VALIDITY EDITS
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1-185-01V
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OCCURRENCE
NUMBER 1--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8).
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1-185-02V
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OCCURRENCE
NUMBER 2--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8).
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1-185-03V
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OCCURRENCE
NUMBER 3--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8).
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1-185-04V
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OCCURRENCE
NUMBER 4--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8).
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1-185-05V
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A
VALUE CANNOT BE CODED MORE THAN ONCE (EXCEPT BLANK).
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1-185-06V
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ALL
OCCURRENCES OF SPECIAL PROCESSING CODE MUST BE BLANK FILLED FOLLOWING
THE FIRST OCCURRENCE OF A BLANK FILLED SPECIAL PROCESSING CODE.
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1-185-07V
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IF 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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|
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AR
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SHCP - MTF/eMSM
REFERRED CARE
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THEN BEGIN
DATE OF CARE MUST BE < 06/01/2004
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1-185-08V
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IF ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
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GF
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TPR FOR ELIGIBLE ADFM RESIDING WITH A TPR ELIGIBLE
SERVICE MEMBER
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THEN BEGIN
DATE OF CARE MUST BE < 09/01/2002
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1-185-10V
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IF ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
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MN
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TSP -
NON-NETWORK OR
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|
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MS
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TSP - NETWORK
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THEN BEGIN
DATE OF CARE MUST BE < 12/31/2001
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1-185-11V
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IF ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
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SN
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TSS -
NON-NETWORK OR
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|
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SS
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TSS - NETWORK
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THEN BEGIN
DATE OF CARE MUST BE < 12/31/2002
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1-185-14V
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IF ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
|
ST
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SPECIALIZED
TREATMENT
|
|
THEN BEGIN
DATE OF CARE MUST BE < 10/01/2004
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Relational Edits
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1-185-08R
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IF ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
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PO
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TRICARE
PRIME - POS
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THEN ENROLLMENT/HEALTH
PLAN CODE MUST =
|
U
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TRICARE
PRIME (CIVILIAN PCM) OR
|
|
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Z
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TRICARE PRIME,
MTF/eMSM/PCM OR
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|
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WF
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TPR FOR ENROLLED
ADFM RESIDING WITH A TPR ELIGIBLE SERVICE MEMBER OR
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|
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XF
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FOREIGN ADFM
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1-185-14R
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IF ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
|
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
|
|
|
CE
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SHCP - CCEP OR
|
|
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SC
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SHCP - NON-TRICARE
ELIGIBLE OR
|
|
|
SE
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SHCP - TRICARE
ELIGIBLE OR
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|
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SM
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SHCP - EMERGENCY
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THEN ENROLLMENT/HEALTH
PLAN CODE MUST =
|
SR
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SHCP - MTF/eMSM
REFERRED CARE OR
|
|
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SN
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SHCP - NON-MTF/eMSM
REFERRED CARE OR
|
|
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SO
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SHCP - NON-TRICARE
ELIGIBLE OR
|
|
|
ST
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SHCP - TRICARE
ELIGIBLE
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1-185-32R
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IF ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
|
E
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HHC/CM DEMO (AFTER 03/15/1999, GRANDFATHERED INTO
THE ICMP)
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THEN BEGIN
DATE OF CARE IS ≥ 03/15/1999
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AND AT
LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
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CM
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ICMP
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1-185-34R
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• TFL CLAIMS: THE BEGIN DATE OF CARE MUST
BE ≥ 10/01/2001.
IF
BEGIN DATE OF CARE IS < 10/01/2001, THE LINE ITEMS MUST CONTAIN
AN ADJUSTMENT/DENIAL REASON CODE LISTED IN THIS EDIT.
|
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IF ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
|
FF
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TFL (FIRST
PAYOR-NOT A MEDICARE BENEFIT) OR
|
|
|
FG
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TFL (FIRST PAYOR-NO
TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) OR
|
|
|
FS
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TFL (SECOND
PAYOR)
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|
AND TYPE
OF INSTITUTION ≠
|
10
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GENERAL MEDICAL
AND SURGICAL
|
|
THEN BEGIN
DATE OF CARE MUST BE ≥ 10/01/2001
|
|
AND ENROLLMENT/HEALTH
PLAN CODE MUST =
|
FE
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TFL - NETWORK OR
|
|
|
FS
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TFL - NON-NETWORK
|
|
ELSE
IF BEGIN DATE OF CARE IS < 10/01/2001
|
|
THEN ADJUSTMENT/DENIAL
REASON CODE FOR THAT DETAILED LINE ITEM (EXCEPT LINE CONTAINING
REVENUE CODE 0001) MUST =
|
15
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PAYMENT ADJUSTED BECAUSE THE SUBMITTED AUTHORIZATION
NUMBER IS MISSING, INVALID, OR DOES NOT APPLY TO THE
BILLED SERVICES OR PROVIDER OR
|
|
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26
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EXPENSES INCURRED
PRIOR TO COVERAGE OR
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|
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27
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EXPENSES INCURRED
AFTER COVERAGE TERMINATED OR
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|
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30
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PAYMENT ADJUSTED
BECAUSE THE PATIENT HAS NOT MET THE REQUIRED ELIGIBILITY, SPEND
DOWN, WAITING, OR RESIDENCY REQUIREMENTS OR
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|
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31
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CLAIM DENIED
AS PATIENT CANNOT BE IDENTIFIED AS OUR INSURED OR
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|
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32
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OUR RECORDS
INDICATE THAT THIS DEPENDENT IS NOT AN ELIGIBLE DEPENDENT AS DEFINED OR
|
|
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33
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CLAIM DENIED.
INSURED HAS NO DEPENDENT COVERAGE OR
|
|
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34
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CLAIM DENIED.
INSURED HAS NO COVERAGE FOR NEWBORNS OR
|
|
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62
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PAYMENT DENIED/REDUCED
FOR ABSENCE OF, OR EXCEEDED, PRE-CERTIFICATION/AUTHORIZATION OR
|
|
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141
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CLAIM ADJUSTMENT
BECAUSE THE CLAIM SPANS ELIGIBLE AND INELIGIBLE PERIODS OF COVERAGE
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1-185-35R
|
• TFL CLAIMS: THE BEGIN DATE OF CARE MUST
BE ≥ 10/01/2001
UNLESS THE
BENEFICIARY IS AN INPATIENT AND THE ADMISSION DATE WAS PRIOR TO
10/01/2001, TFL WILL PAY FOR THE ENTIRE HOSPITAL STAY.
|
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IF ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
|
FF
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TFL (FIRST
PAYOR-NOT A MEDICARE BENEFIT) OR
|
|
|
FG
|
TFL (FIRST PAYOR-NO
TRICARE PROVIDER CERTIFICATION, I.E., MEDICARE
BENEFITS HAVE BEEN EXHAUSTED) OR
|
|
|
FS
|
TFL (SECOND
PAYOR)
|
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AND TYPE
OF INSTITUTION =
|
10
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GENERAL MEDICAL
AND SURGICAL
|
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THEN END
DATE OF CARE MUST BE ≥ 10/01/2001
|
|
AND ENROLLMENT/HEALTH
PLAN CODE MUST =
|
FE
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TFL - NETWORK OR
|
|
|
FS
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TFL - NON-NETWORK
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1-185-39R
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IF ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
|
PF
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ECHO
|
|
THEN HCDP
PLAN COVERAGE CODE
MUST ≠
|
305
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TRICARE SELECT
- RETIRED SPONSORS AND FAMILY MEMBERS OR
|
|
|
306
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TRICARE SELECT
- RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR
|
|
|
307
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TRICARE SELECT
- RETIRED RESERVE SPONSORS AND FAMILY MEMBERS OR
|
|
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401
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TRS TIER 1 MEMBER-ONLY
COVERAGE (CONTINGENCY OPERATIONS) OR
|
|
|
402
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TRS TIER 1 MEMBER
AND FAMILY COVERAGE (CONTINGENCY OPERATIONS) OR
|
|
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405
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TRS TIER 2 MEMBER-ONLY
COVERAGE (CERTIFIED QUALIFICATIONS) OR
|
|
|
406
|
TRS TIER 2 MEMBER
AND FAMILY COVERAGE (CERTIFIED QUALIFICATIONS) OR
|
|
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407
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TRS TIER 3 MEMBER-ONLY
COVERAGE (SERVICE AGREEMENT) OR
|
|
|
408
|
TRS TIER 3 MEMBER
AND FAMILY COVERAGE (SERVICE AGREEMENT) OR
|
|
|
409
|
TRS SURVIVOR
CONTINUING WITH INDIVIDUAL COVERAGE OR
|
|
|
410
|
TRS SURVIVOR
CONTINUING WITH FAMILY COVERAGE OR
|
|
|
411
|
TRS SURVIVOR
NEW INDIVIDUAL COVERAGE OR
|
|
|
412
|
TRS SURVIVOR
NEW FAMILY COVERAGE OR
|
|
|
413
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TRS MEMBER-ONLY
COVERAGE OR
|
|
|
414
|
TRS MEMBER AND
FAMILY COVERAGE OR
|
|
|
418
|
TRR MEMBER-ONLY
COVERAGE OR
|
|
|
419
|
TRR MEMBER AND
FAMILY COVERAGE OR
|
|
|
420
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TRR SURVIVOR
INDIVIDUAL COVERAGE OR
|
|
|
421
|
TRR SURVIVOR
FAMILY COVERAGE
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1-185-49R
|
IF ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
|
AU
|
AUTISM
DEMONSTRATION
|
|
THEN BEGIN
DATE OF CARE MUST BE ≥ 03/15/2008
|
|
AND AT
LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
|
PF
|
ECHO
|
|
AND PATIENT
AGE1 MUST BE ≥ 18 MONTHS
|
1-185-50R
|
IF ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
|
49
|
HOSPITAL REIMBURSEMENT REDUCED BY MANUFACTURER
CREDIT/REPLACEMENT OF DEVICE DURING WARRANTY PERIOD OR
|
|
|
50
|
HOSPITAL REIMBURSEMENT
REDUCED BY MANUFACTURER CREDIT/RECALLED DEVICE
|
|
THEN DRG
NUMBER MUST EQUAL A DRG SUBJECT TO THE REPLACEMENT DEVICE POLICY
POSTED ON TRICARE’S DRG WEB PAGE AT HTTP://WWW.HEALTH.MIL/DRG.
|
|
AND IF
END DATE OF CARE < 10/01/2014
|
|
THEN DATE
OF ADMISSION MUST BE ≥ THE DRG EFFECTIVE DATE AND ≤ THE DRG TERMINATION
DATE AS PER THE REPLACEMENT DEVICE POLICY POSTED ON TRICARE’S DRG
WEB PAGE AT
HTTP://WWW.HEALTH.MIL/DRG.
|
|
ELSE END
DATE OF CARE MUST BE ≥ THE DRG EFFECTIVE DATE AND ≤ THE DRG TERMINATION
DATE
|
1-185-51R
|
IF ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
|
PH
|
PHILIPPINES
DEMONSTRATION PROJECT
|
|
THEN BEGIN
DATE OF CARE MUST BE ≥ 01/01/2013
|
|
AND HCDP
PLAN COVERAGE CODE MUST =
|
003
|
TRICARE
STANDARD FOR ADFMs OR
|
|
|
005
|
TRICARE
STANDARD SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
|
|
|
007
|
TRICARE
STANDARD TRANSITIONAL ASSISTANCE SPONSORS AND FAMILY MEMBERS OR
|
|
|
009
|
TRICARE
STANDARD RETIRED AND MOH SPONSORS AND FAMILY MEMBERS OR
|
|
|
010
|
TRICARE
STANDARD TRANSITIONAL SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
|
|
|
015
|
TRICARE
STANDARD TRANSITIONAL SURVIVORS OF NG/RESERVE DECEASED SPONSORS OR
|
|
|
017
|
TRICARE
STANDARD SURVIVORS OF NG/RESERVE DECEASED SPONSORS OR
|
|
|
018
|
TFL RETIRED
SPONSORS AND FAMILY MEMBERS AND MOH OR
|
|
|
020
|
TFL TRANSITIONAL
SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
|
|
|
021
|
TFL SURVIVORS
OF ACTIVE DUTY DECEASED SPONSORS OR
|
|
|
022
|
TFL TRANSITIONAL
SURVIVORS OF NG/RESERVE DECEASED SPONSORS OR
|
|
|
023
|
TFL SURVIVORS
OF NG/RESERVE DECEASED SPONSORS OR
|
|
|
028
|
TRICARE
STANDARD FOR MEDICALLY RETIRED SPONSORS AND FAMILY MEMBERS OR
|
|
|
029
|
TFL FOR
MEDICALLY RETIRED SPONSORS AND FAMILY MEMBERS OR
|
|
|
303
|
TRICARE SELECT
- ADFMs OR
|
|
|
304
|
TRICARE SELECT
- TAMP SPONSORS AND FAMILY MEMBERS OR
|
|
|
305
|
TRICARE SELECT
- RETIRED SPONSORS AND FAMILY MEMBERS 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
|
|
|
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
|
|
|
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 STANDARD
FOR ADFMs OR
|
|
|
423
|
TYA STANDARD
FOR RETIRED AND MOH FAMILY MEMBERS OR
|
|
|
424
|
TYA RESERVE
SELECT OR
|
|
|
425
|
TYA RETIRED
RESERVE OR
|
|
|
999
|
UNVERIFIED
NEWBORN
|
|
OR ENROLLMENT/HEALTH
PLAN
CODE =
|
AS
|
TRICARE
SELECT - ACTIVE DUTY SURVIVORS OR
|
|
|
AT
|
TRICARE SELECT
- ACTIVE DUTY TRANSITIONAL SURVIVORS OR
|
|
|
GS
|
TRICARE SELECT
- GUARD/RESERVE SURVIVORSOR
|
|
|
GT
|
TRICARE SELECT
- GUARD/RESERVE TRANSITIONAL SURVIVORS
|
|
AND PATIENT
ZIP CODE MUST =
|
PHL
|
PHILIPPINES
|
|
AND PROVIDER
STATE OR COUNTRY CODE MUST =
|
PHL
|
PHILIPPINES
|
1-185-52R
|
IF
BEGIN DATE OF CARE IS ≥ 01/01/2018
|
|
AND ANY
OCCURRENCE OF SPECIAL PROCESSING CODE =
|
R
|
MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NOT
A MEDICARE BENEFIT) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
|
|
|
T
|
MEDICARE/TRICARE
DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
|
|
|
RS
|
MEDICARE/TRICARE
DUAL ENTITLEMENT (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION,
i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) AND BEGIN DATE OF CARE
≥ 10/01/2001
|
|
THEN ENROLLMENT/HEALTH
PLAN CODE MUST =
|
U
|
TRICARE
PRIME, CIVILIAN CARE OR
|
|
|
Z
|
TRICARE PRIME,
MTF/eMSM/PCM OR
|
|
|
ME
|
MEDICARE/TRICARE
DUAL ELIGIBLE UNDER 65/NETWORK OR
|
|
|
MS
|
MEDICARE/TRICARE
DUAL ELIGIBLE UNDER 65/NON-NETWORK OR
|
|
|
WF
|
TPR FOR ENROLLMENT
ADFM RESIDING WITH A TPR ELIGIBLE SERVICE MEMBER
|