Military Health System

Extract claim set control number. A unique reference to tie together a set of potential duplicate claims.

Claim set match criteria category: EXACT MATCH, NEAR MATCH, DATE OVERLAP, CPT-4, CODE, OTHER. Determined during the initial extract and set construction.

Claim match criteria category. Same as claim set categories.

Line item match criteria category. Same as claim set categories.

Financially underwritten, non-financially underwritten indicator for claim. Please note that for the purposes of this system:

The latest MASS CHANGE cluster rule applied to the claim.

Patient health service region code.

Provider health service region code.

Owner FI represents, for the claim set, the contractor that has been assigned responsibility for resolving particular potential duplicate claim sets. Typically, all claims within a set will have the same responsible FI/contractor (Resp FI), in which case the Owner FI will be the same as the responsible FI/contractor. However, for “multi-contractor” claim sets where the responsible FI/contractors are not the same for all claims within the set, an Owner FI is originally assigned by the system to be the responsible FI/Contractor from the claim within the set having the latest PTC date.

Resp FI or Rsp FI represents, for the claim, the contractor that is currently responsible for administering the claim. When the claim is initially extracted from TED, the Resp FI is identical to the Proc FI (Processing FI). However, contract awarding and transitions may require claim administration by a new contractor, in which case the system will assign a new Resp FI for the claim.

Owner Region is a narrative descriptor of the contract number and represents, for the claim set, the Owner FI/contractor region. Typically, all claims within a set will have the same Responsible Contract, in which case the Owner Region will be the same as the Responsible Contract. However, for multi-contractor claim sets where the contractors are not the same for all claims within the set, an Owner Region is assigned by the system to be the Responsible Contract from the claim within the set having the latest processed-to-completion date. The initial assignment is done in tandem with the assignment of Owner FI.

Responsible Contract represents, for the claim, the contract under which the claim is currently administered. When the claim is initially extracted from TED, the Responsible Contract is identical to the Processing Contract. However, contract awarding and transitions may require claim administration under a new contract, in which case the system will assign a new Responsible Contract for the claim.

Dupe? is an indicator to describe whether or not the claim or line item is a duplicate. During the extract processes Dupe? will be set to N (no) for the base claim within a set and will be set to blank for the remaining claims and line items.

Reason Code is a code used for each claim within a set to designate why the claim in the set is or is not a duplicate. During the initial loading of a set into the system, the base claim within a set will be assigned (in conjunction with Dupe? being set to N) a reason code of BASE representing initial submission. The system will provide an option list of valid codes intended to cover the majority of possible conditions and a code for an “other” option for the occasions when the condition cannot be classified. Some Reason Code selections will require an additional explanation field for further elaboration.

TED Adjust? is a flag for the user to designate which adjustment or cancellation corrects the duplicate condition. All adjustments and cancellations that apply are checked Y (yes), and those that do not apply can be left blank or checked N (no). The TED Adjustment field is the sum (for the claim) of paid dollar amounts for those that apply. Display screens enable TED Adjust? to be checked for any institutional claim and any non-institutional line item.

Status indicates the claim set life cycle phase from initial system loading to final purging. Status is set by the system as a consequence of specific user actions or periodic system functions.

Identified Recoup is a dollar amount that is entered by the user or by the system upon initial determination that a claim or a line item is a duplicate. It represents the amount of overpayment for the claim or line item that has been identified for recoupment.

Actual Recoup is a dollar amount that is entered by the user upon completion of recoupment for a duplicate claim. It represents the amount of overpayment for the claim that has actually been recouped.

TED Adjustment is a dollar amount that is maintained by the system (not by the user) to accumulate TED adjustment or cancellations made during resolution of a duplicate claim. It is calculated as the sum of all adjustment and cancellation paid amounts that have been flagged by the user as being associated with correcting the duplicate. This is the sum of claim level paid amounts for institutional claims and line item paid amounts for non-institutional claims.

ID Recoup is a dollar amount calculated by the system as the sum of Identified Recoup amounts for all claims within a set. It represents the total amount of overpayment for the claim set that has been identified for recoupment.

Actual Recoup is a dollar amount calculated by the system as the sum of claim level actual recoupment amounts for all claims within a set. It represents the total amount of overpayment for the set that has actually been recouped.

Adjustment Amount is a dollar amount calculated by the system as the sum of TED Adjustment amounts for all claims within a set. It represents the total amount of adjustments and cancellations that have been flagged by the user as being associated with correcting all duplicate claims within the set.

Initial Load Date represents the date the claim set was initially loaded into the system. The LASTDATE reflects the most recent claim set update date - for specific types of updates.

Current Load Date represents the date the claim set was initially loaded into the system or the date set ownership changed, or the date a new claim was appended to the set, whichever is the latest date.

Last Update Date represents the most recent date a claim set was updated. Changes to the following will change the Last Update Date: Status, Match Type, Multi-FI Indicator, Owner FI, Owner Region, ID Recoup, Actual Recoup, Set Adjustment Amount, and Adjust Indicator. The Last Update Date will not change solely due to a change to: User Defined Codes, Dupe? field, Solicited (S?) Indicator, TED Adjust?, Reason Code, Reason Code Explanation, or Notepad.

S? is the Solicited Indicator.