RULE-1259

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	CLT00002
Data Element Name	CLAIM-HEADER-RECORD-LT.MEDICAID-PAID-DATE • CLAIM-LINE-RECORD-LT.XIX-MBESCBES-CATEGORY-OF-SERVICE • CLAIM-LINE-RECORD-LT.ADJUDICATION-DATE
Validation Logic	'if CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-LINE-RECORD-LT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', then If the field is populated, the value must be contained in the set of valid values with id: 'XIX-MBESCBES-CATEGORY-OF-SERVICE' and ((if CLAIM-LINE-RECORD-LT.ADJUDICATION-DATE is non-null then CLAIM-LINE-RECORD-LT.ADJUDICATION-DATE >= Valid Values Effective-Date and CLAIM-LINE-RECORD-LT.ADJUDICATION-DATE <= Valid Values End-Date) OR (if CLAIM-HEADER-RECORD-LT.MEDICAID-PAID-DATE is non-null then CLAIM-HEADER-RECORD-LT.MEDICAID-PAID-DATE >= Valid Values Effective-Date and CLAIM-HEADER-RECORD-LT.MEDICAID-PAID-DATE <= Valid Values End-Date))'
Rule Definition	If the XIX MBESCBES category of service is populated on a non-denied claim line LT file, then the value reported must be in the list of valid values for XIX MBESCBES category of service.
Denominator Logic	# of LT claim lines with CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY not equal to 'F2' and with CLAIM-LINE-RECORD-LT.CLAIM-LINE-STATUS not in: '26', '87', '542', '585', '654' and with CLAIM-LINE-RECORD-LT.XIX-MBESCBES-CATEGORY-OF-SERVICE equal to a valid, non-null value

Published Date	Data Guide Version	Validation Rule	Action	Field	Before	After
08/21/2020	2.4.0	RULE-1259	UPDATE	Data Dictionary - Validation Rules	Rule only triggered on adjustment claim lines, not on original claims.	Rules will also be triggered on original claim lines and ADJUSTMENT-IND and LINE-ADJUSTMENT-IND will be used to join claim headers and claim lines for the purpose of applying line-level validation rules. 'if CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-LINE-RECORD-LT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', then If the field is populated, the value must be contained in the set of valid values with id: 'XIX-MBESCBES-CATEGORY-OF-SERVICE' and (if CLAIM-LINE-RECORD-LT.ENDING-DATE-OF-SERVICE is non-null then CLAIM-LINE-RECORD-LT.ENDING-DATE-OF-SERVICE >= Valid Values Effective-Date and CLAIM-LINE-RECORD-LT.ENDING-DATE-OF-SERVICE <= Valid Values End-Date)'
08/05/2022	3.0.1	RULE-1259	UPDATE	Data Dictionary - Validation Rules	if CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-LINE-RECORD-LT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', then If the field is populated, the value must be contained in the set of valid values with id: 'XIX-MBESCBES-CATEGORY-OF-SERVICE' and (if CLAIM-LINE-RECORD-LT.ENDING-DATE-OF-SERVICE is non-null then CLAIM-LINE-RECORD-LT.ENDING-DATE-OF-SERVICE >= Valid Values Effective-Date and CLAIM-LINE-RECORD-LT.ENDING-DATE-OF-SERVICE <= Valid Values End-Date)'	if CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-LINE-RECORD-LT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', then If the field is populated, the value must be contained in the set of valid values with id: 'XIX-MBESCBES-CATEGORY-OF-SERVICE' and (((if CLAIM-LINE-RECORD-LT.ADJUDICATION-DATE is non-null then (CLAIM-LINE-RECORD-LT.ADJUDICATION-DATE >= Valid Values Effective-Date and CLAIM-LINE-RECORD-LT.ADJUDICATION-DATE <= Valid Values End-Date)) OR (if CLAIM-HEADER-RECORD-LT.MEDICAID-PAID-DATE is non-null then (CLAIM-HEADER-RECORD-LT.MEDICAID-PAID-DATE >= Valid Values Effective-Date and CLAIM-HEADER-RECORD-LT.MEDICAID-PAID-DATE <= Valid Values End-Date)))'
01/31/2020	2.4.0	RULE-1259	UPDATE	Data Dictionary - Validation Rules	'if CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-LINE-RECORD-LT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', then If the field is populated, the value must be contained in the set of valid values with id: 'XIX-MBESCBES-CATEGORY-OF-SERVICE''	if CLAIM-HEADER-RECORD-LT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-LINE-RECORD-LT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', then If the field is populated, the value must be contained in the set of valid values with id: 'XIX-MBESCBES-CATEGORY-OF-SERVICE' and CLAIM-LINE-RECORD-LT.ENDING-DATE-OF-SERVICE has non null value and CLAIM-LINE-RECORD-LT.ENDING-DATE-OF-SERVICE must be >= Valid Values Effective-Date and CLAIM-LINE-RECORD-LT.ENDING-DATE-OF-SERVICE <= Valid Values End-Date