TRICARE Manuals - Display Chap 2 Sect 5.1 (Change 41, Oct 27, 2020)

TRICARE Encounter Data (TED)

Chapter 2

Section 5.1

Institutional Edit Requirements (ELN 000 - 099)

Revision: C-16, June 22, 2018

ELEMENT NAME: RECORD TYPE INDICATOR (1-001)
VALIDITY EDITS
1-001-01V	RECORD TYPE INDICATOR MUST =	1	INSTITUTIONAL
Relational Edits
1-001-01R	IF TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		C	COMPLETE CANCELLATION OR
		D	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	AND MATCH IS FOUND ON THE DHA DATABASE
	THEN THE RECORD TYPE FOR THE TED ON THE DATABASE MUST EQUAL THE RECORD TYPE ON THE ADJUSTMENT/CANCELLATION TED BEING SUBMITTED.

ELEMENT NAME: FILING DATE (1-015)
VALIDITY EDITS
1-015-01V	MUST BE A VALID JULIAN DATE AND CANNOT BE > DHA CURRENT SYSTEM DATE.
Relational Edits
1-015-01R	FILING DATE MUST BE ≤ DATE TED RECORD PROCESSED TO COMPLETION (PTC)

ELEMENT NAME: FILING STATE/COUNTRY CODE (1-020)
VALIDITY EDITS
1-020-01V	IF TYPE OF SUBMISSION =	D	COMPLETE DENIAL OR
		I	INITIAL SUBMISSION OR
		O	ZERO PAYMENT WITH 100% OHI/TPL OR
		R	RESUBMISSION
	THEN MUST BE A VALID STATE/COUNTRY CODE (REFER TO Addendums A AND B).
Relational Edits
1-020-01R	IF PRICING RATE CODE =	H	TRICARE DRG REIMBURSEMENT WITH SHORT STAY OUTLIER OR
		I	TRICARE DRG REIMBURSEMENT WITH COST OUTLIER OR
		J	TRICARE DRG REIMBURSEMENT WITH NO OUTLIER OR
		CI	CAH INPATIENT REHABILITATION FACILITY (IRF) REIMBURSEMENT OR
		CP	CAH PSYCHIATRIC HOSPITAL PER DIEM RATE OR
		DD	DISCOUNTED DRG OR
		LT	STANDARD LTCH REIMBURSEMENT OR
		RF	TRICARE IRF REIMBURSEMENT OR
		SN	SITE-NEUTRAL LTCH REIMBURSEMENT
	THEN FILING STATE/COUNTRY CODE MUST NOT BE A FOREIGN COUNTRY EXCEPT FOR PUERTO RICO (PRI).

ELEMENT NAME: SEQUENCE NUMBER (1-025)
VALIDITY EDITS
1-025-01V	SEQUENCE NUMBER MUST BE A COMBINATION OF ALPHABETIC OR NUMERIC CHARACTERS
Relational Edits
	NONE

ELEMENT NAME: TIME STAMP (1-030)
VALIDITY EDITS
1-030-01V	MUST BE NUMERIC
Relational Edits
1-030-01R	IF FILING DATE IS ≥ 02/01/1995
	THEN TIME STAMP MUST BE > ZERO

ELEMENT NAME: ADJUSTMENT KEY (1-035)
VALIDITY EDITS
1-035-01V	MUST BE ALPHA, 0, OR 5.
Relational Edits
	NONE

ELEMENT NAME: DATE TED RECORD PROCESSED TO COMPLETION (1-040)
VALIDITY EDITS
1-040-01V	MUST BE VALID GREGORIAN DATE AND CANNOT BE > CURRENT SYSTEM DATE.
Relational Edits
1-040-01R	DATE TED RECORD PROCESSED TO COMPLETION MUST BE ≤ BATCH/VOUCHER DATE.

ELEMENT NAME: DATE ADJUSTMENT IDENTIFIED (1-045)
VALIDITY EDITS
1-045-01V	MUST BE VALID GREGORIAN DATE OR ALL ZEROES AND CANNOT BE > DHA CURRENT SYSTEM DATE.
1-045-02V	IF TYPE OF SUBMISSION =	D	CONTRACTOR DENIAL OR
		I	INITIAL SUBMISSION OR
		O	ZERO PAYMENT WITH 100% OHI/TPL OR
		R	RESUBMISSION
	THEN DATE ADJUSTMENT IDENTIFIED MUST BE ALL ZEROES.
1-045-04V	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 DATE ADJUSTMENT IDENTIFIED MUST BE A VALID GREGORIAN DATE
Relational Edits
1-045-03R	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 DATE ADJUSTMENT IDENTIFIED MUST BE ≤ DATE TED RECORD PROCESSED TO COMPLETION (PTC) AND ≥ FILING DATE

ELEMENT NAME: PERSON IDENTIFIER (SPONSOR) (1-050)
VALIDITY EDITS
1-050-01V	MUST BE NINE NUMERIC DIGITS (CANNOT BE ALL ZEROES, ALL NINES, OR ALL BLANKS).
Relational Edits
	NONE

ELEMENT NAME: PERSON IDENTIFIER TYPE CODE (SPONSOR) (1-051)
VALIDITY EDITS
1-051-01V	MUST BE A VALID VALUE LOCATED IN Section 2.7.
Relational Edits
	NONE

ELEMENT NAME: PAY GRADE CODE (SPONSOR) (1-056)
VALIDITY EDITS
1-056-01V	MUST BE A VALID PAY GRADE CODE (SPONSOR) (REFER TO Section 2.7)
Relational Edits
	NONE

ELEMENT NAME: PAY PLAN CODE (SPONSOR) (1-057)
VALIDITY EDITS
1-057-01V	MUST BE A VALID PAY PLAN CODE (SPONSOR) (REFER TO Addendum K)
Relational Edits
	NONE

ELEMENT NAME: SERVICE BRANCH CLASSIFICATION CODE (SPONSOR) (1-060)
VALIDITY EDITS
1-060-01V	MUST BE A VALID SERVICE BRANCH CLASSIFICATION CODE (SPONSOR) (REFER TO Section 2.8)
Relational Edits
	REFER TO Section 8.1.

ELEMENT NAME: AGR SERVICE LEGAL AUTHORITY CODE (1-065)
VALIDITY EDITS
1-065-01V	MUST BE A VALID AGR SERVICE LEGAL AUTHORITY CODE (REFER TO Section 2.4)
Relational Edits
	REFER TO Section 8.1.

ELEMENT NAME: HEALTH CARE COVERAGE (HCC) MEMBER CATEGORY CODE (1-066)
VALIDITY EDITS
1-066-01V	MUST BE A VALID HCC MEMBER CATEGORY CODE (REFER TO Section 2.5)
Relational Edits
1-066-01R	IF HCC MEMBER RELATIONSHIP CODE =	A	SELF
	THEN HCC MEMBER CATEGORY CODE MUST ≠	A	ACTIVE DUTY OR
		G	NATIONAL GUARD MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
		J	ACADEMY STUDENT OR
		N	NATIONAL GUARD (NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS) OR
		S	RESERVE MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
		T	FOREIGN MILITARY MEMBER OR
		V	RESERVE MEMBER (NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS)
	UNLESS ENROLLMENT/HEALTH PLAN CODE =	W	TPR SERVICE MEMBER - USA OR
		X	FOREIGN SERVICE MEMBER OR
		Y	CHCBP - NON-NETWORK OR
		AA	CHCBP - NETWORK OR
		SN	SHCP - NON-MTF/eMSM-REFERRED CARE OR
		SO	SHCP - NON-TRICARE ELIGIBLE OR
		SR	SHCP - MTF/eMSM REFERRED CARE OR
		ST	SHCP - TRICARE ELIGIBLE OR
		WA	TPR FOREIGN SERVICE MEMBER OR
		WO	TPR FOREIGN ADFM
	OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	SC	SHCP - NON-TRICARE ELIGIBLE OR
		SE	SHCP - TRICARE ELIGIBLE OR
		SM	SHCP - EMERGENCY
	OR HCDP PLAN COVERAGE CODE =	306	TRICARE SELECT - RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR
		307	TRICARE SELECT - RETIRED RESERVE SPONSORS AND FAMILY MEMBERS OR
		401	TRS TIER 1 MEMBER-ONLY COVERAGE (CONTINGENCY OPERATIONS) OR
		402	TRS TIER 1 MEMBER AND FAMILY COVERAGE (CONTINGENCY OPERATIONS) OR
		405	TRS TIER 2 MEMBER-ONLY COVERAGE (CERTIFIED QUALIFICATIONS) OR
		406	TRS TIER 2 MEMBER AND FAMILY COVERAGE (CERTIFIED QUALIFICATIONS) OR
		407	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	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
1-066-02R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	PF	ECHO
	THEN HCC MEMBER CATEGORY CODE MUST =	A	ACTIVE DUTY OR
		G	NATIONAL GUARD MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
		J	ACADEMY STUDENT OR
		P	TAMP MEMBER OR
		S	RESERVE MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE)
1-066-03R	IF HCC MEMBER CATEGORY CODE =	T	FOREIGN MILITARY MEMBER
	THEN ONE OCCURRENCE OF OVERRIDE CODE =	M	NATO

ELEMENT NAME: HEALTH CARE COVERAGE (HCC) MEMBER RELATIONSHIP CODE (1-070)
1 PATIENT AGE IS CALCULATED BASED ON PERSON BIRTH CALENDAR DATE (PATIENT) AND BEGIN DATE OF CARE.
VALIDITY EDITS
1-070-01V	MUST BE A VALID HCC MEMBER RELATIONSHIP CODE (REFER TO Section 2.5).
Relational Edits
1-070-06R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	PF	ECHO
	THEN HCC MEMBER RELATIONSHIP CODE MUST =	A	SELF OR
		B	SPOUSE OR
		C	CHILD OR STEPCHILD OR
		D	PRE-ADOPTIVE CHILD OR
		E	WARD (COURT ORDERED) OR
		G	SURVIVING SPOUSE
1-070-08R	IF HCC MEMBER CATEGORY CODE =	T	FOREIGN MILITARY MEMBER
	AND HCC MEMBER RELATIONSHIP CODE =	A	SELF
	THEN ANY OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	AN	SHCP - NON-REFERRED CARE OR
		AR	SHCP - REFERRED OR
		SC	SHCP - NON-TRICARE ELIGIBLE OR
		SM	SHCP - EMERGENCY
	OR ENROLLMENT/HEALTH PLAN CODE MUST =	SN	SHCP - NON-MTF/eMSM REFERRED OR
		SO	SHCP - NON-TRICARE ELIGIBLE OR
		SR	SHCP - REFERRED
	UNLESS TYPE OF SUBMISSION =	D	COMPLETE DENIAL OF INITIAL TED
	THEN BYPASS THIS EDIT

ELEMENT NAME: PERSON LAST NAME (PATIENT) (1-076)
VALIDITY EDITS
1-076-01V	MUST BE AT LEAST ONE CHARACTER (LEFT-JUSTIFIED).
Relational Edits
	NONE

ELEMENT NAME: PERSON FIRST NAME (PATIENT) (1-077)
VALIDITY EDITS
	NONE
Relational Edits
	NONE

ELEMENT NAME: PERSON MIDDLE NAME (PATIENT) (1-078)
VALIDITY EDITS
	NONE
Relational Edits
	NONE

ELEMENT NAME: PERSON CADENCY NAME (PATIENT) (1-079)
VALIDITY EDITS
	NONE
Relational Edits
	NONE

ELEMENT NAME: PERSON IDENTIFIER (PATIENT) (1-080)
VALIDITY EDITS
1-080-01V	MUST BE NINE NUMERIC DIGITS AND CANNOT EQUAL ALL BLANKS.
Relational Edits
	NONE

ELEMENT NAME: PERSON IDENTIFIER TYPE CODE (PATIENT) (1-081)
VALIDITY EDITS
1-081-01V	MUST HAVE A VALID VALUE LISTED IN Section 2.7.
Relational Edits
	NONE

ELEMENT NAME: PERSON BIRTH CALENDAR DATE (PATIENT) (1-085)
1 PATIENT AGE IS CALCULATED BASED ON PERSON BIRTH CALENDAR DATE (PATIENT) AND BEGIN DATE OF CARE.
VALIDITY EDITS
1-085-01V	MUST BE A VALID GREGORIAN DATE AND CANNOT BE > DHA CURRENT SYSTEM DATE.
Relational Edits
1-085-01R	PATIENT AGE1 MUST BE < 125 YEARS
1-085-02R	PERSON BIRTH CALENDAR DATE (PATIENT) ≤ BEGIN DATE OF CARE
1-085-03R	PERSON BIRTH CALENDAR DATE (PATIENT) ≤ ADMISSION DATE

ELEMENT NAME: PATIENT IDENTIFIER (DoD) (1-095)
VALIDITY EDITS
1-095-01V	MUST NOT BE BLANK FILLED.
1-095-02V	MUST NOT EQUAL ALL ZEROS.
	UNLESS TYPE OF SUBMISSION =	D	COMPLETE DENIAL INITIAL TED RECORD DATA
	OR ALL OCCURRENCES/LINE ITEMS (EXCLUDING REVENUE CODE 0001) CONTAIN AN ADJUSTMENT/DENIAL REASON CODE LISTED IN Addendum G, Figure 2.G-1 OR Figure 2.G-2.
Relational Edits
	NONE

ELEMENT NAME: DEERS IDENTIFIER (PATIENT) (1-097)
VALIDITY EDITS
1-097-01V	POSITIONS 10 AND 11 MUST BE NUMERIC.
Relational Edits
	NONE

- END -

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