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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

RULE-8744

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 FQHC-WRAP-PAYMENT.SUBMITTING-STATE • FQHC-WRAP-PAYMENT.PAYER-ID • PROV-ATTRIBUTES-MAIN.PROV-ATTRIBUTES-EFF-DATE • PROV-ATTRIBUTES-MAIN.PROV-ATTRIBUTES-END-DATE • FQHC-WRAP-PAYMENT.WRAP-PERIOD-START-DATE
Validation Logic if FQHC-WRAP-PAYMENT has a valid, non-null value for PAYER-ID and FQHC-WRAP-PAYMENT.PAYER-ID-TYPE is equal to one of the following: '04' 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-ATTRIBUTES-MAIN that matches on the join keys(PROV-ATTRIBUTES-MAIN[SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID], FQHC-WRAP-PAYMENT[SUBMITTING-STATE, PAYER-ID]) and FQHC-WRAP-PAYMENT.WRAP-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 FQHC Wrap 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 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 PAYER-ID and with FQHC-WRAP-PAYMENT.PAYER-ID-TYPE is equal to '04' and with FQHC-WRAP-PAYMENT.ADJUSTMENT-IND does not equal to '1'