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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

RULE-8767

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 ELG00002
Data Element Name INDIVIDUAL-CAPITATION-PMPM.SUBMITTING-STATE • INDIVIDUAL-CAPITATION-PMPM.PAYEE-ID • PRIMARY-DEMOGRAPHICS-ELIGIBILITY.PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE • PRIMARY-DEMOGRAPHICS-ELIGIBILITY.PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE • INDIVIDUAL-CAPITATION-PMPM.CAPITATION-PERIOD-START-DATE
Validation Logic if INDIVIDUAL-CAPITATION-PMPM has a valid, non-null value for PAYEE-ID and INDIVIDUAL-CAPITATION-PMPM.PAYEE-ID-TYPE equals '08' 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 PRIMARY-DEMOGRAPHICS-ELIGIBILITY that matches on the join keys(PRIMARY-DEMOGRAPHICS-ELIGIBILITY[SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM], INDIVIDUAL-CAPITATION-PMPM[SUBMITTING-STATE, PAYEE-ID]) and INDIVIDUAL-CAPITATION-PMPM.CAPITATION-PERIOD-START-DATE must be in (PRIMARY-DEMOGRAPHICS-ELIGIBILITY.PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE, PRIMARY-DEMOGRAPHICS-ELIGIBILITY.PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE)
Rule Definition If a financial transaction is a non-void, and the PAYEE ID is populated on Individual Capitation Payment segment from the FTX file and the PAYEE ID Type is Beneficiary, then the PAYEE ID value reported must be equal to a MSIS Identification Number on a primary demographics eligibility segment from a ELG file where the primary demographic element effective and end dates of the primary demographics eligibility 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 PAYEE-ID and with INDIVIDUAL-CAPITATION-PMPM.PAYEE-ID-TYPE is equal to '08' and with INDIVIDUAL-CAPITATION-PMPM.ADJUSTMENT-IND does not equal to '1'