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TMSIS Dataguide Medicaid.gov
Version 3.38.0

RULE-1552

Validation Rule
Last updated

Tier 2.1
Tier Description Relational error
Error Category E2102
Error Category Message Values inconsistently specified (multi record, single file)
Rule Type Two Record Type (1 to 1)
File Segment Number COT00002
Data Element Name CLAIM-HEADER-RECORD-OT.REFERRING-PROV-NPI-NUM
Validation Logic 'if CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654' and CLAIM-LINE-RECORD-OT.TYPE-OF-SERVICE equals '121', then CLAIM-HEADER-RECORD-OT has a null or invalid value for REFERRING-PROV-NPI-NUM'
Rule Definition If the type of service is for a premium payment on a non-denied claim line from an OT file, then the referring provider NPI number value must not be populated.
Denominator Logic # of OT claim lines with CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY not equal to 'F2' AND with CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS not in '26', '87', '542', '585', '654' AND with CLAIM-LINE-RECORD-OT.TYPE-OF-SERVICE is '121'