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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

RULE-8769

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 GROUP-INSURANCE-PREMIUM-PAYMENT.SUBMITTING-STATE • GROUP-INSURANCE-PREMIUM-PAYMENT.PAYEE-ID • PRIMARY-DEMOGRAPHICS-ELIGIBILITY.PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE • PRIMARY-DEMOGRAPHICS-ELIGIBILITY.PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE • GROUP-INSURANCE-PREMIUM-PAYMENT.PREMIUM-PERIOD-START-DATE
Validation Logic if GROUP-INSURANCE-PREMIUM-PAYMENT has a valid, non-null value for PAYEE-ID and GROUP-INSURANCE-PREMIUM-PAYMENT.PAYEE-ID-TYPE equals '08' and GROUP-INSURANCE-PREMIUM-PAYMENT.ADJUSTMENT-IND does not equal '1', then for every record of type GROUP-INSURANCE-PREMIUM-PAYMENT, 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], GROUP-INSURANCE-PREMIUM-PAYMENT[SUBMITTING-STATE, PAYEE-ID]) and GROUP-INSURANCE-PREMIUM-PAYMENT.PREMIUM-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 Group Insurance Premium 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 premium period start date on the financial transaction.
Denominator Logic # of FTX Group Insurance Premium Payment Transactions with GROUP-INSURANCE-PREMIUM-PAYMENT has a valid, non-null value for PAYEE-ID and with GROUP-INSURANCE-PREMIUM-PAYMENT.PAYEE-ID-TYPE is equal to '08' and with GROUP-INSURANCE-PREMIUM-PAYMENT.ADJUSTMENT-IND does not equal to '1'