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TMSIS Dataguide Medicaid.gov

Version:

3.39.0

RULE-7636

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 CRX00002
Data Element Name CLAIM-HEADER-RECORD-RX.SUBMITTING-STATE • CLAIM-HEADER-RECORD-RX.ICN-ORIG • CLAIM-HEADER-RECORD-RX.ICN-ADJ • CLAIM-HEADER-RECORD-RX.ADJUDICATION-DATE • CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND • CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS • CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY • CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR • CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM • CLAIM-HEADER-RECORD-RX.CLAIM-STATUS
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.TYPE-OF-CLAIM does not equal 'Z' and CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', then for every record of type CLAIM-HEADER-RECORD-RX, there must be a valid record of type CLAIM-LINE-RECORD-RX that matches on the join keys, and CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654'
Rule Definition All non-denied, paid RX claim header records must have a corresponding non-denied claim line record.
Denominator Logic # of RX claim headers with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' and with CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR does not equal '0' and with CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is not equal to 'Z' and CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND is equal to one of the following: '0', '4' and with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '026', '087', '26', '87', '542', '585', '654'