TRICARE Systems Manual 7950.3-M, April 1, 2015 TRICARE Encounter Data (TED) Chapter 2 Section 5.5 Institutional Edit Requirements (ELN 400 - 499) Revision: ELEMENT NAME: ADJUSTMENT/DENIAL REASON CODE (1-400) VALIDITY EDITS 1-400-01V VALUE MUST BE A VALID ADJUSTMENT/DENIAL REASON CODE (REFER TO Addendum G) OR BLANK. Relational Edits 1-400-01R IF AMOUNT ALLOWED (TOTAL) = ZERO THEN ALL OCCURRENCES/LINE ITEMS (EXCLUDING REVENUE CODE 0001) MUST CONTAIN AN ADJUSTMENT/DENIAL REASON CODE (REFER TO Addendum G, Figure 2.G-1 OR Figure 2.G-2) UNLESS TYPE OF SUBMISSION = B ADJUSTMENT OF NON-TED RECORD (HCSR) DATA OR E COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA 1-400-02R IF TYPE OF SUBMISSION = C COMPLETE CANCELLATION OR D COMPLETE DENIAL THEN ALL OCCURRENCES/LINE ITEMS (EXCLUDING REVENUE CODE 0001) MUST CONTAIN AN ADJUSTMENT/DENIAL REASON CODE (REFER TO Addendum G, Figure 2.G-1 OR Figure 2.G-2) 1-400-03R IF FREQUENCY CODE = 1 ADMIT THROUGH DISCHARGE AND PRICING RATE CODE = 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 DD DISCOUNTED DRG THEN NO OCCURRENCE OF ADJUSTMENT/DENIAL REASON MAY = 135 CLAIM DENIED. INTERIM BILLS CANNOT BE PROCESSED 1-400-04R IF PRICING RATE CODE = 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 DD DISCOUNTED DRG AND REVENUE CODE = 0901, 0914-0918, 096X-098X (PROFESSIONAL SERVICES), OR 081X (ORGAN ACQUISITION) THEN ADJUSTMENT/DENIAL REASON CODE MUST BE A CODE LISTED IN Addendum G, Figure 2.G-1 OR Figure 2.G-2. 1-400-05R IF ANY OCCURRENCE OF ADJUSTMENT/DENIAL REASON CODE = 135 CLAIM DENIED. INTERIM BILLS CANNOT BE PROCESSED THEN ALL OCCURRENCES/LINE ITEMS (EXCLUDING REVENUE CODE 0001) MUST BE DENIED (ADJUSTMENT/DENIAL REASON CODE MUST BE A CODE LISTED IN Addendum G, Figure 2.G-1 OR Figure 2.G-2). - END -