • CLAIM-HEADER-RECORD-LT.MSIS-IDENTIFICATION-NUM • CLAIM-HEADER-RECORD-LT.PLAN-ID-NUMBER • MANAGED-CARE-PARTICIPATION.MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE • MANAGED-CARE-PARTICIPATION.MANAGED-CARE-PLAN-ENROLLMENT-END-DATE • CLAIM-HEADER-RECORD-LT.BEGINNING-DATE-OF-SERVICE
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.TYPE-OF-CLAIM does not equal 'Z' and CLAIM-HEADER-RECORD-LT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM is equal to one of the following: '3', 'C', 'W' and CLAIM-HEADER-RECORD-LT has a valid, non-null value for PLAN-ID-NUMBER, then for every record of type CLAIM-HEADER-RECORD-LT, there must be a valid record of type MANAGED-CARE-PARTICIPATION that matches on the join keys(MANAGED-CARE-PARTICIPATION[SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, MANAGED-CARE-PLAN-ID], CLAIM-HEADER-RECORD-LT[SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, PLAN-ID-NUMBER]) and CLAIM-HEADER-RECORD-LT.BEGINNING-DATE-OF-SERVICE must be in (MANAGED-CARE-PARTICIPATION.MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE, MANAGED-CARE-PARTICIPATION.MANAGED-CARE-PLAN-ENROLLMENT-END-DATE)
Rule Definition 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 participation segment from an ELG file with the same MSIS ID and effective and end dates that overlap the beginning date of service.
Denominator Logic # of LT claim headers 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', '026', '87', '087', '542', '585', '654' AND with CLAIM-HEADER-RECORD-LT.TYPE-OF-CLAIM in: '3', 'C', 'W' AND with CLAIM-HEADER-RECORD-LT.PLAN-ID-NUMBER equal to a valid, non-null value