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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

RULE-8743

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 COST-SETTLEMENT-PAYMENT.SUBMITTING-STATE • COST-SETTLEMENT-PAYMENT.PAYER-ID • PROV-ATTRIBUTES-MAIN.PROV-ATTRIBUTES-EFF-DATE • PROV-ATTRIBUTES-MAIN.PROV-ATTRIBUTES-END-DATE • COST-SETTLEMENT-PAYMENT.COST-SETTLEMENT-PERIOD-START-DATE
Validation Logic if COST-SETTLEMENT-PAYMENT has a valid, non-null value for PAYER-ID and COST-SETTLEMENT-PAYMENT.PAYER-ID-TYPE is equal to one of the following: '04' 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-ATTRIBUTES-MAIN that matches on the join keys(PROV-ATTRIBUTES-MAIN[SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID], COST-SETTLEMENT-PAYMENT[SUBMITTING-STATE, PAYER-ID]) and COST-SETTLEMENT-PAYMENT.COST-SETTLEMENT-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 payer ID is populated on Cost Settlement Payment segment from the FTX file and the payer id type is Sub-capitated network provider ID, then the payer 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 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 PAYER-ID and with COST-SETTLEMENT-PAYMENT.PAYER-ID-TYPE is equal to '04' and with COST-SETTLEMENT-PAYMENT does not equal to '1'