RULE-1964

Tier	3.0
Tier Description	Relational error
Error Category	E3002
Error Category Message	Values inconsistently specified (multiple record types, multi file)
Rule Type	Four Record Type Rule
File Segment Number	CRX00003
Data Element Name	CLAIM-HEADER-RECORD-RX.SUBMITTING-STATE • CLAIM-HEADER-RECORD-RX.DISPENSING-PRESCRIPTION-DRUG-PROV-NUM
Validation Logic	if CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-RX has a valid, non-null value for DISPENSING-PRESCRIPTION-DRUG-PROV-NUM, then for every record of type CLAIM-HEADER-RECORD-RX, (there must be a valid record of type PROV-IDENTIFIERS that matches on the join keys, where PROV-IDENTIFIERS.PROV-IDENTIFIER-TYPE equals '1' and CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE must be in (PROV-IDENTIFIERS.PROV-IDENTIFIER-EFF-DATE, PROV-IDENTIFIERS.PROV-IDENTIFIER-END-DATE)) OR (there must be a valid record of type PROV-ATTRIBUTES-MAIN that matches on the join keys and CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE must be in (PROV-ATTRIBUTES-MAIN.PROV-ATTRIBUTES-EFF-DATE, PROV-ATTRIBUTES-MAIN.PROV-ATTRIBUTES-END-DATE))
Rule Definition	If the dispensing prescription drug provider number is populated on a non-denied claim from the RX file, then either the dispensing prescription drug provider number value reported must be equal to a provider identifier value reported with a provider identifier type value for state-assigned Medicaid provider identifiers on a provider identifiers segment from a PRV file where the effective and end dates of the provider identifiers segment overlap with the prescription fill date on the claim OR the dispensing prescription drug provider number value reported must be equal to a submitting state provider ID on a provider main attributes segment from a PRV file where the effective and end dates of the provider main attributes segment overlap with the prescription fill date on the claim.
Denominator Logic	# of RX claim lines with CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' and with CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR does not equal '0' and with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-RX has a valid, non-null value for DISPENSING-PRESCRIPTION-DRUG-PROV-NUM

Published Date	Data Guide Version	Validation Rule	Action	Field	Before	After
08/21/2020	2.4.0	RULE-1964	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-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is not equal to one of the following: 'Z', '3', 'C', 'W', '2', 'B', 'V', '4', 'D', 'X' and CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-RX has a valid, non-null value for DISPENSING-PRESCRIPTION-DRUG-PROV-NUM, then for every record of type CLAIM-HEADER-RECORD-RX, (there must be a valid record of type PROV-IDENTIFIERS that matches on the join keys, where PROV-IDENTIFIERS.PROV-IDENTIFIER-TYPE equals '1' and CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE must be in (PROV-IDENTIFIERS.PROV-IDENTIFIER-EFF-DATE, PROV-IDENTIFIERS.PROV-IDENTIFIER-END-DATE)) OR (there must be a valid record of type PROV-ATTRIBUTES-MAIN that
02/05/2021	3.0.0	RULE-1964	UPDATE	Data Dictionary - Validation Rules	if CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM is not equal to one of the following: 'Z', '3', 'C', 'W', '2', 'B', 'V', '4', 'D', 'X' and CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-RX has a valid, non-null value for DISPENSING-PRESCRIPTION-DRUG-PROV-NUM, then for every record of type CLAIM-HEADER-RECORD-RX, (there must be a valid record of type PROV-IDENTIFIERS that matches on the join keys, where PROV-IDENTIFIERS.PROV-IDENTIFIER-TYPE equals '1' and CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE must be in (PROV-IDENTIFIERS.PROV-IDENTIFIER-EFF-DATE, PROV-IDENTIFIERS.PROV-IDENTIFIER-END-DATE)) OR (there must be a valid record of type PROV-ATTRIBUTES-MAIN that matches on the join keys and CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE must be in (PROV-ATTRIBUTES-MAIN.PROV-ATTRIBUTES-EFF-DATE, PROV-ATTRIBUTES-MAIN.PROV-ATTRIBUTES-END-DATE))	if CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-RX has a valid, non-null value for DISPENSING-PRESCRIPTION-DRUG-PROV-NUM, then for every record of type CLAIM-HEADER-RECORD-RX, (there must be a valid record of type PROV-IDENTIFIERS that matches on the join keys, where PROV-IDENTIFIERS.PROV-IDENTIFIER-TYPE equals '1' and CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE must be in (PROV-IDENTIFIERS.PROV-IDENTIFIER-EFF-DATE, PROV-IDENTIFIERS.PROV-IDENTIFIER-END-DATE)) OR (there must be a valid record of type PROV-ATTRIBUTES-MAIN that matches on the join keys and CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE must be in (PROV-ATTRIBUTES-MAIN.PROV-ATTRIBUTES-EFF-DATE, PROV-ATTRIBUTES-MAIN.PROV-ATTRIBUTES-END-DATE))
08/30/2018	2.3.0	RULE-1964	UPDATE	Data Dictionary - Validation Rules	if (CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' AND CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR does not equal to '0' AND CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM NOT IN ('Z','3','C','W',"2","B","V"," 4","D","X") AND CLAIM-HEADER-RECORD-RX.CLAIM-STATUS NOT IN ("26","026","87","087","542","585", "654")) AND CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS NOT IN ("26","026","87","087","542","585", "654") AND CLAIM-LINE-RECORD-RX has a valid, non-null value for DISPENSING-PRESCRIPTION-DRUG-PROV-NUM then for every record of type CLAIM-HEADER-RECORD-RX, (there must be a valid record of type PROV-ATTRIBUTES-MAIN that matches on the join keys) OR (there must be a valid record of type PROV-IDENTIFIERS that matches on the join keys, where PROV-IDENTIFIERS.PROV-IDENTIFIER-TYPE equals '1')	DISPENSING-PRESCRIPTION-DRUG-PROV-NUM (CRX) 'if CLAIM-LINE-RECORD-OT has a valid, non-null value for SERVICING-PROV-NUM and CLAIM-HEADER-RECORD-OT has a valid, non-null value for TYPE-OF-CLAIM and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is not equal to one of the following: '3', 'C', 'W' and CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS does not equal '585', then there are greater than 0 PROV-IDENTIFIERS records with matching join keys', where PROV-IDENTIFIERS.PROV-IDENTIFIER-TYPE equals '1'
08/17/2018	2.3.0	RULE-1964	UPDATE	Data Dictionary - Validation Rules	DISPENSING-PRESCRIPTION-DRUG-PROV-NUM (CRX) 'if CLAIM-LINE-RECORD-OT has a valid, non-null value for SERVICING-PROV-NUM and CLAIM-HEADER-RECORD-OT has a valid, non-null value for TYPE-OF-CLAIM and CLAIM-HEADER-RECORD-OT.TYPE-OF-CLAIM is not equal to one of the following: '3', 'C', 'W' and CLAIM-HEADER-RECORD-OT.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-LINE-RECORD-OT.CLAIM-LINE-STATUS does not equal '585', then there are greater than 0 PROV-IDENTIFIERS records with matching join keys', where PROV-IDENTIFIERS.PROV-IDENTIFIER-TYPE equals '1'	if (CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' AND CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR does not equal to '0' AND CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM NOT IN ('Z','3','C','W',"2","B","V"," 4","D","X") AND CLAIM-HEADER-RECORD-RX.CLAIM-STATUS NOT IN ("26","026","87","087","542","585", "654")) AND CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS NOT IN ("26","026","87","087","542","585", "654") AND CLAIM-LINE-RECORD-RX has a valid, non-null value for DISPENSING-PRESCRIPTION-DRUG-PROV-NUM then for every record of type CLAIM-HEADER-RECORD-RX, (there must be a valid record of type PROV-ATTRIBUTES-MAIN that matches on the join keys) OR (there must be a valid record of type PROV-IDENTIFIERS that matches on the join keys, where PROV-IDENTIFIERS.PROV-IDENTIFIER-TYPE equals '1')
12/21/2018	2.3.0	RULE-1964	UPDATE	Data Dictionary - Validation Rules	N/A	if (CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' AND CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR does not equal to '0' AND CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM NOT IN ('Z','3','C','W',"2","B","V"," 4","D","X") AND CLAIM-HEADER-RECORD-RX.CLAIM-STATUS NOT IN ("26","026","87","087","542","585", "654")) AND CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS NOT IN ("26","026","87","087","542","585", "654") AND CLAIM-LINE-RECORD-RX has a valid, non-null value for DISPENSING-PRESCRIPTION-DRUG-PROV-NUM then for every record of type CLAIM-HEADER-RECORD-RX, (there must be a valid record of type PROV-ATTRIBUTES-MAIN that matches on the join keys) OR (there must be a valid record of type PROV-IDENTIFIERS that matches on the join keys, where PROV-IDENTIFIERS.PROV-IDENTIFIER-TYPE equals '1')