1.0 General
1.1 Contractor
Submission of TRICARE Encounter Provider Records (TEPRV) Requirements
1.1.1 Electronic
Media Submission
Contractors are required
to submit TEPRV Records (except for TRICARE For Life (TFL) second payor)
via electronic media to the Defense Health Agency (DHA) for each
provider who rendered care to TRICARE beneficiaries.
1.1.2 Record Content
Required Information for each Health Care Provider:
• A
Unique Provider ID Number (PROVIDER TAXPAYER NUMBER).
• Name.
• Address.
• Medical Specialty
• Authorization Period.
• Denied services and
TRICARE Encounter Data (TED) record cancellations will be excluded
from the TEPRV check.
• The TEPRV must be
present on the Provider File at DHA prior to reporting associated TED
records.
• The
data will be used by DHA to track services rendered by each provider.
1.2 Accountability
For TEPRVs
The contractor having contractual
authority for provider certification in a given region has accountability
for the TEPRVs for providers in that region and is responsible for
ensuring these TEPRVs pass the DHA edits and for performing all
maintenance transactions. This responsibility extends to those TEPRVs
submitted in support of claims processing by another contractor
with the exception of pharmacy TEPRVs which can be submitted by
any contractor.
1.3 Data Submission
The contractor must provide a separate record
for each provider who renders care to a TRICARE beneficiary.
1.3.1 The Initial
Load Of The Provider Information
1.3.1.1 The initial
load of the Provider information must be submitted following the
rules listed below. Every effort must be made to ensure that duplicate
Provider records are not submitted and that only active Provider
records are submitted.
1.3.1.2 For non-institutional
providers, multiple records will be required when more than one provider
is billing under the same PROVIDER TAXPAYER NUMBER (e.g., clinics).
In this case, the PROVIDER ZIP CODE and PROVIDER SUB-IDENTIFIER
must be used to identify unique providers. Refer to these elements
for further instructions.
1.3.2 Transition Of Future Provider
Information Between Contractors
The transition
of future provider information between contractors must retain the
provider record key information. For institutional providers the
record key is: PROVIDER TAXPAYER NUMBER, PROVIDER ZIP CODE, and
PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION. For non-institutional providers
the record key is: PROVIDER TAXPAYER NUMBER, PROVIDER ZIP CODE,
and PROVIDER SUB-IDENTIFIER.
1.3.3 Inactive Providers
When the contractor removes a provider from
their active provider files (e.g., due to long periods of inactivity),
a TEPRV must be submitted to TRICARE as a modify Transaction Code
with a Provider Termination Date reflecting when the Provider was
removed from the contractor’s files.
1.4 Institutional
Providers that are Part of a Multi-Hospital Chain
1.4.1 Providers must be identified
within the PROVIDER TAXPAYER NUMBER by the zip code.
1.4.2 In addition,
multiple records will be required for institutional providers with
both DRG-exempt and DRG-non-exempt units under the same PROVIDER
TAXPAYER NUMBER.
1.4.3 These are to be identified
by the PROVIDER SPECIALTY/TYPE OF INSTITUTION. Only one DRG-non-exempt
TYPE OF INSTITUTION will be allowed per PROVIDER TAXPAYER NUMBER
and zip code, while multiple DRG-exempt types of facility will be
allowed.
1.4.4 No duplicates within the PROVIDER TAXPAYER
NUMBER, PROVIDER ZIP CODE, and PROVIDER MAJOR SPECIALTY/TYPE OF
INSTITUTION will be allowed.
1.5 Institution Provides Outpatient
Care
1.5.1 Additional TEPRVs must be reported to DHA.
For outpatient services (e.g., ambulatory surgery in hospital, emergency
room, hospital services), submit a TEPRV with PROVIDER MAJOR SPECIALTY/TYPE
OF INSTITUTION = FACILITY CHARGES (refer to edit 3-160-05R) and
INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR = N.
1.5.2 If the
institution has a clinic associated with it, additional TEPRVs must
be reported to DHA using the PROVIDER SUB-IDENTIFIER in the same
manner as a stand alone clinic.
2.0 Provider
File Record Maintenance
The Provider File
is a dynamic file where records can be added, modified, or inactivated
when a change is required.
2.1 File Submission
2.1.1 The contractor
must submit TEPRVs indicating the type of change and updated information.
2.1.2 TEPRVs
will be submitted on an as needed basis.
2.1.3 Each group of TEPRVs must
be preceded by a batch header record that identifies the subsequent
records as provider transaction records.
2.2 Add Transactions
2.2.1 The TRANSACTION
CODE must be A.
2.2.2 All required data elements
must be included.
2.2.3 An ADD cannot be made for
institutional providers if the PROVIDER TAXPAYER NUMBER, PROVIDER
SUB-IDENTIFIER, PROVIDER ZIP CODE, and PROVIDER MAJOR SPECIALTY/TYPE
OF INSTITUTION are already on file.
2.2.4 An ADD for non-institutional
providers cannot be made if the PROVIDER TAXPAYER NUMBER, PROVIDER
ZIP CODE and PROVIDER SUB-IDENTIFIER are already on file.
2.3 Modify Transactions
2.3.1 The TRANSACTION
CODE must be M.
2.3.2 All required data elements
must be included.
2.3.3 The MODIFY is used to make
changes to an existing provider record, such as a termination of
authorization or reauthorization.
2.3.4 A MODIFY will replace the
previous record with a new record. Records being replaced will be
held in history. Multiple periods of authorization will be stored
on the DHA master provider file.
2.3.5 For institutional providers,
a MODIFY will not be accepted if the PROVIDER TAXPAYER NUMBER, PROVIDER
SUB-IDENTIFIER, PROVIDER ZIP CODE, and PROVIDER MAJOR SPECIALTY/TYPE
OF INSTITUTION are not already on the file.
2.3.6 For non-institutional
providers, a MODIFY will not be accepted if the PROVIDER TAXPAYER NUMBER,
PROVIDER ZIP CODE and PROVIDER SUB-IDENTIFIER are not already on
the file.
2.4 Inactivate Transactions
The TRANSACTION CODE must be I.
2.4.1 Institutional
Providers
The INACTIVATE process is to be
used when there is an error on the PROVIDER TAXPAYER NUMBER, PROVIDER
SUB-IDENTIFIER, PROVIDER ZIP CODE, or PROVIDER MAJOR SPECIALTY/TYPE
OF INSTITUTION data elements.
2.4.2 Non-Institutional Providers
2.4.2.1 The INACTIVATE
process is used when there is an error on either the PROVIDER TAXPAYER NUMBER,
PROVIDER ZIP CODE, or the PROVIDER SUB-IDENTIFIER data elements.
2.4.2.2 To correct
an error on these data elements, the incorrect record must be inactivated
and the correct record added using two separate transactions.
2.4.2.3 When correcting
an error on these data elements for a clinic, all provider records
associated with the clinic must also be inactivated. This process
also applies when replacing a record containing a contractor Assigned
Provider Number (APN) with a record containing the actual Provider
Taxpayer Number.
3.0 Resubmission
of Provider Batches and Provider Records
3.1 Batches 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 with the appropriate data corrections.
The RESUBMISSION NUMBER must not be incremented from what was reported
on the prior submission.
3.2 TEPRVs that fail
any edits will be rejected and returned to the contractor for correction
and resubmission in a new batch.