TRICARE Systems Manual 7950.3-M, April 1, 2015 TRICARE Encounter Data (TED) Chapter 2 Section 6.1 Non-Institutional Edit Requirements (ELN 000 - 099) Revision: ELEMENT NAME: RECORD TYPE INDICATOR (2-001) VALIDITY EDITS 2-001-01V RECORD TYPE INDICATOR MUST = 2 NON-INSTITUTIONAL Relational Edits 2-001-01R 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 AND A MATCH IS FOUND ON THE DHA DATABASE THEN THE RECORD TYPE FOR THE TED ON THE DATABASE MUST = THE RECORD TYPE ON THE ADJUSTMENT/CANCELLATION TED BEING SUBMITTED. ELEMENT NAME: FILING DATE (2-015) VALIDITY EDITS 2-015-01V MUST BE A VALID JULIAN DATE AND CANNOT BE > DHA CURRENT SYSTEM DATE. Relational Edits 2-015-01R FILING DATE MUST BE ≤ DATE TED RECORD PROCESSED TO COMPLETION (PTC) ELEMENT NAME: FILING STATE/COUNTRY CODE (2-020) VALIDITY EDITS 2-020-01V 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 NONE ELEMENT NAME: SEQUENCE NUMBER (2-025) VALIDITY EDITS 2-025-01V SEQUENCE NUMBER MUST BE A COMBINATION OF ALPHABETIC OR NUMERIC CHARACTERS, LAST TWO CHARACTERS. Relational Edits NONE ELEMENT NAME: TIME STAMP (2-030) VALIDITY EDITS 2-030-01V MUST BE NUMERIC. Relational Edits 2-030-01R IF FILING DATE IS ≥ 02/01/1995 THEN TIME STAMP MUST BE > ZERO ELEMENT NAME: ADJUSTMENT KEY (2-035) VALIDITY EDITS 2-035-01V MUST BE ALPHA, 0, OR 5. Relational Edits NONE ELEMENT NAME: DATE TED RECORD PROCESSED TO COMPLETION (2-040) VALIDITY EDITS 2-040-01V MUST BE A VALID GREGORIAN DATE AND CANNOT BE > DHA CURRENT SYSTEM DATE. Relational Edits 2-040-01R DATE TED RECORD PROCESSED TO COMPLETION (PTC) MUST BE ≤ BATCH/VOUCHER DATE ELEMENT NAME: DATE ADJUSTMENT IDENTIFIED (2-045) VALIDITY EDITS 2-045-01V MUST BE A VALID GREGORIAN DATE OR ALL ZEROES AND CANNOT BE > DHA CURRENT SYSTEM DATE. 2-045-02V IF TYPE OF SUBMISSION = D DENIAL OR I INITIAL SUBMISSION OR O ZERO PAYMENT WITH 100% OHI/TPL OR R RESUBMISSION THEN DATE ADJUSTMENT IDENTIFIED MUST BE ALL ZEROES. 2-045-04V 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 OF ADJUSTMENT IDENTIFIED MUST BE A VALID GREGORIAN DATE Relational Edits 2-045-03R 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 AND ≥ FILING DATE ELEMENT NAME: PERSON IDENTIFIER (SPONSOR) (2-050) VALIDITY EDITS 2-050-01V MUST BE NINE NUMERIC DIGITS (CANNOT BE ALL ZEROES, ALL NINES, OR ALL BLANKS) Relational Edits NONE ELEMENT NAME: PERSON IDENTIFIER TYPE CODE (SPONSOR) (2-051) VALIDITY EDITS 2-051-01V MUST BE A VALID VALUE (REFER TO Section 2.7). Relational Edits NONE ELEMENT NAME: SERVICE BRANCH CLASSIFICATION CODE (SPONSOR) (2-055) VALIDITY EDITS 2-055-01V 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 (2-056) VALIDITY EDITS 2-056-01V MUST BE VALID AGR SERVICE LEGAL AUTHORITY CODE (REFER TO Section 2.4). Relational Edits REFER TO Section 8.1 ELEMENT NAME: PERSON LAST NAME (PATIENT) (2-061) VALIDITY EDITS 2-061-01V MUST BE AT LEAST ONE CHARACTER (LEFT-JUSTIFIED). Relational Edits NONE ELEMENT NAME: PERSON FIRST NAME (PATIENT) (2-062) VALIDITY EDITS NONE Relational Edits NONE ELEMENT NAME: PERSON MIDDLE NAME (PATIENT) (2-063) VALIDITY EDITS NONE Relational Edits NONE ELEMENT NAME: PERSON CADENCY NAME (PATIENT) (2-064) VALIDITY EDITS NONE Relational Edits NONE ELEMENT NAME: PERSON IDENTIFIER (PATIENT) (2-065) VALIDITY EDITS 2-065-01V MUST BE NINE NUMERIC DIGITS AND CANNOT EQUAL ALL BLANKS. Relational Edits NONE ELEMENT NAME: PERSON IDENTIFIER TYPE CODE (PATIENT) (2-066) VALIDITY EDITS 2-066-01V MUST BE A VALID VALUE (REFER TO Section 2.7). Relational Edits NONE ELEMENT NAME: PERSON BIRTH CALENDAR DATE (PATIENT) (2-070) 1 PATIENT AGE IS CALCULATED BASED ON PERSON BIRTH CALENDAR DATE (PATIENT) AND BEGIN DATE OF CARE. VALIDITY EDITS 2-070-01V MUST BE VALID GREGORIAN DATE AND CANNOT BE > DHA CURRENT SYSTEM DATE. Relational Edits 2-070-01R PATIENT AGE1 MUST BE < 125 YEARS 2-070-02R PERSON BIRTH CALENDAR DATE (PATIENT) MUST BE ≤ BEGIN DATE OF CARE. ELEMENT NAME: DEERS DEPENDENT SUFFIX (2-075) VALIDITY EDITS 2-075-01V IF TYPE OF SERVICE (SECOND POSITION) = M MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS OR TYPE OF SUBMISSION = B ADJUSTMENT OF NON-TED RECORD (HCSR) DATA OR E COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA THEN MUST BE A VALID DEERS DEPENDENT SUFFIX OR BLANK (REFER TO Section 2.4) OTHERWISE MUST BE BLANK Relational Edits NONE ELEMENT NAME: PATIENT IDENTIFIER (DoD) (2-080) VALIDITY EDITS 2-080-01V MUST NOT BE BLANK FILLED 2-080-02V MUST NOT EQUAL ALL ZEROES UNLESS TYPE OF SUBMISSION = D COMPLETE DENIAL TED RECORD DATA OR ALL OCCURRENCES/LINE ITEMS CONTAIN AN ADJUSTMENT/DENIAL REASON CODE (REFER TO Addendum G, Figure 2.G-1 OR Figure 2.G-2). AND THE TED RECORD CORRECTION INDICATOR = 1 ADJUSTMENT/CANCELLATION (TYPE OF SUBMISSION A, B, C, OR E) SOLELY TO CORRECT A PROVISIONALLY ACCEPTED TED RECORD OR 3 ADJUSTMENT/CANCELLATION (TYPE OF SUBMISSION A, B, C, OR E) TO CORRECT BOTH EDIT ERRORS ON A PROVISIONALLY ACCEPTED TED RECORD AND TO CORRECT CLAIM PROCESSING ERRORS OR UPDATE PRIOR DATA WITH MORE CURRENT/ACCURATE INFORMATION Relational Edits NONE ELEMENT NAME: DEERS IDENTIFIER (PATIENT) (2-082) VALIDITY EDITS 2-082-01V POSITIONS 10 AND 11 MUST BE NUMERIC Relational Edits NONE ELEMENT NAME: PERSON SEX (PATIENT) (2-085) VALIDITY EDITS 2-085-01V PERSON SEX (PATIENT) MUST = F FEMALE OR M MALE OR Z UNKNOWN Relational Edits NONE ELEMENT NAME: PATIENT ZIP CODE (2-090) 1 WHEN FOREIGN COUNTRY CODES ARE SUBMITTED, THE FIRST THREE CHARACTERS WILL BE EDITED AGAINST Addendum A. VALIDITY EDITS 2-090-01V MUST BE NINE DIGITS OR FIVE DIGITS WITH FOUR BLANKS MUST BE A VALID ZIP CODE (BASED ON BEGIN DATE OF CARE) 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: OVERRIDE CODE (2-095) VALIDITY EDITS 2-095-01V OCCURRENCE NUMBER 1--MUST BE A VALID OVERRIDE CODE (REFER TO Section 2.6) 2-095-02V OCCURRENCE NUMBER 2--MUST BE A VALID OVERRIDE CODE (REFER TO Section 2.6) 2-095-03V OCCURRENCE NUMBER 3--MUST BE A VALID OVERRIDE CODE (REFER TO Section 2.6) 2-095-04V A VALUE CANNOT BE CODED MORE THAN ONCE (EXCEPT BLANK). 2-095-05V ALL OCCURRENCES OF OVERRIDE CODE MUST BE BLANK FILLED FOLLOWING THE FIRST OCCURRENCE OF A BLANK FILLED OVERRIDE CODE. Relational Edits 2-095-11R IF ANY OCCURRENCE OF OVERRIDE CODE = NC NON-CERTIFIED PROVIDER (DOES NOT INCLUDE SANCTIONED/SUSPENDED PROVIDERS) THEN ONE 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 OR SU SHCP - REFERRAL DESIGNATION UNKNOWN - END -