VALIDITY EDITS
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2-160-01V1
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FOR
FILING DATE PRIOR TO 01/01/2005, VALUE MUST BE A VALID PROCEDURE
CODE
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AND PROCEDURE
CODE MUST MATCH ONE OF THE RECORDS IN THE PROCEDURE CODE DATABASE
USING THE FOLLOWING DATE LOGIC:
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FOR TYPE
OF SUBMISSION =
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D
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COMPLETE DENIAL OR
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I
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INITIAL TED
RECORD SUBMISSION OR
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O
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ZERO PAYMENT
WITH 100% OHI/TPL OR
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R
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RESUBMISSION
OF AN INITIAL TED RECORD (TYPE OF SUBMISSION WAS I)
THAT WAS REJECTED DUE TO ERRORS
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THE
DATE TED RECORD PROCESSED TO COMPLETION MUST BE ON OR AFTER THE
PROCESSING EFFECTIVE DATE AND BEFORE THE PROCESSING
TERMINATION DATE
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AND THE
BEGIN DATE OF CARE MUST BE ON OR AFTER THE CARE EFFECTIVE
DATE AND BEFORE THE CARE TERMINATION DATE
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FOR TYPE
OF SUBMISSION =
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A
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ADJUSTMENT TO
TED RECORD DATA OR
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B
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ADJUSTMENT TO
NON-TED RECORD (HCSR) DATA OR
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C
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COMPLETE CANCELLATION OR
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E
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COMPLETE CANCELLATION
OF NON-TED RECORD (HCSR) DATA
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THE
DATE TED RECORD PROCESSED TO COMPLETION MUST BE ON OR AFTER
THE PROCESSING EFFECTIVE DATE
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AND THE
BEGIN DATE OF CARE MUST BE ON OR AFTER THE CARE EFFECTIVE
DATE AND BEFORE THE CARE TERMINATION DATE
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2-160-02V1
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FOR
FILING DATE ON OR AFTER 01/01/2005 VALUE MUST BE A VALID PROCEDURE
CODE
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AND PROCEDURE
CODE MUST MATCH ONE OF THE RECORDS IN THE PROCEDURE CODE REFERENCE
TABLE USING THE FOLLOWING DATE LOGIC:
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BEGIN
DATE OF CARE MUST BE ON OR AFTER THE PROCEDURE CODE
CARE EFFECTIVE DATE AND NOT LATER THAN THE PROCEDURE
CODE CARE TERMINATION DATE.
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Relational Edits
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2-160-01R2
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IF
ON THE MATCHING RECORD THE PROCEDURE CODE DATABASE GOVERNMENT PAY
CODE = N
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THEN AMOUNT
ALLOWED BY PROCEDURE CODE MUST BE ≤ ZERO
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UNLESS ANY
OCCURRENCE OF SPECIAL PROCESSING CODE =
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T
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MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR)
AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
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AD
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FOREIGN ACTIVE
DUTY CLAIMS (EFFECTIVE
06/30/1996) OR
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AN
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SHCP - NON-MTF/eMSM-REFERRED
CARE OR
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AR
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SHCP - MTF/eMSM
REFERRED CARE OR
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CE
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SHCP - CCEP OR
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CL
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CLINICAL TRIALS OR
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CP
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CANCER CLINICAL
TRIALS OR
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FS
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TFL (SECOND
PAYOR) OR
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GU
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SERVICE MEMBER
ENROLLED IN TPR OR
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LD
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LDTs DEMONSTRATION OR
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L2
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NON-FDA APPROVED
LDTs DEMONSTRATION OR
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MN
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TSP - NETWORK OR
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MS
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TSP - NON-NETWORK OR
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RD
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RARE DISEASES OR
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SC
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SHCP - NON-TRICARE
ELIGIBLE OR
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SE
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SHCP - TRICARE
ELIGIBLE OR
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SM
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SHCP - EMERGENCY
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OR ENROLLMENT/HEALTH
PLAN CODE =
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X
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FOREIGN
SERVICE MEMBER OR
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SN
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SHCP - NON-MTF/eMSM-REFERRED
CARE OR
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SR
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SHCP - MTF/eMSM
REFERRED CARE OR
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WA
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TPR - FOREIGN
SERVICE MEMBER
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OR ANY
OCCURRENCE OF SPECIAL PROCESSING CODE =
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AS
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COMPREHENSIVE
AUTISM CARE DEMONSTRATION
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AND PROCEDURE
CODE = 0359T, 0360T, 0361T, 0364T, 0365T, 0368T, 0369T, 0370T, T1023,
97151, 97153, 97155, OR 97156
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OR FILING
DATE < 11/05/2011
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AND FILING
STATE COUNTRY CODE = A FOREIGN COUNTRY CODE (REFER TO Addendum A)
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2-160-05R
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IF
PROCEDURE CODE = A0100, A0110, A0120, A0130, A0140, A0170, E0170
- E0172, E0241- E0245, E0273, E0625, E0701, L3215 - L3219, L3221
- L3223, L3230, L3250 - L3255, L3257, L3265, L3500, L3510, L3520,
L3630, S8940, S9122 - S9124, V5281 - V5290, OR 99082
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AND AMOUNT
ALLOWED BY PROCEDURE CODE > ZERO
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THEN ONE
OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
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PF
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ECHO
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UNLESS ANY
OCCURRENCE OF SPECIAL PROCESSING CODE =
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AD
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FOREIGN ACTIVE DUTY CLAIMS (EFFECTIVE
06/30/1996) OR
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AN
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SHCP -
NON-MTF/eMSM-REFERRED CARE OR
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AR
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SHCP - MTF/eMSM
REFERRED CARE OR
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CE
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SHCP - CCEP OR
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GU
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SERVICE MEMBER
ENROLLED IN TPR OR
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MN
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TSP - NETWORK OR
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MS
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TSP - NON-NETWORK OR
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SC
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SHCP - NON-TRICARE
ELIGIBLE OR
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SE
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SHCP - TRICARE
ELIGIBLE OR
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SM
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SHCP - EMERGENCY
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OR ENROLLMENT/HEALTH
PLAN CODE =
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X
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FOREIGN SERVICE
MEMBER OR
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SN
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SHCP - NON-MTF/eMSM-REFERRED
CARE OR
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SR
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SHCP - MTF/eMSM
REFERRED CARE OR
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WA
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TPR - FOREIGN
SERVICE MEMBER
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2-160-06R
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IF TYPE OF SERVICE
(FIRST POSITION) =
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I
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INPATIENT
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THEN PROCEDURE
CODE MUST NOT BE FOR OUTPATIENT ONLY CARE (REFER TO Addendum E, Figure 2.E-1.
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2-160-08R
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IF PROCEDURE
CODE =
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98800
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FOR DRUGS OR
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00MN
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PRESCRIPTION
MEDICAL NECESSITY REVIEWS OR
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00PA
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PRESCRIPTION
PRIOR AUTHORIZATIONS
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THEN TYPE
OF SERVICE (SECOND POSITION) MUST =
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B
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RETAIL DRUGS, SUPPLIES, PRESCRIPTION, AUTHORIZATIONS,
AND REVIEWS OR
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M
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MOP DRUGS, SUPPLIES,
PRESCRIPTION, AUTHORIZATIONS, AND REVIEWS
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AND NATIONAL
DRUG CODE MUST ≠ BLANK
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UNLESS PROVIDER
STATE OR COUNTRY CODE IS A FOREIGN COUNTRY CODE ( Addendum A)
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2-160-11R
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IF
PROCEDURE CODE = S5108 OR 99080
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THEN ONE
OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
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AP
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ABA PILOT
OR
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AU
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AUTISM
DEMONSTRATION OR
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BA
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ABA (INTERIM
BENEFIT)
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UNLESS ADJUSTMENT/DENIAL
REASON CODE FOR THAT OCCURRENCE/LINE ITEM IS A CODE LISTED IN Addendum G, Figure 2.G-1 OR Figure 2.G-2.
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OR ANY
OCCURRENCE OF SPECIAL PROCESSING CODE =
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AN
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SHCP -
NON-MTF/eMSM-REFERRED CARE OR
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AR
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SHCP - MTF/eMSM
REFERRED CARE OR
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CE
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SHCP - CCEP OR
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GU
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SERVICE MEMBER
ENROLLED IN TPR OR
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MN
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TSP - NETWORK OR
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MS
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TSP - NON-NETWORK OR
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SC
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SHCP - NON-TRICARE
ELIGIBLE OR
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SE
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SHCP - TRICARE
ELIGIBLE OR
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SM
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SHCP - EMERGENCY
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OR ENROLLMENT/HEALTH
PLAN CODE =
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X
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FOREIGN SERVICE
MEMBER OR
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SN
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SHCP - NON-MTF/eMSM-REFERRED
CARE OR
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SR
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SHCP - MTF/eMSM
REFERRED CARE OR
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WA
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TPR - FOREIGN
SERVICE MEMBER
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2-160-12R
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IF
PROCEDURE CODE = 1181F, 1450F, S5115, G8539, G8542, G9165, G9166, OR G9167
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THEN ONE
OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
|
AP
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ABA PILOT
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UNLESS AMOUNT
ALLOWED BY PROCEDURE CODE ≤ ZERO.
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OR ANY
OCCURRENCE OF SPECIAL PROCESSING CODE =
|
AD
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FOREIGN ACTIVE DUTY CLAIMS OR
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AN
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SHCP - NON-MTF/eMSM-REFERRED
CARE OR
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AR
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SHCP - MTF/eMSM
REFERRED CARE OR
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CE
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SHCP - CCEP OR
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GU
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SERVICE MEMBER
ENROLLED IN TPR OR
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MN
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TSP - NETWORK OR
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MS
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TSP - NON-NETWORK OR
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SC
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SHCP - NON-TRICARE
ELIGIBLE OR
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SE
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SHCP - TRICARE
ELIGIBLE OR
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SM
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SHCP - EMERGENCY
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OR ENROLLMENT/HEALTH
PLAN CODE =
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X
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FOREIGN SERVICE
MEMBER OR
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SN
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SHCP - NON-MTF/eMSM-REFERRED
CARE OR
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SR
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SHCP - MTF/eMSM
REFERRED CARE OR
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WA
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TPR - FOREIGN
SERVICE MEMBER
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