TRICARE Manuals - Display Chap 2 Sect 3.1 (Change 41, Oct 27, 2020)

TRICARE Encounter Data (TED)

Chapter 2

Section 3.1

General Edit Requirements - Overview

Revision:

1.0 Defense Health Agency (DHA) Editing System

DHA relies upon the data received from the contractor to account for the expenditure of Government funds and to develop statistical information. This information is used for the analysis of the TRICARE program, for reporting to Congress, and the Executive Branch, and for developing trends and budget projections. DHA processes health care data received from the contractor through the DHA editing system, to ensure the accuracy and integrity of its database. There are two basic types of edits in the DHA editing system:

1.1 Validity Edits

1.1.1 Validity edits are generated when the data submitted for a data element is not one of the code values for that data element as defined in Sections 2.3 through 2.10 or cannot be processed as submitted, or the data in the records is not compatible with respect to associated data on the DHA database. The data submitted on TRICARE Encounter Data (TED) records must be consistent with expected values, and records must be compatible when compared to the DHA database.

1.1.2 TED records with validity edit errors will be returned to the contractor with the same batch/voucher identifier and must be corrected and resubmitted using the same batch/voucher identifier as initially sent. Refer to Sections 1.1 and 1.2 for information on the correction and resubmission of these records.

1.2 Relational Edits

1.2.1 Relational edits are generated when the values of two or more data elements relate to each other and the values are not compatible.

1.2.2 TED records with relational edit errors will be returned to the contractor with the same batch/voucher identifier and must be corrected and resubmitted using the same batch/voucher identifier as initially sent. TRICARE Encounter Provider (TEPRV) records with relational edit errors do not need to be resubmitted within the same batch as initially sent. Refer to Sections 1.1 and 1.2 for information on the correction and resubmission of these records.

1.2.3 Financial Edits

Financial edits are relational edits that identify potential improper payments and must be corrected. The financial (voucher cost allocation) edits with F in the trailing position.

2.0 DHA Error Messages

2.1 DHA edits generate error messages if required conditions are not met. The two major parts of an error message are the error code and the error message text. The error codes are structured to identify the data element in error by using the Element Locator Number (ELN) as the first four digits. Where multiple elements are involved in an edit, the ELN part of the error code represents the leading data element in the edit.

2.2 Edit Error Code Structure

The edit error codes have the following structure:

2.2.1 Four Characters

One digit RECORD TYPE INDICATOR followed by a hyphen, three digit ELN followed by a hyphen.

2.2.2 Two Characters

Number of the Error Code for a given element, followed by a hyphen.

2.2.3 One Character

V - for validity edits, R - for relational edits, and F - for financial edits.

2.2.4 Occurrence/Line Item Number Error (if applicable)

Three additional characters that identify the occurrence(s)/line item(s) within the TED record that contain the error.

2.2.5 Edit Error Message Text

Error Message text provides a description of the error condition. The information in Sections 4.1 through 8.1 contain the pseudo code used by DHA to write the editing program modules. Additional edits or changes may be made by DHA to ensure that the data submitted is in compliance with the TRICARE Policy Manual (TPM) and the TRICARE Operations Manual (TOM). Batch/Voucher, TED and TEPRV records rejected by the DHA editing system, accompanied by error reports, are returned to the contractor for correction and resubmission. Refer to Section 2.2, paragraph 6.0 for additional information on error report format and content.

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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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