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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

RULE-8774

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