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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

RULE-819

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 CIP00002
Data Element Name PROV-IDENTIFIERS.PROV-IDENTIFIER-TYPE
Validation Logic 'if CLAIM-LINE-RECORD-IP has a valid, non-null value for OPERATING-PROV-NPI-NUM and CLAIM-HEADER-RECORD-IP has a valid, non-null value for TYPE-OF-CLAIM and CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM is not equal to one of the following: '3', 'C', 'W' and CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-LINE-RECORD-IP.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', then there are greater than 0 PROV-IDENTIFIERS records with matching join keys, where PROV-IDENTIFIERS.PROV-IDENTIFIER-TYPE equals '2''
Rule Definition If a claim is a non-denied claim from an IP file that is not an encounter claim and the operating provider NPI is populated, then the prov identifier type on the provider identifiers segment must be populated with the value 'NPI'.
Denominator Logic # of IP claim headers with CLAIM-LINE-RECORD-IP.OPERATING-PROV-NPI-NUM equal to a valid, non-null value and CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM equal to a valid, non-null value and CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM not equal to: '3', 'C', 'W' and with CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY not equal to 'F2' and with CLAIM-LINE-RECORD-IP.CLAIM-LINE-STATUS not in: '26', '87', '542', '585', '654'