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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

RULE-8761

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 INDIVIDUAL-CAPITATION-PMPM.SUBMITTING-STATE • INDIVIDUAL-CAPITATION-PMPM.PAYER-ID • MANAGED-CARE-MAIN.MANAGED-CARE-CONTRACT-EFF-DATE • MANAGED-CARE-MAIN.MANAGED-CARE-CONTRACT-END-DATE • INDIVIDUAL-CAPITATION-PMPM.CAPITATION-PERIOD-START-DATE
Validation Logic if INDIVIDUAL-CAPITATION-PMPM has a valid, non-null value for PAYER-ID and INDIVIDUAL-CAPITATION-PMPM.PAYER-ID-TYPE equals '02' 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 MANAGED-CARE-MAIN that matches on the join keys(MANAGED-CARE-MAIN[SUBMITTING-STATE, STATE-PLAN-ID-NUM], INDIVIDUAL-CAPITATION-PMPM[SUBMITTING-STATE, PAYER-ID]) and INDIVIDUAL-CAPITATION-PMPM.CAPITATION-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 PAYER ID is populated on Individual Capitation Payment segment from the FTX file and the PAYER ID Type is Capitated plan ID, then the PAYER 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 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 PAYER-ID and with INDIVIDUAL-CAPITATION-PMPM.PAYER-ID-TYPE is equal to '02' and with INDIVIDUAL-CAPITATION-PMPM.ADJUSTMENT-IND does not equal to '1'