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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

RULE-8746

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 ELG00021
Data Element Name INDIVIDUAL-CAPITATION-PMPM.SUBMITTING-STATE • INDIVIDUAL-CAPITATION-PMPM.MSIS-IDENTIFICATION-NUM • ENROLLMENT-TIME-SPAN-SEGMENT.ENROLLMENT-EFF-DATE • ENROLLMENT-TIME-SPAN-SEGMENT.ENROLLMENT-END-DATE • INDIVIDUAL-CAPITATION-PMPM.CAPITATION-PERIOD-START-DATE
Validation Logic if INDIVIDUAL-CAPITATION-PMPM has a valid, non-null value for MSIS-IDENTIFICATION-NUM 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 ENROLLMENT-TIME-SPAN-SEGMENT that matches on the join keys(ENROLLMENT-TIME-SPAN-SEGMENT[SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM], INDIVIDUAL-CAPITATION-PMPM[SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM]) and INDIVIDUAL-CAPITATION-PMPM.CAPITATION-PERIOD-START-DATE must be in (ENROLLMENT-TIME-SPAN-SEGMENT.ENROLLMENT-EFF-DATE, ENROLLMENT-TIME-SPAN-SEGMENT.ENROLLMENT-END-DATE)
Rule Definition If a financial transaction is a non-void, and the MSIS ID is populated on Individual Capitation Payment segment, then the MSIS ID value reported must be equal to a MSIS ID on a enrollment time span segment from a ELG file where the effective and end dates of the enrollment time span 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 MSIS-ID and with INDIVIDUAL-CAPITATION-PMPM.ADJUSTMENT-IND does not equal to '1'