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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

RULE-8719

Validation Rule
Last updated

No Updates

Tier 3.0
Tier Description Relational error
Error Category E3001
Error Category Message Missing corresponding record (2 record types, multi file) (ex. missing eligibility record for claim header)
Rule Type Two Record Type (1 to 1)
File Segment Number PRV00002
Data Element Name INDIVIDUAL-CAPITATION-PMPM.SUBMITTING-STATE • INDIVIDUAL-CAPITATION-PMPM.PAYEE-ID • PROV-ATTRIBUTES-MAIN.PROV-ATTRIBUTES-EFF-DATE • PROV-ATTRIBUTES-MAIN.PROV-ATTRIBUTES-END-DATE • INDIVIDUAL-CAPITATION-PMPM.CAPITATION-PERIOD-START-DATE
Validation Logic if INDIVIDUAL-CAPITATION-PMPM has a valid, non-null value for PAYEE-ID and INDIVIDUAL-CAPITATION-PMPM.PAYEE-ID-TYPE is equal to one of the following: '04', '05' and INDIVIDUAL-CAPITATION-PMPM.ADJUSTMENT-IND does not equal '1', then for every record of type INDIVIDUAL-CAPITATION-PMPM, there must be a valid record of type PROV-ATTRIBUTES-MAIN that matches on the join keys(PROV-ATTRIBUTES-MAIN[SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID], INDIVIDUAL-CAPITATION-PMPM[SUBMITTING-STATE, PAYEE-ID]) and INDIVIDUAL-CAPITATION-PMPM.CAPITATION-PERIOD-START-DATE must be in (PROV-ATTRIBUTES-MAIN.PROV-ATTRIBUTES-EFF-DATE, PROV-ATTRIBUTES-MAIN.PROV-ATTRIBUTES-END-DATE)
Rule Definition If a financial transaction is a non-void, and the PAYEE ID is populated on Individual Capitation Payment segment from the FTX file and the PAYEE ID type is either Sub-capitated network provider ID or State contracted FFS provider ID assigned by state, then the PAYEE ID value reported must be equal to a submitting state provider ID on a provider main attributes segment from a PRV file where the effective and end dates of the provider main attributes segment overlap with the capitation period start date on the financial transaction.
Denominator Logic # of FTX Individual Capitation Payment Transactions with INDIVIDUAL-CAPITATION-PMPM has a valid, non-null value for PAYEE-ID and with INDIVIDUAL-CAPITATION-PMPM.PAYEE-ID-TYPE is equal to one of the following: '04', '05' and with INDIVIDUAL-CAPITATION-PMPM.ADJUSTMENT-IND does not equal to '1'