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TMSIS Dataguide Medicaid.gov

Version:

3.39.0

RULE-7206

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-RX.CATEGORY-FOR-FEDERAL-REIMBURSEMENT
Validation Logic 'if CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', '686' and CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is not equal to one of the following: 'Z', '3', 'C', 'W' and CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND does not equal '1' and CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', '686' and VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE equals '1', then CLAIM-LINE-RECORD-RX.CATEGORY-FOR-FEDERAL-REIMBURSEMENT equals '01''
Rule Definition If the MSIS ID on a non-denied, non-void claim header from an RX file is equal to the MSIS ID reported with a CHIP code for Medicaid on a variable demographic eligibility segment from an ELG file, then the category for federal reimbursement value reported must be for Title XIX Medicaid funding.
Denominator Logic # of RX claim headers with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY not equal to 'F2' and with CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR not equal to '0' and with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', '686' and with CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is not equal to one of the following: 'Z', '3', 'C', 'W' and with CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND is not equal to '1' and with CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', '686' and with (CLAIM-HEADER-RECORD-RX.SUBMITTING-STATE and CLAIM-HEADER-RECORD-RX.MSIS-IDENTIFICATION-NUM that match VARIABLE-DEMOGRAPHICS-ELIGIBILITY.SUBMITTING-STATE and VARIABLE-DEMOGRAPHICS-ELIGIBILITY.MSIS-IDENTIFICATION-NUM) and with VARIABLE-DEMOGRAPHICS-ELIGIBILITY.CHIP-CODE equals '1'