1.0
General
1.1 TED records
provide detailed information for each treatment encounter and are
required for the Defense Health Agency (DHA) health care and financial
reporting. A TED record is submitted as either an institutional
or non-institutional record.
1.1.1 Institutional TED records usually
reflect a treatment encounter created by the formal acceptance of
a hospital or other authorized institutional provider of a TRICARE
beneficiary for the purpose of occupying a bed with the reasonable
expectation that the patient will remain on inpatient status at
least 24 hours with a registration and assignment of an inpatient
number or designation. Institutional TED records may also reflect
outpatient care in a Hospice or Home Health Program.
1.1.2 Non-institutional
TED records reflect either inpatient or outpatient health care services exclusive
of inpatient institutional facility services, including institutional
care in connection with ambulatory surgery.
1.2 All elements
of the TED records must be maintained in the contractor’s claims
history file. The claims history will reflect the data submitted
to the DHA on the TED record including initial submissions, resubmissions,
adjustments, and cancellations. Claims history will also contain
all data necessary to reproduce a TED record as required by this
manual and to reproduce an Explanation Of Benefits (EOB), if required.
1.3 There are three
types of TED records:
• Initial Submission
• Adjustment/Cancellation
Submission
• Resubmission
1.4 These types
of records are discussed in the following paragraphs. Complete record
layouts and data requirements by Element Locator Number (ELN) are
detailed in
Sections 2.4 through
2.9. Edit criteria are detailed in
Sections 5.1 through
6.4, and
8.1.
1.5 TED records
within a day’s cycle are processed by DHA first in Processed To
Completion (PTC) Date Order, then by TYPE OF SUBMISSION (I, O, D, R first; A, B, C, E second).
2.0 Initial Submission
Of TED Records
Initial submission applies only to the
first submission of a new TED record. Initial submissions are identified
by TYPE OF SUBMISSION codes I, D, and O on
the TED record.
2.1 All
data indicated as “required” in the data element definition must
be reported. If not received in the treatment encounter data, this
data must be developed.
2.2 All signed numeric data elements on the
initial submission must be reported as positive values.
2.3 When institutional
TED records are reported for other than the complete inpatient hospital stay,
the TED records must be reported to DHA in the sequence that the
care was provided (FREQUENCY CODES, 2-Initial, 3-Interim or 4-Final).
Refer to
paragraph 7.0 for requirements on submitting
interim bills for institutional claims.
3.0 Submission
Of Adjustment/Cancellation TED Records
3.1 Adjustment and cancellation TED records
correct records with claims processing errors, or update prior data
on the record with more current/accurate information. For contracts
awarded prior to July 1, 2007, adjustment records also corrected
relational errors that were provisionally accepted on the DHA database.
3.2 Adjustments
and cancellations to complete denial or cancellation TED records
are not permitted. Denied or canceled TED records that require further
processing activity must be submitted as new, initial submissions.
3.3 All adjustments
and cancellations to TED records must be submitted using the same Adjustment
Key that was used on the original submission.
3.4 Adjustments
and cancellations to TED records are identified by TYPE OF SUBMISSION
codes A, B, C, and E on
the TED record. Adjustments and cancellations to non-TED records
must be reported using TYPE OF SUBMISSION codes B or E.
The use of the proper TYPE OF SUBMISSION code is essential for accurate
processing of adjustments.
3.5 Adjustment and cancellation conditions
include, but are not limited to, the following:
• Error in information received from the
provider or beneficiary.
• Late submission of data from providers.
• Error in processing by current or prior
contractor (if applicable).
• Patient liability corrections.
• Successful recoupment of monies, or receipt
of a refund from the provider, beneficiary, or third party.
• Stale dated payment checks.
3.6 When health
care is charged to the wrong Government fund (i.e., financially
underwritten vs. non-financially underwritten) the original record
must be cancelled and a new, initial TED record submitted under
the correct Government fund.
3.7 Adjustment submissions are positive (where
additional monies are being paid by the contractor), negative (where
monies are being credited back to the contractor), or statistical
(serve to correct prior information but have no impact on payment
amount).
Note: If an adjustment to a record results in
the net effect of a complete cancellation of the TED record (i.e.,
where the AMOUNT ALLOWED, AMOUNT GOVERNMENT PAY, and AMOUNT PATIENT
COST-SHARE = zero, and all line items are denied), the adjustment
must be reported with TYPE OF SUBMISSION code C or E.
Refer to the examples later in this Section for an example of a
complete cancellation TED record. An adjustment to a TED record
which would change the TYPE OF SUBMISSION from I, R,
or A to O is not allowed. The original
TED record must be canceled and a new, initial record submitted
with the correct TYPE OF SUBMISSION O.
3.7.1 Adjustment and
cancellation submissions to TED records must be reported using the
TED RECORD INDICATOR (TRI) reported on the initial submission TED
record, regardless of the number of adjustments to the initial TED
record. However, an adjustment that would result in submission of
a different RECORD TYPE INDICATOR (e.g., change an institutional
record, type 1, to a non-institutional record, type 2) is not permitted.
In this instance, the initial TED record must be completely canceled (TYPE
OF SUBMISSION code C or E), and a new
initial TED record submitted with the correct RECORD TYPE INDICATOR.
3.7.2 All data as
reported on the initial TED record must be resubmitted on adjustment
and cancellation TED records except for signed numeric fields, and
those numeric fields requiring correction. Data contained within
each line item in the variable portion of the adjustment or cancellation
TED record must be reported in the same sequence, with the same
LINE ITEM NUMBER as on the initial TED record. An adjustment or
cancellation TED record can add additional detail line items, but
cannot remove previously reported line items. All signed numeric
fields and those non-signed numeric fields requiring correction
must be reported according to the following paragraphs:
3.7.2.1 All signed numeric
data elements affected by the adjustment or cancellation must reflect the difference between
what was initially reported and the correct amount.
If adjustments were made in signed numeric fields prior to the current
adjustment, these data elements must reflect the difference amounts
after combining the amounts in the initial and all prior adjustment
submissions with this submission. Those signed numeric data elements
that are unaffected by the adjustment netting process must be set
to zero.
3.7.2.2 Alphanumeric
data elements requiring correction or update must reflect the most
current information applicable to the service(s) being reported.
All other alphanumeric data elements must be reported as on the
initial submission, or if prior adjustments corrected/updated the
initial data, the data from the most recent submission must be reported.
3.7.2.3 Adjustment and
complete cancellation TED records are matched and applied to their corresponding
initial submission TED record, and any prior adjustment TED records,
using the DHA database which consists of all TED and Health Care
Service Records. The resulting “net” TED record is completely edited
through the DHA edit system as if it were an initial submission
TED record. Thus, the original and any prior adjustments must have
passed all TED edits before a new adjustment is reported.
3.7.3 Examples
Examples
of adjustment and cancellation submissions are located below. Example
paragraph 3.7.3.1 portrays
a positive adjustment, example
paragraph 3.7.3.2 portrays a negative adjustment,
example
paragraph 3.7.3.3 portrays an adjustment correcting
information without impact on payment amount, and example
paragraph 3.7.3.4 portrays
a negative adjustment resulting in a complete cancellation.
3.7.3.1
Positive
Adjustment
A TED record was submitted by the contractor
and processed by DHA with an amount billed of $200, amount allowed
of $100, and $50 applied to the deductible. The amount allowed should have
been $180 and no monies should have been applied to the deductible.
The amount billed, however, was unchanged.
Initial
Ted Record Positive Adjustment Amounts
|
Initial
TED Record
|
|
Amount Billed
|
$200.00
|
|
Amount Allowed
|
100.00
|
|
Amount to Deductible
|
50.00
|
|
Amount Paid
(75%)
|
37.50
|
Initial
Ted Record Positive Adjustment Amounts
|
Adjustment
TED Record
|
|
Amount Billed
|
0
|
|
Amount Allowed
|
80.00
|
|
Amount to Deductible
|
- 50.00
|
|
Amount Paid
(75%)
|
97.50
|
|
Effect
At DHA
|
|
Amount Billed
|
$200.00
|
|
Amount Allowed
|
180.00
|
|
Amount to Deductible
|
0
|
|
Amount Paid
|
135.00
|
3.7.3.2
Negative
Adjustment
A TED record was submitted by the contractor
and processed by DHA with an amount billed of $500, an amount allowed
of $500, and amount paid by the contractor of $500. However, Other Health
Insurance (OHI) was involved and their payment of $400 was recouped.
The amounts billed and allowed were correct but the amount paid
should have been $100.
TED
Record Negative Adjustment Amounts
|
Initial
TED Record
|
|
Amount Billed
|
$500.00
|
|
Amount Allowed
|
500.00
|
|
Amount to OHI
|
0
|
|
Amount Paid
|
500.00
|
|
Adjustment
TED Record
|
|
Amount Billed
|
0
|
|
Amount Allowed
|
0
|
|
Amount to OHI
|
400.00
|
|
Amount Paid
|
- 400.00
|
|
Effect
At DHA
|
|
Amount Billed
|
500.00
|
|
Amount Allowed
|
500.00
|
|
Amount to OHI
|
400.00
|
|
Amount Paid
|
100.00
|
3.7.3.3
Statistical
Adjustment
A TED record was submitted by the contractor
and processed by DHA for a hospitalization spanning 20 bed days
and $2,000 in billed charges. Fifteen of the days were considered
authorized. Subsequently, the total number of bed days was found
to be 30 and billed charges were actually $3,000. However, the allowable
days and amount paid by the contractor remained unchanged.
TED
Record Statistical Adjustment
|
Initial
TED Record
|
|
Amount Billed
|
$2,000.00
|
|
Amount Allowed
|
1,500.00
|
|
Covered Days
|
15
|
|
Amount Paid
(75%)
|
1,125.00
|
|
Adjustment
TED Record
|
|
Amount Billed
|
1,000.00
|
|
Amount Allowed
|
0
|
|
Covered Days
|
0
|
|
Amount Paid
|
0
|
|
Effect
At DHA
|
|
Amount Billed
|
3,000.00
|
|
Amount Allowed
|
1,500.00
|
|
Covered Days
|
15
|
|
Amount Paid
|
1,125.00
|
3.7.3.4
Negative
Adjustment (Complete Cancellation)
A TED record
was submitted by the contractor and processed by DHA with an amount billed
of $500, allowed of $500, and amount paid by Government contractor
of $375. Subsequently, the contractor processed an adjustment to
pay in full, reporting an increase of $125 in the amount paid by Government
contractor. The contractor then determined the care was processed
in error and recouped the entire $500 payment.
TED
Record Negative Adjustment
|
Initial
TED Record
|
|
Amount Billed
|
$500.00
|
|
Amount Allowed
|
500.00
|
|
Patient Cost-Share
|
125.00
|
|
Amount Paid
|
375.00
|
|
Covered Days
|
5
|
|
Adjustment
TED Record
|
|
Amount Billed
|
0
|
|
Amount Allowed
|
0
|
|
Patient Cost-Share
|
- 125.00
|
|
Amount Paid
|
125.00
|
|
Covered Days
|
0
|
|
Effect
At DHA
|
|
Amount Billed
|
500.00
|
|
Amount Allowed
|
500.00
|
|
Patient Cost-Share
|
0
|
|
Amount Paid
|
500.00
|
|
Covered Days
|
5
|
|
Cancellation
TED Record
|
|
Amount Billed
|
0
|
|
Amount Allowed
|
- 500.00
|
|
Patient Cost-Share
|
0
|
|
Amount Paid
|
- 500.00
|
|
Covered Days
|
- 5
|
|
Effect
At DHA
|
|
Amount Billed
|
500.00
|
|
Amount Allowed
|
0
|
|
Patient Cost-Share
|
0
|
|
Amount Paid
|
0
|
|
Covered Days
|
0
|
4.0 Resubmission
of TED Batch/Vouchers and TED Records
4.1 Batches/vouchers that fail any
edits at the header record level will be rejected and returned to
the contractor for correction. Header level rejections require the
resubmission of the entire batch/voucher with the appropriate data
corrections. The BATCH/VOUCHER RESUBMISSION NUMBER must not be incremented
from what was reported on the prior submission.
4.2 Institutional
and Non-Institutional Records which fail any edits will be
rejected and returned to the contractor for correction and resubmission.
All returned records which are contained in a voucher must
be returned by the contractor at the same time and balance to the
outstanding TOTAL AMOUNT PAID and number of outstanding records
for that voucher at DHA. All returned records which are contained
in a batch must be returned by the contractor at the
same time and balance to the outstanding number of records for that
batch at DHA. Upon resubmission, the records will again be processed
through the DHA editing system. Resubmission batch/vouchers are
identified by the BATCH/VOUCHER RESUBMISSION NUMBER in the Header
Record. Resubmission applies to all Institutional and Non-Institutional
TED records which have failed to pass the DHA edits.
4.3 TED record resubmissions
must be reported using the TRI reported on the initial or adjustment TED
record, regardless of the number of times the TED record is resubmitted.
4.4 All data as
reported on the initial or adjustment TED record must be resubmitted
except for that data changed in order to correct the error(s).
4.5 If a TED record
with TYPE OF SUBMISSION =
I (initial) is rejected,
report the correction TED record with TYPE OF SUBMISSION =
R (resubmission).
• All other rejected TED records must retain
their original TYPE OF SUBMISSION throughout the error correction/resubmission
process.
4.6 To liquidate or “clear” a voucher,
both TOTAL AMOUNT PAID and the number of outstanding TED records
must zero out. When a TED record passes editing, the TOTAL NUMBER
OF RECORDS and the TOTAL AMOUNT PAID submitted on the original voucher
are decremented on the DHA database by the corresponding amount.
A voucher “clears” when both totals reach zero and the DHA database
reflects no outstanding record or paid amounts.
4.7 To liquidate
or “clear” a batch, the number of outstanding records
must zero out.
4.8 If DHA edits identify that the dollar
amounts on the voucher are incorrect, the contractor must correct
the related monetary data to balance to the AMOUNT PAID BY GOVERNMENT
CONTRACTOR reported on the TED record. On institutional Ted records, do
not change the AMOUNT PAID BY THE GOVERNMENT CONTRACTOR (TOTAL).
For non-institutional TED records, do not change the AMOUNT
PAID BY THE GOVERNMENT CONTRACTOR BY PROCEDURE CODE.Correction
of the payment error will be reflected through the contractor’s
processing and subsequent submission of the adjustment/cancellation
TED record.
5.0
Assignment
of TED Records to the Accrual Fund For Foreign And Pharmacy Contractors
5.1 All contractors
that are assigned appropriation specific Automated Standard Application
for Payment (ASAP) accounts (appropriated funds and accrual funds)
shall group TED records under the correct Contract Line Item Number
(CLIN)/ASAP Account Number using the BATCH/VOUCHER ASAP ACCOUNT
NUMBER VALIDATION - ACCRUAL FUND CHECK edits in
Section 4.1.
5.2 When
ASAP accounts are assigned to a contractor, the Government will
specify the appropriate fund that the ASAP account shall be linked
to. All claims grouped to the Accrual Fund shall pass edit 0-000-05F
(BATCH/VOUCHER ASAP ACCOUNT NUMBER VALIDATION - ACCRUAL FUND CHECK).
All claims that do not group to the Accrual Fund shall be grouped
to the Appropriated Fund ASAP account.
6.0
Batch/Voucher
CLIN/ASAP Account Number Selection Criteria For Regional Contractors
The
following process is only to be used by contractors submitting both
financially underwritten and non-financially underwritten claims
to DHA.
6.1 Batches -
Header Type Indicator 0 or 9
For all
data submissions sent to DHA using the Batch process (0-001), the
contractor shall zero fill the BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER
(0-025). Under the T-2017 regional contracts, batches are only used
for Provider Files.
6.2 Vouchers - Header Type Indicator 5 or
6
6.2.1 For all
data submissions sent to DHA using the Voucher process (0-001),
the contractor must select one of the BATCH/VOUCHER CLIN/ASAP ACCOUNT
NUMBERs assigned to them by DHA, Contract Resource Management (CRM)
in accordance with Section G of the contract. DHA, CRM shall assign
two types of BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBERs a non-financially
underwritten ASAP Account (formerly known as not-at-risk bank accounts)
that is issued on a federal fiscal year basis and a financially
underwritten CLIN Account that is issued for each contract option
period and is valid until the CLIN is closed for TED data processing.
6.2.2 The eight character
non-financially underwritten BATCH/VOUCHER CLIN/ASAP Account Numbers
are issued based on the following format:
• Positions 1 through 4 is 1889.
• Position 5 is the fiscal year of the ASAP
Account.
• Position 6 and
7 is the Contractor Number (contract specific two digit number assigned by
DHA, CRM).
• Position 8 is 1.
6.2.3 The eight character
financially underwritten BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBERs
are issued based on the following format:
• Positions 1 through 6 are equal to the
contract CLIN/Sub-Contract Line Item (SLIN) found in Section B of
the contract (Note: if the SLIN in Section B is numeric then 00 (zero)
fill positions 5 and 6).
• Positions 7 and 8 are the
contract region: EE for
East and WW for
West region.
6.2.4 The contractor shall use the procedures
outlined below in order to properly group claims under the correct
BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER.
6.2.5
Criteria
For Selecting DHA Non-Financially Underwritten ASAP Account
6.2.5.1 All non-financially
underwritten claims shall be submitted to DHA, CRM using the non-financially
underwritten ASAP Account Number with a 1 in position
8. The contractor shall use the non-financially underwritten ASAP
Account Number for all Service member claims and for all healthcare programs
identified as non-financially underwritten in Section H of the contract.
6.2.5.2 All ASAP
Type BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBERs assigned by DHA, CRM shall
have an active date range assigned. The BATCH/VOUCHER
CLIN/ASAP ACCOUNT NUMBER’s active dates shall not cross
fiscal years unless the contract is in a transition out period.
For all Initial TED data submissions (1-165 and 2-100) the BATCH/VOUCHER
Date (0-030) is the field DHA shall use when editing for proper
selection of ASAP Type BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER based
on date. All disbursements shall be made using a currently active ASAP
Type BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER. All credits where reported
disbursements did not occur (stale dated checks, voids, etc.) shall
be credited back to the BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER originally
used to report the disbursement. All collections (credits) of funds
where the disbursement was originally reported to DHA using an ASAP
Type BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER shall be credited to
DHA using currently active BATCH/VOUCHER CLIN/ASAP
ACCOUNT NUMBER.
6.2.6 Criteria For Selecting Financially Underwritten
CLINs (excludes all claims that meet criteria specified under
paragraph 6.2.5)
6.2.6.1 All financially
underwritten benefit payments must use the BATCH/VOUCHER CLIN/ASAP ACCOUNT
NUMBER containing the DHA Benefit CLIN (positions 1 through 4 of
ASAP) contained in Section B of the contract (positions 5 and 6
is zero filled since the CLIN is numeric). The contractor shall be
assigned one financially underwritten CLIN per contract option period.
In order to determine the correct BATCH/VOUCHER CLIN/ASAP ACCOUNT
NUMBER the contractor must determine the correct option period the
claim falls under. To determine the correct option period the BEGIN
DATE OF CARE (2-150) for non-institutional claims or ADMISSION DATE
(1-265) for institutional claims must be equal to or fall within
the option period begin and end dates.
6.2.6.2 All CLIN
Type BATCH/VOUCHER CLIN/ASAP Account Numbers assigned by DHA, CRM
shall have an
active date range assigned which shall
correspond to the begin and end dates of the
CLIN.
The BATCH/VOUCHER CLIN/ASAP Account Number’s
active dates
shall not cross Option Periods. The BEGIN DATE OF CARE (2-150) or
ADMISSION DATE (1-265) are the fields DHA shall use when editing
for proper selection of CLIN Type BATCH/VOUCHER. For non-institutional
claims all occurrences of BEGIN DATE OF CARE must fall within the
active date
range of the CLIN type BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER used
in the voucher header. For institutional claims the ADMISSION DATE
must fall within the
active date range of the CLIN
type BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER used in the voucher
header. See TRICARE Operations Manual (TOM),
Chapter 8, Section 6, paragraph 9.9.
7.0
Interim
Institutional Payments
7.1 In
certain cases, providers can submit interim bills for institutional
claims as a method to facilitate cash flow. Interim-interim and
interim-final TED records with filing dates before January 1, 2011
must be submitted as an adjustment using the same TRI as the initial
submission.
7.2 Interim-interim and interim-final
TED records (FREQUENCY CODES 3 and 4)
with filing dates on or after January 1, 2011 with the exception
of interim billings reimbursed under the DRG or Home Health Agency
(HHA) payment methodology must be submitted with a unique
TRI and must be submitted on batch/vouchers with HEADER TYPE INDICATOR 0 or 5.
DRG and HHA interim-interim and interim-final TED records will continue
to be submitted as an adjustment using the same TRI as the initial
submission.
7.3 For
claims that are reimbursed under the TRICARE Diagnosis Related Group
(DRG) payment methodology please see the TRICARE Reimbursement Manual
(TRM),
Chapter 6, Section 3 for requirements on submitting
DRG interim bills.
7.4 For claims that are reimbursed under the
Home Health Agency Prospective Payment System (HHA PPS) methodology,
please see the guidelines on submitting interim bills in the TRM,
Chapter 12, Section 6.
7.5 International
Classification of Diseases (ICD) version and Operation/Non-Surgical
Procedure (OP/NSP) codes are determined by patient discharge date.
ICD, 10th Revision, Clinical Modification, (ICD-10-CM) diagnosis
and ICD-10-Procedure Coding System (ICD-10-PCS) OP/NSP codes are appropriate
for claims with discharge dates on or after October 1, 2015 and
ICD, 9th Revision, Clinical Modification (ICD-9-CM) and ICD-9-Procedure
Coding System (ICD-9-PCS) codes are appropriate for discharge dates
on or before September 30, 2015. Since the TED record does not report
discharge date, end date of care will determine ICD version when
PATIENT STATUS indicates discharged, transferred or expired (i.e.,
codes 01, 02, 03). Admission
date will determine ICD version when the PATIENT STATUS indicates
the patient remains hospitalized (i.e., 30).
8.0
Process
for Reporting External Resource Sharing Encounters to DHA
The
following process is to be used by claims processors to submit data
to DHA which relates to External Resource Sharing encounters.
8.1 Special Processing
Code
For External Resource Sharing encounters,
submit a TED record which includes SPECIAL PROCESSING CODE of S Resource
Sharing - External, for each patient encounter.
8.2 “Amount”
Field Reporting
The “amount” fields must contain the following:
8.2.1 Amount Billed
By Procedure Code
If a Resource Sharing provider is being
reimbursed on a fee-for-service basis with negotiated/discounted
rates, report these amounts in the AMOUNT BILLED BY PROCEDURE CODE
field.
8.2.2 Amount Allowed/Amount
Allowed By Procedure Code
The AMOUNT ALLOWED
BY PROCEDURE CODE field must contain the CHAMPUS Maximum Allowable
Charge (CMAC) or negotiated/discounted rates as appropriate.
8.2.3 Amount Paid
By Government Contractor
The AMOUNT PAID
BY GOVERNMENT CONTRACTOR field must equal the “lesser” of the amount
allowed minus (PATIENT COST-SHARE plus AMOUNT APPLIED TOWARD DEDUCTIBLE)
or AMOUNT ALLOWED minus amount of OHI. If the “lesser” computed
amount is negative, AMOUNT PAID BY GOVERNMENT CONTRACTOR must =
$0.00.
9.0 Process for
Reporting Blood Clotting Factor Data to DHA
9.1 Blood clotting factor reimbursement
will be calculated based on the reimbursement methodology described
in the TRM. Blood clotting factor charges will not be submitted
separately from the DRG reimbursable hospital charges but will be
included on the institutional TED record.
9.2 Data Reporting
The following
are data reporting requirements specific for TED records containing
blood clotting factor charges.
• REVENUE CODE 0636 (Drugs Requiring Detailed
Coding) is to be reported for blood clotting factor.
• UNITS OF SERVICE will reflect the
number of units billed on the claim, not the number of payment units.
• AMOUNT BILLED (TOTAL) is the sum of all
billed charges on the claim including charges for the blood clotting
factor.
• AMOUNT ALLOWED
(TOTAL) is the sum of DRG allowed amount and the allowable reimbursement
for the blood clotting factor.