Change Request Log

T-MSIS Open Change Requests
(as of 2015-11-05)
CR #	Summary	Issue Type	Status	Priority	Created	Last Viewed	Updated	Description
TMSIS-1379	RULE-2133 will be deprecated and replaced with a rule that includes PRIMARY-ELIGIBILITY-GROUP-IND	Change Request	Open	Medium	11/4/2015 14:06	11/4/2015 14:14	11/4/2015 14:09	*Feedback from Beta States after the 2015-09-23 Beta States Conference Call* Per JDC - RULE-2133 (EC#s 2444 & 2228) will be deprecated and replaced with a rule that includes PRIMARY-ELIGIBILITY-GROUP-IND as part of the uniqueness criterion. Beta State Feedback "Re: edits 2444 & 2228 – how are states to report primary eligibility when multiple eligibility spans exist and there are no date overlaps, versus when there are date overlaps?"
TMSIS-1378	Deprecated RULE-3087 (EC# 2224)	Change Request	Open	Medium	11/4/2015 13:58	11/4/2015 14:03	11/4/2015 14:03	*Feedback from Beta States after the 2015-09-23 Beta States Conference Call* Per JDC - RULE-3087 (EC# 2224) will be deprecated. Beta State Feedback " Error 2224 which says TPL00003 is a child of TPL00004 has not changed. It is still on the 2.0 list as is, which is incorrect unless CMS has redesigned TPL once again."
TMSIS-1377	Deprecated RULE-428 (EC# 2146)	Change Request	Open	Medium	11/4/2015 13:53	11/4/2015 13:55	11/4/2015 13:55	*Feedback from Beta States after the 2015-09-23 Beta States Conference Call* Per JDC - RULE-428 (EC# 2146) will be deprecated. Beta State feedback "Rule Code 428: The logic for Rule 428 is incorrect.  A provider may bill more than one of a procedure code (both surgical and non-surgical) on a single date of service if the modifiers are different.   For surgical procedure codes they identify more specifically the service performed, such as right-side or left-side mastectomies.For other services such as Home Health visits, more than one procedure code for a visit may be billed if the modifier is there to indicate whether it is a 1st visit, 2nd, visit, etc.    The modifier can also be used to identify whether the visit was made by an RN or LPN."
TMSIS-1376	Deprecated RULE-1402 (EC#s 2428 & 2431)	Change Request	Open	Medium	11/4/2015 13:48	11/4/2015 13:50	11/4/2015 13:50	*Feedback from Beta States after the 2015-09-23 Beta States Conference Call* Per JDC - RULE-428 (EC# 2146) will be deprecated. Beta State Feedback "Rule 1402: The logic for Rule 1402 as it applies to all claim types is not correct.   Co-insurance and Deductible are two discreet fields that are not dependent on one another.  See Errors 2428 and 2431If I begin a calendar year with a $1.000 deductible, and $35.00 in coinsurance for each visit; the provider will ask me to make payment until I've met my $1000.00 deductible.  At that point in time, I will only have to pay coinsurance. It works the same way with Medicaid.  A claims processor will see Medicare cross-overs with both amounts until about mid-year, when it begins to see a lot of claims with just coinsurance because the deductible has been met. If coinsurance is sent on a claim, it is perfectly valid for the deductible field to be 0 or "8's".  "
TMSIS-1375	Deprecate the following validation rules: RULE-2040; RULE-2046; RULE-2058 & RULE-2060	Change Request	Open	Medium	11/4/2015 13:37	11/4/2015 13:41	11/4/2015 13:41	*Feedback from Beta States after the 2015-09-23 Beta States Conference Call* Per JDC - CMS will deprecate the following validation rules: RULE-2040; RULE-2046; RULE-2058 & RULE-2060 (EC#s 2252; 2253, 2132 & 2131). See attachment (Age Calculation per JDC update 2015Nov04.doc ) for Age Calculation explanation and guidance. State feedback "Edits 2131, 2132, 2252, 2253 – should calculate age based off of start of time period and not variable demographic effective date. "
TMSIS-1374	LICENSE-OR-ACCREDITATION-NUMBER - add to the PROV-LICENSING-INFO (PRV00004) record segment key	Change Request	Open	Medium	11/4/2015 13:11	11/4/2015 13:13	11/4/2015 13:13	*Feedback from Beta States after the 2015-09-23 Beta States Conference Call* Per JDC review - A CR will be opened to add LICENSE-OR-ACCREDITATION-NUMBER to the PROV-LICENSING-INFO (PRV00004) record segment key. State feedback "Edit 2309, 2396 – value of 8 = other for License Type.  States may have other license types and ID’s for those license types (Relational edit between LICENSE-OR-ACCREDITATION-NUMBER and LICENSE-TYPE failed). "
TMSIS-1373	Tier 1 edits for DRG-DESCRIPTION / HCPCS-RATE – is there a valid values list	Change Request	Open	Medium	11/4/2015 12:59	11/4/2015 13:00	11/4/2015 13:00	*Feedback from Beta States after the 2015-09-23 Beta States Conference Call* T-MSIS only contains the descriptions for the MS-DRGs.  The state will use the DRG-DESCRIPTION field to provide the descriptions whenever it uses a classification system other than MS-DRGs. On inpatient facility claims, the HCPCS-RATE field should be populated with the applicable accommodation rate, when applicable.  T-MSIS does not maintain a look-up table of valid accommodation rates.  On outpatient hospital facility claims, the field is used to capture the HCPCS code when applicable.  In such cases, the standard HCPCS code set is to be used.
TMSIS-1372	Edits that need to account for historical eligibility spans	Change Request	Open	Medium	11/4/2015 12:47	11/4/2015 12:50	11/4/2015 12:50	*Feedback from Beta States after the 2015-09-23 Beta States Conference Call* h3. a)  RULE-2024 (EC# 2257) will be deprecated (as will RULE-2022 & RULE-2023; (EC#s 2256 & 2258)).  The START-OF-TIME-PERIOD and END-OF-TIME-PERIOD on the file header segment define the reporting period for which the file was submitted.  Currently, T-MSIS reporting periods are defined as monthly, so the dates will be for a month's period of time.  The Eligibility Files submitted every month are "full file refreshes covering a rolling seven year time span.  Therefore, except for the case where the enrollee dies in the reporting period (i.e., the month), the DOD will always be earlier than the START-OF-TIME-PERIOD. h3. b)  Regarding RULE-2066 & RULE-2128 (EC# 2028):  Implementation of the MEDICARE-BENEFICIARY-IDENTIFIER has not been completed.  This validation rule should be suspended until the MBI is in use. Regarding RULE-2129, RULE-2130, RULE-2131 & RULE-2153 (EC#s 2027, 2280 & 2448): There should be separate ELG00005 segments for each time span during which the values of all of the data elements are static.  Whenever one of the data element values changes, the existing segment is end-dated and a new segment created with an eff-date equal to the previous segment's end-date plus 1 day.  (See tab entitled "Example for Multiple Segments.") Regarding RULE-2064 (EC# 2029):  There should be separate ELG00005 and ELG00003 segments for each time span during which the values of all of the data elements are static.  Whenever one of the data element values changes, the existing segment is end-dated and a new segment created with an eff-date equal to the previous segment's end-date plus 1 day.   Since DUAL-ELIGIBLE-CODE and MEDICARE-HIC-NUM are on different segments, the rule logic will be modified to take effective date spans into account. h3. c)  Regarding RULE-825; RULE-1257; RULE-1692; RULE-1956; RULE-2023; RULE-2024; RULE-2123; RULE-2124; RULE-2125; RULE-2129; RULE-2130; RULE-2148; RULE-2149; RULE-2150; RULE-2151; RULE-2152; RULE-2153; RULE-2156; RULE-2158; RULE-2160; RULE-2161; RULE-2187; RULE-2216; RULE-2308; RULE-2312 (EC#s 2014; 2027; 2056; 2065; 2133; 2134; 2135; 2136; 2137; 2138; 2256; 2257; 2326; 2419; 2420; 2448; 3035): These rules will not execute if the MAS or BOE field is blank (or 8-filled). h3. State feedback - Edits that need to account for historical eligibility spans. a. Edit 2257 There may be a date of death, but previous eligibility information prior to the person’s death. b. Edit 2027, 2028, 2029 2448, 2280 At one point the person may have been dual eligible, and at a different time not…if at one point the member was dual eligible, a HIC number is present. c. MBOE and MAS edits (e.g. 2014, 2027, 2056, 2326, 2135, 2419, 2420) should account for ACA and new eligibility group codes effective 1/1/2014
TMSIS-1371	Alpha-numeric characters – expanded elements that are accepted	Change Request	Open	High	11/4/2015 12:15	11/4/2015 12:16	11/4/2015 12:16	*Feedback from Beta States after the 2015-09-23 Beta States Conference Call* In v2.0, validation rules checking alphanumeric fields for acceptable characters have been modified to fire only on | (pipe) or * (asterisk).
TMSIS-1370	Modify rules containing MAS and BOE to incorporate date logic that limits the edit to time periods before 2014-01-01	Change Request	Open	High	11/4/2015 9:39	11/4/2015 11:31	11/4/2015 10:00	*Feedback from Beta States after the 2015-09-23 Beta States Conference Call* Per CMS - CR will be created to the modify rules containing MAS and BOE to incorporate date logic that limits the edit to time periods before 2014-01-01 and new edits created with comparable logic for time periods on or after 2014-01-01. Per Brad - see TMSIS-1054 for Nuna solution. Rules affected: RULE-825; RULE-1257; RULE-1692; RULE-1956; RULE-2023; RULE-2024; RULE-2123; RULE-2124; RULE-2125; RULE-2129; RULE-2130; RULE-2148; RULE-2149; RULE-2150; RULE-2151; RULE-2152; RULE-2153; RULE-2156; RULE-2158; RULE-2160; RULE-2161; RULE-2187; RULE-2216; RULE-2308 & RULE-2312  (EC#s 2014; 2027; 2056; 2065; 2133; 2134; 2135; 2136; 2137; 2138; 2256; 2257; 2326; 2419; 2420; 2448 & 3035) Beta State feedback {color:#205081}"There appears to be conflicting business rules.V2.0 Coding Requirement:  The MEDICAID-BASIS-OF-ELIGIBILITY and MAINTENANCE-ASSISTANCE-STATUS fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files) for enrollment periods encompassing January 1, 2014 and beyond.Yet, for TANF-CASH-CODE, there is validation against MEDICAID-BASIS-OF-ELIGIBILITY and MAINTENANCE-ASSISTANCE-STATUS.  How can that logic be applied for enrollment periods after 01/01/2014?"{color}
TMSIS-1369	Update RULE-1973 per Jeff's clarification	Change Request	Open	Medium	11/3/2015 19:43		11/3/2015 19:43	From Jeff's comment, COMMENT SERVICING-PROV-NUM does not exist in CLAIM-HEADER-RX or CLAIM-LINE-RX RESPONSE The field entitled, “DISPENSING-PRESCRIPTION-DRUG-PROV-NUM” in the Claim-RX file captures the state-specific provider id of the provider who actually dispensed the prescription medication. This field is analogous to the SERVICING-PROV-NUM field in the Claim-IP, Claim-LT and Claim-OT files.
TMSIS-1368	Rules currently under discussion that should be deprecated per Jeff Collier's request	Change Request	In Progress	Medium	11/3/2015 19:37		11/4/2015 11:46	Rules should be deprecated per Jeff Collier's request.
TMSIS-1320	Add new errors for unrecognizable characters in text fields	Change Request	Open	High	10/28/2015 2:04		10/30/2015 13:31	This is a follow-up to TMSIS-1319, and "phase 2" of the change to allow files with some un-decodable binary data past receipt and control. Create rules to report back to the state that there was a non-ASCII character in the field. Current validation rules assume that the character encoding is ASCII, so do not check this. Two rough options for implementation, to be fleshed out and proposed for approval before we move forward: a) incorporate into existing format rules (ex: RULE-7006) and null out these fields in the database (following the "formatting error" handling [here|https://tmsis2.atlassian.net/wiki/display/RTD/Handling+bad+data+submitted+by+states] b) write new rules that warn of having unrecognizable characters, but allow these fields, with replacement characters, to be populated in the database.
TMSIS-1314	WAIVER-ID data element - implement the Waiver Identifier Look-up Table and Waiver Identifier Crosswalk Table in T-MSIS	Change Request	Open	High	10/27/2015 16:35		10/27/2015 16:39	JDC -  issue – States are populating the WAIVER-ID fields with State IDs and not Federal IDs on claim transactions, enrollment files and managed care files. In T-MSIS, the definition calls for the states to submit federal IDs. In MSIS states had been submitting state waiver IDs. While the definition in T-MSIS specifically tells states to submit federal IDs, the associated coding instruction was vague and the business rule was inaccurate, thus giving rise to confusion about whether states should submit federal waiver IDs to T-MSIS or state IDs. Consequently, about half of the States report the federal IDs and half report State IDs.  State IDs generally seem to be at a more granular level of specificity, so there are sometimes multiple state waiver IDs associated with a single federal waiver ID.  (The use of state waiver IDs came to light when states began triggering EC160 edit errors (Overlapping segments with identical record keys are not allowed.)) Remedy/workaround - Implement the Waiver Identifier Look-up Table and Waiver Identifier Crosswalk Table in T-MSIS, see attachment
TMSIS-1312	WAIVER-ID data element - add the WAIVER-ID field to the MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 segment key	Change Request	Open	High	10/27/2015 16:02		11/2/2015 19:08	h3. Summary *add the WAIVER-ID field to the MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 segment primary key* JDC - Issue - When a State inputs multiple MCR00005 segments having overlapping effective time spans into the managed care file for a given MCO, it triggers an EC160 edit error in T-MSIS v1.2 and a RULE-2659 error in T-MSIS v2.0.  The current logic is based on the case that a managed care entity would only have a single operating authority at any point in time. This has proven to be false.  MCOs can have multiple simultaneous operating authorities JDC - Remedy - add the WAIVER-ID field to the MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 segment key See attached email for more background on issue and proposed solution: From Jeff Collier RE: WAIVER-ID issues in T-MSIS. h3. Requirements impact The data validation business rule that will be impacted is RULE-2659, but the key requirement that should be updated is the data dictionary that is published to states. This will need to be updated to include WAIVER-ID as part of the primary key for MANAGED-CARE-OPERATING-AUTHORITY-MCR00005. h3. Development impact Development effort (est. hours): [~everett] to fill out Dependencies: [~everett] to fill out h3. Testing impact Testing effort (est. hours): [~sviswanathan] and [~mtasnim]/[~shana.amadi] to fill out (TODO: ensure any test cases impacted are linked to the requirements above) h3. Schedule impact (pending impacts above; insert any notes about larger impact to the product delivery schedule)
TMSIS-1237	Initiatives on hold - - may not be applicable in November 2015	Change Request	Open	High	10/14/2015 16:43	11/4/2015 12:06	10/14/2015 16:49	**Feedback from Beta States after the 2015-09-23 Beta States Conference Call** Initiatives on hold - - may not be applicable in November: a. 2332, 2333 - If START-OF-TIME-PERIOD >= 20151105, then NATIONAL-HEALTH-CARE-ENTITY-ID must not be (8-filled or 9-filled) b. 2329 - If END-OF-TIME-PERIOD >= "20151110", CROSSOVER-INDICATOR= "1" and MEDICARE-HIC-NUM is 8-filled, then MEDICARE-BENEFICIARY-IDENTIFIER must not be 8-filled Per BA Lead - Rules will be made inactive until further notice. Rules potentially impacted: RULE-1006 RULE-1140 RULE-1181 RULE-1425 RULE-1558 RULE-1593 RULE-1821 RULE-1858 RULE-1898 RULE-2387 RULE-2719 RULE-3187 RULE-567 RULE-713 RULE-749
TMSIS-1236	OCCURRENCE-CODEs–update BR to include logic to only fire if both fields are populated	Change Request	Open	High	10/14/2015 16:05		10/14/2015 16:07	**Feedback from Beta States after the 2015-09-23 Beta States Conference Call** Occurrence code effective and end date relationships - - Occurrence codes only have an effective date - - States may be 8-filling end dates in these cases.  Occurrence span codes have effective and end dates. OCCURRENCE-CODE-EFF-DATE-* must be <= OCCURRENCE-CODE-END-DATE-* Per BA Lead, rule will be updated to include logic to only fire if both fields (OCCURRENCE-CODE-EFF-DATE, OCCURRENCE-CODE-END-DATE) are populated.
TMSIS-1234	CLAIM-HEADER-RECORD-OT - The logic for RULE-1402 is not correct for all claim types.	Change Request	Open	High	10/14/2015 13:07		10/14/2015 13:10	**Feedback from Beta States after the 2015-09-23 Beta States Conference Call** The logic for RULE-1402 as it applies to all claim types is not correct.   Co-insurance and Deductible are two discreet fields that are not dependent on one another.  See Errors 2428 and 2431 If I begin a calendar year with a $1.000 deductible, and $35.00 in coinsurance for each visit; the provider will ask me to make payment until I've met my $1000.00 deductible.  At that point in time, I will only have to pay coinsurance. It works the same way with Medicaid.  A claims processor will see Medicare cross-overs with both amounts until about mid-year, when it begins to see a lot of claims with just coinsurance because the deductible has been met If coinsurance is sent on a claim, it is perfectly valid for the deductible field to be 0 or "8's". 2.0 Validation logic: ({color:#205081}if and only if fns.hasValue(@val.TOT-MEDICARE-DEDUCTIBLE-AMT), then fns.hasValue(@val.TOT-MEDICARE-COINS-AMT){color})
TMSIS-1233	PRIMARY-ELIGIBILITY-GROUP-IND (ELG00005) - correct the BR logic to allow for multiple eligibility spans	Change Request	Open	High	10/14/2015 12:31		10/14/2015 16:03	**Feedback from Beta States after the 2015-09-23 Beta States Conference Call** Re: edits 2444 & 2228 – how are states to report primary eligibility when multiple eligibility spans exist and there are no date overlaps, versus when there are date overlaps? Add the correct logic to allow for multiple eligibility spans when there is more than 1 primary eligibility group indicator for the same individual.  Reference defects #13 and 368.
TMSIS-1229	PRIMARY-ELIGIBILITY-GROUP-IND (ELG00005) – disable RULE-2133	Change Request	Open	High	10/14/2015 10:49		10/14/2015 10:53	**Feedback from Beta States after the 2015-09-23 Beta States Conference Call** Re: edits 2444 & 2228 – how are states to report primary eligibility when multiple eligibility spans exist and there are no date overlaps, versus when there are date overlaps? Disable RULE-2133. The validation logic verifies there is one primary eligibility group.  Reference defects #13 and 368.
TMSIS-1213	DATE-OF-DEATH - Eligibility file - update 2.0 logic for edits	Change Request	Open	High	10/13/2015 14:25		10/13/2015 14:30	**Feedback from Beta States after the 2015-09-23 Beta States Conference Call** Edits for relationship between DATE-OF-DEATH (e.g. 2500, 2138, 2543, among others) and eligible file segments where date of death must be >= end date of segment. {color:#d04437}States may not always close out eligibility information until end of month or until after date of death is reported.{color} see affected edits  2500, 2138, 2543 in the V.2 documentation.
TMSIS-1205	Deactive rules checking for Nov 2015 dates	Change Request	Open	Medium	10/9/2015 21:00		10/9/2015 21:01	*Feedback from Beta States after the 2015-09-23 Beta States Conference Call* "Initiatives on hold - - may not be applicable in November: a. 2332, 2333 - If START-OF-TIME-PERIOD >= 20151105, then NATIONAL-HEALTH-CARE-ENTITY-ID must not be (8-filled or 9-filled) b. 2329 - If END-OF-TIME-PERIOD >= ""20151110"", CROSSOVER-INDICATOR= ""1"" and MEDICARE-HIC-NUM is 8-filled, then MEDICARE-BENEFICIARY-IDENTIFIER must not be 8-filled" RULE-1821 and RULE-1181 should be made inactive until further notice.
TMSIS-1192	FUNDING-SOURCE-NONFEDERAL-SHARE data element - add valid value "06 State appropriations to the CHIP agency"	Change Request	Open	High	10/8/2015 16:59		10/8/2015 17:14	Per CMS add "06 State appropriations to the CHIP agency" valid value to the FUNDING-SOURCE-NONFEDERAL-SHARE data element. This data element is used in all 4 claim files: CIP127 CLT077 COT063 CRX054 FUNDING-SOURCE-NONFEDERAL-SHARE  <new table> 01 State appropriations to the Medicaid agency 02 Intergovernmental transfers (IGT) 03 Certified public expenditures (CPE) 04 Provider taxes 05 Donations {color:#205081}06 State appropriations to the CHIP agency{color} Updated the following documents: T-MSIS DD APPENDICES V1.3
TMSIS-1191	Continue to bypass tier 1, 2 & 3 edits on denied claims and denied claim lines in 2.0	Change Request	Open	High	10/8/2015 13:55		10/27/2015 11:36	**Feedback from Beta States after the 2015-09-23 Beta States Conference Call** Currently all claims and claim lines are treated the same. CMS to enter Change Request (CR) to request this update be made in 2.0. This applies to voids as well. Also include instructions on how to identify a denied /void claim or claim line.
TMSIS-1190	Edits such as 2381, 2382, 2383 need to be corrected to not require a modifier when there is a procedure code	Change Request	Open	High	10/8/2015 13:03	11/4/2015 12:38	11/4/2015 12:38	**Feedback from Beta States after the 2015-09-23 Beta States Conference Call** Edits such as 2381, 2382, 2383 need to be corrected to NOT require a modifier when there is a procedure code (If PROCEDURE-CODE-2 is 8-filled, then PROCEDURE-CODE-MOD-2 must be 8-filled). h3. CR update 2015-11-04 per JDC: 1. Modify logic of rules RULE-417, RULE-430, RULE-443, RULE-456, RULE-470, RULE-483 (EC#s 2382; 2383; 2384; 2385; 2386 & 2387), to assure that the mod field is always blank.  (ICD-9/10 procedure codes don't have modifiers.) 2. Deprecate RULE-1643; RULE-1704; RULE-1707 and RULE-1719  (EC#s 2382; 2383; 2384 & 2085).  (Procedure codes on professional claims may or may not have an associated modifier.)
TMSIS-1188	Edit 2335 logic needs to be corrected – removed “plus 1” requirement from 2.0 logic	Change Request	In Progress	High	10/8/2015 12:24	11/4/2015 12:08	11/4/2015 12:49	**Feedback from Beta States after the 2015-09-23 Beta States Conference Call** Edit 2335 logic needs to be corrected: Sum (NON-COVERED-DAYS plus MEDICAID-COV-INPATIENT-DAYS {color:#d04437}plus 1{color}) must be <= (BEGINNING-DATE-OF-SERVICE minus ENDING-DATE-OF-SERVICE (in days) plus 1).  red plus 1 will be removed from 2.0 logic.  Also, confirm BegDOS-EndDOS has been corrected.
TMSIS-1187	Exclude TYPE-OF-SERVICE or TYPE-OF-CLAIM on edits such as 2002, 2004, 2013, 2024 or 2036	Change Request	Open	High	10/8/2015 11:44	11/4/2015 12:31	10/29/2015 12:54	**Feedback from Beta States after the 2015-09-23 Beta States Conference Call** Edits such as 2002, 2004, 2013, 2024 or 2036 – need to exclude types of services or types of claims, such as capitation to allow for prospective payments (BEGINNING-DATE-OF-SERVICE must be <= END-OF-TIME-PERIOD or ENDING-DATE-OF-SERVICE must be <= END-OF-TIME-PERIOD or ADJUDICATION-DATE must be >= ADMISSION-DATE – where states are instructed to use admit and discharge date to indicate period of time covered by the FT). Additionally must include guidance on how to recognize when and when not to apply the rule.
TMSIS-1185	PROV-NPI-NUM/HEALTH-HOME-PROVIDER-NPI: remove algorithm for APIs tier 1 edit	Change Request	Open	High	10/8/2015 10:45	11/4/2015 12:04	10/27/2015 12:50	**Feedback from Beta States after the 2015-09-23 Beta States Conference Call** Open questions: 1. Do we want to continue with the check digit algorithm or simply do an NPI/API lookup? 2  If check digit logic is kept, do API follow same rules as NPIs?
TMSIS-1016	Provider-id and managed-care-id lookups should be references to provider and managed care files	Change Request	Open	Medium	9/22/2015 13:24		11/3/2015 15:12	Hi Jeff - We had a conversation about this back in June, but I wanted to file this to clarify that the coding requirements for rules like RULE-2381 that say something along the lines of "Value for the ELIGIBLE file must correspond to a managed care ID in a state-provided crosswalk." should actually be "Value for the ELIGIBLE file must correspond to a managed care ID in a managed care file the state has submitted via T-MSIS." If you can confirm here, we'll fix the appropriate rules. Thanks!
TMSIS-932	State Issue: Error Code 103 when submitting the group level DIAGNOSIS-CODE-4.	Change Request	Open	Medium	9/17/2015 22:18		11/4/2015 11:42	State Issue: Alabama received error 103 when submitting the group level DIAGNOSIS-CODE-4. According to Jeff C, our position should be to accept group-level codes on claims/encounters. Therefore, the edit should not set. The group level submitted was 3459. Alabama received error 103 when submitting the group level DIAGNOSIS-CODE-3. Alabama received error 103 when submitting the group level ADMITTING-DIAGNOSIS-CODE. State Reported Issue: AL SP Issue: 5306, 5308, 5309 CR NO: CIP041-0001, CIP041-0001 DE NO:CIP041, CIP032, CIP038, CIP030 Data Element Name: DIAGNOSIS-CODE-4 Error NO: 103 Business rule: Value is not included in the valid code list Coding Requirement: DIAGNOSIS-CODE-3 through DIAGNOSIS-CODE-5: The third through fifth ICD-9/10-CM codes that appear on the claim.
TMSIS-931	State Issue: Error Code 2429 posts to TOT-MEDICARE-COINS-AMT and requires the amount be 8-filled	Change Request	Open	Medium	9/17/2015 22:11	11/4/2015 14:12	11/4/2015 11:41	State Issue: Alex Wright: Edit 2429 posts to TOT-MEDICARE-COINS-AMT and requires the amount be 8-filled if the claim is an encounter (TYPE-OF-CLAIM = ‘3’,’C’,’W’).  States are reporting 0000000.00 which would also be valid…no amount.  Given that 8/9 fill is changing in 2.0, should this edit be revised so amounts for coinsurance and deductible cannot be less than or greater than 0 (if not NULL)? State Reported Issue: All SP Issue: n/a CR NO: CRX044-0006 DE NO: CRX044 Data Element Name: TOT-MEDICARE-COINS-AMT Error NO: 2429 Business rule: If TYPE-OF-CLAIM = "3", "C", "W", then TOT-MEDICARE-COINS-AMT must be 8-filled Coding Requirement: Value must be "Not Applicable" if TYPE-OF-CLAIM indicates the claim is an encounter record.
TMSIS-930	State Issue: Provider license dates overlap with same end-of time date or start and end dates overlap	Change Request	Open	Medium	9/17/2015 22:06	11/4/2015 10:38	11/4/2015 11:40	State Issue: Edit should be adjusted to allow for multiple state licenses recorded by the same licensing entity/type. WV data carries the licenses enrolled as given by the provider enrollment. Rule: Overlapping coverage not allowed for same Submitting state & Prov ID, Location ID, License Type, License Issuing Entity ID. CMS Edit Issue: Provider license dates overlap with same end-of time date or start and end dates overlap. PRZ0009900193 00001 1 STATE BOARD OF MEDICAL EXAMINERS 19981109*2174 20160630 PRZ0009900193 00001 1 STATE BOARD OF MEDICAL EXAMINERS 20140930*2174 20150401 PRZ0009900311 00001 5 DEPARTMENT OF HEALTH SERVICES (LOCAL) 19780701*2174 99991231 PRZ0009900311 00001 5 DEPARTMENT OF HEALTH SERVICES (LOCAL) 20040422*2174 99991231 It is normal for some providers to have what may be considered “over-lapping” licenses. 1. A provider may have multiple service locations. 2. Those service locations can possibly be in multiple states. 3. The provider has to be licensed in every state they practice in, so there can be multiple licenses on one provider’s file. 4. Each state has their own “licensing” expiration policies/dates. So there can be a variety of expiration dates/time frames. a. Some will have all licenses expire on the same day every year b. Some in the same month but different days c. Some will have a license that expires one year from the day the provider originally obtained a license. Please see the Example below: Dr. Mark Pretend works for Tri-State Pediatricians. Tri-State State Reported Issue: WV SP Issue: 5278 CR NO: PRV065-0007 DE NO: PRV065 Data Element Name: PROV-LICENSE-EFF-DATE Error NO: 2174 Business rule: If two or more PROV-LICENSING-INFO record segments have the same SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-LOCATION-ID, LICENSE-TYPE, and LICENSE-ISSUING-ENTITY-ID then for each pair of record segments, (Segment 1 PROV-LICENSE-EFF-DATE must <> Segment 2 PROV-LICENSE-EFF-DATE) AND ( (If Segment 1 PROV-LICENSE-EFF-DATE < Segment 2 PROV-LICENSE-EFF-DATE, then Segment 1 PROV-LICENSE-END-DATE must be < Segment 2 PROV-LICENSE-EFF-DATE) OR (If Segment 2 PROV-LICENSE-EFF-DATE < Segment 1 PROV-LICENSE-EFF-DATE, then Segment 2 PROV-LICENSE-END-DATE must be < Segment 1 PROV-LICENSE-EFF-DATE) ) Coding Requirement: 'Records in a file segment that have the same set of values for the segment key data elements excluding the file segment effective date must not have overlapping coverage dates (e.g., MSIS-IDENTIFICATION-NUMBER and SUBMITTING-STATE in the PRIMARY-DEMOGRAPHICS-ELIGIBILITY segment).
TMSIS-929	State Issue: Error Code 2425 is being posted to valid values	Change Request	Open	Medium	9/17/2015 21:55	11/4/2015 10:39	11/4/2015 11:27	State Issue: Error is being posted to valid values. Possibly related to defect 489 but this is for service tracking claims where the DD says to put in the total billed amount. The DD includes the following instruction regarding TOT-BILLED-AMT for Service Tracking Claims on the ClaimOT ‘02’ record (DE Number COT048): “If TYPE-OF-CLAIM = "4", then TOT-BILLED-AMT must = "00000000".” This should be changed to the total of billed amounts on the service tracking claims or deleted. See below the conflict with edit error code 2425. The data dictionary information for the corresponding field on the ClaimOT ‘03’ record, BILLED-AMT (DE Number COT174), does not contain any instructions specific to service tracking claims. However, it does state the following: “This data element must include a valid dollar amount.” Therefore per these DD instructions: WV is populating TOT-BILLED-AMT with ‘0.00’ and BILLED-AMT with the actual billed amount of the service tracking claim. This, in turn, is causing an error 2425 (Relational edit between TOT-BILLED-AMT and BILLED-AMT) on our service tracking claims. This should be changed to the total of billed amounts on the service tracking claims so the amounts equal or the edit should be ignored for service tracking claims. In the CMS financial transaction reporting guidelines: For service tracking claims, the sum of the claim line MEDICAID-PAID-AMT values on a claim’s claim line record segments should equal the amount reported in the SERVICE-TRACKING-PAYMENT-AMT data element on the claim’s claim header record segment. This is true of our service tracking claim records. State Reported Issue: WV SP Issue: 4897 CR NO: COT048-0005 DE NO: COT048 Data Element Name: TOT-BILLED-AMT Error NO: 2425 Business rule: The absolute value of the sum of BILLED-AMT on each detail line record must = absolute value of TOT-BILLED-AMT Coding Requirement: The absolute value of the sum of the claim line BILLED-AMTs must be equal to the absolute value of the TOT-BILLED-AMT.
TMSIS-928	State Issue: Records are rejecting when the TYPE-OF-OTHER-THIRD-PARTY-LIABILITY value is different	Change Request	Open	Medium	9/17/2015 21:39	11/4/2015 10:39	11/4/2015 11:27	State Issue: Records are rejecting when the TYPE-OF-OTHER-THIRD-PARTY-LIABILITY value is different. Record keys are: Submitting-State, MSIS-Identificiation-Num, and Type-of-Third-Party-Liability. These keys are unique and therefore the edit is setting incorrectly. If the edit does not include the Type of Third Party Liability, CMS needs to have the edit modified. An individual can have many different types of other third party with overlapping dates. Examples: RECORD-NUMBERS - 95836 and 95837 - Dates overlap but the TYPE-OF-OTHER-THIRD-PARTY-LIABILITY are different. One is a '1' and the other is a '5'.” State Reported Issue: OK SP Issue: 4716 CR NO: TPL068-0008 DE NO: TPL068 Data Element Name: OTHER-TPL-EFF-DATE Error NO: 2181 Business rule: If two or more TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION record segments have the same SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and TYPE-OF-OTHER-THIRD-PARTY-LIABILITY then for each pair of record segments, (Segment 1 OTHER-TPL-EFF-DATE must <> Segment 2 OTHER-TPL-EFF-DATE) AND ( (If Segment 1 OTHER-TPL-EFF-DATE < Segment 2 OTHER-TPL-EFF-DATE, then Segment 1 OTHER-TPL-END-DATE must be < Segment 2 OTHER-TPL-EFF-DATE) OR (If Segment 2 OTHER-TPL-EFF-DATE < Segment 1 OTHER-TPL-EFF-DATE, then Segment 2 OTHER-TPL-END-DATE must be < Segment 1 OTHER-TPL-EFF-DATE) ) Coding Requirement: Records in a file segment that have the same set of values for the segment key data elements excluding the file segment effective date must not have overlapping coverage dates (e.g., MSIS-IDENTIFICATION-NUMBER and SUBMITTING-STATE in the PRIMARY-DEMOGRAPHICS-ELIGIBILITY segment).
TMSIS-927	State Issue: Error Code 2038 because the ENDING-DATE-OF-SERVICE is greater thant he ADJUDICATION-DATE	Change Request	Open	Medium	9/17/2015 21:34	11/4/2015 10:40	11/4/2015 11:27	State Issue: Alabama is submitting Type of claim = 2 (capitated payments) and receiving error 2038 because the ENDING-DATE-OF-SERVICE is greater thant he ADJUDICATION-DATE. The Financial guidance states: Adjudication-Date - Date the line-level transaction's approval and payment processes were completed - Medicaid submitted 2015-01-02 Ending-date-of-service - Populate with the last day of the time period covered by this financial transaction (CLAIMOT). Medicaid submitted with 2015-01-31 If states are always to use the end of time period as the ending date of service, this edit needs to be modified to exclude financial transactions. State Reported Issue: AL SP Issue: 4575 CR NO: COT034-0004 DE NO: COT034 Data Element Name: ENDING-DATE-OF-SERVICE Error NO: 2038, 2040 Business rule: ENDING-DATE-OF-SERVICE must be <= ADJUDICATION-DATE [CLAIM-HEADER-RECORD-OT] Coding Requirement: Date must be equal to or before ADJUDICATION-DATE.
TMSIS-926	State Issue: Error Code 2126 for reversals	Change Request	Open	Medium	9/17/2015 21:26	11/4/2015 10:40	11/4/2015 11:37	State Issue: Error is being posted to reversals. Reversals have negative dollar amounts. Relational edit does not take into account that billed amount will be less than total medicare coinsurance amount on a reversal. Relational edit should be using absolute values of the amounts used in the comparison. State Reported Issue: WV SP Issue: 4469 CR NO: CIP117-0003 DE NO: CIP117 Data Element Name: TOT-MEDICARE-COINS-AMT Error NO: 2126, 2127 Business rule: TOT-MEDICARE-COINS-AMT must be < TOT-BILLED-AMT Coding Requirement: Value must be less than TOT-BILLED-AMT.
TMSIS-925	State Issue: ACCREDITATION-ORGANIZATION Updates	Change Request	Open	Medium	9/17/2015 21:20	11/4/2015 10:41	11/4/2015 11:27	State Issue: Please update list as follows: 01 National committee for quality assurance – Excellent 02 National committee for quality assurance – Commendable xx National committee for quality assurance – Accredited 03 National committee for quality assurance – Provisional xx National committee for quality assurance – Interim xx National committee for quality assurance – Denied 04 National committee for quality assurance – new plan (no longer a valid accreditation level) 05 URAC - full 06 URAC - conditional 07 URAC – provisional 08 Accreditation Association for Ambulatory Health Care, Inc. (AAAHC) – 3 years 09 Accreditation Association for Ambulatory Health Care, Inc. (AAAHC) – 1 year (no longer a valid accreditation level) 10 Accreditation Association for Ambulatory Health Care, Inc. (AAAHC) – 6 months (no longer a valid accreditation level) 11 Not accredited 12 Other State Reported Issue: All SP Issue: n/a CR NO: MCR086-0002 DE NO: MCR086 Data Element Name: ACCREDITATION-ORGANIZATION Error NO: 103 Business rule: Value must be equal to a valid value. Coding Requirement: Value must be equal to a valid value.
TMSIS-924	State Issue: Validation rules for email address in the MNGDCARE and PROVIDER files	Change Request	Open	Medium	9/17/2015 21:12	11/4/2015 10:42	11/4/2015 11:36	State Issue: Validation rules for email address in the MNGDCARE and PROVIDER files differ somewhat. The MNGDCARE file validation only requires there be an ‘@’ symbol. The PROVIDER file requires the ‘@’ symbol and that the email address be in the following format: Must have [email protected] format. There are ISO/ANSI standards of allowable characters in an email address which are not accepted in TMSIS. These characters include valid characters, e.g.: JOHN`~1!#$%^&*-_=+{|'[email protected]. State Reported Issue: All SP Issue: 4849 CR NO: n/a DE NO: MCR050, PRV054 Data Element Name: MANAGED-CARE-EMAIL ADDR-EMAIL Error NO: n/a Business rule: Coding Requirement:
TMSIS-923	State Issue: Error code 2434 for TYPE-OF-SERVICE	Change Request	Open	Medium	9/17/2015 21:07	11/4/2015 10:43	11/4/2015 11:35	State Issue: Alabama is receiving error code 2434 for TYPE-OF-SERVICE when value = 086 (Other Pregnancy). However, according to the CMS release notes 22, the Type of Service table, shows 086 being applicable to both CIP and COT. State Reported Issue: AL SP Issue: 4458 CR NO: CRX134-0002 DE NO: CRX134 Data Element Name: TYPE-OF-SERVICE Error NO: 2434 Business rule: If FILE-NAME = "CLAIMRX", then TYPE-OF-SERVICE must = “011”, “033”, “034”, “085” , or “131” Coding Requirement: Value must equal a prescription TYPE-OF-SERVICE value.
TMSIS-922	State Issue: Error code 103 on the FUNDING-SOURCE-NONFEDERAL-SHARE	Change Request	Open	Medium	9/17/2015 20:49	11/4/2015 10:44	11/4/2015 11:34	State Issue: Alabama is receiving error code 103 on the FUNDING-SOURCE-NONFEDERAL-SHARE when providing value = '06'. The Alabama CHIP program is not administered by the state Medicaid Agency. It is administered by the Department of Public Health. Alabama spoke to Barbara Roth about this on October 2014 and was told CMS would add a new value = '06' - State Appropriations to the CHIP Agency and that Alabama CHIP should use this new value but they are getting rejections. State Reported Issue: AL SP Issue: 4415 CR NO: CIP127-0001 DE NO: CIP127 Data Element Name: FUNDING-SOURCE-NONFEDERAL-SHARE Error NO: 103 Business rule: Value is not included in the valid code list. Coding Requirement: A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider.
TMSIS-921	Error code 2432 absolute value of TOT-TPL-AMT	Change Request	Open	High	9/17/2015 20:39	11/4/2015 10:45	11/4/2015 11:26	State Issue: Edit 2432 may be written incorrectly. The current rule states: The absolute value of TOT-TPL-AMT must be <= the absolute value of (TOT-BILLED-AMT minus TOT-MEDICARE-COINS-AMT plus TOT-MEDICARE-DEDUCIBLE-AMT)​. Please speak to CMS (Jeff C) about this because this edit should include the TOT-OTHER-INSURANCE-AMT and NOT the TOT-TPL-AMT. The TOT-OTHER-INSURANCE-AMT is the amount the provider receives from the recipient's health insurance carrier and submits on the claim. The TOT-TPL-AMT is the amount that is not submitted by provider's on claims. It is the amount recovered through other means such as; estates, liens, mal-practice suits, etc. State Reported Issue: AL SP Issue: 4389 CR NO: CLT069-0002 DE NO: CLT069 Data Element Name: TOT-TPL-AMT Error NO: 2432 Business rule: The absolute value of TOT-TPL-AMT must be <= the absolute value of (TOT-BILLED-AMT minus TOT-MEDICARE-COINS-AMT plus TOT-MEDICARE-DEDUCIBLE-AMT) Coding Requirement: The absolute value of TOT-TPL-AMT must be equal to or less than the absolute value of TOT-BILLED-AMT minus TOT-MEDICARE-COINS-AMT plus TOT-MEDICARE-DEDUCTIBLE-AMT.
TMSIS-920	State Issue: Error Code 2254 when 9-filling the Date of Death	Change Request	Open	Medium	9/17/2015 20:32	11/4/2015 10:45	11/4/2015 11:32	State Issue: Alabama is receiving error 2254 when 9-filling the Date of Death and the S2T mapping has Sometimes. CMS should allow to 9-filled date of deaths. The business rule currently states: If DOD is not 8-filled, DOD must be <= END-OF-TIME-PERIOD. Rule needs to include If DOD it not 8 or 9-filled for completeness. Also, Alabama is receiving error 2254 when date of death is > end of time period but this is due to full file replacements. If a state is submitting data for the 05/2015 reporting period but extracting on 06/10/2015, it is very possible the date of death could be > than end of time period which would be State Reported Issue: AL SP Issue: 4364, 4337, 4667, 4744 CR NO: PRV035-0004 DE NO: PRV035 Data Element Name: DATE-OF-DEATH Error NO: 2254 Business rule: If DATE-OF-DEATH is not 8-filled, DATE-OF-DEATH must be <= END-OF-TIME-PERIOD Coding Requirement: Date must be equal to or before END-OF-TIME-PERIOD if DATE-OF-DEATH is not "Not Applicable".
TMSIS-919	State Issue: Error Code 2456 on non-contiguous segments	Change Request	Open	Medium	9/17/2015 20:25	11/4/2015 10:46	11/4/2015 11:27	State Issue: Error 2456 is being posted on non-contiguous segments which impacts most of the provider file. In this case, error posted incorrectly on provider PRV00002 segment dates when the State sends multiple segments with non-contiguous dates. Most States do not maintain segment information in a contiguous manner. The Provider can be active or inactive during different time periods so the the PRV00002 dates do not have to be contiguous, the only requirement is for the parent record to fully cover all children under the parent segments so dates on the parent should not be edited for contiguous dates. In many cases, segment date information is never contigous. State Reported Issue: ME SP Issue: 3744 CR NO: PRV020-0009 DE NO: PRV020 Data Element Name: PROV-ATTRIBUTES-EFF-DATE Error NO: 2456 Business rule: If two or more PROV-ATTRIBUTES-MAIN record segments have the same SUBMITTING-STATE and SUBMITTING-STATE-PROV-ID and these record segments are sorted in ascending order by PROV-ATTRIBUTES-EFF-DATE, then for each consecutive pair (1,2; 2,3; 3,4; etc.) of record segments, Segment N PROV-ATTRIBUTES-END-DATE must = Segment (N+1) PROV-ATTRIBUTES-EFF-DATE minus 1 day Coding Requirement: Record segments that have the same set of values for the segment key data elements excluding the segment effective date must not have gaps in coverage dates (e.g., MSIS-IDENTIFICATION-NUMBER and SUBMITTING-STATE in the PRIMARY-DEMOGRAPHICS-ELIGIBILITY segment).
TMSIS-917	State Issue: Procedure codes and Modifier	Change Request	Open	Medium	9/17/2015 17:52	11/4/2015 10:47	11/4/2015 11:27	State Issue: Business Rule for 2385 is: "If PROCEDURE-CODE-4 is not 8-filled, then PROCEDURE-CODE-MOD-4 must not be 8-filled OR If PROCEDURE-CODE-4 is 8-filled, then PROCEDURE-CODE-MOD-4 must be 8-filled". It is incorrect to validate that if you have a procedure code, you must also have a modifier with it. You can have a Procedure Code without a modifier, but you can not have a Modifier without a Procedure Code, the business rule should read: If PROCEDURE-CODE-MOD-4 is not 8-filled, then PROCEDURE-CODE-4 must not be 8-filled OR If PROCEDURE-CODE-MOD-4 is 8-filled, then PROCEDURE-CODE-4 must be 8-filled. This may also be a duplicate of defect 145. I realize that defect 145 is logged for for DE CIP183, but this edit is used on OT and IP files. Defect 145 needs to also include OT DE's identified in Edit 2385. Also note, the error message is not correct for OT errors. The OT file only contains PROCEDURE-CODE DE. So sharing the error message with IP, where multiple procedure code occur is misleading for OT errors. State Reported Issue: TX SP Issue: 3942 CR NO: COT219-0002 and COT219-0003 DE NO: COT219 Data Element Name: PROCEDURE-CODE-MOD-4 Error NO: 2385 Business rule: If PROCEDURE-CODE-4 is 8-filled, then PROCEDURE-CODE-MOD-4 must be 8-filled Coding Requirement: Value must not be "Not Applicable" if PROCEDURE-CODE-4 is not "Not Applicable".
TMSIS-916	State Issue:Dual Eligibility for members	Change Request	Open	Medium	9/17/2015 17:45	11/4/2015 10:48	11/4/2015 11:26	State Issue: Since states are reporting historical information, at some point a member can be dual eligible, while at a different span they are no longer dual eligible. Because the member was dual eligible, a HIC-NUMBER is present on the file. TA's recommendation is to require a HIC number be present when the member is dual eligible. If there is a HIC number and member is not dual eligible, ignore/disregard the edit. State Reported Issue: n/a SP Issue: n/a CR NO: n/a DE NO: n/a Data Element Name: n/a Error NO: 2029 Business rule: n/a Coding Requirement: n/a
TMSIS-915	State Issue: Error Code 2146 doesn't allow for the same surgical procedure code to be repeated on the same claim	Change Request	Open	Medium	9/17/2015 17:37	11/4/2015 10:48	11/4/2015 11:27	State Issue: ​Edit 2146 doesn't allow for the same surgical procedure code to be repeated on the same claim when the procedure-code-date is not the same as the others. For example, a provider can bill a claim with the same surgical procedure code on different days. The edit should include the procedure-code-date when evaluating for duplicate values of procedure-code entered. The following edits need to EVALUATE the associated PROCEDURE-CODE-DATE (1 through 6) values. State Reported Issue: n/a SP Issue: 2846 CR NO: CIP090-0008 DE NO: n/a Data Element Name: n/a Error NO: 2146 Business rule: n/a Coding Requirement: n/a
TMSIS-914	State Issue: Error Code 2239 functtioning as a Tier 3 edit	Change Request	Open	Medium	9/17/2015 17:32	11/4/2015 10:49	11/4/2015 11:27	State Issue: Edit 2239 needs to be "turned-off".  It is defined as a Tier 2 edit, but it is functioning as a Tier 3 edit.​  The edit is validating the Billing Provider's NPI on the CLAIMIP file to ensure it exists on the PROVIDER file and that the provider is in a group.  This is a Tier 3 edits. State Reported Issue: n/a SP Issue: 3172 CR NO: CIP180-0006 DE NO: Data Element Name: Error NO: n/a Business rule: n/a Coding Requirement: n/a
TMSIS-912	Error code 2424 for Inpatient or LTC claims	Change Request	Open	Medium	9/17/2015 17:12	11/4/2015 10:50	11/4/2015 11:26	State Issue: ​ Edit 2424 needs to be modified to factor in that not all Inpatient or LTC claims are priced based off of line level amounts.  Inpatient and LTC claims are header paid, e.g., per-diem, percent of charges, coins/deductible (crossovers), etc.  Along with edit 2424, the edit should factor in whether the PAYMENT-LEVEL-IND indicates the claim is header paid.  If the value for PAYMENT-LEVEL-IND indicates the claim is header paid the edit should be bypassed. State Reported Issue: n/a SP Issue: 3756, 3758 CR NO: CLT064-0002 DE NO: n/a Data Element Name: n/a Error NO: 2424, 2409, 2125 Business rule: n/a Coding Requirement: n/a
TMSIS-909	Modify program end date and date of death edits	Change Request	Open	Medium	9/17/2015 17:02	11/4/2015 10:51	11/4/2015 11:27	State Issue: Issue logged with CMS to determine if the program end date and date of death edits can be modified as many states end programs and enrollment after the date of death. State is reporting 8-filled dates for state plan option segment. State Reported Issue: n/a SP Issue: n/a CR NO: n/a DE NO: n/a Data Element Name:n/a Error NO: 2543, 2538, 2514, 2507, 2501, 2500, 2497, 2477, 2462 Business rule: n/a Coding Requirement: n/a
TMSIS-908	Error code 103 for states local codes	Change Request	Open	Medium	9/17/2015 16:59	11/4/2015 10:52	11/4/2015 11:26	State Issue: Maggie Siegmund: New York has "Local Codes" - which many states are still using instead of using the standard procedure codes. TMSIS did not take into consideration the "local codes" some states still use. This error is not correct. Local Codes should be accepted. Sample values: 2766, 9708, 7806. State Reported Issue: NY SP Issue: 2752 CR NO: n/a DE NO:CIP030 Data Element Name: ADMITTING-DIAGNOSIS-CODE Error NO: 103 Business rule:n/a Coding Requirement: n/a
TMSIS-906	Error code 127 when submitting 'E' codes in the ADMITTING-DIAGNOSIS-CODE field.	Change Request	Open	Medium	9/17/2015 16:51	11/4/2015 10:53	11/4/2015 11:27	State Issue:Rhonda Downey:Ohio is receiving error code 127 when submitting 'E' codes in the ADMITTING-DIAGNOSIS-CODE field. CMS had stated they were removing this edit. Error code still shows up in Sprint 11 deployment State Reported Issue: OH SP Issue: 3325 CR NO: n/a DE NO: CLT027 Data Element Name: ADMITTING-DIAGNOSIS-CODE Error NO:127 Business rule: n/a Coding Requirement: n/a
TMSIS-905	Rrror code 2328 when 8-filling the MEDICARE-COMB-DED-IND	Change Request	Open	Medium	9/17/2015 16:47	11/4/2015 10:53	11/4/2015 11:27	State Issue: Rhonda Downey: Ohio is receiving error code 2328 when 8-filling the MEDICARE-COMB-DED-IND. May need to have CMS review this edit. The coding requirement states: Value must be zero if claim is not a crossover or an encounter record. Value 0 = Amount not combined with coinsurance amount​ If the claim is not a cross-over or encounter, this field should = 8 because it is not applicable. State Reported Issue: OH SP Issue: 3340 CR NO: CIP128-0004 DE NO: CIP128 Data Element Name: MEDICARE-COMB-DED-IND Error NO: 2328 Business rule: If CROSSOVER-INDICATOR = "0" or TYPE-OF-CLAIM = "3", "C", or "W", then MEDICARE-COMB-DED-IND must = 0 Coding Requirement: Value must be zero if CROSSOVER-INDICATOR indicates the claim is not a crossover or if TYPE-OF-CLAIM indicates the claim is an encounter record.
TMSIS-904	Format to use for positive/negative non-decimal values in FLF files	Change Request	Open	Medium	9/17/2015 16:43	11/4/2015 10:55	11/4/2015 11:27	State Issue: DC is approached DAYS-SUPPLY using instructions from STR (STR 5.4) regarding negative claim values within a FLF file. "Amount and quantity values for claims records can be positive or negative. If the cost or count value for any claims record is negative, it must follow the guidelines below." The following section "Instructions on negative claims values for FLF files" describes the usage of modified zoned decimal approach. All values provided by the state e.g. 0003{ are getting flagged with EC 105. IV&V conducted additionly testing and found out that values such as "-0006" and "00006" are being accepted. Please provide direction as to the format to use for positive and negative non-decimal values for quantities other than dollar amounts reported in FLF files. State Reported Issue: DC SP Issue: 3093 CR NO: CRX138-0001 DE NO: CRX138 Data Element Name: DAYS-SUPPLY Error NO: 105 Business rule: DAYS-SUPPLY must be >=-365 and <=365 Coding Requirement: Number of days supply dispensed.
TMSIS-901	Relationship of indicator 1 to segment TPL00005	Change Request	Open	Medium	9/17/2015 16:34	11/4/2015 10:55	11/4/2015 11:27	State Issue: NY has data that includes Indicator value 1 = Eligible individual does have TPL insurance coverage. NY does not understand the relationship of this indicator to segment TPL00005. They had to 8-filled OTHER-TPL-END-DATE because they do not have Other TPL Coverage information. Requesting exemption to this rule. State Reported Issue: NY SP Issue: 2720 CR NO: TPL069-0007 DE NO: TPL069 Data Element Name: OTHER-TPL-END-DATE Error NO: 2359 Business rule: If HEALTH-INSURANCE-COVERAGE-IND = "1", then OTHER-TPL-END-DATE must not be 8-filled Coding Requirement: Value must not be "Not Applicable" if HEALTH-INSURANCE-COVERAGE-IND indicates the individual has other TPL funding available.
TMSIS-900	Error Code 2477 for members with multiple eligibility periods	Change Request	Open	Medium	9/17/2015 16:29	11/4/2015 10:56	11/4/2015 11:27	State Issue: NY has 2 issues with this business rule: 1. When a member has multiple eligibility periods, error code 2477 is logged on each record, rather than only on the offending record. 2. NY data cannot meet this rule. State Reported Issue: NY SP Issue: 2729 CR NO: ELG254-0006 DE NO: ELG254 Data Element Name: ENROLLMENT-END-DATE Error NO: 2477 Business rule: If DATE-OF-DEATH is not 8-filled, then ENROLLMENT-END-DATE must be <= DATE-OF-DEATH Coding Requirement: Date must be equal to or before DATE-OF-DEATH if DATE-OF-DEATH is not "Not Applicable"
TMSIS-899	Error code 151 on non-claim files for both create and replacement	Change Request	Open	Medium	9/17/2015 16:22	11/4/2015 10:56	11/4/2015 11:27	State Issue: States have been reporting error code 151 on non-claim files for both create and replacement. Additional to the 151 error, the same segments get flagged with Tier 2 error codes i.e. 2194 on ELG00005 (MSIS-IDENTIFICATION-NUM [ELIGIBILITY-DETERMINANTS-ELG00005] must = MSIS-IDENTIFICATION-NUM [PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002] and SUBMITTING-STATE [ELIGIBILITY-DETERMINANTS-ELG00005] must = SUBMITTING-STATE [PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002] on the same record in the file). These Tier 2 error codes are more specific to the parent/child relationships among segments in a file unlike the generic 151. At the same time we're seeing inconsistencies in the ERF and ESR reports which compounds the problem of trying to identify the missing segments. Misu's suggestion to clear up the database might alleviate this problem and allow us to clearly understand the current behavior of the system. State Reported Issue: various SP Issue: n/a CR NO: various DE NO: various Data Element Name: all Error NO: 151 Business rule: varies per error code Coding Requirement: varies per error code
TMSIS-895	Edit 103 is posting to NPI's that are not following the NPI Lunh algorithm	Change Request	Open	Medium	9/17/2015 16:02	11/4/2015 10:57	11/4/2015 11:26	State Issue: Edit 103 is posting to NPI's that are not following the NPI Lunh algorithm.  States assigned atypical provider NPI's for their providers that are not required to have an NPI.  Per conversation with Jeff C. and Jeff S. the system needs to allow for these atypical providers and thus the Luhn algorithm needs to be removed to allow these identifiers (which may even include alpha-characters. Please note that this issue applies to all claims, provider and eligibility files. Any NPI field is currently using this Lunh algorithm, so all NPI related fields need to be updated. Also, if this field is 8-filled (ten 8's) the edit is also posting. State that reported issue: VA SP Issue: n/a CR NO: n/a DE NO: various Data Element Name: *PROVIDER-NPI* Error NO: 103 Business rule: If SERVICING-PROV-NPI-NUM not numeric. If NPI <> 8888888888 or 9999999999 then NPI must pass NPI check digit algorithm. Coding Requirement: The value must consist of digits 0 through 9 only. NPI must be valid. Record the value exactly as it appears in the state system 8-fill field for capitation or premium payments (TYPE-OF-SERVICE = 119, 120, 121, 122)
TMSIS-821	Editing against list of valid values	Change Request	Open	Medium	9/15/2015 16:02	11/4/2015 10:58	11/4/2015 11:26	State Issue: Alex W: This field should not be editing against a list of valid values unless each state provides a set against which to edit. These are alph-numeric fields that should allow all characters and special characters, excluding the pipe delimiter. Maggie S: NY has a problem with the DRG-DESCRIPTION that CMS has put out as acceptable because they use a completely different set of DRG's. This was brought up to Jeff Collier & Jeff Silverman many months back. To date they have not come bck with an answer to NY to address this unusual set up by this state. This needs to again be pointed out to CMS. State that Reported Issue: NY and RI SP Issue NO: n/a CR NO: n/a DE NO: CIP029 Data Element Name: DRG-DESCRIPTION Error NO: 103 Business rule: Value is not included in the valid code list Coding Requirement: Value must originate from the DRGS list or be blank. States using the federal code should leave DRG-description blank; otherwise they should use a code that legitimately belongs to their code set.
TMSIS-722	BMI (CIP201, CLT143, COT125) data elements - Remove Requirement for States to Report Certain Problematic Data Elements	Change Request	Open	High	9/10/2015 10:12		11/3/2015 16:03	BMI (CIP201, CLT143, COT125) data elements - Changed NECESSITY requirement from "Required" to "Optional" in Data Dictionary. Per release note #45 - The table below lists the data elements in the T-MSIS v1.1 data dictionary that have proven to be particularly difficult for the vast majority of states to populate. ||DE#||DE Name||||Record Segment||File Name|| |CIP201|BMI||CLAIM-HEADER-RECORD-IP-CIP00002|Claim-IP| |CLT143|BMI||CLAIM-HEADER-RECORD-LT-CLT00002|Claim-LT| |COT125|BMI||CLAIM-HEADER-RECORD-OT-COT00002|Claim-OT| Therefore, CMS is relieving states of the responsibility to: (a) Provide these data (b) Document a mitigation plan in the Source-to-Target-Mapping Matrix Addendum B whenever the data elements cannot be populated all of the time. Please note, however, if a state determines it can populate one or more of these fields and wishes to do so, they are encouraged to do so and will not incur any Addendum B mitigation plan documentation expectations. Reference: T-MSIS v1.1 Release Notes 1-47 2015-05-25b final
TMSIS-656	State Issue: ELG025 Date of Death > Start of time period for 7 year historical files	Change Request	Open	Medium	9/3/2015 14:07	11/4/2015 10:58	11/4/2015 11:27	State Issue: The issue is that with a 7 year historical file, the date of death will never be > Start of time period. The edit says that If DATE-OF-DEATH is not 8-filled and MAINTENANCE-ASSISTANCE-STATUS (other than not eligible for Medicaid) = "1", "2", "3", "4", or "5", then DATE-OF-DEATH must be >= START-OF-TIME-PERIOD. Historical information will have old dates of death. The TA does not have a recommendation. Clarification to this business rule is required. Perhaps the recommendation is to remove the edit altogether. State that Reported issue: NY, CO SP Issue NO: 2723, 4668, 3237, 5172 CR NO: ELG025-0011 DE NO: ELG025 Data Element Name: DATE-OF-DEATH Error NO:2256 Business Rule: If DATE-OF-DEATH is not 8-filled and MAINTENANCE-ASSISTANCE-STATUS = "1", "2", "3", "4", or "5", then DATE-OF-DEATH must be >= START-OF-TIME-PERIOD Coding Requirement: Date must be equal to or after START-OF-TIME-PERIOD if value for MAINTENANCE-ASSISTANCE-STATUS indicates the individual is eligible for Medicaid and if DATE-OF-DEATH is not "Not Applicable".
TMSIS-655	State Issue: MCR069 Discrepancy in the DD for segment MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 in MNGDCARE file.	Change Request	Open	Medium	9/3/2015 13:59	11/4/2015 10:59	11/4/2015 11:27	State Issue: Discrepancy in the DD for segment MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 in MNGDCARE file. In the Record Keys and Constraints tab of the DD v1.1 the WAIVER-ID is not part of the listed keys in that segment. RECORD-ID 1 SUBMITTING-STATE RECORD-NUMBER 2 STATE-PLAN-ID-NUM 3 OPERATING-AUTHORITY WAIVER-ID (a) MANAGED-CARE-OP-AUTHORITY-EFF-DATE MANAGED-CARE-OP-AUTHORITY-END-DATE STATE-NOTATION FILLER In the same tab, the following information is shown (including the WAIVER-ID). No overlapping date spans for a given combination of SUBMTTING-STATE, STATE-PLAN-ID-NUM, OPERATING-AUTHORITY, and WAIVER-ID. Edit 2162 would post in this case. GA, NV and SC have reported the same WAIVER-ID for multiple records in the segment. Business Rule should be modified to include WAIVER-ID in the edit. State that Reported Issue: SC, GA, NV SP Issue: 3207 CR NO: MCR069-0007 DE NO: MCR069 Data Element Name: MANAGED-CARE-OP-AUTHORITY-EFF-DATE Error NO: 2457 Business Rule: If two or more MANAGED-CARE-OPERATING-AUTHORITY record segments have the same SUBMITTING-STATE, STATE-PLAN-ID-NUM, and OPERATING-AUTHORITY then for each pair of record segments, (Segment 1 MANAGED-CARE-OP-AUTHORITY-EFF-DATE must <> Segment 2 MANAGED-CARE-OP-AUTHORITY-EFF-DATE) AND ( (If Segment 1 MANAGED-CARE-OP-AUTHORITY-EFF-DATE < Segment 2 MANAGED-CARE-OP-AUTHORITY-EFF-DATE, then Segment 1 MANAGED-CARE-OP-AUTHORITY-END-DATE must be < Segment 2 MANAGED-CARE-OP-AUTHORITY-EFF-DATE) OR (If Segment 2 MANAGED-CARE-OP-AUTHORITY-EFF-DATE < Segment 1 MANAGED-CARE-OP-AUTHORITY-EFF-DATE, then Segment 2 MANAGED-CARE-OP-AUTHORITY-END-DATE must be < Segment 1 MANAGED-CARE-OP-AUTHORITY-EFF-DATE) ) Coding Requirement: Records in a file segment that have the same set of values for the segment key data elements excluding the file segment effective date must not have overlapping coverage dates (e.g., MSIS-IDENTIFICATION-NUMBER and SUBMITTING-STATE in the PRIMARY-DEMOGRAPHICS-ELIGIBILITY segment).
TMSIS-653	State Issue: PRV065 Multiple Licenses for key	Change Request	Open	Medium	9/3/2015 13:27	11/4/2015 10:59	11/4/2015 11:26	State Issue: The key for PRV00004 is SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID,  PROV-LOCATION-ID, LICENSE-TYPE, and LICENSE-ISSUING-ENTITY-ID.  NY is using the 000 All Locations for licenses since they apply to all.  However, NY has multiple licenses tied to that key. Without adding LICENSE-OR-ACCREDITATION-NUMBER, NY will only be able to report one license of each type for a provider. CMS will not receive a complete dataset. State that Reported issue: NY SP Issue NO: 2751 CR NO: PRV065-0007 DE NO: PRV065 Date Element Name: PROV-LICENSE-EFF-DATE Error NO: 2174 Business Rule: If two or more PROV-LICENSING-INFO record segments have the same SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-LOCATION-ID, LICENSE-TYPE, and LICENSE-ISSUING-ENTITY-ID then for each pair of record segments, (Segment 1 PROV-LICENSE-EFF-DATE must <> Segment 2 PROV-LICENSE-EFF-DATE) AND ( (If Segment 1 PROV-LICENSE-EFF-DATE < Segment 2 PROV-LICENSE-EFF-DATE, then Segment 1 PROV-LICENSE-END-DATE must be < Segment 2 PROV-LICENSE-EFF-DATE) OR (If Segment 2 PROV-LICENSE-EFF-DATE < Segment 1 PROV-LICENSE-EFF-DATE, then Segment 2 PROV-LICENSE-END-DATE must be < Segment 1 PROV-LICENSE-EFF-DATE) ) Coding Requirement: 'Records in a file segment that have the same set of values for the segment key data elements excluding the file segment effective date must not have overlapping coverage dates (e.g., MSIS-IDENTIFICATION-NUMBER and SUBMITTING-STATE in the PRIMARY-DEMOGRAPHICS-ELIGIBILITY segment).
TMSIS-651	State Issue: PRV044 State cannot meet requirement of no gap between effective dates	Change Request	Open	Medium	9/3/2015 13:17	11/4/2015 11:37	11/4/2015 11:27	State Issue: The business rule states that segment effective dates must not have gaps. NY data does not meet this requirement. Therefore, these data will always be flagged with code 2457. State that reported issue: NY SP Issue NO: 2754 CR NO: PRV044-0009 DE NO: PRV044 Data Element Name: PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE Error NO: 2457 Business Rule: If two or more PROV-LOCATION-AND-CONTACT-INFO record segments have the same SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-LOCATION-ID, and RECORD-NUMBER and these record segments are sorted in ascending order by PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE, then for each consecutive pair (1,2; 2,3; 3,4; etc.) of record segments, Segment N PROV-LOCATION-AND-CONTACT-INFO-END-DATE must = Segment (N+1) PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE minus 1 day Coding Requirement: Record segments that have the same set of values for the segment key data elements excluding the segment effective date must not have gaps in coverage dates (e.g., MSIS-IDENTIFICATION-NUMBER and SUBMITTING-STATE in the PRIMARY-DEMOGRAPHICS-ELIGIBILITY segment).
TMSIS-569	DRUG-UTILIZATION-CODE - CRX143 data element - Update valid values to align w/ NCPDP valid values	Change Request	Open	High	8/24/2015 9:31		10/27/2015 17:27	CRX143 DRUG-UTILIZATION-CODE valid values in v1.1 are not aligned with the NCPDP Valid Values. CMS is advising states that the DRUG-UTILIZATION-CODE Valid Value codes are to be those as defined by the NCPDP see attachment for list of valid values. The DD Appendix A is updated w/ the NCPDP valid values. References: T-MSIS v1.1 Release Notes 1-47 2015-05-25b final T-MSIS DD APPENDICES V1.3
TMSIS-558	STATE-PLAN-ENROLLMENT - PRV101 data element: add to PROV-MEDICAID-ENROLLMENT-PRV00007 segment	Change Request	Open	High	8/19/2015 17:50		10/27/2015 17:25	Per release note #41, add the PRV101:STATE-PLAN-ENROLLMENT data element to the PROV-MEDICAID-ENROLLMENT-PRV00007 record segment. The key structure for the PROV-MEDICAID-ENROLLMENT-PRV00007 record segment, does not include the data element STATE-PLAN-ENROLLMENT as part of the key. Because of this, States are not able to report multiple STATE-PLAN-ENROLLMENT records in PROV-MEDICAID-ENROLLMENT-PRV00007 record segment for a single provider, when the provider has enrolled in Medicaid and CHIP at different times. Until the STATE-PLAN-ENROLLMENT data element is added to PRV00007, release note# 41 provides further guidance to States for coding as they assemble PROVIDER records. Reference: T-MSIS v1.1 Release Notes 1-47 2015-05-25b final