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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

RULE-8734

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 PRV00005
Data Element Name COST-SETTLEMENT-PAYMENT.SUBMITTING-STATE • COST-SETTLEMENT-PAYMENT.PAYEE-ID • PROV-IDENTIFIERS.PROV-IDENTIFIER-TYPE • PROV-IDENTIFIERS.PROV-IDENTIFIER-EFF-DATE • PROV-IDENTIFIERS.PROV-IDENTIFIER-END-DATE • COST-SETTLEMENT-PAYMENT.COST-SETTLEMENT-PERIOD-START-DATE
Validation Logic if COST-SETTLEMENT-PAYMENT has a valid, non-null value for PAYEE-ID and COST-SETTLEMENT-PAYMENT.PAYEE-ID-TYPE equals '06' and COST-SETTLEMENT-PAYMENT.ADJUSTMENT-IND does not equal '1', then for every record of type COST-SETTLEMENT-PAYMENT, there must be a valid record of type PROV-IDENTIFIERS that matches on the join keys(PROV-IDENTIFIERS[SUBMITTING-STATE, PROV-IDENTIFIER], COST-SETTLEMENT-PAYMENT[SUBMITTING-STATE, PAYEE-ID]) and COST-SETTLEMENT-PAYMENT.COST-SETTLEMENT-PERIOD-START-DATE must be in (PROV-IDENTIFIERS.PROV-IDENTIFIER-EFF-DATE, PROV-IDENTIFIERS.PROV-IDENTIFIER-END-DATE), where PROV-IDENTIFIERS.PROV-IDENTIFIER-TYPE equals '2'
Rule Definition If a financial transaction is a non-void, and the PAYEE ID is populated on Cost Settlement Payment segment from the FTX file and the PAYEE ID Type is State contracted FFS provider NPI, then the PAYEE ID value reported must be equal to a provider NPI on a provider identifier segment from a PRV file where the effective and end dates of the provider identifier segment overlap with the cost settlement period start date on the financial transaction.
Denominator Logic # of FTX Cost Settlement Payment Transactions with COST-SETTLEMENT-PAYMENT has a valid, non-null value for PAYEE-ID and with COST-SETTLEMENT-PAYMENT.PAYEE-ID-TYPE is equal to '06' and with COST-SETTLEMENT-PAYMENT.ADJUSTMENT-IND is not equal to '1'