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Tier | 2.1 |
---|---|
Tier Description | Relational error |
Error Category | E2102 |
Error Category Message | Values inconsistently specified (multi record, single file) |
Rule Type | Three Record Type Rule |
File Segment Number | COT00002 |
Data Element Name | CLAIM-DX-OT.DIAGNOSIS-CODE |
Validation Logic | 'if CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-OT.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM does not equal 'Z' and CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is equal to one of the following: '0', '4' and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '1', '3', 'A', 'C' and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and substr(CLAIM-LINE-RECORD-OT.PROCEDURE-CODE, 1, 1) is equal to 'D' and CLAIM-LINE-RECORD-OT.DIAGNOSIS-CODE-POINTER-1 equals 1 and CLAIM-DX-OT has a non-null value for DIAGNOSIS-CODE-FLAG, then CLAIM-DX-OT has a non-null value for DIAGNOSIS-CODE' |
Rule Definition | If a claim is a non-denied claim from an OT file and the adjustment indicator is original or replacement, and the type of claim is Fee for Service Medicaid M-CHIP or S-CHIP or Encounter M-CHIP or S-SHIP, and the procedure code is for dental claims (starts with 'D') and the diagnosis code flag is populated, then the diagnosis code 1 must be populated. |
Denominator Logic | # of OT claim headers with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-OT.CLAIM-DENIED-INDICATOR does not equal '0' and with CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM does not equal 'Z' and with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-OT.ADJUSTMENT-IND is equal to '0' or '4' and with CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is equal to one of the following: '1', '3', 'A', 'C', and with CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with substr(CLAIM-LINE-RECORD-OT.PROCEDURE-CODE, 1, 1) is equal to 'D' and with CLAIM-LINE-RECORD-OT.DIAGNOSIS-CODE-POINTER-1 equals 1 and with CLAIM-DX-OT has a non-null value for DIAGNOSIS-CODE-FLAG |