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TMSIS Dataguide Medicaid.gov

Version:

3.39.0

RULE-7920

Validation Rule
Last updated

No Updates

Tier 1.1
Tier Description Value Error
Error Category E1103
Error Category Message Value not in specified valid value set
Rule Type Valid Value
File Segment Number CRX00002
Data Element Name CLAIM-HEADER-RECORD-RX.BILLING-PROV-TAXONOMY
Validation Logic 'if CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is equal to one of the following: '1', 'A', then If the BILLING-PROV-TAXONOMY field is populated, the value must be contained in the set of valid values with id: 'PROV-TAXONOMY' and (if CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE is non-null then CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE >= Valid Values Effective-Date and CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE <= Valid Values End-Date)'
Rule Definition If the type of claim is a fee for service and billing provider taxonomy is populated on a claim header from an RX file, then the billing provider taxonomy value reported must be in the list of valid values for provider taxonomy.
Denominator Logic # of RX claim headers with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' and with CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is equal to one of the following: '1', 'A' and with CLAIM-HEADER-RECORD-RX.BILLING-PROV-TAXONOMY equal to a non-null value