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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

RULE-8756

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 VALUE-BASED-PAYMENT.SUBMITTING-STATE • VALUE-BASED-PAYMENT.PAYEE-ID • MANAGED-CARE-MAIN.MANAGED-CARE-CONTRACT-EFF-DATE • MANAGED-CARE-MAIN.MANAGED-CARE-CONTRACT-END-DATE • VALUE-BASED-PAYMENT.PERFORMANCE-PERIOD-START-DATE
Validation Logic if VALUE-BASED-PAYMENT has a valid, non-null value for PAYEE-ID and VALUE-BASED-PAYMENT.PAYEE-ID-TYPE is equal to one of the following: '02' and VALUE-BASED-PAYMENT.ADJUSTMENT-IND does not equal '1', then for every record of type VALUE-BASED-PAYMENT, 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], VALUE-BASED-PAYMENT[SUBMITTING-STATE, PAYEE-ID]) and VALUE-BASED-PAYMENT.PERFORMANCE-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 Value Based Payment 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 performance period start date on the financial transaction.
Denominator Logic # of FTX Value Based Payment Transactions with VALUE-BASED-PAYMENT has a valid, non-null value for PAYEE-ID and with VALUE-BASED-PAYMENT.PAYEE-ID-TYPE is equal to '02' and with VALUE-BASED-PAYMENT.ADJUSTMENT-IND does not equal to '1'