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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

RULE-8777

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 TPL00006
Data Element Name INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT.SUBMITTING-STATE • INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT.PAYEE-ID • TPL-ENTITY-CONTACT-INFORMATION.TPL-ENTITY-CONTACT-INFO-EFF-DATE • TPL-ENTITY-CONTACT-INFORMATION.TPL-ENTITY-CONTACT-INFO-END-DATE • INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT.PREMIUM-PERIOD-START-DATE
Validation Logic if INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT has a valid, non-null value for PAYEE-ID and INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT.PAYEE-ID-TYPE equals '07' and INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT.ADJUSTMENT-IND does not equal '1', then for every record of type INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT, there must be a valid record of type TPL-ENTITY-CONTACT-INFORMATION that matches on the join keys(TPL-ENTITY-CONTACT-INFORMATION[SUBMITTING-STATE, INSURANCE-CARRIER-ID-NUM], INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT[SUBMITTING-STATE, PAYEE-ID]) and INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT.PREMIUM-PERIOD-START-DATE must be in (TPL-ENTITY-CONTACT-INFORMATION.TPL-ENTITY-CONTACT-INFO-EFF-DATE, TPL-ENTITY-CONTACT-INFORMATION.TPL-ENTITY-CONTACT-INFO-END-DATE)
Rule Definition If a financial transaction is a non-void, and the PAYEE ID is populated on Individual Health Insurance Premium Payment segment from the FTX file and the PAYEE ID Type is Insurance carrier, then the PAYEE ID value reported must be equal to a Insurance Carrier ID Number on a TPL entity contact information segment from a TPL file where the TPL Entity Contact Information effective and end dates of the TPL entity contact information segment overlap with the premium period start date on the financial transaction.
Denominator Logic # of FTX Individual Health Insurance Premium Payment Transactions with INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT has a valid, non-null value for PAYEE-ID and with INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT.PAYEE-ID-TYPE is equal to '07' and with INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT.ADJUSTMENT-IND does not equal to '1'