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.