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TMSIS Dataguide Medicaid.gov
Version 3.38.0

RULE-7266

Validation Rule
Last updated

Tier 1.1
Tier Description Missing Value Error
Error Category E1105
Error Category Message Data Element Value is Missing
Rule Type One Record Type (Single Record)
File Segment Number CIP00002
Data Element Name CLAIM-HEADER-RECORD-IP.TOT-MEDICAID-PAID-AMT
Validation Logic 'if CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-HEADER-RECORD-IP.CLAIM-DENIED-INDICATOR does not equal '0' and CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM does not equal 'Z' and CLAIM-HEADER-RECORD-IP.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM is equal to one of the following: 'A', '1' and CLAIM-HEADER-RECORD-IP.ADJUSTMENT-IND equals '0' and (CLAIM-HEADER-RECORD-IP.CROSSOVER-INDICATOR equals '0' or CLAIM-HEADER-RECORD-IP has a null value for CROSSOVER-INDICATOR), then CLAIM-HEADER-RECORD-IP has a non-null and not invalidly formatted value for TOT-MEDICAID-PAID-AMT'
Rule Definition If a claim is a non-denied claim from an IP file that is an original claim and is a separate CHIP FFS, Medicaid or Medicaid-expansion FFS claim with a crossover indicator equal to 0 or null, then the total medicaid paid amount must be populated.
Denominator Logic # of IP claim headers with CLAIM-HEADER-RECORD-IP.CLAIM-STATUS-CATEGORY does not equal 'F2' and with CLAIM-HEADER-RECORD-IP.CLAIM-DENIED-INDICATOR does not equal '0' and with CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM does not equal 'Z' and with CLAIM-HEADER-RECORD-IP.CLAIM-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654' and with CLAIM-HEADER-RECORD-IP.TYPE-OF-CLAIM is equal to one of the following: 'A', '1' and with CLAIM-HEADER-RECORD-IP.ADJUSTMENT-IND equals '0' and with (CLAIM-HEADER-RECORD-IP.CROSSOVER-INDICATOR equals '0' or CLAIM-HEADER-RECORD-IP has a null value for CROSSOVER-INDICATOR)