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TMSIS Dataguide Medicaid.gov

Version:

3.39.0

RULE-7460

Validation Rule
Last updated

No Updates

Tier 2.1
Tier Description Relational error
Error Category E2102
Error Category Message Values inconsistently specified (multi record, single file)
Rule Type Two Record Type (1 to 1)
File Segment Number COT00002
Data Element Name CLAIM-HEADER-RECORD-OT.WAIVER-ID
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', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '1', '3', 'A', 'C' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-LINE-RECORD-OT.HCBS-SERVICE-CODE equals '4', then CLAIM-HEADER-RECORD-OT has a non-null value for WAIVER-ID'
Rule Definition If a claim is a non-denied, Medicaid-SCHIP, Separate CHIP FFS or Medicaid-SCHIP, Separate CHIP Encounter, original or adjustment paid claim from an OT file, and the claim line hcbs service code is equal to '4', then the claim has a non-null value for waiver id.
Denominator Logic # of OT claim headers with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and with CLAIM-HEADER-RECORD-OT.CLAIM-DENIED-INDICATOR does not equal '0' and with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '26','026','87','087','542','585', '654' and with CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '1', '3', 'A', 'C' and with CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is equal to '0' or '4' and with CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-LINE-RECORD-OT.HCBS-SERVICE-CODE is equal to '4'