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TMSIS Dataguide Medicaid.gov
Version 3.38.0

RULE-7568

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 CRX00002
Data Element Name CLAIM-HEADER-RECORD-RX.TOT-MEDICAID-PAID-AMT
Validation Logic 'if CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY equals 'F2' or CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR equals '0' or CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM equals 'Z' or CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is equal to one of the following: '26', '026', '87', '087', '542', '585', '654', then CLAIM-HEADER-RECORD-RX has a null value for TOT-MEDICAID-PAID-AMT or CLAIM-HEADER-RECORD-RX.TOT-MEDICAID-PAID-AMT equals '0.00''
Rule Definition If an RX claim header is for a denied claim, then total medicaid paid amount has a missing or zero value.
Denominator Logic # of RX claim headers with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY equals 'F2' or with CLAIM-HEADER-RECORD-RX.CLAIM-DENIED-INDICATOR equals '0' or with CLAIM-HEADER-RECORD-RX.TYPE-OF-CLAIM equals 'Z' or with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS is equal to one of the following: '26', '026', '87', '087', '542', '585', '654'