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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

RULE-8755

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 MCR00002
Data Element Name COST-SHARING-OFFSET.SUBMITTING-STATE • COST-SHARING-OFFSET.PAYEE-ID • MANAGED-CARE-MAIN.MANAGED-CARE-CONTRACT-EFF-DATE • MANAGED-CARE-MAIN.MANAGED-CARE-CONTRACT-END-DATE • COST-SHARING-OFFSET.COVERAGE-PERIOD-START-DATE
Validation Logic if COST-SHARING-OFFSET has a valid, non-null value for PAYEE-ID and COST-SHARING-OFFSET.PAYEE-ID-TYPE is equal to one of the following: '02' and COST-SHARING-OFFSET.ADJUSTMENT-IND does not equal '1', then for every record of type COST-SHARING-OFFSET, there must be a valid record of type MANAGED-CARE-MAIN that matches on the join keys(MANAGED-CARE-MAIN[SUBMITTING-STATE, STATE-PLAN-ID-NUM], COST-SHARING-OFFSET[SUBMITTING-STATE, PAYEE-ID]) and COST-SHARING-OFFSET.COVERAGE-PERIOD-START-DATE must be in (MANAGED-CARE-MAIN.MANAGED-CARE-CONTRACT-EFF-DATE, MANAGED-CARE-MAIN.MANAGED-CARE-CONTRACT-END-DATE)
Rule Definition If a financial transaction is a non-void, and the PAYEE ID is populated on Cost Sharing Offset segment from the FTX file and the PAYEE ID Type is Capitated plan ID, then the PAYEE ID value reported must be equal to a State Plan Identification Number on a managed care main segment from a MCR file where the managed care contract effective and end dates of the managed care main segment overlap with the coverage period start date on the financial transaction.
Denominator Logic # of FTX Cost Sharing Offset Transactions with COST-SHARING-OFFSET has a valid, non-null value for PAYEE-ID and with COST-SHARING-OFFSET.PAYEE-ID-TYPE is equal to '02' and with COST-SHARING-OFFSET.ADJUSTMENT-IND does not equal to '1'