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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

RULE-9150

Validation Rule
Last updated

No Updates

Tier 1.1
Tier Description Value Error
Error Category E1103
Error Category Message Value not in specified valid value set
Rule Type Valid Value
File Segment Number CRX00002
Data Element Name CLAIM-LINE-RECORD-RX.PROCEDURE-CODE-MOD-10
Validation Logic 'if CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and the PROCEDURE-CODE-MOD-10 field is populated, then the value must be contained in the set of valid values with id: 'PROCEDURE-CODE-MOD' and (if CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE is non-null then CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE >= Valid Values Effective-Date and CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE <= Valid Values End-Date)'
Rule Definition If the procedure code modifier-10 is populated on a non-denied claim line from a RX file, then the procedure code modifier10 value reported must be in the list of valid values.
Denominator Logic # of RX claim lines with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY not equal to 'F2' and with CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS not in: '26', '87', '542', '585', '654' and with CLAIM-LINE-RECORD-RX.PROCEDURE-CODE-MOD-10 equal to a valid, non-null value