TRICARE Manuals - Display Chap 2 Sect 6.2 (Change 35, Mar 26, 2020)

TRICARE Encounter Data (TED)

Chapter 2

Section 6.2

Non-Institutional Edit Requirements (ELN 100 - 199)

Revision: C-32, December 5, 2019

ELEMENT NAME: TYPE OF SUBMISSION (2-100)
VALIDITY EDITS
2-100-01V	VALUE MUST BE A VALID TYPE OF SUBMISSION.
2-100-02V	IF TYPE OF SUBMISSION =	B	ADJUSTMENT OF NON-TED RECORD (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	THEN ADJUSTMENT KEY CANNOT =	0	BATCH OR
		5	VOUCHER
	AND REGION INDICATOR MUST = BLANK
2-100-03V	IF TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		B	ADJUSTMENT OF NON-TED RECORD (HCSR) DATA OR
		C	COMPLETE CANCELLATION OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	THEN A MATCH MUST BE FOUND ON THE DHA DATABASE
	AND TYPE OF SUBMISSION ON THE EXISTING DHA DATABASE RECORD ≠	C	COMPLETE CANCELLATION OR
		D	COMPLETE DENIAL OR
		E	COMPLETE CANCELLATION NON-TED RECORD (HCSR) DATA
	UNLESS THE RECORD HAS PROVISIONAL ERRORS
2-100-04V	IF TYPE OF SUBMISSION =	D	COMPLETE DENIAL OR
		I	INITIAL SUBMISSION OR
		O	ZERO PAYMENT WITH 100% OHI/TPL OR
		R	RESUBMISSION
	THEN A TED RECORD MUST NOT BE PRESENT ON THE DATABASE WITH THE SAME TRI
Relational Edits
2-100-01R	IF TYPE OF SUBMISSION =	O	ZERO PAYMENT WITH 100% OHI/TPL
	THEN THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT OF OHI MUST BE > ZERO.
	AND THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT ALLOWED BY PROCEDURE CODE MUST BE > ZERO.
	AND THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT PAID BY GOVERNMENT CONTRACTOR BY PROCEDURE CODE MUST = ZERO.
2-100-02R	IF ALL OCCURRENCES/LINE ITEMS ARE DENIED (REFER TO Addendum G, Figure 2.G-1)
	THEN TYPE OF SUBMISSION MUST =	C	COMPLETE CANCELLATION OR
		D	COMPLETE DENIAL OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
2-100-04R	IF RESUBMISSION NUMBER = ZERO FOR THIS BATCH OR VOUCHER
	THEN TYPE OF SUBMISSION MUST ≠	R	RESUBMISSION
2-100-05R	IF RESUBMISSION NUMBER > ZERO FOR THIS BATCH OR VOUCHER
	THEN TYPE OF SUBMISSION MUST ≠	I	INITIAL TED RECORD SUBMISSION
2-100-06R	IF TYPE OF SUBMISSION =	I	INITIAL SUBMISSION OR
		R	RESUBMISSION
	THEN THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT BILLED BY PROCEDURE CODE, AND THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT ALLOWED BY PROCEDURE CODE MUST BE > 0.
2-100-07R	IF TYPE OF SUBMISSION =	B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HSCR) DATA
	THEN BEGIN DATE OF CARE MUST BE < 10/01/2010
2-100-09R	IF TYPE OF SUBMISSION =	B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	THEN TYPE OF SERVICE (SECOND POSITION) MUST ≠	M	MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
2-100-10R	IF THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT PAID BY OTHER HEALTH INSURANCE > 0
	AND THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT ALLOWED (TOTAL) BY PROCEDURE CODE > 0
	AND THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT PAID BY GOVERNMENT CONTRACTOR BY PROCEDURE CODE = 0
	AND DATE ADJUSTMENT IDENTIFIED = ZEROES
	THEN TYPE OF SUBMISSION MUST =	O	ZERO PAYMENT TED RECORD DUE TO 100% OHI
	UNLESS THE SUM OF THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT PATIENT COST-SHARE AND THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT APPLIED TOWARD DEDUCTIBLE ≥ THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT ALLOWED BY PROCEDURE CODE

ELEMENT NAME: CLAIM FORM TYPE/EMC INDICATOR (2-105)
VALIDITY EDITS
2-105-01V	MUST BE A VALID CLAIM FORM TYPE/EMC INDICATOR.
Relational Edits
2-105-01R	IF CLAIM FORM TYPE/EMC INDICATOR =	I	ELECTRONIC DRUG CLAIM SUBMISSION
	THEN TYPE OF SERVICE (SECOND POSITION) MUST =	B	RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS OR
		M	MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
2-105-02R	IF CLAIM FORM TYPE/EMC INDICATOR =	J	OTHER
	AND TYPE OF SERVICE SECOND POSITION =	B	RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS OR
		M	MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
	THEN PROCEDURE CODE MUST =	000MN	PRESCRIPTION MEDICAL NECESSITY REVIEWS OR
		000PA	PRESCRIPTION PRIOR AUTHORIZATIONS
	UNLESS PROVIDER STATE OR COUNTRY CODE IS A FOREIGN COUNTRY CODE (Addendum A)

ELEMENT NAME: ADMINISTRATIVE CLIN (2-108)
VALIDITY EDITS
2-108-01V	MUST BE BLANKS.
Relational Edits
	REFER TO Section 8.1.

ELEMENT NAME: PCM LOCATION DMIS-ID (ENROLLMENT) CODE (2-110)
VALIDITY EDITS
2-110-01V	MUST BE A VALID FOUR DIGIT DMIS-ID CODE.
2-110-03V	IF FILING DATE ≥ 09/01/2007
	AND PCM LOCATION DMIS-ID =	0190	JOHNS HOPKINS MEDICAL SERVICES CORPORATION OR
		0191	BRIGHTON MARINE OR
		0192	CHRISTUS HEALTH/ST JOHN’S OR
		0193	ST VINCENTS CATHOLIC MEDICAL CENTERS OF NY OR
		0194	PACIFIC MEDICAL CLINICS OR
		0196	CHRISTUS HEALTH/ST JOSEPH’S OR
		0194	CHRISTUS HEALTH/ST MARY’S OR
		0198	MARTIN’S POINT HEALTH CARE OR
		0199	FAIRVIEW HEALTH SYSTEM
	THEN THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT ALLOWED BY PROCEDURE CODE MUST = ZERO
Relational Edits
	NONE

ELEMENT NAME: AMOUNT INTEREST PAYMENT (2-112)
1 REDUCTIONS IN INTEREST MUST BE PROCESSED USING SAME REASON CODE AS PAYMENT TO ENSURE DHA ACCOUNTING SYSTEM PROCESSES TRANSACTION CORRECTLY.
VALIDITY EDITS
2-112-01V	MUST BE NUMERIC
Relational Edits
2-112-01R	IF TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		C	COMPLETE CANCELLATION OR
		I	INITIAL SUBMISSION OR
		O	ZERO PAYMENT WITH 100% OHI/TPL OR
		R	RESUBMISSION
	THEN AMOUNT INTEREST PAYMENT MUST BE ≥ ZERO
2-112-02R	IF TYPE OF SUBMISSION =	C	COMPLETE CANCELLATION OR
		D	COMPLETE DENIAL
	THEN AMOUNT INTEREST PAYMENT MUST = ZERO
2-112-03R	IF TRANSACTION RECORD AMOUNT INTEREST PAYMENT ≠ ZERO
	THEN TRANSACTION RECORD REASON FOR INTEREST PAYMENT MUST =	A	CLAIMS PENDED AT GOVERNMENT DIRECTION (TERMINATED 07/08/2019) OR
		B	CLAIMS REQUIRING GOVERNMENT INTERVENTION (TERMINATED 07/08/2019) OR
		C	CLAIMS REQUIRING DEVELOPMENT FOR POTENTIAL TPL (TERMINATED 07/08/2019) OR
		D	CLAIMS REQUIRING AN ACTION/INTERFACE WITH ANOTHER PRIME CONTRACTOR (TERMINATED 07/08/2019) OR
		E	CLAIMS RETAINED BY THE CONTRACTOR THAT DO NOT FALL INTO ONE OF THE ABOVE CATEGORIES (TERMINATED 07/08/2019) OR
		F	10 USC 1095c(a)(2) INTEREST PAYMENT (THE CONTRACTOR IS FISCALLY REPONSIBILE FOR ANY INTEREST) (EFFECTIVE DATE 07/09/2019) OR
		G	10 USC 1095c(a)(2) INTEREST PAYMENT (THE GOVERNMENT IS FISCALLY REPONSIBILE FOR ANY INTEREST) (EFFECTIVE DATE 07/09/2019)
2-112-04R	IF TRANSACTION RECORD AMOUNT INTEREST PAYMENT < ZERO AND REASON FOR INTEREST PAYMENT =	F	10 USC 1095c(a)(2) INTEREST PAYMENT (THE CONTRACTOR IS FISCALLY RESPONSIBLE FOR ANY INTEREST) (EFFECTIVE DATE 07/09/2019) OR
		G	10 USC 1095c(a)(2) INTEREST PAYMENT (THE GOVERNMENT IS FISCALLY RESPONSIBLE FOR ANY INTEREST) (EFFECTIVE DATE 07/09/2019)
	THEN TRANSACTION RECORD REASON FOR INTEREST PAYMENT MUST = REASON FOR INTEREST PAYMENT FOUND ON DATABASE1

ELEMENT NAME: REASON FOR INTEREST PAYMENT (2-113)
VALIDITY EDITS
2-113-01V	MUST BE A VALID REASON FOR INTEREST PAYMENT CODE (BASED ON BEGIN DATE OF CARE) (REFER TO Section 2.8).
	AND AT LEAST ONE OCCURRENCE OF BEGIN DATE OF CARE MUST BE ON OR AFTER THE CARE EFFECTIVE DATE AND ON OR BEFORE THE CARE TERMINATION DATE
Relational Edits
2-113-01R	IF TRANSACTION RECORD REASON FOR INTEREST PAYMENT =	A	CLAIMS PENDED AT GOVERNMENT DIRECTION (TERMINATED 07/08/2019) OR
		B	CLAIMS REQUIRING GOVERNMENT INTERVENTION (TERMINATED 07/08/2019) OR
		C	CLAIMS REQUIRING DEVELOPMENT FOR POTENTIAL TPL (TERMINATED 07/08/2019) OR
		D	CLAIMS REQUIRING AN ACTION/INTERFACE WITH ANOTHER PRIME CONTRACTOR (TERMINATED 07/08/2019) OR
		E	CLAIMS RETAINED BY THE CONTRACTOR THAT DO NOT FALL INTO ONE OF THE ABOVE CATEGORIES (TERMINATED 07/08/2019) OR
		F	10 USC 1095c(a)(2) INTEREST PAYMENT (THE CONTRACTOR IS FISCALLY REPONSIBILE FOR ANY INTEREST) (EFFECTIVE DATE 07/09/2019) OR
		G	10 USC 1095c(a)(2) INTEREST PAYMENT (THE GOVERNMENT IS FISCALLY REPONSIBILE FOR ANY INTEREST) (EFFECTIVE DATE 07/09/2019)
	THEN TRANSACTION RECORD AMOUNT INTEREST PAYMENT MUST ≠ ZERO

ELEMENT NAME: ICD VERSION (2-114)
VALIDITY EDITS
2-114-01V	VALUE MUST BE A VALID ICD VERSION
Relational Edits
NO ERROR	IF THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT ALLOWED BY PROCEDURE CODE = ZERO
2-114-01R	IF ICD VERSION =	9	ICD-9
	THEN END DATE OF CARE OF EACH LINE ITEM MUST BE < 10/01/2015.
2-114-02R	IF ICD VERSION =	0	ICD-10
	THEN BEGIN DATE OF CARE OF EACH LINE ITEM MUST BE ON OR AFTER ≥ 10/01/2015.

ELEMENT NAME: PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (2-115)
VALIDITY EDITS
2-115-01V	IF FILING DATE IS PRIOR TO 10/01/2004
	THEN VALUE IN POSITIONS 1-7 MUST BE A VALID ICD DIAGNOSIS CODE, EXCLUDING E000.0-E999.1
2-115-02V	IF FILING DATE IS ON OR AFTER 10/01/2004
	THEN VALUE IN POSITIONS 1-7 MUST BE A VALID ICD DIAGNOSIS CODE, EXCLUDING E000.0-E999.1 (ICD-9-CM) AND V00-Y99.9 (ICD-10-CM)
	AND FOR AT LEAST ONE LINE ITEM
	EITHER BEGIN DATE OF CARE MUST BE ON OR AFTER THE DIAGNOSIS EFFECTIVE DATE AND NOT LATER THAN THE DIAGNOSIS TERMINATION DATE ON THE ICD DIAGNOSIS REFERENCE TABLE
	OR END DATE OF CARE MUST BE ON OR AFTER THE DIAGNOSIS EFFECTIVE DATE AND NOT LATER THAN THE DIAGNOSIS TERMINATION DATE ON THE ICD DIAGNOSIS REFERENCE TABLE
2-115-03V	POA INDICATOR (POSITION 8 OF THE PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR) MUST BE A VALID VALUE.
Relational Edits
2-115-01R	IF PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) IS FOR FEMALE
	AND PERSON SEX (PATIENT) IS MALE
	THEN AT LEAST ONE OVERRIDE CODE MUST =	G	DIAGNOSIS/PROCEDURAL CODE FOR FEMALE: SEX INDICATES MALE
2-115-02R	IF PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) IS FOR MALE
	AND PERSON SEX (PATIENT) IS FEMALE
	THEN AT LEAST ONE OVERRIDE CODE MUST =	H	DIAGNOSIS/PROCEDURAL CODE FOR MALE: SEX INDICATES FEMALE
2-115-06R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	PF	ECHO
	THEN PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) CANNOT =	799.9	ICD-9-CM OR
		R69	ICD-10-CM OR
		R99	ICD-10-CM
	UNLESS TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT ALLOWED BY PROCEDURE CODE = ZERO
	OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	1	MEDICAID

ELEMENT NAME: SECONDARY TREATMENT DIAGNOSIS/POA INDICATOR OCCURRENCES 1 - 24 (2-116 THROUGH 2-138, 2-340)
1 XXX EQUALS ELN (116 THROUGH 138, 2-340) FOR EACH OCCURRENCE OF SECONDARY TREATMENT DIAGNOSIS/POA INDICATOR.
VALIDITY EDITS
2-XXX-01V1	IF FILING DATE IS PRIOR TO 10/01/2004
	THEN VALUE IN POSITIONS 1-7 MUST BE A VALID ICD DIAGNOSIS CODE OR BLANK FILLED.
2-XXX-02V1	IF FILING DATE IS ON OR AFTER 10/01/2004
	THEN VALUE IN POSITIONS 1-7 MUST BE A VALID ICD DIAGNOSIS CODE OR BLANK FILLED.
	AND BEGIN DATE OF CARE MUST BE ON OR AFTER THE DIAGNOSIS EFFECTIVE DATE AND NOT LATER THAN THE DIAGNOSIS TERMINATION DATE ON THE ICD DIAGNOSIS REFERENCE TABLE
	OR END DATE OF CARE MUST BE ON OR AFTER THE DIAGNOSIS EFFECTIVE DATE AND NOT LATER THAN THE DIAGNOSIS TERMINATION DATE ON THE ICD DIAGNOSIS REFERENCE TABLE
2-XXX-03V1	ALL OCCURRENCES OF SECONDARY TREATMENT DIAGNOSIS/POA INDICATOR MUST BE BLANK FILLED FOLLOWING THE FIRST OCCURRENCE OF A BLANK FILLED SECONDARY TREATMENT DIAGNOSIS/POA INDICATOR
2-XXX-04V	POA INDICATOR (POSITION 8 OF THE PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR) MUST BE A VALID VALUE.
Relational Edits
2-XXX-01R1	IF ANY SECONDARY TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) IS FOR FEMALE
	AND PERSON SEX (PATIENT) IS MALE
	THEN AT LEAST ONE OVERRIDE CODE MUST =	G	DIAGNOSIS/PROCEDURAL CODE FOR FEMALE: SEX INDICATES MALE
2-XXX-02R1	IF ANY SECONDARY TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) IS FOR MALE
	AND PERSON SEX (PATIENT) IS FEMALE
	THEN AT LEAST ONE OVERRIDE CODE MUST =	H	DIAGNOSIS/PROCEDURAL CODE FOR MALE: SEX INDICATES FEMALE

ELEMENT NAME: TED RECORD CORRECTION INDICATOR (2-139)
VALIDITY EDITS
2-139-01V	VALUE MUST BE BLANK.
Relational Edits
	NONE

ELEMENT NAME: TOTAL OCCURRENCE/LINE ITEM COUNT (2-140)
VALIDITY EDITS
2-140-01V	VALUE MUST BE IN RANGE: 001-099
	AND MUST EQUAL THE PHYSICAL COUNT OF THE DETAIL OCCURRENCE/LINE ITEM ON THE TED RECORD.
2-140-02V	IF TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		B	ADJUSTMENT OF NON-TED RECORD (HCSR) DATA OR
		C	COMPLETE CANCELLATION OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	THEN TOTAL OCCURRENCE/LINE ITEM COUNT MUST BE ≥ TOTAL OCCURRENCE/LINE ITEM COUNT FROM DHA DATABASE
Relational Edits
	NONE

ELEMENT NAME: ADJUSTMENT SEQUENCE NUMBER (2-141)1
1 BYPASS ALL 2-141 EDITS FOR CONTRACT NUMBERS MDA906-02-C-0013 (TMOP), MDA906-03-C-0019 (TRRx), MDA906-03-C-0009 (WEST), MDA906-03-C-0010 (SOUTH), MDA906-03-C-0011 (NORTH), AND MDA906-03-C-0015 (TDEFIC).
VALIDITY EDITS
2-141-01V	MUST BE NUMERIC.
Relational Edits
2-141-01R	IF TYPE OF SUBMISSION =	D	COMPLETE DENIAL OR
		I	INITIAL SUBMISSION OR
		O	ZERO PAYMENT WITH 100% OHI/TPL OR
		R	RESUBMISSION
	THEN ADJUSTMENT SEQUENCE NUMBER MUST = 000 (ZEROES)
2-141-02R	IF TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		C	COMPLETE CANCELLATION
	THEN ADJUSTMENT SEQUENCE NUMBER MUST BE ONE GREATER THAN THE CURRENT VALUE IN THE TED DATABASE
2-141-03R	IF TYPE OF SUBMISSION =	B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	THEN ADJUSTMENT SEQUENCE NUMBER MUST = 000 (ZEROES)

ELEMENT NAME: OCCURRENCE/LINE ITEM NUMBER (2-145)
VALIDITY EDITS
2-145-01V	EACH VALUE MUST BE NUMERIC AND NOT EQUAL TO ZERO.
2-145-02V	OCCURRENCE/LINE ITEM NUMBER MUST BE CODED FOR EACH NUMBER OF OCCURRENCES SPECIFIED BY THE TOTAL OCCURRENCE/LINE ITEM COUNT.
2-145-03V	OCCURRENCE/LINE ITEM NUMBER MUST BE REPORTED IN ASCENDING CONSECUTIVE ORDER.
Relational Edits
	NONE

ELEMENT NAME: BEGIN DATE OF CARE (2-150)
1 “AUTHORIZED” RECORD ON PROVIDER FILE IS BASED ON NON-INSTITUTIONAL PROVIDER TAXPAYER NUMBER, PROVIDER SUB-IDENTIFIER, PROVIDER MAJOR SPECIALTY, PROVIDER ZIP CODE, AND PROVIDER ACCEPTANCE AND TERMINATION DATES. THIS IS ONLY DETERMINED ONCE A PROVIDER MATCH HAS BEEN OBTAINED (2-240-04R).
VALIDITY EDITS
2-150-01V	MUST BE A VALID GREGORIAN DATE AND CANNOT BE > DHA CURRENT SYSTEM DATE.
2-150-02V	CANNOT BE MORE THAN 10 YEARS PRIOR TO DHA CURRENT SYSTEM DATE.
2-150-03V	BEGIN DATE OF CARE MUST BE ≤ END DATE OF CARE.
Relational Edits
2-150-01R	BEGIN DATE OF CARE MUST BE ≤ END DATE OF CARE.
2-150-02R	BEGIN DATE OF CARE MUST BE ≤ FILING DATE.
2-150-03R	BEGIN DATE OF CARE MUST BE ≤ DATE TED RECORD PROCESSED TO COMPLETION.
2-150-04R	BEGIN DATE OF CARE MUST BE ≥ PERSON BIRTH CALENDAR DATE (PATIENT).
2-150-05R	IF TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		C	COMPLETE CANCELLATION OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	THEN BEGIN DATE OF CARE MUST BE ≤ DATE ADJUSTMENT IDENTIFIED.
2-150-06R	PROVIDER MUST BE “AUTHORIZED”1 ON PROVIDER FILE FOR EACH BEGIN DATE OF CARE
	UNLESS AMOUNT ALLOWED BY PROCEDURE CODE ≤ ZERO
	OR ADJUSTMENT/DENIAL REASON CODE FOR THAT OCCURRENCE/LINE ITEM =	38	SERVICES NOT PROVIDED OR AUTHORIZED BY DESIGNATED (NETWORK) PROVIDERS OR
		52	THE REFERRING/PRESCRIBING/RENDERING PROVIDER IS NOT ELIGIBLE TO REFER/PRESCRIBE/ORDER/PERFORM THE SERVICE BILLED OR
		B7	THIS PROVIDER WAS NOT CERTIFIED/ELIGIBLE TO BE PAID FOR THIS PROCEDURE/SERVICE ON THIS DATE OF SERVICE
	OR PROVIDER SPECIALTY =	172A00000X (OTHER SERVICE PROVIDER/DRIVERS) OR
		344600000X (TRANSPORTATION SERVICES/TAXI)
	OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	T	MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
		FG	TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICAL BENEFITS HAVE BEEN EXHAUSTED) OR
		FS	TFL (SECOND PAYOR) 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 DO NOT CHECK PROVIDER FILE

ELEMENT NAME: END DATE OF CARE (2-155)
1 “AUTHORIZED” RECORD ON PROVIDER FILE IS BASED ON NON-INSTITUTIONAL PROVIDER TAXPAYER NUMBER, PROVIDER SUB-IDENTIFIER, PROVIDER MAJOR SPECIALTY, PROVIDER ZIP CODE, AND PROVIDER ACCEPTANCE AND TERMINATION DATES. THIS IS ONLY DETERMINED ONCE A PROVIDER MATCH HAS BEEN OBTAINED (2-240-04R).
VALIDITY EDITS
2-155-01V	MUST BE A VALID GREGORIAN DATE AND CANNOT BE > DHA CURRENT SYSTEM DATE.
2-155-02V	CANNOT BE MORE THAN 10 YEARS PRIOR TO DHA CURRENT SYSTEM DATE.
2-155-03V	END DATE OF CARE MUST BE > OR EQUAL TO BEGIN DATE OF CARE.
Relational Edits
2-155-02R	END DATE OF CARE MUST BE ≤ FILING DATE.
2-155-03R	END DATE OF CARE MUST BE ≤ DATE TED RECORD PROCESSED TO COMPLETION.
2-155-04R	IF TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		C	COMPLETE CANCELLATION OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	THEN END DATE OF CARE MUST BE ≤ DATE ADJUSTMENT IDENTIFIED.
2-155-05R	PROVIDER MUST BE “AUTHORIZED”1 ON PROVIDER FILE FOR EACH END DATE OF CARE
	UNLESS AMOUNT ALLOWED BY PROCEDURE CODE ≤ ZERO
	OR ADJUSTMENT/DENIAL REASON CODE FOR THAT OCCURRENCE/LINE ITEM =	38	SERVICES NOT PROVIDED OR AUTHORIZED BY DESIGNATED (NETWORK) PROVIDERS OR
		52	THE REFERRING/PRESCRIBING/RENDERING PROVIDER IS NOT ELIGIBLE TO REFER/PRESCRIBE/ORDER/PERFORM THE SERVICE BILLED OR
		B7	THIS PROVIDER WAS NOT CERTIFIED/ELIGIBLE TO BE PAID FOR THIS PROCEDURE/SERVICE ON THIS DATE OF SERVICE
	OR PROVIDER SPECIALTY =	172A00000X (OTHER SERVICE PROVIDER/DRIVERS) OR
		344600000X (TRANSPORTATION SERVICES/TAXI)
	OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	T	MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
		FG	TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICAL BENEFITS HAVE BEEN EXHAUSTED) OR
		FS	TFL (SECOND PAYOR) 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 DO NOT CHECK PROVIDER FILE
2-155-06R	END DATE OF CARE MUST BE IN THE SAME FISCAL YEAR AS THE BEGIN DATE OF CARE

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

ELEMENT NAME: PROCEDURE CODE MODIFIER (2-165)
VALIDITY EDITS
2-165-01V	MUST BE A VALID PROCEDURE CODE MODIFIER AS DEFINED IN Section 2.7.
Relational Edits
	NONE

ELEMENT NAME: NATIONAL DRUG CODE (2-170)
VALIDITY EDITS
2-170-01V	MUST BE A VALID NATIONAL DRUG CODE OR BLANK
Relational Edits
2-170-01R	IF NATIONAL DRUG CODE = BLANK
	THEN TYPE OF SERVICE (SECOND POSITION) MUST ≠	B	RETAIL DRUGS, SUPPLIES, PRESCRIPTION, AUTHORIZATIONS, AND REVIEWS OR
		M	MOP DRUGS, SUPPLIES, PRESCRIPTION, AUTHORIZATIONS, AND REVIEWS
	AND PROCEDURE CODE MUST ≠	98800	FOR DRUGS
	UNLESS PROVIDER STATE OR COUNTRY CODE IS A FOREIGN COUNTRY CODE (Addendum A)
2-170-02R	IF NATIONAL DRUG CODE ≠ BLANK
	THEN TYPE OF SERVICE (SECOND POSITION) MUST =	B	RETAIL DRUGS, SUPPLIES, PRESCRIPTION, AUTHORIZATIONS, AND REVIEWS OR
		M	MOP DRUGS, SUPPLIES, PRESCRIPTION, AUTHORIZATIONS, AND REVIEWS
	AND PROCEDURE CODE MUST =	98800	FOR DRUGS OR
		99070	FOR SUPPLIES OR
		000MN	PRESCRIPTION MEDICAL NECESSITY REVIEWS OR
		000PA	PRESCRIPTION PRIOR AUTHORIZATIONS

ELEMENT NAME: NUMBER OF SERVICES (2-175)
1 EDITS 2-175-02R, 2-175-03R, 2-175-04R, AND 2-175-06R ARE ONLY EXECUTED FOR FILING DATES < 02/01/2010. 2 EDIT 2-175-07R IS ONLY EXECUTED FOR FILING DATES ≥ 02/01/2010. PROCEDURE CODE RECORD MATCH MADE IN 2-160-01V OR 2-160-02V WILL BE USED IN EDIT 2-175-07R. BYPASS EDIT 2-175-07R IF RECORD FAILS EDIT 2-160-01V OR 2-160-02V. 3 TO DETERMINE MAXIMUM NUMBER OF SERVICES REFER TO THE MAXIMUM NUMBER OF SERVICES CODE LIST AT HTTP://HEALTH.MIL/MILITARY-HEALTH-TOPICS/BUSINESS-SUPPORT/RATES-AND-REIMBURSEMENT.
VALIDITY EDITS
2-175-01V	MUST BE NUMERIC.
Relational Edits
2-175-01R	IF TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		C	COMPLETE CANCELLATION OR
		D	COMPLETE DENIAL OR
		I	INITIAL SUBMISSION OR
		O	ZERO PAYMENT WITH 100% OHI/TPL OR
		R	RESUBMISSION
	THEN NUMBER OF SERVICES FOR EACH OCCURRENCE MUST BE > ZERO
	UNLESS TYPE OF SERVICE (SECOND POSITION) =	M	MOP DRUGS, SUPPLIES, PRESCRIPTION, AUTHORIZATIONS, AND REVIEWS
	AND OCCURRENCE/LINE ITEM NUMBER = 002
	THEN NUMBER OF SERVICES ON THIS LINE ITEM MUST = ZERO
2-175-02R1	• SURGERY PROCEDURE CODES
	IF AMOUNT ALLOWED BY PROCEDURE CODE > ZERO
	AND PROCEDURE CODE = 10000-36399 OR 36800-69999 (SURGERY)
	THEN NUMBER OF SERVICES PER PROCEDURE CODE ON A LINE ITEM CANNOT EXCEED 10 PER DAY
	UNLESS PROCEDURE CODE = 11201, 11721, 13102, 13122, 13133, 13153, 15001, 15003, 15101, 15201, 15221, 15241, 15261, 15301, 15321, 15331, 15341, 15343, 15361, 15366, 15401, 15421, 15431, 17003, 17004, 17110, 17111, OR 17310
	OR ANY OCCURRENCE OF OVERRIDE CODE =	NS	CONTRACTOR HAS DETERMINED THE NUMBER OF SERVICES IS MEDICALLY NECESSARY
2-175-03R1	• E/M PROCEDURE CODES
	IF AMOUNT ALLOWED BY PROCEDURE CODE > ZERO
	AND PROCEDURE CODE =	99201-99205 (OFFICE VISITS - NEW PATIENTS) OR
		99211-99215 (OFFICE VISITS - ESTABLISHED PATIENTS) OR
		99217 (DISCHARGE SERVICES) OR
		99221-99233 (HOSPITAL CARE PER DAY) OR
		99234-99236 (OBSERVATION OR INPATIENT CARE SERVICES) OR
		99238-99239 (HOSPITAL DISCHARGE SERVICES) OR
		99241-99245 (OFFICE CONSULTATIONS) OR
		99251-99255 (INITIAL INPATIENT CONSULTATIONS) OR
		99261-99263 (FOLLOW-UP INPATIENT CONSULTATIONS) OR
		99271-99275 (CONFIRMATORY CONSULTATIONS) OR
		99281-99285 (EMERGENCY DEPARTMENT VISIT) OR
		99291 (CRITICAL CARE) (NOTE: CODE 99292 EXCLUDED BECAUSE UTILIZED TO REPORT FOR EACH ADDITIONAL 15 MINUTES OF CARE) OR
		99295-99298 (NEONATAL INTENSIVE CARE) OR
		99301-99315 (NURSING FACILITY CHARGES) OR
		99321-99333 (DOMICILIARY, REST HOME, OR CUSTODIAL CARE SERVICES) OR
		99341-99350 (HOME SERVICES) OR
		99354 (PROLONGED SERVICES) (NOTE: CODE 99355 EXCLUDED BECAUSE UTILIZED TO REPORT FOR EACH ADDITIONAL 30 MINUTES OF CARE) OR
		99356 (PROLONGED SERVICES) (NOTE: CODE 99357 EXCLUDED BECAUSE UTILIZED TO REPORT FOR EACH ADDITIONAL 30 MINUTES OF CARE) OR
		99361-99373 (CASE MANAGEMENT SERVICES) OR
		99374-99380 (CARE PLAN OVERSIGHT) OR
		99381-99429 (PREVENTIVE MEDICINE SERVICES) OR
		99431-99440 (NEWBORN CARE) OR
		99450-99456 (SPECIAL EVALUATION AND MANAGEMENT SERVICES)
	THEN NUMBER OF SERVICES PER PROCEDURE CODE ON A LINE ITEM CANNOT EXCEED THREE PER DAY
	UNLESS ANY OCCURRENCE OF OVERRIDE CODE =	NS	CONTRACTOR HAS DETERMINED THAT NUMBER OF SERVICES IS MEDICALLY NECESSARY
2-175-04R1	• MEDICAL PROCEDURE CODES
	IF AMOUNT ALLOWED BY PROCEDURE CODE > ZERO
	AND PROCEDURE CODE =	99500-99512 (HOME HEALTH VISIT) OR
		99551-99568 (HOME INFUSION PER DIEM CODES)
	THEN NUMBER OF SERVICES PER PROCEDURE CODE ON A LINE ITEM CANNOT EXCEED THREE PER DAY
	UNLESS ANY OCCURRENCE OF OVERRIDE CODE =	NS	CONTRACTOR HAS DETERMINED THAT NUMBER OF SERVICES IS MEDICALLY NECESSARY
2-175-06R1	• VACCINES (VACCINE PRODUCT ONLY) PROCEDURE CODES
	IF AMOUNT ALLOWED BY PROCEDURE CODE > ZERO
	AND PROCEDURE CODE =	90476-90479 (VACCINES, TOXOIDS)
	THEN NUMBER OF SERVICES PER PROCEDURE CODE ON A LINE ITEM CANNOT EXCEED THREE PER DAY
	UNLESS ANY OCCURRENCE OF OVERRIDE CODE =	NS	CONTRACTOR HAS DETERMINED THAT NUMBER OF SERVICES IS MEDICALLY NECESSARY
2-175-07R2	IF AMOUNT ALLOWED BY PROCEDURE CODE = ZERO
	OR PRICING RATE CODE =	P1	OPPS OR
		P2	OPPS WITH COST OUTLIER OR
		P3	OPPS WITH DISCOUNT OR
		P5	HOSPITAL-BASED PARTIAL HOSPITALIZATION PAID AS OPPS
	OR NO OCCURRENCE OF SPECIAL PROCESSING CODE =	T	MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
		FS	TFL (SECOND PAYOR)
	THEN BYPASS THIS EDIT
	ELSE NUMBER OF SERVICES CANNOT EXCEED THE MAXIMUM ALLOWED NUMBER OF SERVICES PER DAY FOR THE PROCEDURE CODE ON THIS LINE ITEM3 (BEGIN DATE OF CARE MUST BE ON OR AFTER THE MAXIMUM NUMBER OF SERVICES TABLE EFFECTIVE DATE AND NOT LATER THAN THE MAXIMUM NUMBER OF SERVICES TABLE TERMINATION DATE)
	UNLESS ANY OCCURRENCE OF OVERRIDE CODE =	NS	CONTRACTOR HAS DETERMINED THAT NUMBER OF SERVICES IS MEDICALLY NECESSARY

ELEMENT NAME: AMOUNT BILLED BY PROCEDURE CODE (2-180)
VALIDITY EDITS
2-180-01V	MUST BE NUMERIC.
2-180-02V	IF CONTRACT NUMBER =	MDA906-02-C-0013 (TMOP)
	THEN IF PROCEDURE CODE =	000MN	PRESCRIPTION MEDICAL NECESSITY REVIEWS OR
		000PA	PRESCRIPTION PRIOR AUTHORIZATIONS
	THEN AMOUNT BILLED BY PROCEDURE CODE MUST > ZERO
	ELSE IF TYPE OF SUBMISSION =	C	COMPLETE CANCELLATION TO TED RECORD DATA
	OR ADJUSTMENT/DENIAL REASON CODE IS A DENIAL REASON CODE LISTED IN Addendum G, Figure 2.G-1 FOR THAT OCCURRENCE/LINE ITEM
	THEN AMOUNT BILLED BY PROCEDURE CODE MUST = ZERO
	AND AMOUNT ALLOWED BY PROCEDURE CODE MUST = ZERO
	AND AMOUNT PAID BY OHI MUST = ZERO
	AND AMOUNT PAID BY GOVERNMENT CONTRACTOR BY PROCEDURE CODE MUST = ZERO
	AND AMOUNT PATIENT COST-SHARE MUST = ZERO
	ELSE IF OCCURRENCE/LINE ITEM NUMBER = 002
	THEN AMOUNT BILLED BY PROCEDURE CODE MUST = ZERO
	ELSE AMOUNT BILLED BY PROCEDURE CODE MUST BE ≥ $10.20 AND ≤ $11.48
2-180-03V	IF CONTRACT NUMBER =	MDA906-02-C-0013 (TMOP)
	AND AMOUNT BILLED BY PROCEDURE CODE = ZERO
	THEN TYPE OF SUBMISSION MUST =	C	COMPLETE CANCELLATION TO TED RECORD DATA
	OR OCCURRENCE/LINE ITEM NUMBER MUST = 002
	OR ADJUSTMENT/DENIAL REASON CODE MUST BE A DENIAL REASON CODE LISTED IN Addendum G, Figure 2.G-1 FOR THAT OCCURRENCE/LINE ITEM
Relational Edits
2-180-00R	IF TYPE OF SUBMISSION ≠	D	COMPLETE DENIAL
	THEN TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT BILLED BY PROCEDURE CODE FOR THIS TED RECORD MUST NOT EXCEED DHA LIMIT OF $1,000,000.00

ELEMENT NAME: AMOUNT ALLOWED BY PROCEDURE CODE (2-185)
VALIDITY EDITS
2-185-01V	MUST BE NUMERIC.
Relational Edits
2-185-00R	TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT ALLOWED BY PROCEDURE CODE FOR THIS TED RECORD EXCEEDS DHA LIMIT OF $1,000,000.00.
2-185-01R	IF TYPE OF SUBMISSION =	C	COMPLETE CANCELLATION OR
		D	COMPLETE DENIAL
	THEN AMOUNT ALLOWED BY PROCEDURE CODE MUST = ZERO FOR ALL OCCURRENCES/LINE ITEMS
2-185-02R	IF PRICING RATE CODE =	b	NO SPECIAL RATE OR
		D	DISCOUNT RATE OR
		V	MEDICARE REIMBURSEMENT RATE
	AND NO OCCURRENCE OF SPECIAL PROCESSING CODE =	T	MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
		FS	TFL (SECOND PAYOR) OR
		16	AMBULATORY SURGERY FACILITY CHARGE
	AND TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		I	INITIAL SUBMISSION OR
		O	ZERO PAYMENT WITH 100% OHI/TPL OR
		R	RESUBMISSION
	THEN AMOUNT ALLOWED BY PROCEDURE CODE MUST BE ≤ AMOUNT BILLED BY PROCEDURE CODE FOR EACH OCCURRENCE/LINE ITEM
2-185-03R	IF PRICING RATE CODE =	4	PAID AS BILLED OR
		I	CLAIM AUDITING SOFTWARE-ADDED PROCEDURE, PAID AS BILLED
	AND TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		I	INITIAL SUBMISSION OR
		O	ZERO PAYMENT WITH 100% OHI/TPL OR
		R	RESUBMISSION
	THEN AMOUNT ALLOWED BY PROCEDURE CODE MUST BE = AMOUNT BILLED BY PROCEDURE CODE
2-185-04R	IF AMOUNT ALLOWED BY PROCEDURE CODE = ZERO
	THEN ADJUSTMENT/DENIAL REASON CODE FOR THAT OCCURRENCE/LINE ITEM MUST BE A CODE LISTED IN Addendum G, Figure 2.G-1 OR Figure 2.G-2.
	UNLESS TYPE OF SUBMISSION =	B	ADJUSTMENT NON-TED DATA (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
2-185-05R	IF TYPE OF SUBMISSION =	E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	THEN AMOUNT ALLOWED BY PROCEDURE CODE ≤ ZERO
2-185-06R	IF AMOUNT ALLOWED BY PROCEDURE CODE > ZERO
	THEN TYPE OF SUBMISSION MUST =	A	ADJUSTMENT OR
		B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		I	INITIAL SUBMISSION OR
		O	ZERO PAYMENT WITH 100% OHI/TPL OR
		R	RESUBMISSION
2-185-07R	IF AMOUNT ALLOWED BY PROCEDURE CODE = ZERO
	THEN AMOUNT PAID BY GOVERNMENT CONTRACTOR BY PROCEDURE CODE MUST = ZERO
	UNLESS TYPE OF SUBMISSION =	B	ADJUSTMENT NON-TED DATA (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA

ELEMENT NAME: AMOUNT PAID BY OTHER HEALTH INSURANCE (2-190)
VALIDITY EDITS
2-190-01V	MUST BE NUMERIC.
Relational Edits
2-190-00R	TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT PAID BY OTHER HEALTH INSURANCE FOR THIS TED RECORD EXCEEDS DHA LIMIT OF $1,000,000.00.
2-190-01R	IF TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		C	COMPLETE CANCELLATION OR
		D	COMPLETE DENIAL OR
		I	INITIAL SUBMISSION OR
		O	ZERO PAYMENT WITH 100% OHI/TPL OR
		R	RESUBMISSION
	THEN AMOUNT PAID BY OTHER HEALTH INSURANCE MUST BE ≥ ZERO.

ELEMENT NAME: OTHER GOVERNMENT PROGRAM (OGP) TYPE CODE (2-191)
VALIDITY EDITS
2-191-01V	MUST BE A VALID OGP TYPE CODE LISTING IN Section 2.6.
Relational Edits
2-191-01R	IF OGP TYPE CODE =	V	CHAMPVA
	THEN TYPE OF SUBMISSION MUST =	C	COMPLETE CANCELLATION OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA

ELEMENT NAME: OTHER GOVERNMENT PROGRAM (OGP) BEGIN REASON CODE (2-192)
VALIDITY EDITS
2-192-01V	MUST BE A VALID OGP BEGIN REASON CODE LISTING IN Section 2.6.
Relational Edits
	NONE

ELEMENT NAME: AMOUNT APPLIED TOWARD DEDUCTIBLE (2-195)
VALIDITY EDITS
2-195-01V	MUST BE NUMERIC.
Relational Edits
2-195-00R	TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT APPLIED TOWARD DEDUCTIBLE FOR THIS TED RECORD EXCEEDS DHA LIMIT OF $1,000,000.00.
2-195-01R	IF TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		I	INITIAL SUBMISSION OR
		O	ZERO PAYMENT WITH 100% OHI/TPL OR
		R	RESUBMISSION
	THEN AMOUNT APPLIED TOWARD DEDUCTIBLE MUST BE ≥ ZERO
2-195-02R	IF TYPE OF SUBMISSION =	C	COMPLETE CANCELLATION OR
		D	COMPLETE DENIAL
	THEN AMOUNT APPLIED TOWARD DEDUCTIBLE MUST BE = ZERO
2-195-03R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	NE	OPERATION NOBLE EAGLE/OPERATION ENDURING FREEDOM DEMONSTRATION
	AND BEGIN DATE OF CARE ≥ 09/14/2001 AND < 11/01/2008
	AND ENROLLMENT/HEALTH PLAN CODE =	T	TRICARE STANDARD PROGRAM OR
		V	TRICARE EXTRA
	THEN AMOUNT APPLIED TOWARD DEDUCTIBLE MUST = ZERO
2-195-04R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	DE	TDRL PHYSICAL EXAMS OR
		PF	ECHO
	THEN AMOUNT APPLIED TOWARD DEDUCTIBLE MUST = ZERO

- END -

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