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# | Location | File | Last Modified |
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1 | CCRS.zip\CCRS\CCRS-BUSRULES-v1.5.3.zip\CCRS-BUSRULES-v1.5.3-436e6fff1115001d614ccd45b469ad60a9bdb27b\docs\Rule_Specification\word_format | leie_rule_specification.docx | Tue Apr 10 06:18:41 2018 UTC |
2 | CCRS.zip\CCRS\CCRS-BUSRULES-v1.5.3.zip\CCRS-BUSRULES-v1.5.3-436e6fff1115001d614ccd45b469ad60a9bdb27b\docs\Rule_Specification\word_format | leie_rule_specification.docx | Fri Jun 15 14:52:05 2018 UTC |
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1 | LeieRules | |
2 | Descriptio n | |
3 | Verify the provider is not on the LEIE, so that th e claim is accepted if the pro vider of s ervice is not includ ed in the LEIE and d enied if t he provide r of servi ce is incl uded in th e LEIE. | |
4 | In process of furthe r elaborat ion to ide ntify if t he LEIE ed iting rule will be v alidating if the pro vider was on the LEI E at the d ate of ref erral or i f the prov ider was o n the LEIE at the da te of serv ice | |
5 | Validation Descripti on | |
6 | Sanctioned Provider | |
7 | Provider o f service must not h ave been s anctioned during the Claimline date of s ervice. | |
8 | Logic | |
9 | Applies to INST-IO, PROF, DENT : | |
10 | FOREACH (C laimLine r elated to the Claim) { IF (the Clai mLine.prov iderOfInte rest exist s in Table LKUP_PROV IDER_SANCT ION) THEN { IF (the ClaimLine. serviceDat e is after the Provi derSanctio n.exclusio nDate) THE N { IF (the Claim Line.servi ceDate is before the ProviderS anction.re instateDat e) THEN { creat e Validati onFailure: sanctione dProvider, CARC: B7, RARC: N13 2 for Clai mLine } } }} | |
11 | Data Eleme nts | |
12 | BRENGINE | |
13 | CCRSDB | |
14 | Claim.clai mLines | |
15 | F_*_CLAIM_ DETAILS | |
16 | ClaimLine. providerOf Interest** | |
17 | DIM_PROVID ER | |
18 | ClaimLine. serviceDat e | |
19 | F_*_CLAIM_ DETAILS.se rvice_date | |
20 | ProviderSa nction** | |
21 | LKUP_PROVI DER_SANCTI ON | |
22 | ProviderSa nction.npi OrTaxId** | |
23 | LKUP_PROVI DER_SANCTI ON | |
24 | ProviderSa nction.exc lusionDate | |
25 | LKUP_PROVI DER_SANCTI ON.exclusi on_date | |
26 | ProviderSa nction.rei nstateDate | |
27 | LKUP_PROVI DER_SANCTI ON.reinsta te_date | |
28 | Provider.n piOrTaxId* * | |
29 | DIM_PROVID ER | |
30 | Provider.n pi | |
31 | DIM_PROVID ER.npi | |
32 | Provider.t axId | |
33 | DIM_PROVID ER.tax_id |
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