TRICARE Manuals - Display Chap 2 Sect 5.2 (Change 49, Jul 14, 2021)

TRICARE Encounter Data (TED)

Chapter 2

Section 5.2

Institutional Edit Requirements (ELN 100 - 199)

Revision: C-48, April 9, 2021

ELEMENT NAME: PERSON SEX (PATIENT) (1-100)
VALIDITY EDITS
1-100-01V	PERSON SEX (PATIENT) MUST =	F	FEMALE OR
		M	MALE OR
		Z	UNKNOWN
Relational Edits
	NONE

ELEMENT NAME: PATIENT ZIP CODE (1-105)
1 WHEN FOREIGN COUNTRY CODES ARE SUBMITTED, THE FIRST THREE CHARACTERS WILL BE EDITED AGAINST Addendum A.
VALIDITY EDITS
1-105-01V	MUST BE NINE DIGITS OR FIVE DIGITS WITH FOUR BLANKS
	MUST BE A VALID ZIP CODE (BASED ON ADMISSION 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: ENROLLMENT/HEALTH PLAN CODE (1-110)
1 PATIENT AGE IS CALCULATED BASED ON PERSON BIRTH CALENDAR DATE (PATIENT) AND BEGIN DATE OF CARE.
VALIDITY EDITS
1-110-01V	MUST BE A VALID ENROLLMENT/HEALTH PLAN CODE (REFER TO Section 2.5).
Relational Edits
1-110-02R	IF ENROLLMENT/HEALTH PLAN CODE =	Y	CHCBP - NON-NETWORK OR
		AA	CHCBP - NETWORK
	THEN NO OCCURRENCE OF SPECIAL PROCESSING CODE CAN =	CL	CLINICAL TRIALS OR
		PF	ECHO
1-110-06R	IF ENROLLMENT/HEALTH PLAN CODE =	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
	THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	AN	SHCP - NON-MTF/eMSM-REFERRED CARE OR
		AR	SHCP - MTF/eMSM REFERRED CARE OR
		CE	SHCP - CCEP OR
		SC	SHCP - NON-TRICARE ELIGIBLE OR
		SE	SHCP - TRICARE ELIGIBLE OR
		SM	SHCP - EMERGENCY
1-110-09R	• TFL CLAIMS: THE BEGIN DATE OF CARE MUST BE ≥ 10/01/2001. WHEN BEGIN DATE OF CARE IS < 10/01/2001, THE OCCURRENCE/LINE ITEM MUST CONTAIN AN ADJUSTMENT/DENIAL REASON CODE LISTED IN THIS EDIT.
	IF ENROLLMENT/HEALTH PLAN CODE =	FE	TFL - NETWORK OR
		FS	TFL - NON-NETWORK
	AND TYPE OF INSTITUTION ≠	10	GENERAL MEDICAL AND SURGICAL
	THEN BEGIN DATE OF CARE MUST BE ≥ 10/01/2001
	AND AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	FF	TFL (FIRST PAYOR-NOT A MEDICARE BENEFIT) OR
		FG	TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) OR
		FS	TFL (SECOND PAYOR)
	ELSE IF BEGIN DATE OF CARE IS < 10/01/2001
	THEN ADJUSTMENT/DENIAL REASON CODE FOR THAT DETAILED OCCURRENCE/LINE ITEM (EXCEPT FOR LINE CONTAINING REVENUE CODE 0001) MUST =	15	PAYMENT ADJUSTED BECAUSE THE SUBMITTED AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES NOT APPLY TO THE BILLED SERVICES OR PROVIDER OR
		26	EXPENSES INCURRED PRIOR TO COVERAGE OR
		27	EXPENSES INCURRED AFTER COVERAGE TERMINATED OR
		30	PAYMENT ADJUSTED BECAUSE THE PATIENT HAS NOT MET THE REQUIRED ELIGIBILITY, SPEND DOWN, WAITING OR RESIDENCY REQUIREMENTS O
		31	CLAIM DENIED AS PATIENT CANNOT BE IDENTIFIED AS OUR INSURED OR
		32	OUR RECORDS INDICATE THAT THIS DEPENDENT IS NOT AN ELIGIBLE DEPENDENT AS DEFINED OR
		33	CLAIM DENIED. INSURED HAS NO DEPENDENT COVERAGE OR
		34	CLAIM DENIED. INSURED HAS NO COVERAGE FOR NEWBORN OR
		62	PAYMENT DENIED/REDUCED FOR ABSENCE OF, OR EXCEEDED, PRE-CERTIFICATION/AUTHORIZATION OR
		141	CLAIM ADJUSTMENT BECAUSE THE CLAIM SPANS ELIGIBLE AND INELIGIBLE PERIODS OF COVERAGE
1-110-10R	• TFL CLAIMS: THE BEGIN DATE OF CARE MUST BE ≥ 10/01/2001 UNLESS THE BENEFICIARY IS AN INPATIENT AND THE ADMISSION DATE WAS PRIOR TO 10/01/2001, TFL WILL PAY FOR THE ENTIRE HOSPITAL STAY.
	IF ENROLLMENT/HEALTH PLAN CODE =	FE	TFL - NETWORK OR
		FS	TFL - NON-NETWORK
	AND TYPE OF INSTITUTION =	10	GENERAL MEDICAL AND SURGICAL
	THEN END DATE OF CARE ≥ 10/01/2001
	AND AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	FF	TFL (FIRST PAYOR-NOT A MEDICARE BENEFIT) OR
		FG	TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) OR
		FS	TFL (SECOND PAYOR)
1-110-12R	IF BEGIN DATE OF CARE IS ≥ 01/01/2018
	AND ENROLLMENT/HEALTH PLAN CODE =	ME	MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NETWORK OR
		MS	MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NON-NETWORK
	THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	R	MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NOT A MEDICARE BENEFIT) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
		T	MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 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

ELEMENT NAME: HEALTH CARE DELIVERY PROGRAM (HCDP) PLAN COVERAGE CODE (1-111)
VALIDITY EDITS
1-111-01V	MUST BE A VALID HCDP PLAN COVERAGE CODE LISTED IN Addendum L.
1-111-02V	IF FILING DATE ≥ 09/01/2007
	AND HCDP PLAN COVERAGE CODE =	109	TRICARE USFHP DIRECT CARE COVERAGE FOR ADFMs OR
		114	TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
		115	TRICARE USFHP DIRECT CARE FAMILY COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
		118	TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE FOR RETIRED SPONSORS AND FAMILY MEMBERS OR
		119	TRICARE USFHP DIRECT CARE FAMILY COVERAGE FOR RETIRED SPONSORS AND FAMILY MEMBERS OR
		133	TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE FOR TRANSITIONAL SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
		138	TRICARE USFHP DIRECT CARE INDIVUDUAL COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
		139	TRICARE USFHP DIRECT CARE FAMILY COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
		316	USFHP PRIME - SPONSOR AND FAMILY MEMBERS (PRESENTATION ONLY)
	THEN AMOUNT ALLOWED (TOTAL) MUST = ZERO
Relational Edits
1-111-01R	IF 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	TRICARE RETIRED RESERVE (TRR) MEMBER-ONLY COVERAGE OR
		419	TRR MEMBER AND FAMILY COVERAGE OR
		420	TRR SURVIVOR INDIVIDUAL COVERAGE OR
		421	TRR SURVIVOR FAMILY COVERAGE
	THEN ENROLLMENT/HEALTH PLAN CODE MUST =	T	TRICARE STANDARD OR
		V	TRICARE EXTRA OR
		FE	TFL - NETWORK OR
		FS	TFL - NON-NETWORK OR
		ME	MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NETWORK OR
		MS	MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NON NETWORK OR
		PS	TSRX OR
		SR	SHCP - MTF/eMSM REFERRED CARE
		TV	TRICARE SELECT
1-111-02R	IF HCDP PLAN COVERAGE CODE =	305	TRICARE SELECT - RETIRED SPONSORS AND FAMILY MEMBERS OR
		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
	THEN NO OCCURRENCE OF SPECIAL PROCESSING CODE CAN =	PF	ECHO
1-111-03R	IF HCDP PLAN COVERAGE CODE =	417	TCSRC
	THEN ENROLLMENT/HEALTH PLAN CODE MUST =	X	FOREIGN SERVICE MEMBER OR
		SR	SHCP - MTF/eMSM REFERRED CARE

ELEMENT NAME: REGION INDICATOR (1-112)
VALIDITY EDITS
1-112-01V	MUST BE VALID REGION INDICATOR (REFER TO Section 2.8).
1-112-02V	IF TYPE OF SUBMISSION ≠	B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	AND REGION INDICATOR =	NC	NORTH CONTRACT OR
		OC	OVERSEAS CONTRACT OR
		SC	SOUTH CONTRACT OR
		WC	WEST CONTRACT OR
		E7	EAST CONTRACT 2017 OR
		W7	WEST CONTRACT 2017
	THEN ADJUSTMENT KEY MUST =	0	BATCH OR
		5	VOUCHER
Relational Edits
	NONE

ELEMENT NAME: PCM LOCATION DMIS-ID (ENROLLMENT) CODE (1-115)
VALIDITY EDITS
1-115-01V	MUST BE A VALID FOUR DIGIT PCM LOCATION DMIS-ID.
1-115-03V	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
		0197	CHRISTUS HEALTH/ST MARY’S OR
		0198	MARTIN’S POINT HEALTH CARE OR
		0199	FAIRVIEW HEALTH SYSTEM
	THEN AMOUNT ALLOWED (TOTAL) MUST = ZERO
Relational Edits
	NONE

ELEMENT NAME: AMOUNT BILLED (TOTAL) (1-120)
VALIDITY EDITS
1-120-01V	MUST BE NUMERIC.
Relational Edits
1-120-01R	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 BILLED (TOTAL) MUST BE > ZERO
	UNLESS ANY OCCURRENCE/LINE ITEM REVENUE CODE = 0022, 0023, OR 0024
	AND AMOUNT ALLOWED (TOTAL) = ZERO
1-120-02R	AMOUNT BILLED (TOTAL) MUST = TOTAL CHARGE BY REVENUE CODE FOR REVENUE CODE 0001

ELEMENT NAME: AMOUNT ALLOWED (TOTAL) (1-125)
VALIDITY EDITS
1-125-01V	MUST BE NUMERIC.
Relational Edits
1-125-01R	IF TYPE OF SUBMISSION =	C	COMPLETE CANCELLATION OR
		D	COMPLETE DENIAL
	THEN AMOUNT ALLOWED (TOTAL) MUST = ZERO
	AND ALL OCCURRENCES/LINE ITEMS (EXCLUDING REVENUE CODE 0001) MUST CONTAIN A DENIAL CODE LISTED IN Addendum G, Figure 2.G-1 OR Figure 2.G-2.
1-125-02R	IF ALL DETAIL ADJUSTMENT/DENIAL REASON CODES CONTAIN A DENIAL CODE (REFER TO Addendum G, Figure 2.G-1 OR Figure 2.G-2).
	AND TYPE OF SUBMISSION =	B	ADJUSTMENT NON-TED RECORD (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	THEN AMOUNT ALLOWED (TOTAL) MUST BE ≤ ZERO
1-125-03R	IF TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		I	INITIAL SUBMISSION OR
		O	ZERO PAYMENT WITH 100% OHI/TPL OR
		R	RESUBMISSION
	THEN AMOUNT ALLOWED (TOTAL) MUST BE > ZERO
1-125-04R	IF AMOUNT ALLOWED (TOTAL) = ZERO
	THEN AMOUNT PAID BY GOVERNMENT CONTRACTOR (TOTAL) MUST = ZERO
	UNLESS TYPE OF SUBMISSION =	B	ADJUSTMENT NON-TED RECORD (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA

ELEMENT NAME: AMOUNT PAID BY OTHER HEALTH INSURANCE (1-130)
VALIDITY EDITS
1-130-01V	MUST BE NUMERIC.
Relational Edits
1-130-01R	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 OF OTHER HEALTH INSURANCE MUST BE ≥ ZERO
1-130-03R	IF AMOUNT PAID BY OTHER HEALTH INSURANCE > ZERO
	AND AMOUNT ALLOWED (TOTAL) > ZERO
	AND AMOUNT PAID BY GOVERNMENT CONTRACTOR (TOTAL) = ZERO
	AND DATE ADJUSTMENT IDENTIFIER = ZEROES
	THEN TYPE OF SUBMISSION MUST =	O	ZERO PAYMENT TED RECORD DUE TO 100% OHI
	UNLESS THE AMOUNT PATIENT COST-SHARE = THE AMOUNT ALLOWED (TOTAL)

ELEMENT NAME: OTHER GOVERNMENT PROGRAM (OGP) TYPE CODE (1-131)
VALIDITY EDITS
1-131-01V	MUST BE A VALID OGP TYPE CODE LISTING IN Section 2.6.
Relational Edits
1-131-01R	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 (1-132)
VALIDITY EDITS
1-132-01V	MUST BE A VALID OGP BEGIN REASON CODE LISTING IN Section 2.6.
Relational Edits
	NONE

ELEMENT NAME: AMOUNT PATIENT COST-SHARE (1-135)
VALIDITY EDITS
1-135-01V	MUST BE NUMERIC.
Relational Edits
1-135-01R	IF TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		I	INITIAL SUBMISSION OR
		O	ZERO PAYMENT WITH 100% OHI/TPL OR
		R	RESUBMISSION
	THEN AMOUNT PATIENT COST-SHARE MUST BE ≥ ZERO
1-135-02R	IF TYPE OF SUBMISSION =	C	COMPLETE CANCELLATION OR
		D	COMPLETE DENIAL
	THEN AMOUNT PATIENT COST-SHARE MUST BE = ZERO

ELEMENT NAME: HEALTH CARE COVERAGE (HCC) COPAYMENT FACTOR CODE (1-136)
VALIDITY EDITS
1-136-01V	MUST BE A VALID HCC COPAYMENT FACTOR CODE LISTING IN Section 2.5.
Relational Edits
	NONE

ELEMENT NAME: AMOUNT PAID BY GOVERNMENT CONTRACTOR (TOTAL) (1-140)
VALIDITY EDITS
1-140-01V	MUST BE NUMERIC.
Relational Edits
1-140-01R	IF TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		I	INITIAL SUBMISSION OR
		R	RESUBMISSION
	THEN AMOUNT PAID BY GOVERNMENT CONTRACTOR (TOTAL) MUST BE ≥ ZERO
1-140-02R	IF TYPE OF SUBMISSION =	C	COMPLETE CANCELLATION OR
		D	COMPLETE DENIAL OR
		O	ZERO PAYMENT WITH 100% OHI/TPL
	THEN AMOUNT PAID BY GOVERNMENT CONTRACTOR (TOTAL) MUST = ZERO

ELEMENT NAME: AMOUNT INTEREST PAYMENT (1-145)
1 REDUCTIONS IN INTEREST MUST BE PROCESSED USING SAME REASON CODE AS PAYMENT TO ENSURE DHA ACCOUNTING SYSTEM PROCESSES TRANSACTION CORRECTLY.
VALIDITY EDITS
1-145-01V	MUST BE NUMERIC.
Relational Edits
1-145-01R	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
1-145-02R	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 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)
1-145-04R	IF TYPE OF SUBMISSION =	C	COMPLETE CANCELLATION OR
		D	COMPLETE DENIAL
	THEN AMOUNT INTEREST PAYMENT MUST BE = ZERO
1-145-05R	IF TRANSACTION RECORD AMOUNT INTEREST PAYMENT < ZERO AND REASON FOR INTEREST PAYMENT =	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 REASON FOR INTEREST PAYMENT MUST = REASON FOR INTEREST PAYMENT FOUND ON DATABASE1

ELEMENT NAME: REASON FOR INTEREST PAYMENT (1-150)
VALIDITY EDITS
1-150-01V	MUST BE A VALID REASON FOR INTEREST PAYMENT CODE (BASED ON BEGIN DATE OF CARE) (REFER TO Section 2.8).
	AND THE BEGIN DATE OF CARE MUST BE ON OR AFTER THE CARE EFFECTIVE DATE AND ON OR BEFORE THE CARE TERMINATION DATE
Relational Edits
1-150-01R	IF TRANSACTION RECORD REASON FOR INTEREST PAYMENT =	A	CLAIMS PENDED AT GOVERNMENT DIRECTION (TERMINATED 07/08/2019) OR
		B	CLAIMS REQUIRING GOVERNMENT INTERVENTION 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 07/09/2019)
	THEN TRANSACTION RECORD AMOUNT INTEREST PAYMENT MUST ≠ ZERO

ELEMENT NAME: OVERRIDE CODE (1-160)
VALIDITY EDITS
1-160-01V	OCCURRENCE NUMBER 1--MUST BE A VALID OVERRIDE CODE (REFER TO Section 2.6).
1-160-02V	OCCURRENCE NUMBER 2--MUST BE A VALID OVERRIDE CODE (REFER TO Section 2.6).
1-160-03V	OCCURRENCE NUMBER 3--MUST BE A VALID OVERRIDE CODE (REFER TO Section 2.6).
1-160-04V	A VALUE CANNOT BE CODED MORE THAN ONCE (EXCEPT BLANK).
1-160-05V	ALL OCCURRENCES OF OVERRIDE CODE MUST BE BLANK FILLED FOLLOWING THE FIRST OCCURRENCE OF A BLANK FILLED OVERRIDE CODE.
Relational Edits
1-160-13R	IF ANY OCCURRENCE OF OVERRIDE CODE =	NC	NON-CERTIFIED PROVIDER (DOES NOT INCLUDE SANCTIONED/SUSPENDED PROVIDERS)
	THEN ANY OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	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
		EU	EMERGENCY SERVICES RENDERED BY AN UNAUTHORIZED PROVIDER 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 MUST =	SN	SHCP - NON-MTF/eMSM-REFERRED CARE OR
		SR	SHCP - MTF/eMSM REFERRED CARE

ELEMENT NAME: TYPE OF SUBMISSION (1-165)
VALIDITY EDITS
1-165-01V	VALUE MUST BE A VALID TYPE OF SUBMISSION.
1-165-02V	IF TYPE OF SUBMISSION =	B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	THEN ADJUSTMENT KEY CANNOT =	0	BATCH OR
		5	VOUCHER
1-165-03V	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 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 OF NON-TED RECORD (HCSR) DATA
	UNLESS THE RECORD HAS PROVISIONAL ERRORS
1-165-04V	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
1-165-01R	IF TYPE OF SUBMISSION =	O	ZERO PAYMENT WITH 100% OHI/TPL
	THEN THE AMOUNT OF OHI MUST BE > ZERO
	AND AMOUNT ALLOWED (TOTAL) MUST BE > ZERO
	AND AMOUNT PAID BY GOVERNMENT CONTRACTOR (TOTAL) MUST BE = ZERO
1-165-02R	IF ALL OCCURRENCES/LINE ITEMS (EXCLUDING REVENUE CODE 0001) CONTAIN AN ADJUSTMENT/DENIAL REASON CODE LISTED IN 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
1-165-04R	IF BATCH/VOUCHER RESUBMISSION NUMBER = ZERO FOR THIS BATCH OR VOUCHER
	THEN TYPE OF SUBMISSION MUST ≠	R	RESUBMISSION
1-165-05R	IF BATCH/VOUCHER RESUBMISSION NUMBER > ZERO FOR THIS BATCH OR VOUCHER
	THEN TYPE OF SUBMISSION MUST BE ≠	I	INITIAL TED RECORD SUBMISSION
1-165-06R	IF TYPE OF SUBMISSION =	I	INITIAL SUBMISSION OR
		R	RESUBMISSION
	AND TYPE OF INSTITUTION ≠	70	HHA OR
		71	SNF
	AND SPECIAL PROCESSING CODE ≠	11	HOSPICE
	THEN AMOUNT BILLED (TOTAL), AMOUNT ALLOWED (TOTAL), COVERED DAYS, AND TOTAL CHARGE BY REVENUE CODE MUST BE > 0.
1-165-07R	IF TYPE OF SUBMISSION =	B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	THEN BEGIN DATE OF CARE MUST BE < 10/01/2010

ELEMENT NAME: CA/NAS NUMBER (1-170)
1 CATCHMENT AREA DETERMINATION IS BASED ON ADMISSION DATE. 2 MTF/eMSM IS A 40 MILES CATCHMENT AREA.
VALIDITY EDITS
1-170-01V	IF BEGIN DATE OF CARE ≥ 03/28/2013
	THEN CA/NAS NUMBER MUST BE BLANK
	ELSE IF CA/NAS NUMBER IS NOT BLANK.
	THEN MUST BE 1 TO 11 OR 1 TO 15 ALPHANUMERIC CHARACTERS.
Relational Edits
NO ERROR	IF TYPE OF SUBMISSION =	C	COMPLETE CANCELLATION OR
		D	COMPLETE DENIAL
	THEN BYPASS ALL CA/NAS NUMBER RELATIONAL EDITING.
NO ERROR	IF ADMISSION DATE IS OLDER THAN SIX YEARS
	THEN DO NOT CHECK IF ZIP CODE IS IN CATCHMENT AREA
NO ERROR	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	R	MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NOT A MEDICARE BENEFIT) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
		T	MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
		AN	SHCP - NON-MTF/eMSM-REFERRED CARE OR
		AR	SHCP - MTF/eMSM REFERRED CARE OR
		CE	SHCP - CCEP OR
		PF	ECHO 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 OR
		SC	SHCP - NON-TRICARE ELIGIBLE OR
		SE	SHCP - TRICARE ELIGIBLE OR
		SM	SHCP - EMERGENCY OR
		ST	SPECIALIZED TREATMENT OR
		WR	MENTAL HEALTH WRAP AROUND
	THEN BYPASS ALL CA/NAS NUMBER EDITING
NO ERROR	IF ENROLLMENT/HEALTH PLAN CODE =	U	TRICARE PRIME, CIVILIAN PCM OR
		W	TPR SERVICE MEMBER - USA OR
		X	FOREIGN SERVICE MEMBER OR
		Y	CHCBP - NON-NETWORK OR
		Z	TRICARE PRIME, MTF/eMSM/PCM OR
		AA	CHCBP - NETWORK OR
		BB	TSP OR
		FE	TFL - NETWORK OR
		FS	TFL - NON-NETWORK OR
		SN	SHCP - NON-MTF/eMSM-REFERRED CARE OR
		SR	SHCP - MTF/eMSM REFERRED CARE OR
		WF	TPR FOR ENROLLED ADFM RESIDING WITH A TPR ELIGIBLE SERVICE MEMBER
	THEN BYPASS ALL CA/NAS NUMBER EDITING
NO ERROR	IF HCC MEMBER CATEGORY CODE =	T	FOREIGN MILITARY MEMBER
	THEN BYPASS ALL CA/NAS NUMBER EDITING
NO ERROR	IF ANY OCCURRENCE OF ADJUSTMENT/DENIAL REASON CODE =	15	PAYMENT ADJUSTED BECAUSE THE SUBMITTED AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES NOT APPLY TO THE BILLED SERVICES OR PROVIDER OR
		26	EXPENSES INCURRED PRIOR TO COVERAGE OR
		27	EXPENSES INCURRED AFTER COVERAGE TERMINATED OR
		30	PAYMENT ADJUSTED BECAUSE THE PATIENT HAS NOT MET THE REQUIRED ELIGIBILITY, SPEND DOWN, WAITING, OR RESIDENCY REQUIREMENTS OR
		31	CLAIM DENIED AS PATIENT CANNOT BE IDENTIFIED AS OUR INSURED OR
		32	OUR RECORDS INDICATE THAT THIS DEPENDENT IS NOT AN ELIGIBLE DEPENDENT AS DEFINED OR
		33	CLAIM DENIED. INSURED HAS NO DEPENDENT COVERAGE OR
		34	CLAIM DENIED. INSURED HAS NO COVERAGE FOR NEWBORNS OR
		62	PAYMENT DENIED/REDUCED FOR ABSENCE OF, OR EXCEEDED, PRE-CERTIFICATION/AUTHORIZATION OR
		141	CLAIM ADJUSTMENT BECAUSE THE CLAIM SPANS ELIGIBLE AND INELIGIBLE PERIODS OF COVERAGE
	THEN BYPASS ALL CA/NAS NUMBER EDITING
NO ERROR	IF AMOUNT OF OTHER HEALTH INSURANCE PAID IS > ZERO
	THEN NO CA/NAS IS REQUIRED -- BYPASS ALL CA/NAS NUMBER EDITING.
1-170-02R	IF CA/NAS EXCEPTION REASON IS NOT BLANK
	THEN CA/NAS NUMBER MUST = BLANK
1-170-03R	IF CA/NAS EXCEPTION REASON = BLANK
	AND PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) =	290-316 (MENTAL HEALTH, ICD-9-CM)
	AND PATIENT ZIP CODE IS IN AN MTF/eMSM2 CATCHMENT AREA1
	AND BEGIN DATE OF CARE IS < 03/28/2013
	THEN CA/NAS NUMBER MUST BE CODED
	UNLESS ANY OCCURRENCE OF OVERRIDE CODE =	C	GOOD FAITH PAYMENT
1-170-04R	IF CA/NAS NUMBER IS CODED
	THEN CA/NAS EXCEPTION REASON MUST = BLANK

ELEMENT NAME: CA/NAS REASON FOR ISSUANCE (1-175)
VALIDITY EDITS
1-175-01V	IF BEGIN DATE OF CARE ≥ 03/28/2013
	THEN CA/NAS REASON FOR ISSUANCE MUST BE BLANK
	ELSE VALUE MUST BE A VALID CA/NAS REASON OF ISSUANCE OR BLANK.
Relational Edits
1-175-02R	IF CA/NAS NUMBER IS BLANK
	THEN CA/NAS REASON FOR ISSUANCE MUST = BLANK.

ELEMENT NAME: CA/NAS EXCEPTION REASON (1-180)
1 CATCHMENT AREA DETERMINATION IS BASED ON ADMISSION DATE. 2 MTF/eMSM IS A 40 MILES CATCHMENT AREA.
VALIDITY EDITS
1-180-01V	IF BEGIN DATE OF CARE ≥ 03/28/2013
	THEN CA/NAS EXCEPTION REASON MUST BE BLANK
	ELSE VALUE MUST BE A VALID CA/NAS EXCEPTION REASON CODE OR BLANK (REFER TO Section 2.4).
Relational Edits
NO ERROR	IF TYPE OF SUBMISSION =	C	COMPLETE CANCELLATION OR
		D	COMPLETE DENIAL
	THEN BYPASS ALL CA/NAS EXCEPTION REASON EDITING.
NO ERROR	IF ADMISSION DATE IS OLDER THAN SIX YEARS
	THEN DO NOT CHECK IF ZIP CODE IS IN CATCHMENT AREA
NO ERROR	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	R	MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NOT A MEDICARE BENEFIT) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
		T	MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
		AN	SHCP - NON-MTF/eMSM-REFERRED CARE OR
		AR	SHCP - MTF/eMSM REFERRED CARE OR
		CE	SHCP - CCEP OR
		PF	ECHO 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 OR
		SC	SHCP - NON-TRICARE ELIGIBLE OR
		SE	SHCP - TRICARE ELIGIBLE OR
		SM	SHCP - EMERGENCY OR
		ST	SPECIALIZED TREATMENT OR
		WR	MENTAL HEALTH WRAP AROUND
	THEN BYPASS ALL CA/NAS EXCEPTION REASON EDITING
NO ERROR	IF ENROLLMENT/HEALTH PLAN CODE =	U	TRICARE PRIME, CIVILIAN PCM OR
		W	TPR SERVICE MEMBER - USA OR
		X	FOREIGN SERVICE MEMBER OR
		Y	CHCBP - NON-NETWORK OR
		Z	TRICARE PRIME, MTF/eMSM/PCM OR
		AA	CHCBP - NETWORK OR
		BB	TSP OR
		FE	TFL - NETWORK OR
		FS	TFL - NON-NETWORK OR
		SN	SHCP - NON-MTF/eMSM-REFERRED CARE OR
		SR	SHCP - MTF/eMSM REFERRED CARE OR
		WF	TPR FOR ENROLLED ADFM RESIDING WITH A TPR ELIGIBLE SERVICE MEMBER
	THEN BYPASS ALL CA/NAS EXCEPTION REASON EDITING
NO ERROR	IF HCC MEMBER CATEGORY CODE =	T	FOREIGN MILITARY MEMBER
	THEN BYPASS ALL CA/NAS EXCEPTION REASON EDITING
NO ERROR	IF ANY OCCURRENCE OF ADJUSTMENT/DENIAL REASON CODE =	15	PAYMENT ADJUSTED BECAUSE THE SUBMITTED AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES NOT APPLY TO THE BILLED SERVICES OR PROVIDER OR
		26	EXPENSES INCURRED PRIOR TO COVERAGE OR
		27	EXPENSES INCURRED AFTER COVERAGE TERMINATED OR
		30	PAYMENT ADJUSTED BECAUSE THE PATIENT HAS NOT MET THE REQUIRED ELIGIBILITY, SPEND DOWN, WAITING, OR RESIDENCY REQUIREMENTS OR
		31	CLAIM DENIED AS PATIENT CANNOT BE IDENTIFIED AS OUR INSURED OR
		32	OUR RECORDS INDICATE THAT THIS DEPENDENT IS NOT AN ELIGIBLE DEPENDENT AS DEFINED OR
		33	CLAIM DENIED. INSURED HAS NO DEPENDENT COVERAGE OR
		34	CLAIM DENIED. INSURED HAS NO COVERAGE FOR NEWBORNS OR
		62	PAYMENT DENIED/REDUCED FOR ABSENCE OF, OR EXCEEDED, PRE-CERTIFICATION/AUTHORIZATION OR
		141	CLAIM ADJUSTMENT BECAUSE THE CLAIM SPANS ELIGIBLE AND INELIGIBLE PERIODS OF COVERAGE
	THEN BYPASS ALL CA/NAS EXCEPTION REASON EDITING
NO ERROR	IF AMOUNT OF OTHER HEALTH INSURANCE PAID IS > ZERO
	THEN NO CA/NAS IS REQUIRED -- BYPASS ALL CA/NAS EXCEPTION REASON EDITING.
1-180-03R	IF PATIENT ZIP CODE IS IN AN MTF/eMSM2 CATCHMENT AREA1
	AND PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) =	290-316 (MENTAL HEALTH, ICD-9-CM)
	AND CA/NAS NUMBER IS NOT CODED
	AND BEGIN DATE OF CARE IS < 03/28/2013
	THEN CA/NAS EXCEPTION REASON MUST BE CODED
1-180-07R	IF CA/NAS EXCEPTION REASON =	5	RTC
	AND PATIENT ZIP CODE IS IN AN MTF/eMSM2 CATCHMENT AREA1
	THEN TYPE OF INSTITUTION =	72	RTC
1-180-08R	IF CA/NAS EXCEPTION REASON =	S	HHA PPS
	THEN TYPE OF INSTITUTION MUST =	70	HHA
	AND ONE OCCURRENCE OF REVENUE CODE MUST =	0023	HHA PPS

ELEMENT NAME: SPECIAL PROCESSING CODE (1-185)
1 PATIENT AGE IS CALCULATED BASED ON PERSON BIRTH CALENDAR DATE (PATIENT) AND CARE DATES.
VALIDITY EDITS
1-185-01V	OCCURRENCE NUMBER 1--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8).
1-185-02V	OCCURRENCE NUMBER 2--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8).
1-185-03V	OCCURRENCE NUMBER 3--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8).
1-185-04V	OCCURRENCE NUMBER 4--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8).
1-185-05V	A VALUE CANNOT BE CODED MORE THAN ONCE (EXCEPT BLANK).
1-185-06V	ALL OCCURRENCES OF SPECIAL PROCESSING CODE MUST BE BLANK FILLED FOLLOWING THE FIRST OCCURRENCE OF A BLANK FILLED SPECIAL PROCESSING CODE.
1-185-07V	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	AN	SHCP - NON-MTF/eMSM-REFERRED CARE OR
		AR	SHCP - MTF/eMSM REFERRED CARE
	THEN BEGIN DATE OF CARE MUST BE < 06/01/2004
1-185-08V	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	GF	TPR FOR ELIGIBLE ADFM RESIDING WITH A TPR ELIGIBLE SERVICE MEMBER
	THEN BEGIN DATE OF CARE MUST BE < 09/01/2002
1-185-10V	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	MN	TSP - NON-NETWORK OR
		MS	TSP - NETWORK
	THEN BEGIN DATE OF CARE MUST BE < 12/31/2001
1-185-11V	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	SN	TSS - NON-NETWORK OR
		SS	TSS - NETWORK
	THEN BEGIN DATE OF CARE MUST BE < 12/31/2002
1-185-14V	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	ST	SPECIALIZED TREATMENT
	THEN BEGIN DATE OF CARE MUST BE < 10/01/2004
Relational Edits
1-185-08R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	PO	TRICARE PRIME - POS
	THEN ENROLLMENT/HEALTH PLAN CODE MUST =	U	TRICARE PRIME (CIVILIAN PCM) OR
		Z	TRICARE PRIME, MTF/eMSM/PCM OR
		WF	TPR FOR ENROLLED ADFM RESIDING WITH A TPR ELIGIBLE SERVICE MEMBER OR
		XF	FOREIGN ADFM
1-185-14R	IF 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
		SC	SHCP - NON-TRICARE ELIGIBLE OR
		SE	SHCP - TRICARE ELIGIBLE OR
		SM	SHCP - EMERGENCY
	THEN ENROLLMENT/HEALTH PLAN CODE MUST =	SR	SHCP - MTF/eMSM REFERRED CARE OR
		SN	SHCP - NON-MTF/eMSM REFERRED CARE OR
		SO	SHCP - NON-TRICARE ELIGIBLE OR
		ST	SHCP - TRICARE ELIGIBLE
1-185-32R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	E	HHC/CM DEMO (AFTER 03/15/1999, GRANDFATHERED INTO THE ICMP)
	THEN BEGIN DATE OF CARE IS ≥ 03/15/1999
	AND AT LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	CM	ICMP
1-185-34R	• TFL CLAIMS: THE BEGIN DATE OF CARE MUST BE ≥ 10/01/2001. IF BEGIN DATE OF CARE IS < 10/01/2001, THE LINE ITEMS MUST CONTAIN AN ADJUSTMENT/DENIAL REASON CODE LISTED IN THIS EDIT.
	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	FF	TFL (FIRST PAYOR-NOT A MEDICARE BENEFIT) OR
		FG	TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) OR
		FS	TFL (SECOND PAYOR)
	AND TYPE OF INSTITUTION ≠	10	GENERAL MEDICAL AND SURGICAL
	THEN BEGIN DATE OF CARE MUST BE ≥ 10/01/2001
	AND ENROLLMENT/HEALTH PLAN CODE MUST =	FE	TFL - NETWORK OR
		FS	TFL - NON-NETWORK
	ELSE IF BEGIN DATE OF CARE IS < 10/01/2001
	THEN ADJUSTMENT/DENIAL REASON CODE FOR THAT DETAILED LINE ITEM (EXCEPT LINE CONTAINING REVENUE CODE 0001) MUST =	15	PAYMENT ADJUSTED BECAUSE THE SUBMITTED AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES NOT APPLY TO THE BILLED SERVICES OR PROVIDER OR
		26	EXPENSES INCURRED PRIOR TO COVERAGE OR
		27	EXPENSES INCURRED AFTER COVERAGE TERMINATED OR
		30	PAYMENT ADJUSTED BECAUSE THE PATIENT HAS NOT MET THE REQUIRED ELIGIBILITY, SPEND DOWN, WAITING, OR RESIDENCY REQUIREMENTS OR
		31	CLAIM DENIED AS PATIENT CANNOT BE IDENTIFIED AS OUR INSURED OR
		32	OUR RECORDS INDICATE THAT THIS DEPENDENT IS NOT AN ELIGIBLE DEPENDENT AS DEFINED OR
		33	CLAIM DENIED. INSURED HAS NO DEPENDENT COVERAGE OR
		34	CLAIM DENIED. INSURED HAS NO COVERAGE FOR NEWBORNS OR
		62	PAYMENT DENIED/REDUCED FOR ABSENCE OF, OR EXCEEDED, PRE-CERTIFICATION/AUTHORIZATION OR
		141	CLAIM ADJUSTMENT BECAUSE THE CLAIM SPANS ELIGIBLE AND INELIGIBLE PERIODS OF COVERAGE
1-185-35R	• TFL CLAIMS: THE BEGIN DATE OF CARE MUST BE ≥ 10/01/2001 UNLESS THE BENEFICIARY IS AN INPATIENT AND THE ADMISSION DATE WAS PRIOR TO 10/01/2001, TFL WILL PAY FOR THE ENTIRE HOSPITAL STAY.
	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	FF	TFL (FIRST PAYOR-NOT A MEDICARE BENEFIT) OR
		FG	TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, I.E., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) OR
		FS	TFL (SECOND PAYOR)
	AND TYPE OF INSTITUTION =	10	GENERAL MEDICAL AND SURGICAL
	THEN END DATE OF CARE MUST BE ≥ 10/01/2001
	AND ENROLLMENT/HEALTH PLAN CODE MUST =	FE	TFL - NETWORK OR
		FS	TFL - NON-NETWORK
1-185-39R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	PF	ECHO
	THEN HCDP PLAN COVERAGE CODE MUST ≠	305	TRICARE SELECT - RETIRED SPONSORS AND FAMILY MEMBERS OR
		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
1-185-49R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	AU	AUTISM DEMONSTRATION
	THEN BEGIN DATE OF CARE MUST BE ≥ 03/15/2008
	AND AT LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	PF	ECHO
	AND PATIENT AGE1 MUST BE ≥ 18 MONTHS
1-185-50R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	49	HOSPITAL REIMBURSEMENT REDUCED BY MANUFACTURER CREDIT/REPLACEMENT OF DEVICE DURING WARRANTY PERIOD OR
		50	HOSPITAL REIMBURSEMENT REDUCED BY MANUFACTURER CREDIT/RECALLED DEVICE
	THEN DRG NUMBER MUST EQUAL A DRG SUBJECT TO THE REPLACEMENT DEVICE POLICY POSTED ON TRICARE’S DRG WEB PAGE AT HTTP://WWW.HEALTH.MIL/DRG.
	AND IF END DATE OF CARE < 10/01/2014
	THEN DATE OF ADMISSION MUST BE ≥ THE DRG EFFECTIVE DATE AND ≤ THE DRG TERMINATION DATE AS PER THE REPLACEMENT DEVICE POLICY POSTED ON TRICARE’S DRG WEB PAGE AT HTTP://WWW.HEALTH.MIL/DRG.
	ELSE END DATE OF CARE MUST BE ≥ THE DRG EFFECTIVE DATE AND ≤ THE DRG TERMINATION DATE
1-185-51R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	PH	PHILIPPINES DEMONSTRATION PROJECT
	THEN BEGIN DATE OF CARE MUST BE ≥ 01/01/2013
	AND HCDP PLAN COVERAGE CODE MUST =	003	TRICARE STANDARD FOR ADFMs OR
		005	TRICARE STANDARD SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
		007	TRICARE STANDARD TRANSITIONAL ASSISTANCE SPONSORS AND FAMILY MEMBERS OR
		009	TRICARE STANDARD RETIRED AND MOH SPONSORS AND FAMILY MEMBERS OR
		010	TRICARE STANDARD TRANSITIONAL SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
		015	TRICARE STANDARD TRANSITIONAL SURVIVORS OF NG/RESERVE DECEASED SPONSORS OR
		017	TRICARE STANDARD SURVIVORS OF NG/RESERVE DECEASED SPONSORS OR
		018	TFL RETIRED SPONSORS AND FAMILY MEMBERS AND MOH OR
		020	TFL TRANSITIONAL SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
		021	TFL SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
		022	TFL TRANSITIONAL SURVIVORS OF NG/RESERVE DECEASED SPONSORS OR
		023	TFL SURVIVORS OF NG/RESERVE DECEASED SPONSORS OR
		028	TRICARE STANDARD FOR MEDICALLY RETIRED SPONSORS AND FAMILY MEMBERS OR
		029	TFL FOR MEDICALLY RETIRED SPONSORS AND FAMILY MEMBERS OR
		303	TRICARE SELECT - ADFMs OR
		304	TRICARE SELECT - TAMP SPONSORS AND FAMILY MEMBERS OR
		305	TRICARE SELECT - RETIRED SPONSORS AND FAMILY MEMBERS OR
		306	TRICARE SELECT - RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR
		307	TRICARE SELECT - RETIRED RESERVE SPONSORS AND FAMILY MEMBERS OR
		308	TRICARE SELECT - YOUNG ADULT OR
		409	TRS SURVIVOR CONTINUING INDIVIDUAL COVERAGE OR
		410	TRS SURVIVOR CONTINUING 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 OR
		422	TYA STANDARD FOR ADFMs OR
		423	TYA STANDARD FOR RETIRED AND MOH FAMILY MEMBERS OR
		424	TYA RESERVE SELECT OR
		425	TYA RETIRED RESERVE OR
		999	UNVERIFIED NEWBORN
	OR ENROLLMENT/HEALTH PLAN CODE =	AS	TRICARE SELECT - ACTIVE DUTY SURVIVORS OR
		AT	TRICARE SELECT - ACTIVE DUTY TRANSITIONAL SURVIVORS OR
		GS	TRICARE SELECT - GUARD/RESERVE SURVIVORSOR
		GT	TRICARE SELECT - GUARD/RESERVE TRANSITIONAL SURVIVORS
	AND PATIENT ZIP CODE MUST =	PHL	PHILIPPINES
	AND PROVIDER STATE OR COUNTRY CODE MUST =	PHL	PHILIPPINES
1-185-52R	IF BEGIN DATE OF CARE IS ≥ 01/01/2018
	AND ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	R	MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NOT A MEDICARE BENEFIT) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
		T	MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 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 ENROLLMENT/HEALTH PLAN CODE MUST =	U	TRICARE PRIME, CIVILIAN CARE OR
		Z	TRICARE PRIME, MTF/eMSM/PCM OR
		ME	MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NETWORK OR
		MS	MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NON-NETWORK OR
		WF	TPR FOR ENROLLMENT ADFM RESIDING WITH A TPR ELIGIBLE SERVICE MEMBER

ELEMENT NAME: HEALTH CARE DELIVERY PROGRAM (HCDP) SPECIAL ENTITLEMENT CODE (1-186)
VALIDITY EDITS
1-186-01V	MUST BE A VALID HCDP SPECIAL ENTITLEMENT CODE (REFER TO Section 2.5).
Relational Edits
	NONE

ELEMENT NAME: PRICING RATE CODE (1-190)
VALIDITY EDITS
1-190-01V	VALUE MUST BE A VALID INSTITUTIONAL PRICING RATE CODE.
Relational Edits
1-190-01R	IF FILING STATE/COUNTRY CODE =	MD	MARYLAND
	THEN PRICING RATE CODE MUST ≠	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
		S	HVBP ADJUSTMENT FACTOR OR
		CV	COVID-19 ADJUSTMENT FACTOR OR
		DD	DISCOUNTED DRG
1-190-02R	IF DRG NUMBER IS CODED (OTHER THAN ZERO)
	THEN PRICING RATE CODE MUST =	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
		S	HVBP ADJUSTMENT FACTOR OR
		U	SHCP CLAIM OR ACTIVE DUTY MEMBER GSU CLAIM PAID OUTSIDE NORMAL LIMITS OR
		V	MEDICARE REIMBURSEMENT RATE OR
		CV	COVID-19 ADJUSTMENT FACTOR OR
		DD	DISCOUNTED DRG
1-190-03R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	11	HOSPICE
	THEN PRICING RATE CODE MUST =	D	DISCOUNT RATE AGREEMENT OR
		P	PER DIEM RATE AGREEMENT OR
		U	SHCP CLAIM OR ACTIVE DUTY MEMBER GSU CLAIM PAID OUTSIDE NORMAL LIMITS OR
		V	MEDICARE REIMBURSEMENT RATE
	UNLESS TYPE OF SUBMISSION =	D	COMPLETE DENIAL
	OR AMOUNT ALLOWED (TOTAL) = ZERO
1-190-04R	IF PRICING RATE CODE =	V	MEDICARE REIMBURSEMENT RATE
	THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	T	MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND EARLIEST BEGIN DATE OF CARE ≥ 10/01/2001 OR
		FS	TFL (SECOND PAYOR) OR
		MN	TSP - NON-NETWORK OR
		MS	TSP - NETWORK
	OR TYPE OF INSTITUTION =	70	HHA OR
		76	SNF
1-190-05R	IF PRICING RATE CODE =	U	SHCP CLAIM OR ACTIVE DUTY MEMBER TPR CLAIM PAID OUTSIDE NORMAL LIMITS
	THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	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
		SC	SHCP - NON-TRICARE ELIGIBLE OR
		SE	SHCP - TRICARE ELIGIBLE OR
		SM	SHCP - EMERGENCY
	OR ENROLLMENT/HEALTH PLAN CODE MUST =	SN	SHCP - NON-MTF/eMSM-REFERRED CARE OR
		SR	SHCP - MTF/eMSM REFERRED CARE
1-190-06R	IF ANY OCCURRENCE OF REVENUE CODE =	0022	SNF - PPS
	THEN PRICING RATE CODE MUST =	D	DISCOUNT RATE AGREEMENT OR
		V	MEDICARE REIMBURSEMENT RATE
	UNLESS AMOUNT ALLOWED (TOTAL) = ZERO
1-190-07R	IF ANY OCCURRENCE OF REVENUE CODE =	0023	HHA PPS
	THEN PRICING RATE CODE MUST =	D	DISCOUNT RATE AGREEMENT OR
		V	MEDICARE REIMBURSEMENT RATE
	UNLESS AMOUNT ALLOWED (TOTAL) = ZERO
1-190-08R	IF PRICING RATE CODE =	CA	CAH REIMBURSEMENT
	THEN ADMISSION DATE MUST BE ≥ 12/01/2009
	UNLESS PROVIDER STATE OR COUNTRY CODE =	AK	ALASKA
	THEN ADMISSION DATE MUST BE ≥ 07/01/2007
1-190-09R	IF PRICING RATE CODE =	CR	CCR
	THEN ADMISSION DATE MUST BE ≥ 01/01/2014.
1-190-10R	IF PRICING RATE CODE =	CA	CAH REIMBURSEMENT
	AND ADMISSION DATE ≥ 01/01/2014.
	THEN TYPE OF INSTITUTION MUST =	93	CAH

ELEMENT NAME: PROVIDER STATE OR COUNTRY CODE (1-195)
1 “CORRESPONDING RECORD” ON PROVIDER FILE IS BASED ON INSTITUTIONAL TAXPAYER NUMBER, PROVIDER SUB-IDENTIFIER, PROVIDER ZIP CODE, AND TYPE OF INSTITUTION. THIS IS ONLY DETERMINED ONCE A PROVIDER MATCH HAS BEEN OBTAINED (1-200-02R).
VALIDITY EDITS
1-195-01V	VALUE MUST BE A VALID STATE OR COUNTRY CODE (REFER TO Addendums A OR B).
Relational Edits
1-195-01R	PROVIDER STATE/COUNTRY CODE MUST MATCH THE CORRESPONDING RECORD1 IN THE PROVIDER FILE.
	UNLESS AMOUNT ALLOWED (TOTAL) ≤ ZERO
	OR ADJUSTMENT/DENIAL REASON CODE =	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 ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	T	MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001
		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 FOR MATCH ON PROVIDER FILE

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