1.0 General
1.1 Contractor
Submission of TRICARE Encounter Provider Records (TEPRV) Requirements
1.1.1 Electronic
Media Submission
Contractors are required to submit TEPRV
Records (except for TRICARE For Life (TFL) second payor) via electronic
media to the Defense Health Agency (DHA) for each provider who rendered
care to TRICARE beneficiaries.
1.1.2 Record Content
Required Information
for each Health Care Provider:
• A Unique Provider ID Number (PROVIDER TAXPAYER
NUMBER).
• Name.
• Address.
• Medical Specialty
• Authorization Period.
• Denied services and TRICARE Encounter
Data (TED) record cancellations will be excluded from the TEPRV
check.
• The TEPRV must
be present on the Provider File at DHA prior to reporting associated TED
records.
• The data
will be used by DHA to track services rendered by each provider.
1.2 Accountability
For TEPRVs
The contractor having contractual authority
for provider certification in a given region has accountability
for the TEPRVs for providers in that region and is responsible for
ensuring these TEPRVs pass the DHA edits and for performing all
maintenance transactions. This responsibility extends to those TEPRVs
submitted in support of claims processing by another contractor
with the exception of pharmacy TEPRVs which can be submitted by
any contractor.
1.3 Data Submission
The contractor
must provide a separate record for each provider who renders care
to a TRICARE beneficiary.
1.3.1 The Initial Load Of The Provider Information
1.3.1.1 The initial
load of the Provider information must be submitted following the
rules listed below. Every effort must be made to ensure that duplicate
Provider records are not submitted and that only active Provider
records are submitted.
1.3.1.2 For non-institutional
providers, multiple records will be required when more than one provider
is billing under the same PROVIDER TAXPAYER NUMBER (e.g., clinics).
In this case, the PROVIDER ZIP CODE and PROVIDER SUB-IDENTIFIER
must be used to identify unique providers. Refer to these elements
for further instructions.
1.3.2 Transition Of Future Provider Information
Between Contractors
The transition of future provider information
between contractors must retain the provider record key information.
For institutional providers the record key is: PROVIDER TAXPAYER
NUMBER, PROVIDER ZIP CODE, and PROVIDER MAJOR SPECIALTY/TYPE OF
INSTITUTION. For non-institutional providers the record key is:
PROVIDER TAXPAYER NUMBER, PROVIDER ZIP CODE, and PROVIDER SUB-IDENTIFIER.
1.3.3 Inactive
Providers
When the contractor removes a provider
from their active provider files (e.g., due to long periods of inactivity),
a TEPRV must be submitted to TRICARE as a modify Transaction Code
with a Provider Termination Date reflecting when the Provider was
removed from the contractor’s files.
1.4 Institutional
Providers that are Part of a Multi-Hospital Chain
1.4.1 Providers must be identified within the
PROVIDER TAXPAYER NUMBER by the zip code.
1.4.2 In addition, multiple records will
be required for institutional providers with both DRG-exempt and
DRG-non-exempt units under the same PROVIDER TAXPAYER NUMBER.
1.4.3 These are
to be identified by the PROVIDER SPECIALTY/TYPE OF INSTITUTION.
Only one DRG-non-exempt TYPE OF INSTITUTION will be allowed per
PROVIDER TAXPAYER NUMBER and zip code, while multiple DRG-exempt
types of facility will be allowed.
1.4.4 No duplicates within the PROVIDER
TAXPAYER NUMBER, PROVIDER ZIP CODE, and PROVIDER MAJOR SPECIALTY/TYPE
OF INSTITUTION will be allowed.
1.5 Institution Provides Outpatient Care
1.5.1 Additional TEPRVs
must be reported to DHA. For outpatient services (e.g., ambulatory surgery
in hospital, emergency room, hospital services), submit a TEPRV
with PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION = FACILITY CHARGES
(refer to edit 3-160-05R) and INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR
= N.
1.5.2 If the institution has a clinic associated
with it, additional TEPRVs must be reported to DHA using the PROVIDER
SUB-IDENTIFIER in the same manner as a stand alone clinic.
2.0 Provider
File Record Maintenance
The Provider
File is a dynamic file where records can be added, modified, or
inactivated when a change is required.
2.1 File Submission
2.1.1 The contractor must submit TEPRVs indicating
the type of change and updated information.
2.1.2 TEPRVs
will be submitted on an as needed basis.
2.1.3 Each group of TEPRVs must be preceded by
a batch header record that identifies the subsequent records as
provider transaction records.
2.2 Add Transactions
2.2.1 The TRANSACTION CODE must be A.
2.2.2 All required
data elements must be included.
2.2.3 An ADD cannot be made for institutional
providers if the PROVIDER TAXPAYER NUMBER, PROVIDER SUB-IDENTIFIER,
PROVIDER ZIP CODE, and PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION
are already on file.
2.2.4 An ADD for non-institutional providers
cannot be made if the PROVIDER TAXPAYER NUMBER, PROVIDER ZIP CODE
and PROVIDER SUB-IDENTIFIER are already on file.
2.3 Modify Transactions
2.3.1 The TRANSACTION
CODE must be M.
2.3.2 All required data elements must be included.
2.3.3 The MODIFY is
used to make changes to an existing provider record, such as a termination of
authorization or reauthorization.
2.3.4 A MODIFY will replace the previous
record with a new record. Records being replaced will be held in
history. Multiple periods of authorization will be stored on the
DHA master provider file.
2.3.5 For institutional providers, a MODIFY
will not be accepted if the PROVIDER TAXPAYER NUMBER, PROVIDER SUB-IDENTIFIER,
PROVIDER ZIP CODE, and PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION
are not already on the file.
2.3.6 For non-institutional providers, a
MODIFY will not be accepted if the PROVIDER TAXPAYER NUMBER, PROVIDER
ZIP CODE and PROVIDER SUB-IDENTIFIER are not already on the file.
2.4 Inactivate
Transactions
The TRANSACTION CODE must be I.
2.4.1 Institutional
Providers
The INACTIVATE process is to be used when
there is an error on the PROVIDER TAXPAYER NUMBER, PROVIDER SUB-IDENTIFIER,
PROVIDER ZIP CODE, or PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION
data elements.
2.4.2 Non-Institutional Providers
2.4.2.1 The INACTIVATE
process is used when there is an error on either the PROVIDER TAXPAYER NUMBER,
PROVIDER ZIP CODE, or the PROVIDER SUB-IDENTIFIER data elements.
2.4.2.2 To correct an
error on these data elements, the incorrect record must be inactivated
and the correct record added using two separate transactions.
2.4.2.3 When correcting
an error on these data elements for a clinic, all provider records
associated with the clinic must also be inactivated. This process
also applies when replacing a record containing a contractor Assigned
Provider Number (APN) with a record containing the actual Provider
Taxpayer Number.
3.0 Resubmission
of Provider Batches and Provider Records
3.1 Batches 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 with the appropriate data corrections. The RESUBMISSION
NUMBER must not be incremented from what was reported on the prior
submission.
3.2 TEPRVs that fail any
edits will be rejected and returned to the contractor for correction
and resubmission in a new batch.