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TMSIS Dataguide Medicaid.gov

Version:

3.39.0

RULE-7816

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-LINE-RECORD-RX.DAYS-SUPPLY
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.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is equal to one of the following: '1', 'A' and CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND equals '0' and CLAIM-HEADER-RECORD-RX.CROSSOVER-INDICATOR equals '0' and CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654', then CLAIM-LINE-RECORD-RX has a non-null value for DAYS-SUPPLY'
Rule Definition If a non-denied claim from an RX file has the type of claim Medicaid or Medicaid-expansion CHIP Managed Care Fee-for-service or Separate CHIP Fee-for-service, and is not a crossover claim, then the claim line days supply must be populated.
Denominator Logic # of RX claim lines 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 does not equal 'Z' and with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is equal to one of the following: '1', 'A' and with CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND is equal to '0' and with CLAIM-HEADER-RECORD-RX.CROSSOVER-INDICATOR is equal to '0' and with CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654'