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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

RULE-8735

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 FQHC-WRAP-PAYMENT.SUBMITTING-STATE • FQHC-WRAP-PAYMENT.PAYEE-ID • PROV-IDENTIFIERS.PROV-IDENTIFIER-TYPE • PROV-IDENTIFIERS.PROV-IDENTIFIER-EFF-DATE • PROV-IDENTIFIERS.PROV-IDENTIFIER-END-DATE • FQHC-WRAP-PAYMENT.WRAP-PERIOD-START-DATE
Validation Logic if FQHC-WRAP-PAYMENT has a valid, non-null value for PAYEE-ID and FQHC-WRAP-PAYMENT.PAYEE-ID-TYPE equals '06' and FQHC-WRAP-PAYMENT.ADJUSTMENT-IND does not equal '1', then for every record of type FQHC-WRAP-PAYMENT, there must be a valid record of type PROV-IDENTIFIERS that matches on the join keys(PROV-IDENTIFIERS[SUBMITTING-STATE, PROV-IDENTIFIER], FQHC-WRAP-PAYMENT[SUBMITTING-STATE, PAYEE-ID]) and FQHC-WRAP-PAYMENT.WRAP-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 FQHC Wrap 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 wrap period start date on the financial transaction.
Denominator Logic # of FTX FQHC Wrap Payment Transactions with FQHC-WRAP-PAYMENT has a valid, non-null value for PAYEE-ID and with FQHC-WRAP-PAYMENT.PAYEE-ID-TYPE is equal to '06' and with FQHC-WRAP-PAYMENT.ADJUSTMENT-IND is not equal to '1'