TRICARE Systems Manual 7950.3-M, April 1, 2015 TRICARE Encounter Data (TED) Chapter 2 Section 7.1 Provider Edit Requirements (ELN 000 - 099) Revision: C-4, October 20, 2017 ELEMENT NAME: RECORD TYPE INDICATOR (3-001) VALIDITY EDITS 3-001-01V RECORD TYPE INDICATOR MUST = 3 PROVIDER Relational Edits NONE ELEMENT NAME: PROVIDER TAXPAYER NUMBER (3-005) VALIDITY EDITS NONE Relational Edits 3-005-01R IF PROVIDER TAXPAYER NUMBER IDENTIFIER = E INDICATES EIN OR S INDICATES SSN (VALID FOR NON-INSTITUTIONAL ONLY) THEN PROVIDER TAXPAYER NUMBER MUST BE NUMERIC 3-005-02R IF PROVIDER TAXPAYER NUMBER IDENTIFIER = A ASSIGNED BY CONTRACTOR • OUTSIDE CONTRACTOR JURISDICTION THEN FIRST THREE POSITIONS MUST EQUAL THE PROVIDER STATE/COUNTRY CODE IN THE PROVIDER ADDRESS AND THE FOURTH POSITION MUST = A AND THE LAST FIVE POSITIONS MUST BE NUMERIC. • INSIDE CONTRACTOR JURISDICTION THEN FIRST THREE POSITIONS MUST EQUAL THE PROVIDER STATE/COUNTRY CODE IN THE PROVIDER ADDRESS AND THE LAST SIX POSITIONS MUST BE NUMERIC. ELEMENT NAME: PROVIDER SUB-IDENTIFIER (3-010) VALIDITY EDITS 3-010-01V LAST TWO DIGITS MUST BE NUMERIC. Relational Edits NONE ELEMENT NAME: PROVIDER TAXPAYER NUMBER IDENTIFIER (3-015) VALIDITY EDITS 3-015-01V MUST BE A VALID PROVIDER TAXPAYER NUMBER IDENTIFIER. Relational Edits 3-015-01R IF THIRD POSITION OF PROVIDER STATE/COUNTRY CODE = BLANK (NOT A FOREIGN COUNTRY) OR PROVIDER STATE/COUNTRY CODE = PRI PUERTO RICO AND INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR = I INSTITUTIONAL THEN PROVIDER TAXPAYER NUMBER IDENTIFIER MUST = E INDICATES EIN ELEMENT NAME: CONTRACTOR NUMBER (3-020) VALIDITY EDITS 3-020-01V MUST BE A VALID CONTRACTOR NUMBER (REFER TO Section 2.10). Relational Edits NONE ELEMENT NAME: PROVIDER CONTRACT AFFILIATION CODE (3-025) VALIDITY EDITS 3-025-01V MUST BE A VALID PROVIDER CONTRACT AFFILIATION CODE (REFER TO Section 2.10). Relational Edits 3-025-02R IF PROVIDER CONTRACT AFFILIATION CODE = 5 NON-CERTIFIED PROVIDERS THEN PROVIDER ACCEPTANCE DATE MUST = ZEROES AND PROVIDER TERMINATION DATE MUST = ZEROES ELEMENT NAME: INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR (3-030) VALIDITY EDITS 3-030-01V MUST BE A VALID INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR Relational Edits NONE ELEMENT NAME: PROVIDER NAME1 (3-035) 1 AN APOSTROPHE IS AN ALLOWED CHARACTER IN PROVIDER’S NAME. VALIDITY EDITS 3-035-01V MUST BE LEFT JUSTIFIED AND BLANK FILLED. MUST NOT BE ALL SPACES. NO BLANKS IN A ROW ALLOWED UNTIL BLANK FILLING. Relational Edits NONE ELEMENT NAME: PROVIDER STREET ADDRESS (3-045) VALIDITY EDITS 3-045-01V IF THIRD POSITION OF PROVIDER STATE/COUNTRY CODE = BLANK (NOT A FOREIGN COUNTRY) THEN PROVIDER STREET ADDRESS MUST BE LEFT JUSTIFIED AND BLANK FILLED. NO BLANKS IN A ROW ALLOWED UNTIL BLANK FILLING. MUST NOT BE ALL BLANKS. Relational Edits NONE ELEMENT NAME: PROVIDER CITY (3-050) VALIDITY EDITS 3-050-01V MUST BE LEFT JUSTIFIED AND BLANK FILLED. TWO BLANKS IN A ROW NOT ALLOWED UNTIL BLANK FILLING. MUST NOT BE ALL BLANKS. Relational Edits NONE ELEMENT NAME: PROVIDER STATE OR COUNTRY CODE (3-055) VALIDITY EDITS 3-055-01V MUST BE A VALID PROVIDER STATE OR COUNTRY CODE IN Addendums A OR B. Relational Edits NONE ELEMENT NAME: PROVIDER ZIP CODE (3-060) 1 WHEN FOREIGN COUNTRY CODES ARE SUBMITTED, THE FIRST THREE CHARACTERS WILL BE EDITED AGAINST Addendum A. 2 DO NOT PERFORM THIS EDIT IF PROVIDER ZIP CODE IS A THREE CHARACTER COUNTRY CODE (BASED ON THE COUNTRY CODES TABLE). VALIDITY EDITS 3-060-01V MUST BE NINE DIGITS OR FIVE DIGITS WITH FOUR BLANKS MUST BE A VALID ZIP CODE (BASED ON CURRENT SYSTEM DATE) IN THE GOVERNMENT PROVIDED ELECTRONIC ZIP CODE FILE UNLESS TRANSACTION CODE = I INACTIVATE A RECORD OR M MODIFY A RECORD OR MUST BE A THREE CHARACTER FOREIGN COUNTRY CODE (BASED ON THE COUNTRY CODES TABLE1) FOLLOWED BY SIX BLANKS Relational Edits 3-060-01R PROVIDER ZIP CODE MUST BE WITHIN THE CONTRACTOR NUMBER AREA OF RESPONSIBILITY (REFER TO Addendum I FOR A LISTING OF VALID STATES FOR EACH CONTRACTOR NUMBER)2. ELEMENT NAME: PROVIDER BILLING STREET ADDRESS (3-070) VALIDITY EDITS 3-070-01V MUST BE LEFT JUSTIFIED AND BLANK FILLED. TWO BLANKS IN A ROW NOT ALLOWED UNTIL BLANK FILLING. Relational Edits NONE ELEMENT NAME: PROVIDER BILLING CITY (3-075) VALIDITY EDITS 3-075-01V MUST BE LEFT JUSTIFIED AND BLANK FILLED. TWO BLANKS IN A ROW NOT ALLOWED UNTIL BLANK FILLING. Relational Edits NONE ELEMENT NAME: PROVIDER BILLING STATE OR COUNTRY CODE (3-080) VALIDITY EDITS 3-080-01V MUST BE ALL BLANKS OR AS LISTED IN Addendums A OR B. Relational Edits NONE ELEMENT NAME: PROVIDER BILLING ZIP CODE (3-085) 1 WHEN FOREIGN COUNTRY CODES ARE SUBMITTED, THE FIRST THREE CHARACTERS WILL BE EDITED AGAINST Addendum A. VALIDITY EDITS 3-085-01V MUST BE 9 BLANKS OR MUST BE NINE DIGITS OR FIVE DIGITS WITH FOUR BLANKS MUST BE A VALID ZIP CODE (BASED ON CURRENT SYSTEM DATE) IN THE GOVERNMENT PROVIDED ELECTRONIC ZIP CODE FILE OR MUST BE A THREE CHARACTER FOREIGN COUNTRY CODE (BASED ON THE COUNTRY CODES TABLE1) FOLLOWED BY SIX BLANKS Relational Edits NONE ELEMENT NAME: PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION (3-090) VALIDITY EDITS NONE Relational Edits 3-090-01R IF INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR = I INSTITUTIONAL THEN MUST BE VALID PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION (REFER TO Addendum D, Figure 2.D-1). 3-090-02R IF INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR = N NON-INSTITUTIONAL THEN MUST BE A VALID PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION (REFER TO HTTP://WWW.WPC-EDI.COM/REFERENCE/). 3-090-03R IF PROVIDER MAJOR SPECIALTY/TYPE INSTITUTION = 183500000X (PHARMACY SERVICE PROVIDERS/PHARMACIST) THEN CONTRACTOR NUMBER MUST = 02 TMOP OR 70 TPHARM OR 73 TPHARM ELEMENT NAME: TYPE OF INSTITUTION TERM INDICATOR CODE (3-095) VALIDITY EDITS 3-095-01V MUST BE A VALID TYPE OF INSTITUTION TERM INDICATOR CODE. Relational Edits 3-095-01R IF TYPE OF INSTITUTION CODE TERM INDICATOR = L LONG TERM OR S SHORT TERM THEN INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR MUST = I INSTITUTIONAL - END -