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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

RULE-9226

Validation Rule
Last updated

No Updates

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