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TMSIS Dataguide Medicaid.gov
Version 3.38.0

RULE-543

Validation Rule
Last updated

Tier 2.0
Tier Description Relational error
Error Category E2001
Error Category Message Values inconsistently specified (single record type, single record)
Rule Type One Record Type (Single Record)
File Segment Number CIP00002
Data Element Name CLAIM-HEADER-RECORD-IP.TOT-MEDICARE-COINS-AMT • CLAIM-HEADER-RECORD-IP.TOT-BILLED-AMT
Validation Logic 'if CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-IP has a valid, non-null value for TOT-MEDICARE-COINS-AMT and CLAIM-HEADER-RECORD-IP has a valid, non-null value for TOT-BILLED-AMT and CLAIM-HEADER-RECORD-IP.TOT-MEDICARE-COINS-AMT is greater than zero and CLAIM-HEADER-RECORD-IP.TOT-BILLED-AMT is greater than zero, then CLAIM-HEADER-RECORD-IP.TOT-MEDICARE-COINS-AMT is less than or equal to CLAIM-HEADER-RECORD-IP.TOT-BILLED-AMT'
Rule Definition If the total Medicare coinsurance amount and total billed amount are populated and greater than zero on a non-denied claim from an IP file, then the total Medicare coinsurance amount value reported must be less than or equal to the total billed amount value
Denominator Logic # of IP claim headers with CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY not equal to 'F2' AND with CLAIM-HEADER-RECORD-IP.TOT-MEDICARE-COINS-AMT equal to a valid, non-null value AND with CLAIM-HEADER-RECORD-IP.TOT-BILLED-AMT equal to a valid, non-null value AND with CLAIM-HEADER-RECORD-IP.TOT-BILLED-AMT greater than zero AND with CLAIM-HEADER-RECORD-IP.TOT-MEDICARE-COINS-AMT greater than zero