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VALIDITY
EDITS
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1-400-01V
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VALUE MUST BE A VALID ADJUSTMENT/DENIAL
REASON CODE (REFER TO Addendum G) OR BLANK. |
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Relational
Edits
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1-400-01R
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IF AMOUNT ALLOWED (TOTAL) =
ZERO
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|
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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)
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|
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UNLESS TYPE OF
SUBMISSION =
|
B
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ADJUSTMENT OF NON-TED RECORD
(HCSR) DATA OR
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|
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E
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COMPLETE CANCELLATION OF NON-TED
RECORD (HCSR) DATA
|
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1-400-02R
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IF TYPE OF SUBMISSION =
|
C
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COMPLETE CANCELLATION OR
|
|
|
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D
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COMPLETE DENIAL
|
|
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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)
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1-400-03R
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IF FREQUENCY CODE =
|
1
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ADMIT THROUGH DISCHARGE
|
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AND PRICING RATE
CODE =
|
H
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TRICARE DRG REIMBURSEMENT WITH
SHORT STAY OUTLIER OR
|
|
|
|
I
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TRICARE DRG REIMBURSEMENT WITH
COST OUTLIER OR
|
|
|
|
J
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TRICARE DRG REIMBURSEMENT WITH
NO OUTLIER OR
|
|
|
|
S
|
HVBP ADJUSTMENT
FACTOR OR
|
|
|
|
CV
|
COVID-19 ADJUSTMENT
FACTOR OR
|
|
|
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DD
|
DISCOUNTED DRG
|
|
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THEN NO OCCURRENCE
OF ADJUSTMENT/DENIAL REASON MAY =
|
135
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CLAIM DENIED. INTERIM BILLS
CANNOT BE PROCESSED
|
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1-400-04R
|
IF PRICING RATE CODE =
|
H
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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
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DISCOUNTED DRG
|
|
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AND REVENUE CODE
= 0901, 0914-0918, 096X-098X (PROFESSIONAL SERVICES), OR 081X
(ORGAN ACQUISITION)
|
|
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THEN ADJUSTMENT/DENIAL
REASON CODE MUST BE A CODE LISTED IN Addendum G, Figure 2.G-1 OR Figure 2.G-2.
|
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1-400-05R
|
IF ANY OCCURRENCE OF ADJUSTMENT/DENIAL
REASON CODE =
|
135
|
CLAIM DENIED. INTERIM BILLS
CANNOT BE PROCESSED
|
|
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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).
|