TRICARE Manuals - Display Chap 2 Sect 1.1 (Change 29, Sep 20, 2019)

1.0 General

1.1 TED records provide detailed information for each treatment encounter and are required for the Defense Health Agency (DHA) health care and financial reporting. A TED record is submitted as either an institutional or non-institutional record.

1.1.1 Institutional TED records usually reflect a treatment encounter created by the formal acceptance of a hospital or other authorized institutional provider of a TRICARE beneficiary for the purpose of occupying a bed with the reasonable expectation that the patient will remain on inpatient status at least 24 hours with a registration and assignment of an inpatient number or designation. Institutional TED records may also reflect outpatient care in a Hospice or Home Health Program.

1.1.2 Non-institutional TED records reflect either inpatient or outpatient health care services exclusive of inpatient institutional facility services, including institutional care in connection with ambulatory surgery.

1.2 All elements of the TED records must be maintained in the contractor’s claims history file. The claims history will reflect the data submitted to the DHA on the TED record including initial submissions, resubmissions, adjustments, and cancellations. Claims history will also contain all data necessary to reproduce a TED record as required by this manual and to reproduce an Explanation Of Benefits (EOB), if required.

1.3 There are three types of TED records:

• Initial Submission

• Adjustment/Cancellation Submission

• Resubmission

1.4 These types of records are discussed in the following paragraphs. Complete record layouts and data requirements by Element Locator Number (ELN) are detailed in Sections 2.4 through 2.9. Edit criteria are detailed in Sections 5.1 through 6.4, and 8.1.

1.5 TED records within a day’s cycle are processed by DHA first in Processed To Completion (PTC) Date Order, then by TYPE OF SUBMISSION (I, O, D, R first; A, B, C, E second).

2.0 Initial Submission Of TED Records

Initial submission applies only to the first submission of a new TED record. Initial submissions are identified by TYPE OF SUBMISSION codes I, D, and O on the TED record.

2.1 All data indicated as “required” in the data element definition must be reported. If not received in the treatment encounter data, this data must be developed.

2.2 All signed numeric data elements on the initial submission must be reported as positive values.

2.3 When institutional TED records are reported for other than the complete inpatient hospital stay, the TED records must be reported to DHA in the sequence that the care was provided (FREQUENCY CODES, 2-Initial, 3-Interim or 4-Final). Refer to paragraph 7.0 for requirements on submitting interim bills for institutional claims.

3.0 Submission Of Adjustment/Cancellation TED Records

3.1 Adjustment and cancellation TED records correct records with claims processing errors, or update prior data on the record with more current/accurate information. For contracts awarded prior to July 1, 2007, adjustment records also corrected relational errors that were provisionally accepted on the DHA database.

3.2 Adjustments and cancellations to complete denial or cancellation TED records are not permitted. Denied or canceled TED records that require further processing activity must be submitted as new, initial submissions.

3.3 All adjustments and cancellations to TED records must be submitted using the same Adjustment Key that was used on the original submission.

3.4 Adjustments and cancellations to TED records are identified by TYPE OF SUBMISSION codes A, B, C, and E on the TED record. Adjustments and cancellations to non-TED records must be reported using TYPE OF SUBMISSION codes B or E. The use of the proper TYPE OF SUBMISSION code is essential for accurate processing of adjustments.

3.5 Adjustment and cancellation conditions include, but are not limited to, the following:

• Error in information received from the provider or beneficiary.

• Late submission of data from providers.

• Error in processing by current or prior contractor (if applicable).

• Patient liability corrections.

• Successful recoupment of monies, or receipt of a refund from the provider, beneficiary, or third party.

• Stale dated payment checks.

3.6 When health care is charged to the wrong Government fund (i.e., financially underwritten vs. non-financially underwritten) the original record must be cancelled and a new, initial TED record submitted under the correct Government fund.

3.7 Adjustment submissions are positive (where additional monies are being paid by the contractor), negative (where monies are being credited back to the contractor), or statistical (serve to correct prior information but have no impact on payment amount).

Note: If an adjustment to a record results in the net effect of a complete cancellation of the TED record (i.e., where the AMOUNT ALLOWED, AMOUNT GOVERNMENT PAY, and AMOUNT PATIENT COST-SHARE = zero, and all line items are denied), the adjustment must be reported with TYPE OF SUBMISSION code C or E. Refer to the examples later in this Section for an example of a complete cancellation TED record. An adjustment to a TED record which would change the TYPE OF SUBMISSION from I, R, or A to O is not allowed. The original TED record must be canceled and a new, initial record submitted with the correct TYPE OF SUBMISSION O.

3.7.1 Adjustment and cancellation submissions to TED records must be reported using the TED RECORD INDICATOR (TRI) reported on the initial submission TED record, regardless of the number of adjustments to the initial TED record. However, an adjustment that would result in submission of a different RECORD TYPE INDICATOR (e.g., change an institutional record, type 1, to a non-institutional record, type 2) is not permitted. In this instance, the initial TED record must be completely canceled (TYPE OF SUBMISSION code C or E), and a new initial TED record submitted with the correct RECORD TYPE INDICATOR.

3.7.2 All data as reported on the initial TED record must be resubmitted on adjustment and cancellation TED records except for signed numeric fields, and those numeric fields requiring correction. Data contained within each line item in the variable portion of the adjustment or cancellation TED record must be reported in the same sequence, with the same LINE ITEM NUMBER as on the initial TED record. An adjustment or cancellation TED record can add additional detail line items, but cannot remove previously reported line items. All signed numeric fields and those non-signed numeric fields requiring correction must be reported according to the following paragraphs:

3.7.2.1 All signed numeric data elements affected by the adjustment or cancellation must reflect the difference between what was initially reported and the correct amount. If adjustments were made in signed numeric fields prior to the current adjustment, these data elements must reflect the difference amounts after combining the amounts in the initial and all prior adjustment submissions with this submission. Those signed numeric data elements that are unaffected by the adjustment netting process must be set to zero.

3.7.2.2 Alphanumeric data elements requiring correction or update must reflect the most current information applicable to the service(s) being reported. All other alphanumeric data elements must be reported as on the initial submission, or if prior adjustments corrected/updated the initial data, the data from the most recent submission must be reported.

3.7.2.3 Adjustment and complete cancellation TED records are matched and applied to their corresponding initial submission TED record, and any prior adjustment TED records, using the DHA database which consists of all TED and Health Care Service Records. The resulting “net” TED record is completely edited through the DHA edit system as if it were an initial submission TED record. Thus, the original and any prior adjustments must have passed all TED edits before a new adjustment is reported.

3.7.3 Examples

Examples of adjustment and cancellation submissions are located below. Example paragraph 3.7.3.1 portrays a positive adjustment, example paragraph 3.7.3.2 portrays a negative adjustment, example paragraph 3.7.3.3 portrays an adjustment correcting information without impact on payment amount, and example paragraph 3.7.3.4 portrays a negative adjustment resulting in a complete cancellation.

3.7.3.1 Positive Adjustment

A TED record was submitted by the contractor and processed by DHA with an amount billed of $200, amount allowed of $100, and $50 applied to the deductible. The amount allowed should have been $180 and no monies should have been applied to the deductible. The amount billed, however, was unchanged.

Initial Ted Record Positive Adjustment Amounts
Initial TED Record
Amount Billed	$200.00
Amount Allowed	100.00
Amount to Deductible	50.00
Amount Paid (75%)	37.50

Initial Ted Record Positive Adjustment Amounts
Adjustment TED Record
Amount Billed	0
Amount Allowed	80.00
Amount to Deductible	- 50.00
Amount Paid (75%)	97.50
Effect At DHA
Amount Billed	$200.00
Amount Allowed	180.00
Amount to Deductible	0
Amount Paid	135.00

3.7.3.2 Negative Adjustment

A TED record was submitted by the contractor and processed by DHA with an amount billed of $500, an amount allowed of $500, and amount paid by the contractor of $500. However, Other Health Insurance (OHI) was involved and their payment of $400 was recouped. The amounts billed and allowed were correct but the amount paid should have been $100.

TED Record Negative Adjustment Amounts
Initial TED Record
Amount Billed	$500.00
Amount Allowed	500.00
Amount to OHI	0
Amount Paid	500.00
Adjustment TED Record
Amount Billed	0
Amount Allowed	0
Amount to OHI	400.00
Amount Paid	- 400.00
Effect At DHA
Amount Billed	500.00
Amount Allowed	500.00
Amount to OHI	400.00
Amount Paid	100.00

3.7.3.3 Statistical Adjustment

A TED record was submitted by the contractor and processed by DHA for a hospitalization spanning 20 bed days and $2,000 in billed charges. Fifteen of the days were considered authorized. Subsequently, the total number of bed days was found to be 30 and billed charges were actually $3,000. However, the allowable days and amount paid by the contractor remained unchanged.

TED Record Statistical Adjustment
Initial TED Record
Amount Billed	$2,000.00
Amount Allowed	1,500.00
Covered Days	15
Amount Paid (75%)	1,125.00
Adjustment TED Record
Amount Billed	1,000.00
Amount Allowed	0
Covered Days	0
Amount Paid	0
Effect At DHA
Amount Billed	3,000.00
Amount Allowed	1,500.00
Covered Days	15
Amount Paid	1,125.00

3.7.3.4 Negative Adjustment (Complete Cancellation)

A TED record was submitted by the contractor and processed by DHA with an amount billed of $500, allowed of $500, and amount paid by Government contractor of $375. Subsequently, the contractor processed an adjustment to pay in full, reporting an increase of $125 in the amount paid by Government contractor. The contractor then determined the care was processed in error and recouped the entire $500 payment.

TED Record Negative Adjustment
Initial TED Record
Amount Billed	$500.00
Amount Allowed	500.00
Patient Cost-Share	125.00
Amount Paid	375.00
Covered Days	5
Adjustment TED Record
Amount Billed	0
Amount Allowed	0
Patient Cost-Share	- 125.00
Amount Paid	125.00
Covered Days	0
Effect At DHA
Amount Billed	500.00
Amount Allowed	500.00
Patient Cost-Share	0
Amount Paid	500.00
Covered Days	5
Cancellation TED Record
Amount Billed	0
Amount Allowed	- 500.00
Patient Cost-Share	0
Amount Paid	- 500.00
Covered Days	- 5
Effect At DHA
Amount Billed	500.00
Amount Allowed	0
Patient Cost-Share	0
Amount Paid	0
Covered Days	0

4.0 Resubmission of TED Batch/Vouchers and TED Records

4.1 Batches/vouchers that fail any edits at the header record level will be rejected and returned to the contractor for correction. Header level rejections require the resubmission of the entire batch/voucher with the appropriate data corrections. The BATCH/VOUCHER RESUBMISSION NUMBER must not be incremented from what was reported on the prior submission.

4.2 Institutional and Non-Institutional Records which fail any edits will be rejected and returned to the contractor for correction and resubmission. All returned records which are contained in a voucher must be returned by the contractor at the same time and balance to the outstanding TOTAL AMOUNT PAID and number of outstanding records for that voucher at DHA. All returned records which are contained in a batch must be returned by the contractor at the same time and balance to the outstanding number of records for that batch at DHA. Upon resubmission, the records will again be processed through the DHA editing system. Resubmission batch/vouchers are identified by the BATCH/VOUCHER RESUBMISSION NUMBER in the Header Record. Resubmission applies to all Institutional and Non-Institutional TED records which have failed to pass the DHA edits.

4.3 TED record resubmissions must be reported using the TRI reported on the initial or adjustment TED record, regardless of the number of times the TED record is resubmitted.

4.4 All data as reported on the initial or adjustment TED record must be resubmitted except for that data changed in order to correct the error(s).

4.5 If a TED record with TYPE OF SUBMISSION = I (initial) is rejected, report the correction TED record with TYPE OF SUBMISSION = R (resubmission).

• All other rejected TED records must retain their original TYPE OF SUBMISSION throughout the error correction/resubmission process.

4.6 To liquidate or “clear” a voucher, both TOTAL AMOUNT PAID and the number of outstanding TED records must zero out. When a TED record passes editing, the TOTAL NUMBER OF RECORDS and the TOTAL AMOUNT PAID submitted on the original voucher are decremented on the DHA database by the corresponding amount. A voucher “clears” when both totals reach zero and the DHA database reflects no outstanding record or paid amounts.

4.7 To liquidate or “clear” a batch, the number of outstanding records must zero out.

4.8 If DHA edits identify that the dollar amounts on the voucher are incorrect, the contractor must correct the related monetary data to balance to the AMOUNT PAID BY GOVERNMENT CONTRACTOR reported on the TED record. On institutional Ted records, do not change the AMOUNT PAID BY THE GOVERNMENT CONTRACTOR (TOTAL). For non-institutional TED records, do not change the AMOUNT PAID BY THE GOVERNMENT CONTRACTOR BY PROCEDURE CODE.Correction of the payment error will be reflected through the contractor’s processing and subsequent submission of the adjustment/cancellation TED record.

5.0 Assignment of TED Records to the Accrual Fund For Foreign And Pharmacy Contractors

5.1 All contractors that are assigned appropriation specific Automated Standard Application for Payment (ASAP) accounts (appropriated funds and accrual funds) shall group TED records under the correct Contract Line Item Number (CLIN)/ASAP Account Number using the BATCH/VOUCHER ASAP ACCOUNT NUMBER VALIDATION - ACCRUAL FUND CHECK edits in Section 4.1.

5.2 When ASAP accounts are assigned to a contractor, the Government will specify the appropriate fund that the ASAP account shall be linked to. All claims grouped to the Accrual Fund shall pass edit 0-000-05F (BATCH/VOUCHER ASAP ACCOUNT NUMBER VALIDATION - ACCRUAL FUND CHECK). All claims that do not group to the Accrual Fund shall be grouped to the Appropriated Fund ASAP account.

6.0 Batch/Voucher CLIN/ASAP Account Number Selection Criteria For Regional Contractors1

The following process is only to be used by contractors submitting both financially underwritten and non-financially underwritten claims to DHA.

6.1 Batches - Header Type Indicator 0 or 9

For all data submissions sent to DHA using the Batch process (0-001), the contractor shall zero fill the BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER (0-025). Under the T-2017 regional contracts, batches are only used for Provider Files.

6.2 Vouchers - Header Type Indicator 5 or 6

6.2.1 For all data submissions sent to DHA using the Voucher process (0-001), the contractor must select one of the BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBERs assigned to them by DHA, Contract Resource Management (CRM) in accordance with Section G of the contract. DHA, CRM shall assign two types of BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBERs a non-financially underwritten ASAP Account (formerly known as not-at-risk bank accounts) that is issued on a federal fiscal year basis and a financially underwritten CLIN Account that is issued for each contract option period and is valid until the CLIN is closed for TED data processing.

6.2.2 The eight character non-financially underwritten BATCH/VOUCHER CLIN/ASAP Account Numbers are issued based on the following format:

• Positions 1 through 4 is 1889.

• Position 5 is the fiscal year of the ASAP Account.

• Position 6 and 7 is the Contractor Number (contract specific two digit number assigned by DHA, CRM).

• Position 8 is 1.

6.2.3 The eight character financially underwritten BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBERs are issued based on the following format:

• Positions 1 through 6 are equal to the contract CLIN/Sub-Contract Line Item (SLIN) found in Section B of the contract (Note: if the SLIN in Section B is numeric then 00 (zero) fill positions 5 and 6).

• Positions 7 and 8 are the contract region: EE for East and WW for West region.

6.2.4 The contractor shall use the procedures outlined below in order to properly group claims under the correct BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER.

6.2.5 Criteria For Selecting DHA Non-Financially Underwritten ASAP Account

6.2.5.1 All non-financially underwritten claims shall be submitted to DHA, CRM using the non-financially underwritten ASAP Account Number with a 1 in position 8. The contractor shall use the non-financially underwritten ASAP Account Number for all Service member claims and for all healthcare programs identified as non-financially underwritten in Section H of the contract.

6.2.5.2 All ASAP Type BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBERs assigned by DHA, CRM shall have an active date range assigned. The BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER’s active dates shall not cross fiscal years unless the contract is in a transition out period. For all Initial TED data submissions (1-165 and 2-100) the BATCH/VOUCHER Date (0-030) is the field DHA shall use when editing for proper selection of ASAP Type BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER based on date. All disbursements shall be made using a currently active ASAP Type BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER. All credits where reported disbursements did not occur (stale dated checks, voids, etc.) shall be credited back to the BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER originally used to report the disbursement. All collections (credits) of funds where the disbursement was originally reported to DHA using an ASAP Type BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER shall be credited to DHA using currently active BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER.

6.2.6 Criteria For Selecting Financially Underwritten CLINs (excludes all claims that meet criteria specified under paragraph 6.2.5)

6.2.6.1 All financially underwritten benefit payments must use the BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER containing the DHA Benefit CLIN (positions 1 through 4 of ASAP) contained in Section B of the contract (positions 5 and 6 is zero filled since the CLIN is numeric). The contractor shall be assigned one financially underwritten CLIN per contract option period. In order to determine the correct BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER the contractor must determine the correct option period the claim falls under. To determine the correct option period the BEGIN DATE OF CARE (2-150) for non-institutional claims or ADMISSION DATE (1-265) for institutional claims must be equal to or fall within the option period begin and end dates.

6.2.6.2 All CLIN Type BATCH/VOUCHER CLIN/ASAP Account Numbers assigned by DHA, CRM shall have an active date range assigned which shall correspond to the begin and end dates of the CLIN. The BATCH/VOUCHER CLIN/ASAP Account Number’s active dates shall not cross Option Periods. The BEGIN DATE OF CARE (2-150) or ADMISSION DATE (1-265) are the fields DHA shall use when editing for proper selection of CLIN Type BATCH/VOUCHER. For non-institutional claims all occurrences of BEGIN DATE OF CARE must fall within the active date range of the CLIN type BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER used in the voucher header. For institutional claims the ADMISSION DATE must fall within the active date range of the CLIN type BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER used in the voucher header. See TRICARE Operations Manual (TOM), Chapter 8, Section 6, paragraph 9.9.

7.0 Interim Institutional Payments

7.1 In certain cases, providers can submit interim bills for institutional claims as a method to facilitate cash flow. Interim-interim and interim-final TED records with filing dates before January 1, 2011 must be submitted as an adjustment using the same TRI as the initial submission.

7.2 Interim-interim and interim-final TED records (FREQUENCY CODES 3 and 4) with filing dates on or after January 1, 2011 with the exception of interim billings reimbursed under the DRG or Home Health Agency (HHA) payment methodology must be submitted with a unique TRI and must be submitted on batch/vouchers with HEADER TYPE INDICATOR 0 or 5. DRG and HHA interim-interim and interim-final TED records will continue to be submitted as an adjustment using the same TRI as the initial submission.

7.3 For claims that are reimbursed under the TRICARE Diagnosis Related Group (DRG) payment methodology please see the TRICARE Reimbursement Manual (TRM), Chapter 6, Section 3 for requirements on submitting DRG interim bills.

7.4 For claims that are reimbursed under the Home Health Agency Prospective Payment System (HHA PPS) methodology, please see the guidelines on submitting interim bills in the TRM, Chapter 12, Section 6.

7.5 International Classification of Diseases (ICD) version and Operation/Non-Surgical Procedure (OP/NSP) codes are determined by patient discharge date. ICD, 10th Revision, Clinical Modification, (ICD-10-CM) diagnosis and ICD-10-Procedure Coding System (ICD-10-PCS) OP/NSP codes are appropriate for claims with discharge dates on or after October 1, 2015 and ICD, 9th Revision, Clinical Modification (ICD-9-CM) and ICD-9-Procedure Coding System (ICD-9-PCS) codes are appropriate for discharge dates on or before September 30, 2015. Since the TED record does not report discharge date, end date of care will determine ICD version when PATIENT STATUS indicates discharged, transferred or expired (i.e., codes 01, 02, 03). Admission date will determine ICD version when the PATIENT STATUS indicates the patient remains hospitalized (i.e., 30).

8.0 Process for Reporting External Resource Sharing Encounters to DHA

The following process is to be used by claims processors to submit data to DHA which relates to External Resource Sharing encounters.

8.1 Special Processing Code

For External Resource Sharing encounters, submit a TED record which includes SPECIAL PROCESSING CODE of S Resource Sharing - External, for each patient encounter.

8.2 “Amount” Field Reporting

The “amount” fields must contain the following:

8.2.1 Amount Billed By Procedure Code

If a Resource Sharing provider is being reimbursed on a fee-for-service basis with negotiated/discounted rates, report these amounts in the AMOUNT BILLED BY PROCEDURE CODE field.

8.2.2 Amount Allowed/Amount Allowed By Procedure Code

The AMOUNT ALLOWED BY PROCEDURE CODE field must contain the CHAMPUS Maximum Allowable Charge (CMAC) or negotiated/discounted rates as appropriate.

8.2.3 Amount Paid By Government Contractor

The AMOUNT PAID BY GOVERNMENT CONTRACTOR field must equal the “lesser” of the amount allowed minus (PATIENT COST-SHARE plus AMOUNT APPLIED TOWARD DEDUCTIBLE) or AMOUNT ALLOWED minus amount of OHI. If the “lesser” computed amount is negative, AMOUNT PAID BY GOVERNMENT CONTRACTOR must = $0.00.

9.0 Process for Reporting Blood Clotting Factor Data to DHA

9.1 Blood clotting factor reimbursement will be calculated based on the reimbursement methodology described in the TRM. Blood clotting factor charges will not be submitted separately from the DRG reimbursable hospital charges but will be included on the institutional TED record.

9.2 Data Reporting

The following are data reporting requirements specific for TED records containing blood clotting factor charges.

• REVENUE CODE 0636 (Drugs Requiring Detailed Coding) is to be reported for blood clotting factor.

• UNITS OF SERVICE will reflect the number of units billed on the claim, not the number of payment units.

• AMOUNT BILLED (TOTAL) is the sum of all billed charges on the claim including charges for the blood clotting factor.

• AMOUNT ALLOWED (TOTAL) is the sum of DRG allowed amount and the allowable reimbursement for the blood clotting factor.