VALIDITY EDITS
|
0-025-01V
|
MUST
BE ALPHANUMERIC.
|
Relational Edits
|
0-025-01R
|
IF HEADER TYPE
INDICATOR =
|
0
|
BATCH HEADER
(USED ON ALL PROVIDER BATCHES, AND FOR INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY
UNDERWRITTEN NON-ADMIN CLAIM RATE ELIGIBLE TED RECORDS) OR
|
|
|
9
|
BATCH HEADER
(INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN
CLAIM RATE ELIGIBLE TED RECORDS)
|
|
THEN BATCH/VOUCHER
ASAP ACCOUNT NUMBER MUST BE ZERO.
|
0-025-02R
|
IF HEADER TYPE
INDICATOR =
|
5
|
VOUCHER HEADER
NON-ADMIN CLAIM RATE ELIGIBLE OR
|
|
|
6
|
VOUCHER HEADER
ADMIN CLAIM RATE ELIGIBLE
|
|
AND BATCH/VOUCHER
RESUBMISSION NUMBER = ZERO
|
|
THEN ASAP
ACCOUNT NUMBER MUST BE VALID1 AND ACTIVE2 FOR
THE CONTRACT NUMBER ON THE TED BATCH/VOUCHER RECORD.
|
0-025-05R
|
IF BATCH/VOUCHER
RESUBMISSION NUMBER > 00
|
|
OR HEADER
TYPE INDICATOR =
|
0
|
BATCH HEADER
(USED ON ALL PROVIDER, PRICING BATCHES, AND FOR INSTITUTIONAL/NON-INSTITUTIONAL
AT-RISK NON-ADMIN CLAIM RATE ELIGIBLE TED RECORDS) OR
|
|
|
9
|
BATCH HEADER
(INSTITUTIONAL/NON-INSTITUTIONAL AT-RISK ADMIN CLAIM RATE ELIGIBLE
TED RECORDS)
|
|
THEN BYPASS
THIS EDIT
|
|
ELSE IF HCDP
PLAN COVERAGE CODE =
|
000
|
NO HEALTH CARE
COVERAGE PLAN OR
|
|
|
121
|
CHCBP - NON-NETWORK -
INDIVIDUAL COVERAGE OR
|
|
|
122
|
CHCBP - NETWORK -
FAMILY COVERAGE OR
|
|
|
306
|
TRICARE SELECT
- RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR
|
|
|
307
|
TRICARE SELECT
- RETIRED RESERVE SPONSORS AND FAMILY MEMBERS OR
|
|
|
308
|
TRICARE SELECT
- YOUNG ADULT OR
|
|
|
330
|
TRICARE PRIME
- YOUNG ADULT ACTIVE DUTY/TAMP OR
|
|
|
331
|
TRICARE PRIME
- YOUNG ADULT RETIRED OR
|
|
|
332
|
TPR - YOUNG
ADULT ACTIVE DUTY OR
|
|
|
401
|
TRS TIER 1 MEMBER-ONLY OR
|
|
|
402
|
TRS TIER 1 MEMBER
AND FAMILY OR
|
|
|
403
|
TOBACCO CESSATION
DEMONSTRATION PROGRAM OR
|
|
|
404
|
WEIGHT MANAGEMENT
DEMONSTRATION PROGRAM OR
|
|
|
405
|
TRS TIER 2 MEMBER-ONLY OR
|
|
|
406
|
TRS TIER 2 MEMBER
AND FAMILY OR
|
|
|
407
|
TRS TIER 3 MEMBER-ONLY OR
|
|
|
408
|
TRS TIER 3 MEMBER
AND FAMILY OR
|
|
|
409
|
TRS SURVIVOR
CONTINUING INDIVIDUAL COVERAGE OR
|
|
|
410
|
TRS SURVIVOR
CONTINUING FAMILY COVERAGE OR
|
|
|
411
|
TRS SURVIVOR
NEW INDIVIDUAL COVERAGE OR
|
|
|
412
|
TRS SURVIVOR
NEW FAMILY COVERAGE OR
|
|
|
413
|
TRS MEMBER-ONLY
COVERAGE OR
|
|
|
414
|
TRS MEMBER AND
FAMILY COVERAGE OR
|
|
|
417
|
TRANSITIONAL
CARE FOR SERVICE-RELATED CONDITIONS (TCSRC) OR
|
|
|
418
|
TRR MEMBER-ONLY
COVERAGE OR
|
|
|
419
|
TRR MEMBER AND
FAMILY COVERAGE OR
|
|
|
420
|
TRR SURVIVOR
INDIVIDUAL COVERAGE OR
|
|
|
421
|
TRR SURVIVOR
FAMILY COVERAGE OR
|
|
|
422
|
TYA TRICARE
STANDARD FOR ADFMs OR
|
|
|
423
|
TYA TRICARE
STANDARD FOR RETIRED AND MOH FAMILY MEMBERS OR
|
|
|
424
|
TYA TRS OR
|
|
|
425
|
TYA TRR OR
|
|
|
426
|
TYA PRIME FOR
ADFMs OR
|
|
|
427
|
TYA TPR
FOR ADFMs OR
|
|
|
428
|
TYA PRIME FOR
RETIRED AND MOH FAMILY MEMBERS OR
|
|
|
429
|
TYA TRICARE
OVERSEAS PRIME FOR ADFMs OR
|
|
|
430
|
TYA TRICARE
OVERSEAS PRIME REMOTE FOR ADFMs
|
|
OR ENROLLMENT/HEALTH
PLAN CODE =
|
Y
|
CHCBP - NON-NETWORK -
INDIVIDUAL COVERAGE OR
|
|
|
AA
|
CHCBP - NETWORK -
FAMILY COVERAGE OR
|
|
|
SN
|
SHCP - NON-MTF/eMSM
REFERRED CARE OR
|
|
|
SR
|
SHCP - MTF/eMSM
REFERRED CARE
|
|
OR SPECIAL
PROCESSING CODE =
|
AN
|
SHCP - NON-MTF/eMSM
REFERRED CARE OR
|
|
|
AR
|
SHCP - MTF/eMSM
REFERRED CARE OR
|
|
|
A2
|
ACO
PILOT FOR PART A SERVICES RENDERED BY KP CONTRACTED PROVIDERS OR
|
|
|
A3
|
ACO
PILOT FOR PART A SERVICES RENDERED BY NON-KP PROVIDERS OR
|
|
|
B2
|
ACO
PILOT FOR PART B SERVICES RENDERED BY KP CONTRACTED PROVIDERS OR
|
|
|
B3
|
ACO
PILOT FOR PART B SERVICES RENDERED BY NON-KP PROVIDERS OR
|
|
|
DC
|
DCPE-DVA/VHA OR
|
|
|
DE
|
TDRL PHYSICAL
EXAM OR
|
|
|
D2
|
ACO
PILOT FOR PART B SERVICES RENDERED BY NON-KP PHARMACIES OR
|
|
|
MM
|
MMPCMHP OR
|
|
|
PV
|
RETAIL PHARMACY
FOR DVA/VHA
|
|
OR HCC
MEMBER CATEGORY CODE =
|
A
|
ACTIVE DUTY OR
|
|
|
G
|
NATIONAL GUARD
ACTIVE > 30 DAYS; AGR CODE A-H OR
|
|
|
J
|
ACADEMY STUDENT,
NOT OCS OR
|
|
|
N
|
NATIONAL GUARD
NOT ACTIVE OR < 31 DAYS OR
|
|
|
S
|
RESERVE MEMBER
ACTIVE > 30 DAYS OR
|
|
|
T
|
FOREIGN MILITARY OR
|
|
|
V
|
RESERVE MEMBER
NOT ACTIVE OR < 31 DAYS OR
|
|
|
Y
|
SERVICE AFFILIATES
(ROTC, MERCHANT MARINE)
|
|
AND HCC
MEMBER RELATIONSHIP CODE =
|
A
|
SELF
|
|
THEN BATCH/VOUCHER
CLIN/ASAP ACCOUNT NUMBER APPROPRIATION TYPE FOUND IN CORAMS MUST
≠
|
TF
|
TRUST/ACCRUAL
FUND
|
|
ELSE IF OGP
TYPE CODE =
|
A
|
MEDICARE
PART A OR
|
|
|
C
|
MEDICARE PART
A & B OR
|
|
|
I
|
MEDICARE PART
A & D OR
|
|
|
L
|
MEDICARE PART
A, B AND D
|
|
AND OGP
BEGIN REASON CODE ≠
|
N
|
NOT ELIGIBLE
FOR MEDICARE
|
|
AND HCDP
PLAN COVERAGE CODE =
|
004
|
DIRECT CARE
FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
|
|
|
005
|
TRICARE STANDARD
FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
|
|
|
016
|
DIRECT CARE
FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
|
|
|
017
|
TRICARE STANDARD
FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
|
|
|
021
|
TFL FOR SURVIVORS
OF ACTIVE DUTY DECEASED SPONSORS OR
|
|
|
023
|
TFL FOR SURVIVORS
OF GUARD/RESERVE DECEASED SPONSORS OR
|
|
|
110
|
TRICARE PRIME
FOR INDIVIDUAL COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
|
|
|
111
|
TRICARE PRIME
FAMILY COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
|
|
|
114
|
TRICARE USFHP
DIRECT CARE INDIVIDUAL COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
|
|
|
115
|
TRICARE USFHP
DIRECT CARE FAMILY COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED
SPONSORS OR
|
|
|
136
|
TRICARE PRIME
INDIVIDUAL COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
|
|
|
137
|
TRICARE PRIME
FAMILY COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
|
|
|
138
|
TRICARE USFHP
DIRECT CARE INDIVIDUAL COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
|
|
|
139
|
TRICARE USFHP
DIRECT CARE FAMILY COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
|
|
|
143
|
TRICARE PLUS
COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
|
|
|
144
|
TRICARE PLUS
WITH CHC COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
|
|
|
148
|
TRICARE PLUS
COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
|
|
|
149
|
TRICARE PLUS
COVERAGE WITH CHC COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
|
|
|
151
|
TRICARE PLUS
COVERAGE FOR TRANSITIONAL SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS
|
|
OR ENROLLMENT/HEALTH
PLAN
CODE =
|
AS
|
TRICARE
SELECT - ACTIVE DUTY SURVIVORS OR
|
|
|
GS
|
TRICARE SELECT
- GUARD/RESERVE SURVIVORS
|
|
OR HCC
MEMBER CATEGORY CODE =
|
F
|
FORMER MEMBER OR
|
|
|
H
|
MOH RECIPIENT OR
|
|
|
R
|
RETIRED OR
|
|
|
W
|
FORMER SPOUSE
|
|
THEN BATCH/VOUCHER
CLIN/ASAP ACCOUNT NUMBER APPROPRIATION TYPE FOUND IN CORAMS MUST
=
|
TF
|
TRUST/ACCRUAL
FUND
|
|
ELSE BATCH/VOUCHER
CLIN/ASAP ACCOUNT NUMBER APPROPRIATION TYPE FOUND IN CORAMS MUST
≠
|
TF
|
TRUST/ACCRUAL
FUND
|
0-025-08R
|
IF ANY
OCCURRENCE OF TYPE OF SUBMISSION =
|
B
|
ADJUSTMENT
TO NON-TED RECORD (HCSR) DATA OR
|
|
|
E
|
COMPLETE CANCELLATION
OF NON-TED RECORD (HCSR) DATA
|
|
OR BATCH/VOUCHER
RESUBMISSION NUMBER > 00
|
|
OR HEADER
TYPE INDICATOR =
|
0
|
BATCH
HEADER (USED ON ALL PROVIDER BATCHES, AND FOR INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY
UNDERWRITTEN NON-ADMIN CLAIM RATE ELIGIBLE TED RECORDS) OR
|
|
|
9
|
BATCH HEADER
(INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN
CLAIM RATE ELIGIBLE TED RECORDS)
|
|
THEN BYPASS
THIS EDIT
|
|
ELSE IF BATCH/VOUCHER
CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN CORAMS =
|
TD
|
TRICARE
DOMESTIC
|
|
AND CONTRACT
NUMBER =
|
T3
NORTH
|
|
AND BEGIN
DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE
(INSTITUTIONAL) ≥ START OF CONTRACT
|
|
OR CONTRACT
NUMBER =
|
T3
SOUTH
|
|
AND BEGIN
DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE
(INSTITUTIONAL) ≥ START OF CONTRACT
|
|
OR CONTRACT
NUMBER =
|
T3
WEST
|
|
AND BEGIN
DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE
(INSTITUTIONAL) ≥ START OF CONTRACT
|
|
OR CONTRACT
NUMBER =
|
T2017
EAST
|
|
AND BEGIN
DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE
(INSTITUTIONAL) ≥ BEGIN DATE OF OLDEST OPEN OPTION PERIOD
|
|
OR CONTRACT
NUMBER =
|
T2017
WEST
|
|
AND BEGIN
DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE
(INSTITUTIONAL) ≥ BEGIN DATE OF OLDEST OPEN OPTION PERIOD
|
|
THEN SPECIAL
PROCESSING CODE MUST =
|
AN
|
SHCP -
NON-MTF/eMSM REFERRED CARE OR
|
|
|
AP
|
ABA PILOT OR
|
|
|
AR
|
SHCP - MTF/eMSM
REFERRED CARE OR
|
|
|
AS
|
COMPREHENSIVE
AUTISM CARE DEMONSTRATION OR
|
|
|
AU
|
AUTISM DEMONSTRATION OR
|
|
|
A2
|
ACO
PILOT FOR PART A SERVICES RENDERED BY KP CONTRACTED PROVIDERS OR
|
|
|
A3
|
ACO
PILOT FOR PART A SERVICES RENDERED BY NON-KP PROVIDERS OR
|
|
|
B2
|
ACO
PILOT FOR PART B SERVICES RENDERED BY KP CONTRACTED PROVIDERS OR
|
|
|
B3
|
ACO
PILOT FOR PART B SERVICES RENDERED BY NON-KP PROVIDERS OR
|
|
|
CE
|
SHCP - CCEP OR
|
|
|
CL
|
CLINICAL TRIALS OR
|
|
|
CM
|
INDIVIDUAL CASE
MANAGEMENT OR
|
|
|
CT
|
CUSTODIAL CARE OR
|
|
|
DB
|
DBT (EFFECTIVE
01/01/2020) OR
|
|
|
DC
|
DCPE-DVA/VHA OR
|
|
|
DE
|
TDRL PHYSICAL
EXAM OR
|
|
|
D2
|
ACO
PILOT FOR PART B SERVICES RENDERED BY NON-KP PHARMACIES OR
|
|
|
GU
|
SERVICE MEMBER
ENROLLED IN TPR OR
|
|
|
G1
|
GOOD FAITH PAYMENT
DEBT TRANSFER3 OR
|
|
|
G2
|
GOOD FAITH PAYMENT OR
|
|
|
LD
|
LDTs DEMONSTRATION OR
|
|
|
L2
|
NON-FDA APPROVED
LDTs DEMONSTRATION OR
|
|
|
PC
|
PROVISIONAL
COVERAGE FOR EMERGING SERVICES AND
SUPPLIES OR
|
|
|
PV
|
RETAIL PHARMACY
FOR DVA/VHA OR
|
|
|
RB
|
RESPITE BENEFIT OR
|
|
|
SC
|
SHCP - NON-TRICARE
ELIGIBLE OR
|
|
|
SE
|
SHCP - TRICARE
ELIGIBLE OR
|
|
|
SM
|
SHCP - EMERGENCY
|
|
OR ENROLLMENT/HEALTH
PLAN CODE MUST =
|
Y
|
CHCBP
- NON-NETWORK OR
|
|
|
AA
|
CHCBP - NETWORK OR
|
|
|
SN
|
SHCP -
NON-MTF/eMSM REFERRED CARE OR
|
|
|
SR
|
SHCP - MTF/eMSM
REFERRED CARE
|
|
OR HCDP
PLAN COVERAGE CODE MUST =
|
000
|
CARE DELIVERED TO
INELIGIBLES OR
|
|
|
121
|
CHCBP
- NON-NETWORK INDIVIDUAL COVERAGE OR
|
|
|
122
|
CHCBP - NETWORK FAMILY
COVERAGE OR
|
|
|
306
|
TRICARE SELECT
- RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR
|
|
|
307
|
TRICARE SELECT
- RETIRED RESERVE SPONSORS AND FAMILY MEMBERS OR
|
|
|
308
|
TRICARE SELECT
- YOUNG ADULT OR
|
|
|
330
|
TRICARE PRIME
- YOUNG ADULT ACTIVE DUTY/TAMP OR
|
|
|
331
|
TRICARE PRIME
- YOUNG ADULT RETIRED OR
|
|
|
332
|
TPR - YOUNG
ADULT ACTIVE DUTY OR
|
|
|
401
|
TRS TIER 1 MEMBER-ONLY OR
|
|
|
402
|
TRS TIER 1 MEMBER
AND FAMILY OR
|
|
|
403
|
TOBACCO CESSATION
DEMONSTRATION PROGRAM OR
|
|
|
404
|
WEIGHT MANAGEMENT
DEMONSTRATION PROGRAM OR
|
|
|
405
|
TRS TIER 2 MEMBER-ONLY OR
|
|
|
406
|
TRS TIER 2 MEMBER
AND FAMILY OR
|
|
|
407
|
TRS TIER 3 MEMBER-ONLY OR
|
|
|
408
|
TRS TIER 3 MEMBER
AND FAMILY OR
|
|
|
409
|
TRS SURVIVOR
CONTINUING INDIVIDUAL COVERAGE OR
|
|
|
410
|
TRS SURVIVOR
CONTINUING FAMILY COVERAGE OR
|
|
|
411
|
TRS SURVIVOR
NEW INDIVIDUAL COVERAGE OR
|
|
|
412
|
TRS SURVIVOR
NEW FAMILY COVERAGE OR
|
|
|
413
|
TRS MEMBER-ONLY
COVERAGE OR
|
|
|
414
|
TRS MEMBER AND
FAMILY COVERAGE OR
|
|
|
417
|
TRANSITIONAL
CARE FOR SERVICE-RELATED CONDITIONS (TCSRC) OR
|
|
|
418
|
TRR MEMBER-ONLY
COVERAGE OR
|
|
|
419
|
TRR MEMBER AND
FAMILY COVERAGE OR
|
|
|
420
|
TRR SURVIVOR
INDIVIDUAL COVERAGE OR
|
|
|
421
|
TRR SURVIVOR
FAMILY COVERAGE OR
|
|
|
422
|
TYA TRICARE
STANDARD FOR ADSMs OR
|
|
|
423
|
TYA TRICARE
STANDARD FOR RETIRED AND MOH FAMILY MEMBERS OR
|
|
|
424
|
TYA TRS OR
|
|
|
425
|
TYA TRR OR
|
|
|
426
|
TYA PRIME FOR
ADFMs OR
|
|
|
427
|
TYA TPR FOR
ADFMs OR
|
|
|
428
|
TYA PRIME FOR
RETIRED AND MOH FAMILY MEMBERS OR
|
|
|
429
|
TYA TRICARE
OVERSEAS PRIME FOR ADFMs OR
|
|
|
430
|
TYA TRICARE
OVERSEAS PRIME REMOTE FOR ADFMs OR
|
|
|
999
|
UNVERIFIED NEWBORN
|
|
OR PATIENT
ZIP CODE IS IN ALASKA
|
|
OR PCM
DMIS-ID MUST =
|
0005
|
BASSETT
ACH-FT. WAINWRIGHT OR
|
|
|
0006
|
3rd MED
GRP-ELMENDORF OR
|
|
|
0130
|
USCG CLINIC
KODIAK OR
|
|
|
0202
|
AHC-GREELY OR
|
|
|
0203
|
354th
MED GRP-EIELSON OR
|
|
|
0204
|
TMC FT.
RICHARDSON OR
|
|
|
0417
|
USCG CLINIC
KETCHIKAN OR
|
|
|
6033
|
KAMISH
CLINIC-FT. WAINWRIGHT OR
|
|
|
7044
|
USCG CLINIC
JUNEAU OR
|
|
|
7047
|
USCG CLINIC
SITKA
|
|
OR HCC
MEMBER CATEGORY CODE MUST =
|
A
|
ACTIVE
DUTY OR
|
|
|
G
|
NATIONAL GUARD
> 30 DAYS OR
|
|
|
J
|
ACADEMY STUDENT OR
|
|
|
N
|
NATIONAL GUARD
< 30 DAYS OR
|
|
|
S
|
RESERVE > 30
DAYS OR
|
|
|
T
|
FOREIGN MILITARY
MEMBER OR
|
|
|
V
|
RESERVE <
30 DAYS OR
|
|
|
Z
|
UNKNOWN
|
|
AND HCC
MEMBER RELATIONSHIP CODE MUST =
|
A
|
SELF OR
|
|
|
Z
|
UNKNOWN
|
0-025-09R
|
IF ANY
OCCURRENCE OF TYPE OF SUBMISSION =
|
B
|
ADJUSTMENT
TO NON-TED RECORD (HCSR) DATA OR
|
|
|
E
|
COMPLETE CANCELLATION
OF NON-TED RECORD (HCSR) DATA
|
|
THEN BYPASS
THIS EDIT
|
|
ELSE IF BATCH/VOUCHER
CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN CORAMS =
|
TC
|
TRICARE
CIVILIAN PRIME
|
|
THEN ENROLLMENT/HEALTH PLAN
CODE MUST =
|
U
|
TRICARE
PRIME CIVILIAN PCM
|
|
AND BEGIN
DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE
(INSTITUTIONAL) ≥ START DATE OF HEALTH CARE DELIVERY FOR THE CONTRACT
NUMBER.
|
0-025-10R
|
IF ANY
OCCURRENCE OF TYPE OF SUBMISSION =
|
B
|
ADJUSTMENT
TO NON-TED RECORD (HCSR) DATA OR
|
|
|
E
|
COMPLETE CANCELLATION
OF NON-TED RECORD (HCSR) DATA
|
|
THEN BYPASS
THIS EDIT
|
|
ELSE IF BATCH/VOUCHER
CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN CORAMS =
|
TN
|
TRICARE
NON-CIVILIAN PRIME
|
|
THEN ENROLLMENT/HEALTH PLAN
CODE MUST =
|
T
|
TRICARE
STANDARD PROGRAM OR
|
|
|
V
|
TRICARE EXTRA OR
|
|
|
Z
|
TRICARE PRIME,
MTF/eMSM/PCM OR
|
|
|
WF
|
TRICARE PRIME
REMOTE ADFM
|
|
AND BEGIN
DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE
(INSTITUTIONAL) ≥ START DATE OF HEALTH CARE DELIVERY FOR THE CONTRACT
NUMBER.
|
0-025-11R
|
IF HEADER TYPE
INDICATOR =
|
5
|
VOUCHER HEADER
NON-ADMIN CLAIM RATE-ELIGIBLE OR
|
|
|
6
|
VOUCHER HEADER
ADMIN CLAIM RATE ELIGIBLE
|
|
AND POSITION
1 THRU 4 OF THE CLIN/ASAP NUMBER = MIPR
|
|
THEN ALL
OCCURRENCES OF TYPE OF SERVICE (POSITION 2) MUST =
|
M
|
MOP
|
0-025-12R
|
IF HEADER TYPE
INDICATOR =
|
5
|
VOUCHER HEADER
NON-ADMIN CLAIM RATE-ELIGIBLE OR
|
|
|
6
|
VOUCHER HEADER
ADMIN CLAIM RATE ELIGIBLE
|
|
AND TYPE
OF SERVICE (POSITION 2) =
|
M
|
MOP
|
|
THEN POSITION
1 THRU 4 OF THE CLIN/ASAP NUMBER MUST = MIPR
|
0-025-13R
|
IF HEADER TYPE
INDICATOR =
|
5
|
VOUCHER HEADER
NON-ADMIN CLAIM RATE-ELIGIBLE OR
|
|
|
6
|
VOUCHER HEADER
ADMIN CLAIM RATE ELIGIBLE
|
|
AND CONTRACT
NUMBER =
|
H94002-08-C-0003
TPHARM OR
|
|
|
HT9402-14-D-0002
TPHARM
|
|
AND POSITION
1 THRU 4 OF THE CLIN/ASAP NUMBER ≠ MIPR
|
|
THEN ALL
OCCURRENCES OF TYPE OF SERVICE (POSITION 2) MUST =
|
B
|
RETAIL
PHARMACY
|
0-025-14R
|
IF HCDP PLAN
COVERAGE CODE =
|
018
|
TFL FOR RETIRED
SPONSORS AND FAMILY MEMBERS AND MOH OR
|
|
|
020
|
TFL FOR TRANSITIONAL
SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
|
|
|
021
|
TFL FOR SURVIVORS
OF ACTIVE DUTY DECEASED SPONSORS OR
|
|
|
022
|
TFL FOR TRANSITIONAL
SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
|
|
|
023
|
TFL FOR SURVIVORS
OF GUARD/RESERVE DECEASED SPONSORS OR
|
|
|
029
|
TFL FOR MEDICALLY
RETIRED SPONSORS AND FAMILY MEMBERS
|
|
AND TYPE
OF SUBMISSION =
|
I
|
INITIAL SUBMISSION OR
|
|
|
R
|
RESUBMISSION
|
|
THEN OGP
TYPE CODE MUST ≠
|
N
|
NO MEDICARE OR
|
|
|
V
|
CHAMPVA
|
|
AND OGP
BEGIN REASON CODE MUST ≠
|
N
|
NOT ELIGIBLE
FOR MEDICARE OR
|
|
|
W
|
NOT APPLICABLE
|