RULE-7281

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 Many)
File Segment Number	CRX00002
Data Element Name	CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS • CLAIM-HEADER-RECORD-RX.TOT-MEDICAID-PAID-AMT
Validation Logic	'if 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 does not equal 'Z' 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.TYPE-OF-CLAIM is equal to one of the following: 'A', '1', 'C', '3' and CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND equals '0' and CLAIM-HEADER-RECORD-RX.PAYMENT-LEVEL-IND equals '2', then CLAIM-HEADER-RECORD-RX.TOT-MEDICAID-PAID-AMT is equal to the sum of all CLAIM-LINE-RECORD-RX.MEDICAID-PAID-AMT values, where CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654''
Rule Definition	If a claim is a non-denied claim from an RX file that is an original claim and is a Medicaid or Medicaid-expansion CHIP, Medicaid or Medicaid-expansion CHIP encounter, separate CHIP FFS or encounter claim, and the payment level indicator is for line, then the sum of the claim line medicaid paid amount is equal to the claim header total medicaid paid amount
Denominator Logic	# of RX claim headers 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.TYPE-OF-CLAIM does not equal 'Z' 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.TYPE-OF-CLAIM is equal to one of the following: 'A', '1', 'C', '3' and with CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND equals '0', and with CLAIM-HEADER-RECORD-RX.PAYMENT-LEVEL-IND equals '2'

Published Date	Data Guide Version	Validation Rule	Action	Field	Before	After
08/21/2020	2.4.0	RULE-7281	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-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 does not equal 'Z' 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.TYPE-OF-CLAIM is equal to one of the following: 'A', '1', 'C', '3' and CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND equals '0', then CLAIM-HEADER-RECORD-RX.TOT-MEDICAID-PAID-AMT is equal to the sum of all CLAIM-LINE-RECORD-RX.MEDICAID-PAID-AMT values', where CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654'
05/29/2020	2.4.0	RULE-7281	ADD	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 '0' AND CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM not equal to "Z" 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-HEADER-RECORD-RX.TYPE-OF-CLAIM IN ("A", "1", "C", "3") AND CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND is equal to "0" then Sum of CLAIM-LINE-RECORD-RX.MEDICAID-PAID-AMT is equal to CLAIM-HEADER-RECORD-RX.TOT-MEDICAID-PAID-AMT.'
07/23/2021	3.0.0	RULE-7281	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 '0' and CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM does not equal 'Z' 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.TYPE-OF-CLAIM is equal to one of the following: 'A', '1', 'C', '3' and CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND equals '0', then CLAIM-HEADER-RECORD-RX.TOT-MEDICAID-PAID-AMT is equal to the sum of all CLAIM-LINE-RECORD-RX.MEDICAID-PAID-AMT values', where CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654'	if 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 does not equal 'Z' 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.TYPE-OF-CLAIM is equal to one of the following: 'A', '1', 'C', '3' and CLAIM-HEADER-RECORD-RX.ADJUSTMENT-IND equals '0', and CLAIM-HEADER-RECORD-RX.PAYMENT-LEVEL-IND equals '2', then CLAIM-HEADER-RECORD-RX.TOT-MEDICAID-PAID-AMT is equal to the sum of all CLAIM-LINE-RECORD-RX.MEDICAID-PAID-AMT values' where CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '026', '87', '087', '542', '585', '654'