TRICARE Manuals - Display Chap 2 Sect 6.3 (Change 57, Dec 23, 2021)

TRICARE Encounter Data (TED)

Chapter 2

Section 6.3

Non-Institutional Edit Requirements (ELN 200 - 299)

Revision: C-21, January 31, 2019

ELEMENT NAME: AMOUNT PATIENT COST-SHARE (2-200)
VALIDITY EDITS
2-200-01V	MUST BE NUMERIC.
Relational Edits
2-200-00R	TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT PATIENT COST-SHARE FOR THIS TED RECORD EXCEEDS DHA LIMIT OF $1,000,000.00.
2-200-01R	IF TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		I	INITIAL SUBMISSION OR
		O	ZERO PAYMENT WITH 100% OHI/TPL OR
		R	RESUBMISSION
	THEN AMOUNT PATIENT COST-SHARE MUST BE ≥ ZERO
2-200-02R	IF TYPE OF SUBMISSION =	C	COMPLETE CANCELLATION OR
		D	COMPLETE DENIAL
	THEN AMOUNT PATIENT COST-SHARE MUST BE = ZERO
2-200-03R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	DE	TDRL PHYSICAL EXAMS
	THEN AMOUNT PATIENT COST-SHARE MUST BE = ZERO

ELEMENT NAME: HEALTH CARE COVERAGE (HCC) COPAYMENT FACTOR CODE (2-201)
VALIDITY EDITS
2-201-01V	MUST BE A VALID HCC COPAYMENT FACTOR CODE LISTED IN Section 2.5.
Relational Edits
	NONE

ELEMENT NAME: AMOUNT PAID BY GOVERNMENT CONTRACTOR BY PROCEDURE CODE (2-205)
VALIDITY EDITS
2-205-01V	MUST BE NUMERIC.
Relational Edits
2-205-00R	TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT PAID BY GOVERNMENT CONTRACTOR BY PROCEDURE CODE FOR THIS TED RECORD EXCEEDS DHA LIMIT OF $1,000,000.00.
2-205-01R	IF TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		I	INITIAL SUBMISSION OR
		O	ZERO PAYMENT WITH 100% OHI/TPL OR
		R	RESUBMISSION
	THEN AMOUNT PAID BY GOVERNMENT CONTRACTOR BY PROCEDURE CODE MUST BE ≥ ZERO
2-205-02R	IF TYPE OF SUBMISSION =	C	COMPLETE CANCELLATION OR
		D	COMPLETE DENIAL
	THEN AMOUNT PAID BY GOVERNMENT CONTRACTOR BY PROCEDURE CODE MUST BE = ZERO

ELEMENT NAME: ADJUSTMENT/DENIAL REASON CODE (2-220)
VALIDITY EDITS
2-220-01V	VALUE MUST BE A VALID ADJUSTMENT/DENIAL REASON CODE (REFER TO Addendum G).
Relational Edits
2-220-01R	IF TYPE OF SUBMISSION =	C	COMPLETE CANCELLATION OR
		D	COMPLETE DENIAL
	THEN ALL OCCURRENCES/LINE ITEMS MUST CONTAIN AN ADJUSTMENT/DENIAL REASON CODE LISTED IN Addendum G, Figure 2.G-1 OR Figure 2.G-2
2-220-02R	IF ADJUSTMENT/DENIAL REASON CODE IS A DENIAL REASON CODE LISTED IN Addendum G, Figure 2.G-1, FOR THAT OCCURRENCE/LINE ITEM
	AND TYPE OF SUBMISSION =	A	ADJUSTMENT OR
		C	COMPLETE CANCELLATION OR
		D	COMPLETE DENIAL OR
		I	INITIAL SUBMISSION OR
		O	ZERO PAYMENT WITH 100% OHI/TPL OR
		R	RESUBMISSION
	THEN AMOUNT ALLOWED BY PROCEDURE CODE MUST = ZERO
2-220-03R	IF TYPE OF SUBMISSION =	B	ADJUSTMENT TO NON-TED (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	AND ADJUSTMENT/DENIAL REASON CODE IS A DENIAL REASON CODE LISTED IN Addendum G, Figure 2.G-1, FOR THAT OCCURRENCE/LINE ITEM
	THEN AMOUNT ALLOWED BY PROCEDURE CODE MUST BE ≤ ZERO

ELEMENT NAME: PROVIDER INDIVIDUAL NPI NUMBER (TYPE 1) (2-225)
VALIDITY EDITS
2-225-01V	MUST BE ALL BLANKS OR 10 DIGITS (MUST NOT BE ALL ZEROES)
2-225-02V	IF PROVIDER INDIVIDUAL NPI NUMBER IS ALL DIGITS
	THEN THE CHECK DIGIT (POSITION 10 OF THE PROVIDER ORGANIZATIONAL NPI NUMBER) MUST EQUAL THE VALUE COMPUTED USING LUHN FORMULA FOR MODULES 10 “DOUBLE-ADD-DOUBLE” CHECK DIGIT ALGORITHM
Relational Edits
	NONE

ELEMENT NAME: PROVIDER ORGANIZATIONAL NPI NUMBER (TYPE 2) (2-230)
VALIDITY EDITS
2-230-01V	MUST BE ALL BLANKS OR 10 DIGITS (MUST NOT BE ALL ZEROES)
2-230-02V	IF PROVIDER ORGANIZATIONAL NPI NUMBER IS ALL DIGITS
	THEN THE CHECK DIGIT (POSITION 10 OF THE PROVIDER ORGANIZATIONAL NPI NUMBER) MUST EQUAL THE VALUE COMPUTED USING LUHN FORMULA FOR MODULES 10 “DOUBLE-ADD-DOUBLE” CHECK DIGIT ALGORITHM
Relational Edits
	NONE

ELEMENT NAME: PROVIDER STATE OR COUNTRY CODE (2-235)
1 “CORRESPONDING RECORD” ON PROVIDER FILE IS BASED ON NON-INSTITUTIONAL PROVIDER TAXPAYER NUMBER, PROVIDER MAJOR SPECIALTY, PROVIDER SUB-IDENTIFIER, AND PROVIDER ZIP CODE. THIS IS ONLY DETERMINED ONCE A PROVIDER MATCH HAS BEEN OBTAINED (2-240-04R).
VALIDITY EDITS
2-235-01V	VALUE MUST BE A VALID STATE (REFER TO Addendum B) OR COUNTRY CODE (REFER TO Addendum A).
Relational Edits
2-235-01R	PROVIDER STATE/COUNTRY CODE MUST MATCH THE CORRESPONDING RECORD1 IN THE PROVIDER FILE.
	UNLESS AMOUNT ALLOWED BY PROCEDURE CODE IS ≤ ZERO
	OR ADJUSTMENT/DENIAL REASON CODE FOR THAT OCCURRENCE/LINE ITEM =	38	SERVICES NOT PROVIDED OR AUTHORIZED BY DESIGNATED (NETWORK) PROVIDERS OR
		52	THE REFERRING/PRESCRIBING/RENDERING PROVIDER IS NOT ELIGIBLE TO REFER/PRESCRIBE/ORDER/PERFORM THE SERVICE BILLED OR
		B7	THIS PROVIDER WAS NOT CERTIFIED/ELIGIBLE TO BE PAID FOR THIS PROCEDURE/SERVICE ON THIS DATE OF SERVICE
	OR PROVIDER SPECIALTY =	172A00000X (OTHER SERVICE PROVIDER/DRIVERS) OR
		344600000X (TRANSPORTATION SERVICES/TAXI)
	OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	T	MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
		FG	TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) OR
		FS	TFL (SECOND PAYOR) OR
		RS	MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) AND BEGIN DATE OF CARE ≥ 10/01/2001
	THEN DO NOT CHECK PROVIDER FILE

ELEMENT NAME: PROVIDER TAXPAYER NUMBER (2-240)
1 ONLY THE FIRST FIVE DIGITS OF THE PROVIDER ZIP CODE IS USED IN THE MATCH.
VALIDITY EDITS
2-240-01V	MUST BE NUMERIC
	OR (FIRST THREE POSITIONS MUST BE A VALID STATE/COUNTRY CODE
	AND LAST SIX POSITIONS MUST BE NUMERIC)
	OR (FIRST THREE POSITIONS MUST BE A VALID STATE/COUNTRY CODE
	AND FOURTH POSITION MUST BE = A
	AND LAST 5 POSITIONS MUST BE NUMERIC)
Relational Edits
NO ERROR	IF ADJUSTMENT/DENIAL REASON CODE FOR THAT OCCURRENCE/LINE ITEM =	38	SERVICES NOT PROVIDED OR AUTHORIZED BY DESIGNATED (NETWORK) PROVIDERS OR
		52	THE REFERRING/PRESCRIBING/RENDERING PROVIDER IS NOT ELIGIBLE TO REFER/PRESCRIBE/ORDER/PERFORM THE SERVICE BILLED OR
		B7	THIS PROVIDER WAS NOT CERTIFIED/ELIGIBLE TO BE PAID FOR THIS PROCEDURE/SERVICE ON THIS DATE OF SERVICE
	THEN DO NOT CHECK FOR MATCH ON PROVIDER FILE FOR THAT PROVIDER
NO ERROR	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE FOR THAT OCCURRENCE =	T	MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
		FG	TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) OR
		FS	TFL (SECOND PAYOR) OR
		RS	MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) AND BEGIN DATE OF CARE ≥ 10/01/2001
	THEN DO NOT CHECK FOR MATCH ON PROVIDER FILE FOR THAT PROVIDER
NO ERROR	IF AMOUNT ALLOWED BY PROCEDURE CODE ≤ ZERO
	THEN DO NOT CHECK PROVIDER FILE FOR THAT PROVIDER
NO ERROR	IF PROVIDER SPECIALTY =	172A00000X (OTHER SERVICE PROVIDERS/DRIVER) OR
		344600000X (TRANSPORTATION SERVICES/TAXI)
	THEN DO NOT CHECK PROVIDER FILE FOR THAT PROVIDER
2-240-02R	IF PROVIDER TAXPAYER NUMBER IS ALL NINES
	THEN PROVIDER SPECIALTY MUST =	172A00000X (OTHER SERVICE PROVIDERS/DRIVER) OR
		344600000X (TRANSPORTATION SERVICES/TAXI)
	AND PROVIDER PARTICIPATION INDICATOR MUST =	N	NO
2-240-04R	IF ANY OCCURRENCE OF OVERRIDE CODE =	NC	NON-CERTIFIED PROVIDER
	THEN THE NON-CERTIFIED PROVIDER MUST MATCH THE PROVIDER ON THE PROVIDER FILE USING THE FOLLOWING: NON-INSTITUTIONAL PROVIDER TAXPAYER NUMBER AND PROVIDER MAJOR SPECIALITY AND PROVIDER ZIP CODE1 AND PROVIDER SUB-IDENTIFIER AND ACCEPTANCE AND TERMINATION DATES MUST = ZEROES AND PROVIDER CONTRACT AFFILIATION CODE MUST = 5 (NON-CERTIFIED PROVIDER)
	IF NO OCCURRENCE OF OVERRIDE CODE =	NC	NON-CERTIFIED PROVIDER
	THEN THE CERTIFIED PROVIDER MUST MATCH THE PROVIDER ON THE PROVIDER FILE USING THE FOLLOWING: NON-INSTITUTIONAL PROVIDER TAXPAYER NUMBER AND PROVIDER MAJOR SPECIALTY AND PROVIDER ZIP CODE1 AND PROVIDER SUB-IDENTIFIER

ELEMENT NAME: PROVIDER SUB-IDENTIFIER (2-245)
VALIDITY EDITS
2-245-01V	MUST BE FOUR CHARACTERS FIRST CHARACTER ALPHANUMERIC, LAST THREE CHARACTERS NUMERIC
	OR FIRST TWO CHARACTERS ALPHANUMERIC, LAST TWO CHARACTERS NUMERIC
	OR ALL FOUR NUMERIC
Relational Edits
	NONE

ELEMENT NAME: PROVIDER ZIP CODE (2-250)
1 WHEN FOREIGN COUNTRY CODES ARE SUBMITTED, THE FIRST THREE CHARACTERS WILL BE EDITED AGAINST Addendum A.
VALIDITY EDITS
2-250-01V	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: PROVIDER TAXONOMY (SPECIALTY) (2-255)
VALIDITY EDITS
2-255-01V	THIS FIELD MUST BE A VALID PROVIDER SPECIALTY (REFER TO HTTP://WWW.WPC-EDI.COM/REFERENCE/).
Relational Edits
2-255-03R	IF PROVIDER SPECIALTY =	333600000X (SUPPLIERS/PHARMACY)
	THEN TYPE OF SERVICE (SECOND POSITION) =	B	RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
2-255-04R	IF PROVIDER SPECIALTY =	183500000X (PHARMACY SERVICE PROVIDERS/PHARMACIST)
	THEN TYPE OF SERVICE (SECOND POSITION) =	M	MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS

ELEMENT NAME: PROVIDER PARTICIPATION INDICATOR (2-260)
VALIDITY EDITS
2-260-01V	MUST BE A VALID PROVIDER PARTICIPATION INDICATOR.
Relational Edits
	NONE

ELEMENT NAME: PROVIDER NETWORK STATUS INDICATOR (2-265)
VALIDITY EDITS
2-265-01V	PROVIDER NETWORK STATUS INDICATOR MUST =	1	NETWORK PROVIDER OR
		2	NON-NETWORK PROVIDER
Relational Edits
	NONE

ELEMENT NAME: PHYSICIAN REFERRAL NUMBER (2-270)
VALIDITY EDITS
2-270-01V	MUST BE ALL BLANKS
	OR 9 CHARACTERS (INCLUDING IMBEDDED BLANKS)
	OR 13 CHARACTERS (INCLUDING IMBEDDED BLANKS)
	OR 10 CHARACTERS
2-270-02V	IF PHYSICIAN REFERRAL NUMBERS IS 10 CHARACTERS
	THEN THE 10 CHARACTERS MUST BE ALL NUMBERIC
	AND THE CHECK DIGIT (POSITION 10 OF THE PHYSICIAN REFERRAL NUMBER) MUST EQUAL THE VALUE COMPUTED USING LUHN FORMULA FOR MODULES 10 “DOUBLE-ADD-DOUBLE” CHECK DIGIT ALGORITHM
Relational Edits
	NONE

ELEMENT NAME: PLACE OF SERVICE (2-275)
VALIDITY EDITS
2-275-01V	VALUE MUST BE A VALID PLACE OF SERVICE.
Relational Edits
2-275-01R	IF ADJUSTMENT/DENIAL REASON CODE IS NOT A CODE LISTED IN Addendum G, Figure 2.G-2.
	THEN PLACE OF SERVICE MUST BE CONSISTENT WITH TYPE OF SERVICE, REFER TO Addendum F.
2-275-06R	IF PLACE OF SERVICE =	21	INPATIENT HOSPITAL
	THEN TYPE OF SERVICE (FIRST POSITION) MUST =	I	INPATIENT

ELEMENT NAME: TYPE OF SERVICE (2-280)
VALIDITY EDITS
2-280-01V	FIRST POSITION MUST BE = A, I, K, M, N, O, OR P.
	SECOND POSITION MUST BE = 1-9; A-M.
	IF FIRST POSITION = A; SECOND POSITION MUST ≠ C.
	IF FIRST POSITION = P; SECOND POSITION MUST = H.
	IF FIRST POSITION = N; SECOND POSITION MUST = I.
Relational Edits
2-280-07R	IF TYPE OF SERVICE (FIRST POSITION) =	A	AMBULATORY SURGERY COST-SHARED AS INPATIENT (ACTIVE DUTY DEPENDENTS ONLY) OR
		M	OUTPATIENT MATERNITY COST-SHARED AS INPATIENT OR
		N	OUTPATIENT COST-SHARED AS INPATIENT OR
		O	OUTPATIENT, EXCLUDING M, N, OR P OR
		P	OUTPATIENT PARTIAL PSYCHIATRIC HOSPITALIZATION COST-SHARED AS INPATIENT
	THEN PLACE OF SERVICE CANNOT =	21	INPATIENT HOSPITAL
2-280-08R	IF TYPE OF SERVICE (SECOND POSITION) =	B	RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
	THEN NATIONAL DRUG CODE MUST ≠ BLANK
	UNLESS PROVIDER STATE OR COUNTRY CODE IS A FOREIGN COUNTRY CODE (Addendum A)
2-280-09R	IF TYPE OF SERVICE (SECOND POSITION) =	M	MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
	THEN TYPE OF SUBMISSION MUST ≠	B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	AND CA/NAS EXCEPTION REASON MUST = BLANK
	AND CA/NAS NUMBER MUST = BLANK
	AND CA/NAS REASON FOR ISSUANCE MUST = BLANK
	AND NATIONAL DRUG CODE MUST ≠ BLANK
	AND IF BEGIN DATE OF CARE < 01/01/2016
	THEN PLACE OF SERVICE MUST =	19	PHARMACY
	ELSE PLACE OF SERVICE MUST =	01	PHARMACY
	AND PRICING RATE CODE MUST = 0
	AND PROVIDER NETWORK STATUS INDICATOR MUST =	1	NETWORK PROVIDER
	AND PROVIDER PARTICIPATING INDICATOR MUST =	Y	YES
	AND PROVIDER SPECIALTY MUST =	183500000X (PHARMACY SERVICE PROVIDERS/PHARMACIST)
	AND IF PROCEDURE CODE =	000MN	PRESCRIPTION MEDICAL NECESSITY REVIEWS OR
		000PA	PRESCRIPTION PRIOR AUTHORIZATIONS
	THEN AMOUNT PATIENT COST-SHARE MUST = ZERO
	AND CLAIM FORM TYPE/EMC INDICATOR MUST =	J	OTHER
	ELSE IF OCCURRENCE/LINE ITEM NUMBER = 002
	THEN AMOUNT BILLED BY PROCEDURE CODE ON THIS LINE ITEM MUST = ZERO
	AND AMOUNT PATIENT COST-SHARE ON THIS LINE ITEM MUST = ZERO
	AND NUMBER OF SERVICES ON THIS LINE ITEM MUST = ZERO
	ELSE CLAIM FORM TYPE/EMC INDICATOR MUST =	I	ELECTRONIC DRUG CLAIM SUBMISSION
	AND NUMBER OF SERVICES = 1
2-280-10R	IF TYPE OF SERVICE (SECOND POSITION) =	B	RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS OR
		M	MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
	THEN REGION INDICATOR MUST = BLANK
	UNLESS PROVIDER STATE OR COUNTRY CODE IS A FOREIGN COUNTRY CODE (Addendum A)
2-280-11R	IF TYPE OF SERVICE (SECOND POSITION) =	M	MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
	AND OCCURRENCE/LINE ITEM COUNT = 002
	THEN PROCEDURE CODE MUST =	99070	SUPPLIES
2-280-12R	IF TYPE OF SERVICE (SECOND POSITION) =	G	DENTAL
	THEN PROCEDURE CODE ≠ 00100 - 09999
2-280-13R	IF TYPE OF SERVICE (SECOND POSITION) =	B	RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS OR
		M	MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
	AND CLAIM FORM TYPE/EMC INDICATOR =	J	OTHER
	THEN PROCEDURE CODE MUST =	000MN	PRESCRIPTION MEDICAL NECESSITY REVIEWS OR
		000PA	PRESCRIPTION PRIOR AUTHORIZATIONS

ELEMENT NAME: HEALTH CARE COVERAGE (HCC) MEMBER CATEGORY CODE (2-285)
VALIDITY EDITS
2-285-01V	MUST BE A VALID HCC MEMBER CATEGORY CODE (REFER TO Section 2.5)
Relational Edits
2-285-01R	IF HCC MEMBER RELATIONSHIP CODE =	A	SELF
	THEN HCC MEMBER CATEGORY MUST ≠	A	ACTIVE DUTY OR
		G	NATIONAL GUARD MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
		J	ACADEMY STUDENT OR
		N	NATIONAL GUARD (NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS) OR
		S	RESERVE MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
		T	FOREIGN MILITARY MEMBER OR
		V	RESERVE MEMBER (NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS)
	UNLESS ENROLLMENT/HEALTH PLAN CODE =	W	TPR SERVICE MEMBER - USA OR
		X	FOREIGN SERVICE MEMBER OR
		Y	CHCBP - NON-NETWORK OR
		AA	CHCBP - NETWORK OR
		SN	SHCP - NON-MTF/eMSM-REFERRED CARE OR
		SO	SHCP - NON-TRICARE ELIGIBLE OR
		SR	SHCP - MTF/eMSM REFERRED CARE OR
		ST	SHCP - TRICARE ELIGIBLE OR
		SU	SHCP - REFERRAL DESIGNATION UNKNOWN OR
		WA	TPR FOREIGN SERVICE MEMBER
	OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	SC	SHCP - NON-TRICARE ELIGIBLE OR
		SE	SHCP - TRICARE ELIGIBLE OR
		SM	SHCP - EMERGENCY
	OR HCDP PLAN COVERAGE CODE =	306	TRICARE SELECT - RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR
		307	TRICARE SELECT - RETIRED RESERVE SPONSORS AND FAMILY MEMBERS OR
		401	TRS TIER 1 MEMBER-ONLY COVERAGE (CONTINGENCY OPERATIONS) OR
		402	TRS TIER 1 MEMBER AND FAMILY COVERAGE (CONTINGENCY OPERATIONS) OR
		405	TRS TIER 2 MEMBER-ONLY COVERAGE (CERTIFIED QUALIFICATIONS) OR
		406	TRS TIER 2 MEMBER AND FAMILY COVERAGE (CERTIFIED QUALIFICATIONS) OR
		407	TRS TIER 3 MEMBER-ONLY COVERAGE (SERVICE AGREEMENT) OR
		408	TRS TIER 3 MEMBER AND FAMILY COVERAGE (SERVICE AGREEMENT) OR
		409	TRS SURVIVOR CONTINUING WITH INDIVIDUAL COVERAGE OR
		410	TRS SURVIVOR CONTINUING WITH FAMILY COVERAGE OR
		411	TRS SURVIVOR NEW INDIVIDUAL COVERAGE OR
		412	TRS SURVIVOR NEW FAMILY COVERAGE OR
		413	TRS MEMBER-ONLY COVERAGE OR
		414	TRS MEMBER AND FAMILY COVERAGE OR
		418	TRICARE RETIRED RESERVE (TRR) MEMBER-ONLY COVERAGE OR
		419	TRR MEMBER AND FAMILY COVERAGE OR
		420	TRR SURVIVOR INDIVIDUAL COVERAGE OR
		421	TRR SURVIVOR FAMILY COVERAGE
2-285-02R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	PF	ECHO
	THEN HHC MEMBER CATEGORY CODE MUST =	A	ACTIVE DUTY OR
		G	NATIONAL GUARD MEMBER (MOBILIZED OR ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
		J	ACADEMY STUDENT OR
		P	TAMP MEMBER OR
		S	RESERVE MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE)
2-285-03R	IF TYPE OF SERVICE (FIRST POSITION) =	A	AMBULATORY SURGERY COST-SHARED AS INPATIENT
	THEN HCC MEMBER CATEGORY CODE MUST =	A	ACTIVE DUTY OR
		G	NATIONAL GUARD MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
		J	ACADEMY STUDENT OR
		N	NATIONAL GUARD MEMBER (NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS) OR
		P	TAMP MEMBER OR
		S	RESERVE MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
		T	FOREIGN MILITARY MEMBER OR
		V	RESERVE MEMBER (NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS) OR
		Z	UNKNOWN
	UNLESS AMOUNT ALLOWED BY PROCEDURE CODE = 0
2-285-04R	IF HCDP PLAN COVERAGE CODE =	004	DIRECT CARE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
		005	TRICARE STANDARD FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
		016	DIRECT CARE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
		017	TRICARE STANDARD FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
		021	TFL FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
		023	TFL FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
		110	TRICARE PRIME FOR INDIVIDUAL COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
		111	TRICARE PRIME FAMILY COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
		114	TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
		115	TRICARE USFHP DIRECT CARE FAMILY COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
		136	TRICARE PRIME INDIVIDUAL COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
		137	TRICARE PRIME FAMILY COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
		138	TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
		139	TRICARE USFHP DIRECT CARE FAMILY COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
		143	TRICARE PLUS COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
		144	TRICARE PLUS WITH CHC COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
		148	TRICARE PLUS COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
		149	TRICARE PLUS COVERAGE WITH CHC FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
		205	TDP INDIVIDUAL COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
		206	TDP FAMILY COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPNSORS OR
		212	TDP INDIVIDUAL COVERAGE FOR SURVIVORS OF SELECTED RESERVE (SelRes) DECEASED SPONSORS OR
		213	TDP FAMILY COVERAGE FOR SURVIVORS OF SELECTED RESERVE (SelRes) DECEASED SPONSORS OR
		306	TRICARE SELECT - RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR
		345	TRICARE PLUS - DIRECT CARE ONLY (PRESENTATION LAYER) OR
		346	TRICARE PLUS OR
		409	RESERVE SELECT SURVIVOR CONTINUING WITH INDIVIDUAL COVERAGE OR
		410	RESERVE SELECT SURVIVOR CONTINUING WITH FAMILY COVERAGE OR
		411	RESERVE SELECT SURVIVOR NEW INDIVIDUAL COVERAGE OR
		412	RESERVE SELECT SURVIVOR NEW FAMILY COVERAGE
	OR ENROLLMENT/HEALTH PLAN CODE =	AS	TRICARE SELECT - ACTIVE DUTY SURVIVORS OR
		GS	TRICARE SELECT - GUARD/RESERVE SURVIVORS
	OR AMOUNT ALLOWED BY PROCEDURE CODE = 0
	THEN BYPASS THIS EDIT
	ELSE IF TYPE OF SERVICE (SECOND POSITION) =	C	AMBULATORY SURGERY
	THEN HCC MEMBER CATEGORY CODE MUST =	D	DISABLED AMERICAN VETERAN OR
		F	FORMER MEMBER OR
		H	MOH RECIPIENT OR
		R	RETIRED OR
		W	FORMER SPOUSE OR
		Z	UNKNOWN
2-285-05R	IF HCC MEMBER CATEGORY CODE =	T	FOREIGN MILITARY MEMBER
	THEN ONE OCCURRENCE OF OVERRIDE CODE =	M	NATO

ELEMENT NAME: PAY GRADE CODE (SPONSOR) (2-291)
VALIDITY EDITS
2-291-01V	MUST BE A VALID PAY GRADE CODE (SPONSOR) (REFER TO Section 2.7)
Relational Edits
	NONE

ELEMENT NAME: PAY PLAN CODE (SPONSOR) (2-292)
VALIDITY EDITS
2-292-01V	MUST BE A VALID PAY PLAN CODE (SPONSOR) (REFER TO Addendum K)
Relational Edits
	NONE

ELEMENT NAME: HEALTH CARE COVERAGE (HCC) MEMBER RELATIONSHIP CODE (2-295)
1 PATIENT AGE IS CALCULATED BASED ON PERSON BIRTH CALENDAR DATE (PATIENT) AND BEGIN CARE DATE.
VALIDITY EDITS
2-295-01V	MUST BE A VALID HCC MEMBER RELATIONSHIP CODE (REFER TO Section 2.5)
Relational Edits
2-295-06R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	PF	ECHO
	THEN HCC MEMBER RELATIONSHIP CODE MUST =	A	SELF OR
		B	SPOUSE OR
		C	CHILD OR STEPCHILD OR
		D	PRE-ADOPTIVE CHILD OR
		E	WARD (COURT ORDERED) OR
		G	SURVIVING SPOUSE
2-295-07R	IF TYPE OF SERVICE (FIRST POSITION) =	A	AMBULATORY SURGERY COST-SHARED AS INPATIENT
	THEN HCC MEMBER RELATIONSHIP CODE MUST =	A	SELF OR
		B	SPOUSE OR
		C	CHILD OR STEPCHILD OR
		D	PRE-ADOPTIVE CHILD OR
		E	WARD (COURT ORDERED) OR
		G	SURVIVING SPOUSE OR
		Z	UNKNOWN
	AND HCC MEMBER CATEGORY CODE ≠	W	FORMER SPOUSE
	UNLESS ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	SC	SHCP - NON-TRICARE ELIGIBLE
2-295-10R	IF HCC MEMBER CATEGORY CODE =	T	FOREIGN MILITARY MEMBER
	AND HCC MEMBER RELATIONSHIP CODE =	A	SELF
	THEN ANY OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	AN	SHCP - NON-REFERRED CARE OR
		AR	SHCP - MTF/eMSM REFERRED CARE OR
		SC	SHCP - NON-TRICARE ELIGIBLE OR
		SM	SHCP - EMERGENCY
	OR ENROLLMENT/HEALTH PLAN CODE MUST =	SN	SHCP - NON-MTF/eMSM REFERRED OR
		SO	SHCP - NON-TRICARE ELIGIBLE OR
		SR	SHCP - REFERRED OR
		SU	SHCP - REFERRAL DESIGNATION UNKNOWN
	UNLESS AMOUNT ALLOWED BY PROCEDURE CODE = ZERO
	THEN BYPASS THIS EDIT

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