VALIDITY EDITS
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2-285-01V
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MUST
BE A VALID HCC MEMBER CATEGORY CODE (REFER TO Section 2.5)
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Relational Edits
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2-285-01R
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IF HCC MEMBER
RELATIONSHIP CODE =
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A
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SELF
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THEN HCC
MEMBER CATEGORY MUST ≠
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A
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ACTIVE DUTY OR
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G
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NATIONAL GUARD
MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
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J
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ACADEMY STUDENT OR
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N
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NATIONAL GUARD
(NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS) OR
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S
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RESERVE MEMBER
(MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
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|
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T
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FOREIGN MILITARY
MEMBER OR
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V
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RESERVE MEMBER
(NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS)
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UNLESS ENROLLMENT/HEALTH
PLAN
CODE =
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W
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TPR SERVICE
MEMBER - USA OR
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X
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FOREIGN SERVICE
MEMBER OR
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Y
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CHCBP - NON-NETWORK OR
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AA
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CHCBP - NETWORK 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
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SR
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SHCP - MTF/eMSM
REFERRED CARE OR
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ST
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SHCP - TRICARE
ELIGIBLE OR
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SU
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SHCP - REFERRAL
DESIGNATION UNKNOWN OR
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WA
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TPR FOREIGN
SERVICE MEMBER
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OR ANY
OCCURRENCE OF SPECIAL PROCESSING CODE =
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SC
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SHCP -
NON-TRICARE ELIGIBLE OR
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SE
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SHCP - TRICARE
ELIGIBLE OR
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SM
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SHCP - EMERGENCY
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OR HCDP
PLAN COVERAGE CODE =
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306
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TRICARE SELECT
- RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR
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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
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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
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406
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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
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408
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TRS TIER 3 MEMBER
AND FAMILY COVERAGE (SERVICE AGREEMENT) OR
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409
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TRS SURVIVOR
CONTINUING WITH INDIVIDUAL COVERAGE OR
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410
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TRS SURVIVOR
CONTINUING WITH FAMILY COVERAGE OR
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411
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TRS SURVIVOR
NEW INDIVIDUAL COVERAGE OR
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412
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TRS SURVIVOR
NEW FAMILY COVERAGE OR
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413
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TRS MEMBER-ONLY
COVERAGE OR
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414
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TRS MEMBER AND
FAMILY COVERAGE OR
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418
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TRICARE RETIRED
RESERVE (TRR) MEMBER-ONLY COVERAGE OR
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419
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TRR MEMBER AND
FAMILY COVERAGE OR
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420
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TRR SURVIVOR
INDIVIDUAL COVERAGE OR
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421
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TRR SURVIVOR
FAMILY COVERAGE
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2-285-02R
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IF ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
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PF
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ECHO
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THEN HHC
MEMBER CATEGORY CODE MUST =
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A
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ACTIVE
DUTY OR
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|
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G
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NATIONAL GUARD
MEMBER (MOBILIZED OR ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 31 DAYS
OR MORE) OR
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|
|
J
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ACADEMY STUDENT OR
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|
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P
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TAMP MEMBER OR
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S
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RESERVE MEMBER
(MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE)
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2-285-03R
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IF TYPE OF SERVICE
(FIRST POSITION) =
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A
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AMBULATORY SURGERY
COST-SHARED AS INPATIENT
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THEN HCC
MEMBER CATEGORY CODE MUST =
|
A
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ACTIVE
DUTY OR
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|
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G
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NATIONAL GUARD
MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
|
|
|
J
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ACADEMY STUDENT OR
|
|
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N
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NATIONAL GUARD
MEMBER (NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS) OR
|
|
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P
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TAMP MEMBER OR
|
|
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S
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RESERVE MEMBER
(MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
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|
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T
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FOREIGN MILITARY
MEMBER OR
|
|
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V
|
RESERVE MEMBER
(NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS) OR
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|
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Z
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UNKNOWN
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UNLESS AMOUNT
ALLOWED BY PROCEDURE CODE = 0
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2-285-04R
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IF HCDP PLAN
COVERAGE CODE =
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004
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DIRECT CARE
FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
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005
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TRICARE STANDARD
FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
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016
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DIRECT CARE
FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
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017
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TRICARE STANDARD
FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
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021
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TFL FOR SURVIVORS
OF ACTIVE DUTY DECEASED SPONSORS OR
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023
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TFL FOR SURVIVORS
OF GUARD/RESERVE DECEASED SPONSORS OR
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110
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TRICARE PRIME
FOR INDIVIDUAL COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
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111
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TRICARE PRIME
FAMILY COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
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114
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TRICARE USFHP
DIRECT CARE INDIVIDUAL COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
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115
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TRICARE USFHP
DIRECT CARE FAMILY COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED
SPONSORS OR
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136
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TRICARE PRIME
INDIVIDUAL COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
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137
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TRICARE PRIME
FAMILY COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
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138
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TRICARE USFHP
DIRECT CARE INDIVIDUAL COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
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139
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TRICARE USFHP
DIRECT CARE FAMILY COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
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143
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TRICARE PLUS
COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
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144
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TRICARE PLUS
WITH CHC COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
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148
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TRICARE PLUS
COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
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149
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TRICARE PLUS
COVERAGE WITH CHC FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
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205
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TDP INDIVIDUAL
COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
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206
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TDP FAMILY COVERAGE
FOR SURVIVORS OF ACTIVE DUTY DECEASED SPNSORS OR
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212
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TDP INDIVIDUAL
COVERAGE FOR SURVIVORS OF SELECTED RESERVE (SelRes) DECEASED SPONSORS OR
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|
|
213
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TDP FAMILY COVERAGE
FOR SURVIVORS OF SELECTED RESERVE (SelRes) DECEASED SPONSORS OR
|
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306
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TRICARE SELECT
- RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR
|
|
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345
|
TRICARE PLUS
- DIRECT CARE ONLY (PRESENTATION LAYER) OR
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346
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TRICARE PLUS OR
|
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409
|
RESERVE SELECT
SURVIVOR CONTINUING WITH INDIVIDUAL COVERAGE OR
|
|
|
410
|
RESERVE SELECT
SURVIVOR CONTINUING WITH FAMILY COVERAGE OR
|
|
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411
|
RESERVE SELECT
SURVIVOR NEW INDIVIDUAL COVERAGE OR
|
|
|
412
|
RESERVE SELECT
SURVIVOR NEW FAMILY COVERAGE
|
|
OR ENROLLMENT/HEALTH
PLAN CODE =
|
AS
|
TRICARE
SELECT - ACTIVE DUTY SURVIVORS OR
|
|
|
GS
|
TRICARE SELECT
- GUARD/RESERVE SURVIVORS
|
|
OR AMOUNT
ALLOWED BY PROCEDURE CODE = 0
|
|
THEN BYPASS
THIS EDIT
|
|
|
|
ELSE IF
TYPE OF SERVICE (SECOND POSITION) =
|
C
|
AMBULATORY SURGERY
|
|
THEN HCC
MEMBER CATEGORY CODE MUST =
|
D
|
DISABLED
AMERICAN VETERAN OR
|
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F
|
FORMER MEMBER OR
|
|
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H
|
MOH RECIPIENT OR
|
|
|
R
|
RETIRED OR
|
|
|
W
|
FORMER SPOUSE OR
|
|
|
Z
|
UNKNOWN
|
2-285-05R
|
IF HCC MEMBER
CATEGORY CODE =
|
T
|
FOREIGN MILITARY
MEMBER
|
|
THEN ONE
OCCURRENCE OF OVERRIDE CODE =
|
M
|
NATO
|