TRICARE Manuals - Display Chap 2 Sect 4.1 (Change 63, Oct 18, 2022)

TRICARE Encounter Data (TED)

Chapter 2

Section 4.1

Header Edit Requirements (ELN 000 - 099)

Revision: C-57, December 23, 2021

ELEMENT NAME: HEADER TYPE INDICATOR (0-001)
1 IF THE FIRST POSITION OF EACH BATCH/VOUCHER HEADER RECORD IS NOT A 0, 5, 6, OR 9. THEN THE ENTIRE BATCH/VOUCHER WILL BE REJECTED. 2 IDHA DATABASE: CONTRACT INFOMATION PROVIDED TO THE TED FROM THE DHA ACCOUNTING SYSTEM VIA ‘CORAMS’ FILE.
VALIDITY EDITS
0-001-01V1	HEADER TYPE INDICATOR MUST =	0	BATCH HEADER (USED ON ALL PROVIDER BATCHES, AND FOR INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN NON-ADMIN CLAIM RATE ELIGIBLE TED RECORDS) OR
		5	VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR
		6	VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE OR
		9	BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECORDS)
Relational Edits
0-001-01R	IF HEADER TYPE INDICATOR =	5	VOUCHER HEADER NON-ADMIN CLAIM RATE-ELIGIBLE OR
		6	VOUCHER HEADER ADMIN CLAIM RATE-ELIGIBLE OR
		9	BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECORDS)
	THEN BATCH/VOUCHER IDENTIFIER MUST =	5	INSTITUTIONAL/NON-INSTITUTIONAL (BATCH/VOUCHER)
0-001-02R	IF CONTRACT NUMBER = H94002-10-D-0001
	THEN BYPASS THIS EDIT
	ELSE IF HEADER TYPE INDICATOR =	5	VOUCHER HEADER NON-ADMIN CLAIM RATE-ELIGIBLE OR
		6	VOUCHER HEADER ADMIN CLAIM RATE-ELIGIBLE
	AND TYPE OF SUBMISSION ≠	B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	THEN ADJUSTMENT KEY MUST =	5	VOUCHER
0-001-03R	IF HEADER TYPE INDICATOR =	0	BATCH HEADER (USED ON ALL PROVIDER, PRICING BATCHES, AND FOR INSTITUTIONAL/NON-INSTITUTIONAL AT-RISK NON-ADMIN CLAIM RATE ELIGIBLE TED RECORDS) OR
		9	BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL AT-RISK ADMIN CLAIM RATE ELIGIBLE TED RECORDS)
	AND TYPE OF SUBMISSION ≠	B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	AND BATCH/VOUCHER IDENTIFIER =	5	INSTITUTIONAL/NON-INSTITUTIONAL
	THEN ADJUSTMENT KEY MUST =	0	BATCH
0-001-04R	IF HEADER TYPE INDICATOR =	5	VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR
		6	VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE
	AND TYPE OF SUBMISSION =	D	COMPLETE DENIAL OR
		O	ZERO PAYMENT TED RECORD DUE TO 100% OHI
	THEN AMOUNT INTEREST PAYMENT MUST = ZERO
	AND FOR INSTITUTIONAL RECORDS AMOUNT PAID BY GOVERNMENT CONTRACTOR (TOTAL) MUST = ZERO
	FOR NON-INSTITUTIONAL RECORDS THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT PAID BY GOVERNMENT CONTRACTOR BY PROCEDURE CODE MUST = ZERO
0-001-05R	IF DRG NUMBER IS NOT BLANK OR
	TYPE OF INSTITUTION =	70	HHA
	THEN BYPASS THIS EDIT
	ELSE IF FILING DATE IS ≥ 03/01/2012
	AND FREQUENCY CODE ON ANY INSTITUTIONAL RECORD =	3	INTERIM-INTERIM OR
		4	INTERIM-FINAL
	THEN HEADER TYPE INDICATOR MUST =	0	BATCH HEADER (USED ON ALL PROVIDER BATCHES, AND FOR INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN NON-ADMIN CLAIM RATE ELIGIBLE TED RECORDS) OR
		5	VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE
0-001-06R	IF HEADER TYPE INDICATOR =	6	VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE OR
		9	BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECORDS)
	THEN AN ADMINISTRATIVE CLIN MUST BE FOUND IN DHA DATABASE2

ELEMENT NAME: CONTRACT NUMBER (0-010)
1 DHA DATABASE: CONTRACT INFORMATION PROVIDED TO THE TED FROM THE DHA ACCOUNTING SYSTEM VIA ‘CORAMS’ FILE.
VALIDITY EDITS
0-010-01V	MUST BE A VALID VALUE FOUND ON THE DHA DATABASE1.
Relational Edits
0-010-01R	IF CONTRACT NUMBER =	H94002-08-C-0003 TPHARM OR
		HT9402-14-D-0002 TPHARM
	AND BATCH/VOUCHER INDICATOR =	5	INSTITUTIONAL/NON-INSTITUTIONAL
	THEN ALL OCCURRENCES OF RECORD TYPE INDICATOR MUST =	2	NON-INSTITUTIONAL
	AND ALL OCCURRENCES OF TYPE OF SERVICE (POSITION 2) MUST =	M	MOP
	OR ALL OCCURRENCES OF TYPE OF SERVICE (POSITION 2) MUST =	B	RETAIL PHARMACY
0-010-02R	IF CONTRACT NUMBER ≠	HT9402-14-D-0002 TPHARM OR
		HT9402-16-C-0001 T17 EAST
	THEN NO OCCURRENCE OF ENROLLMENT/HEALTH PLAN CODE CAN =	Y	CHCBP - NON-NETWORK - INDIVIDUAL COVERAGE OR
		AA	CHCBP - NETWORK - FAMILY COVERAGE
	AND NO OCCURRENCE OF HEALTH CARE PLAN COVERAGE CAN =	121	CHCBP - NON-NETWORK - INDIVIDUAL COVERAGE OR
		122	CHCBP - NETWORK - FAMILY COVERAGE

ELEMENT NAME: BATCH/VOUCHER IDENTIFIER (0-015)
NOTE: IF ANY TED RECORD FAILS A HEADER EDIT, THE ENTIRE BATCH/VOUCHER FAILS.
VALIDITY EDITS
0-015-01V	MUST =	3	PROVIDER OR
		5	INSTITUTIONAL/NON-INSTITUTIONAL
Relational Edits
0-015-01R	IF BATCH/VOUCHER IDENTIFIER =	5	INSTITUTIONAL/NON-INSTITUTIONAL
	THEN RECORD TYPE (FOR EVERY TED RECORD IN THE BATCH/VOUCHER) MUST =	1	INSTITUTIONAL OR
		2	NON-INSTITUTIONAL
0-015-02R	IF BATCH/VOUCHER IDENTIFIER =	3	PROVIDER
	THEN RECORD TYPE (FOR EVERY TED RECORD IN THE BATCH/VOUCHER) MUST =	3	PROVIDER

ELEMENT NAME: BATCH/VOUCHER NUMBER (0-020)
1 DHADATABASE: CONTRACT INFORMATION PROVIDED TO THE TED FROM THE DHA ACCOUNTING SYSTEM VIA ‘CORAMS FILE. 2 CONTRACT IDENTIFIER: A UNIQUE (KEY) COMBINATION OF CONTRACT NUMBER, BATCH/VOUCHER IDENTIFIER AND BATCH/VOUCHER NUMBER.
VALIDITY EDITS
	NONE
Relational Edits
0-020-01R	IF BATCH/VOUCHER IDENTIFIER =	5	INSTITUTIONAL/NON-INSTITUTIONAL
	AND BATCH/VOUCHER RESUBMISSION NUMBER > 0
	THEN CONTRACT IDENTIFIER2 MUST BE ON THE DHA DATABASE1.
0-020-02R	IF BATCH/VOUCHER IDENTIFIER =	5	INSTITUTIONAL/NON-INSTITUTIONAL
	AND BATCH/VOUCHER RESUBMISSION NUMBER > 0
	THEN CONTRACT NUMBER AND BATCH/VOUCHER NUMBER AND HEADER TYPE INDICATOR MUST BE ON THE DHA DATABASE.
0-020-03R	IF HEADER TYPE INDICATOR =	0	BATCH HEADER (USED ON ALL PROVIDER, PRICING BATCHES, AND FOR INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN NON-ADMIN CLAIM RATE ELIGIBLE TED RECORDS) OR
		5	VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR
		6	VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE OR
		9	BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECORDS)
	AND BATCH/VOUCHER RESUBMISSION NUMBER = 0
	THEN CONTRACT NUMBER AND BATCH/VOUCHER NUMBER MUST NOT EXIST ON THE DHA DATABASE
	AND CONTRACT IDENTIFIER2 MUST BE UNIQUE WITHIN THIS DHA PROCESSING CYCLE.
0-020-04R	IF HEADER TYPE INDICATOR =	0	BATCH HEADER (USED ON ALL PROVIDER, PRICING BATCHES, AND FOR INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN NON-ADMIN CLAIM RATE ELIGIBLE TED RECORDS) OR
		5	VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR
		6	VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE OR
		9	BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECORDS)
	AND BATCH/VOUCHER RESUBMISSION NUMBER > 0
	THEN CONTRACT IDENTIFIER2 MUST BE UNIQUE WITHIN THIS DHA PROCESSING CYCLE.

ELEMENT NAME: BATCH/VOUCHER ASAP ACCOUNT NUMBER (0-025)
1 DHA DATABASE: CONTRACT INFORMATION PROVIDED TO THE TED SYSTEM FROM THE DHA ACCOUNTING SYSTEM VIA ‘CORAMS’ FILE. 2 DEFINED IN THE TRICARE OPERATIONS MANUAL (TOM), CHAPTER 3. IF CONTRACTOR REQUIRES THE ABILITY TO SUBMIT ‘INITIAL SUBMISSIONS’ ON A CLOSED BATCH/VOUCHER CLIN/ASAP ACCOUNT, THEN CONTACT DHA, CRM FOR INSTRUCTIONS ON HOW TO PROCEED.
VALIDITY EDITS
0-025-01V	MUST BE ALPHANUMERIC.
Relational Edits
0-025-01R	IF HEADER TYPE INDICATOR =	0	BATCH HEADER (USED ON ALL PROVIDER BATCHES, AND FOR INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN NON-ADMIN CLAIM RATE ELIGIBLE TED RECORDS) OR
		9	BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECORDS)
	THEN BATCH/VOUCHER ASAP ACCOUNT NUMBER MUST BE ALL ZEROS.
0-025-02R	IF HEADER TYPE INDICATOR =	5	VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR
		6	VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE
	AND BATCH/VOUCHER RESUBMISSION NUMBER = ZERO
	THEN ASAP ACCOUNT NUMBER FOUND ON THE DHA DATABASE1 MUST BE VALID AND ACTIVE2 FOR THE CONTRACT NUMBER ON THE TED BATCH/VOUCHER RECORD.
0-025-05R	IF BATCH/VOUCHER RESUBMISSION NUMBER > 00
	OR HEADER TYPE INDICATOR =	0	BATCH HEADER (USED ON ALL PROVIDER, PRICING BATCHES, AND FOR INSTITUTIONAL/NON-INSTITUTIONAL AT-RISK NON-ADMIN CLAIM RATE ELIGIBLE TED RECORDS) OR
		9	BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL AT-RISK ADMIN CLAIM RATE ELIGIBLE TED RECORDS)
	THEN BYPASS THIS EDIT
	ELSE IF HCDP PLAN COVERAGE CODE =	000	NO HEALTH CARE COVERAGE PLAN OR
		121	CHCBP - NON-NETWORK - INDIVIDUAL COVERAGE OR
		122	CHCBP - NETWORK - FAMILY COVERAGE OR
		306	TRICARE SELECT - RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR
		307	TRICARE SELECT - RETIRED RESERVE SPONSORS AND FAMILY MEMBERS OR
		308	TRICARE SELECT - YOUNG ADULT OR
		330	TRICARE PRIME - YOUNG ADULT ACTIVE DUTY/TAMP OR
		331	TRICARE PRIME - YOUNG ADULT RETIRED OR
		332	TPR - YOUNG ADULT ACTIVE DUTY OR
		401	TRS TIER 1 MEMBER-ONLY OR
		402	TRS TIER 1 MEMBER AND FAMILY OR
		403	TOBACCO CESSATION DEMONSTRATION PROGRAM OR
		404	WEIGHT MANAGEMENT DEMONSTRATION PROGRAM OR
		405	TRS TIER 2 MEMBER-ONLY OR
		406	TRS TIER 2 MEMBER AND FAMILY OR
		407	TRS TIER 3 MEMBER-ONLY OR
		408	TRS TIER 3 MEMBER AND FAMILY OR
		409	TRS SURVIVOR CONTINUING INDIVIDUAL COVERAGE OR
		410	TRS SURVIVOR CONTINUING 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
		417	TRANSITIONAL CARE FOR SERVICE-RELATED CONDITIONS (TCSRC) OR
		418	TRR MEMBER-ONLY COVERAGE OR
		419	TRR MEMBER AND FAMILY COVERAGE OR
		420	TRR SURVIVOR INDIVIDUAL COVERAGE OR
		421	TRR SURVIVOR FAMILY COVERAGE OR
		422	TYA TRICARE STANDARD FOR ADFMs OR
		423	TYA TRICARE STANDARD FOR RETIRED AND MOH FAMILY MEMBERS OR
		424	TYA TRS OR
		425	TYA TRR OR
		426	TYA PRIME FOR ADFMs OR
		427	TYA TPR FOR ADFMs OR
		428	TYA PRIME FOR RETIRED AND MOH FAMILY MEMBERS OR
		429	TYA TRICARE OVERSEAS PRIME FOR ADFMs OR
		430	TYA TRICARE OVERSEAS PRIME REMOTE FOR ADFMs
	OR ENROLLMENT/HEALTH PLAN CODE =	Y	CHCBP - NON-NETWORK - INDIVIDUAL COVERAGE OR
		AA	CHCBP - NETWORK - FAMILY COVERAGE OR
		SN	SHCP - NON-MTF/eMSM REFERRED CARE OR
		SR	SHCP - MTF/eMSM REFERRED CARE
	OR SPECIAL PROCESSING CODE =	AN	SHCP - NON-MTF/eMSM REFERRED CARE OR
		AR	SHCP - MTF/eMSM REFERRED CARE OR
		A2	ACO PILOT FOR PART A SERVICES RENDERED BY KP CONTRACTED PROVIDERS OR
		A3	ACO PILOT FOR PART A SERVICES RENDERED BY NON-KP PROVIDERS OR
		BF	BREASTFEEDING SUPPORT DEMONSTRATION OR
		B2	ACO PILOT FOR PART B SERVICES RENDERED BY KP CONTRACTED PROVIDERS OR
		B3	ACO PILOT FOR PART B SERVICES RENDERED BY NON-KP PROVIDERS OR
		CB	CHILDBIRTH SUPPORT DEMONSTRATION OR
		DC	DCPE-DVA/VHA OR
		DE	TDRL PHYSICAL EXAM OR
		D2	ACO PILOT FOR PART B SERVICES RENDERED BY NON-KP PHARMACIES OR
		MM	MMPCMHP OR
		PV	RETAIL PHARMACY FOR DVA/VHA
	OR HCC MEMBER CATEGORY CODE =	A	ACTIVE DUTY OR
		G	NATIONAL GUARD ACTIVE > 30 DAYS; AGR CODE A-H OR
		J	ACADEMY STUDENT, NOT OCS OR
		N	NATIONAL GUARD NOT ACTIVE OR < 31 DAYS OR
		S	RESERVE MEMBER ACTIVE > 30 DAYS OR
		T	FOREIGN MILITARY OR
		V	RESERVE MEMBER NOT ACTIVE OR < 31 DAYS OR
		Y	SERVICE AFFILIATES (ROTC, MERCHANT MARINE)
	AND HCC MEMBER RELATIONSHIP CODE =	A	SELF
	THEN BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER APPROPRIATION TYPE FOUND IN DHA DATABASE1 MUST ≠	TF	TRUST/ACCRUAL FUND
	ELSE IF OGP TYPE CODE =	A	MEDICARE PART A OR
		C	MEDICARE PART A & B OR
		I	MEDICARE PART A & D OR
		L	MEDICARE PART A, B AND D
	AND OGP BEGIN REASON CODE ≠	N	NOT ELIGIBLE FOR MEDICARE
	AND 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 COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
		151	TRICARE PLUS COVERAGE FOR TRANSITIONAL SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS
	OR ENROLLMENT/HEALTH PLAN CODE =	AS	TRICARE SELECT - ACTIVE DUTY SURVIVORS OR
		GS	TRICARE SELECT - GUARD/RESERVE SURVIVORS
	OR HCC MEMBER CATEGORY CODE =	F	FORMER MEMBER OR
		H	MOH RECIPIENT OR
		R	RETIRED OR
		W	FORMER SPOUSE
	THEN BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER APPROPRIATION TYPE FOUND IN DHA DATABASE1 MUST =	TF	TRUST/ACCRUAL FUND
	ELSE BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER APPROPRIATION TYPE FOUND IN DHA DATABASE1 MUST ≠	TF	TRUST/ACCRUAL FUND
0-025-08R	IF ANY OCCURRENCE OF TYPE OF SUBMISSION =	B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	OR BATCH/VOUCHER RESUBMISSION NUMBER > 00
	OR HEADER TYPE INDICATOR =	0	BATCH HEADER (USED ON ALL PROVIDER BATCHES, AND FOR INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN NON-ADMIN CLAIM RATE ELIGIBLE TED RECORDS) OR
		9	BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECORDS)
	THEN BYPASS THIS EDIT
	ELSE IF BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 =	TD	TRICARE DOMESTIC
	AND CONTRACT NUMBER =	T3 NORTH
	AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) ≥ START OF CONTRACT
	OR CONTRACT NUMBER =	T3 SOUTH
	AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) ≥ START OF CONTRACT
	OR CONTRACT NUMBER =	T3 WEST
	AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) ≥ START OF CONTRACT
	OR CONTRACT NUMBER =	T2017 EAST
	AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) ≥ BEGIN DATE OF OLDEST OPEN OPTION PERIOD
	OR CONTRACT NUMBER =	T2017 WEST
	AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) ≥ BEGIN DATE OF OLDEST OPEN OPTION PERIOD
	THEN SPECIAL PROCESSING CODE (ANY OCCURRANCE) MUST =	AN	SHCP - NON-MTF/eMSM REFERRED CARE OR
		AP	ABA PILOT OR
		AR	SHCP - MTF/eMSM REFERRED CARE OR
		AS	COMPREHENSIVE AUTISM CARE DEMONSTRATION OR
		AT	AFL TREATMENTS FOR SYMPTOMATIC BURNS AND SCARS (EFFECTIVE 02/24/2021 THROUGH 02/23/2026) OR
		AU	AUTISM DEMONSTRATION OR
		A2	ACO PILOT FOR PART A SERVICES RENDERED BY KP CONTRACTED PROVIDERS OR
		A3	ACO PILOT FOR PART A SERVICES RENDERED BY NON-KP PROVIDERS OR
		BF	BREASTFEEDING SUPPORT DEMONSTRATION OR
		B2	ACO PILOT FOR PART B SERVICES RENDERED BY KP CONTRACTED PROVIDERS OR
		B3	ACO PILOT FOR PART B SERVICES RENDERED BY NON-KP PROVIDERS OR
		CB	CHILDBIRTH SUPPORT DEMONSTRATION OR
		CE	SHCP - CCEP OR
		CL	CLINICAL TRIALS OR
		CM	INDIVIDUAL CASE MANAGEMENT OR
		CT	CUSTODIAL CARE OR
		DC	DCPE-DVA/VHA OR
		DE	TDRL PHYSICAL EXAM OR
		D2	ACO PILOT FOR PART B SERVICES RENDERED BY NON-KP PHARMACIES OR
		GU	SERVICE MEMBER ENROLLED IN TPR OR
		G2	GOOD FAITH PAYMENT OR
		HH	HHVBP OR
		LD	LDTs DEMONSTRATION OR
		L2	NON-FDA APPROVED LDTs DEMONSTRATION OR
		MC	PLATELET RICH PLASMA INJECTIONS FOR THE TREATMENT OF MUSCULOSKELETAL CONDITIONS (EFFECTIVE 10/01/2019) OR
		NQ	PI TEMPORARILY SUSPENDED PROVIDER, PHARMACY, ENTITY, OR CLIENT BENEFICIARY CLAIM IN ‘PROCESS STATUS’ OR
		PC	PROVISIONAL COVERAGE FOR EMERGING SERVICES AND SUPPLIES OR
		PV	RETAIL PHARMACY FOR DVA/VHA OR
		RB	RESPITE BENEFIT OR
		SC	SHCP - NON-TRICARE ELIGIBLE OR
		SE	SHCP - TRICARE ELIGIBLE OR
		SM	SHCP - EMERGENCY
	OR ENROLLMENT/HEALTH PLAN CODE MUST =	Y	CHCBP - NON-NETWORK - INDIVIDUAL COVERAGE OR
		AA	CHCBP - NETWORK - FAMILY COVERAGE OR
		SN	SHCP - NON-MTF/eMSM REFERRED CARE OR
		SR	SHCP - MTF/eMSM REFERRED CARE
	OR HCDP PLAN COVERAGE CODE MUST =	000	CARE DELIVERED TO INELIGIBLES OR
		121	CHCBP - INDIVIDUAL COVERAGE OR
		122	CHCBP - FAMILY COVERAGE OR
		306	TRICARE SELECT - RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR
		307	TRICARE SELECT - RETIRED RESERVE SPONSORS AND FAMILY MEMBERS OR
		308	TRICARE SELECT - YOUNG ADULT OR
		330	TRICARE PRIME - YOUNG ADULT ACTIVE DUTY/TAMP OR
		331	TRICARE PRIME - YOUNG ADULT RETIRED OR
		332	TPR - YOUNG ADULT ACTIVE DUTY OR
		401	TRS TIER 1 MEMBER-ONLY OR
		402	TRS TIER 1 MEMBER AND FAMILY OR
		403	TOBACCO CESSATION DEMONSTRATION PROGRAM OR
		404	WEIGHT MANAGEMENT DEMONSTRATION PROGRAM OR
		405	TRS TIER 2 MEMBER-ONLY OR
		406	TRS TIER 2 MEMBER AND FAMILY OR
		407	TRS TIER 3 MEMBER-ONLY OR
		408	TRS TIER 3 MEMBER AND FAMILY OR
		409	TRS SURVIVOR CONTINUING INDIVIDUAL COVERAGE OR
		410	TRS SURVIVOR CONTINUING 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
		417	TRANSITIONAL CARE FOR SERVICE-RELATED CONDITIONS (TCSRC) OR
		418	TRR MEMBER-ONLY COVERAGE OR
		419	TRR MEMBER AND FAMILY COVERAGE OR
		420	TRR SURVIVOR INDIVIDUAL COVERAGE OR
		421	TRR SURVIVOR FAMILY COVERAGE OR
		422	TYA TRICARE STANDARD FOR ADSMs OR
		423	TYA TRICARE STANDARD FOR RETIRED AND MOH FAMILY MEMBERS OR
		424	TYA TRS OR
		425	TYA TRR OR
		426	TYA PRIME FOR ADFMs OR
		427	TYA TPR FOR ADFMs OR
		428	TYA PRIME FOR RETIRED AND MOH FAMILY MEMBERS OR
		429	TYA TRICARE OVERSEAS PRIME FOR ADFMs OR
		430	TYA TRICARE OVERSEAS PRIME REMOTE FOR ADFMs OR
		999	UNVERIFIED NEWBORN
	OR PATIENT ZIP CODE IS IN ALASKA
	OR PCM DMIS-ID MUST =	0005	BASSETT ACH-FT. WAINWRIGHT OR
		0006	3rd MED GRP-ELMENDORF OR
		0130	USCG CLINIC KODIAK OR
		0202	AHC-GREELY OR
		0203	354th MED GRP-EIELSON OR
		0204	TMC FT. RICHARDSON OR
		0417	USCG CLINIC KETCHIKAN OR
		1340	AF-C-673RD FLT MED-ELMENDORF OR
		6033	KAMISH CLINIC-FT. WAINWRIGHT OR
		6083	PREVENTIVE MEDICINE- BASSETT OR
		7044	USCG CLINIC JUNEAU OR
		7047	USCG CLINIC SITKA
	OR HCC MEMBER CATEGORY CODE MUST =	A	ACTIVE DUTY OR
		G	NATIONAL GUARD > 30 DAYS OR
		J	ACADEMY STUDENT OR
		N	NATIONAL GUARD < 30 DAYS OR
		S	RESERVE > 30 DAYS OR
		T	FOREIGN MILITARY MEMBER OR
		V	RESERVE < 30 DAYS OR
		Z	UNKNOWN
	AND HCC MEMBER RELATIONSHIP CODE MUST =	A	SELF OR
		Z	UNKNOWN
0-025-09R	IF ANY OCCURRENCE OF TYPE OF SUBMISSION =	B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	THEN BYPASS THIS EDIT
	ELSE IF BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 =	TC	TRICARE CIVILIAN PRIME
	THEN ENROLLMENT/HEALTH PLAN CODE MUST =	U	TRICARE PRIME CIVILIAN PCM
	AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) ≥ START DATE OF HEALTH CARE DELIVERY FOR THE CONTRACT NUMBER.
0-025-10R	IF ANY OCCURRENCE OF TYPE OF SUBMISSION =	B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	THEN BYPASS THIS EDIT
	ELSE IF BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 =	TN	TRICARE NON-CIVILIAN PRIME
	THEN ENROLLMENT/HEALTH PLAN CODE MUST =	T	TRICARE STANDARD PROGRAM OR
		V	TRICARE EXTRA OR
		Z	TRICARE PRIME, MTF/eMSM/PCM OR
		WF	TRICARE PRIME REMOTE ADFM
	AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) ≥ START DATE OF HEALTH CARE DELIVERY FOR THE CONTRACT NUMBER.
0-025-11R	IF HEADER TYPE INDICATOR =	5	VOUCHER HEADER NON-ADMIN CLAIM RATE-ELIGIBLE OR
		6	VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE
	AND BATCH/VOUCHER CLIN/ASP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 =	TM	TRICARE MAIL ORDER PHARMACY
	THEN THE FIRST OCCURRENCE OF TYPE OF SERVICE (POSITION 2) MUST =	M	MOP
0-025-12R	IF HEADER TYPE INDICATOR =	5	VOUCHER HEADER NON-ADMIN CLAIM RATE-ELIGIBLE OR
		6	VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE
	AND THE FIRST OCCURRANCE OF TYPE OF SERVICE (POSITION 2) =	M	MOP
	THEN BATCH/VOUCHER CLIN/ASP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 MUST =	TM	TRICARE MAIL ORDER PHARMACY
0-025-13R	IF HEADER TYPE INDICATOR =	5	VOUCHER HEADER NON-ADMIN CLAIM RATE-ELIGIBLE OR
		6	VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE
	AND BATCH/VOUCHER CLIN/ASP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 =	TR	TRICARE RETAIL PHARMACY
	THEN THE FIRST OCCURRENCE OF TYPE OF SERVICE (POSITION 2) MUST =	B	RETAIL PHARMACY
0-025-14R	IF HCDP PLAN COVERAGE CODE =	018	TFL FOR RETIRED SPONSORS AND FAMILY MEMBERS AND MOH OR
		020	TFL FOR TRANSITIONAL SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
		021	TFL FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
		022	TFL FOR TRANSITIONAL SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
		023	TFL FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
		029	TFL FOR MEDICALLY RETIRED SPONSORS AND FAMILY MEMBERS
	AND TYPE OF SUBMISSION =	I	INITIAL SUBMISSION OR
		R	RESUBMISSION
	THEN OGP TYPE CODE MUST ≠	N	NO MEDICARE OR
		V	CHAMPVA
	AND OGP BEGIN REASON CODE MUST ≠	N	NOT ELIGIBLE FOR MEDICARE OR
		W	NOT APPLICABLE

ELEMENT NAME: BATCH/VOUCHER DATE (0-030)
1 DHA DATABASE: CONTRACT INFORMATION PROVIDED TO THE TED FROM THE DHA ACCOUNTING SYSTEM VIA ‘CORAMS’ FILE.
VALIDITY EDITS
0-030-01V	MUST BE A VALID JULIAN DATE AND CANNOT BE > DHA CURRENT SYSTEM DATE.
0-030-02V	BATCH/VOUCHER DATE MUST BE ≥ CONTRACT BEGIN DATE1
	AND BATCH/VOUCHER DATE MUST BE ≤ CONTRACT END DATE1
Relational Edits
0-030-01R	IF HEADER TYPE INDICATOR =	5	VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR
		6	VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE
	AND BATCH/VOUCHER RESUBMISSION NUMBER =	00
	AND BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 =	TD	TRICARE DOMESTIC OR
		TF	TRICARE FOREIGN OR
		TT	TRICARE TARGET
	AND TYPE OF SUBMISSION =	D	COMPLETE DENIAL OR
		I	INITIAL SUBMISSION OR
		O	ZERO PAYMENT WITH 100% OHI/TPL OR
		R	RESUBMISSION
	THEN BATCH/VOUCHER DATE IN HEADER MUST BE EQUAL TO OR WITHIN ASAP BEGIN AND END DATES ON THE DHA DATABASE.
0-030-02R	IF HEADER TYPE INDICATOR =	5	VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR
		6	VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE
	THEN BATCH/VOUCHER DATE IN HEADER MUST NOT BE LESS THAN THE ASAP BEGIN DATE ON THE DHA DATABASE.
0-030-03R	IF BATCH/VOUCHER RESUBMISSION NUMBER =	00
	THEN BATCH/VOUCHER DATE MUST ≠	09/29/XXXX OR
		09/30/XXXX
	UNLESS BATCH/VOUCHER IDENTIFIER =	3	PROVIDER (BATCH ONLY)
0-030-04R	IF BATCH/VOUCHER RESUBMISSION NUMBER =	00
	AND TRANSMISSION FILE RECEIVED TIME/DATE STAMP > 10:00 AM 09/28/(CURRENT YEAR)
	AND BATCH/VOUCHER IDENTIFIER =	5	INSTITUTIONAL/NON-INSTITUTIONAL (BATCH/VOUCHER)
	THEN BATCH/VOUCHER DATE MUST NOT BE < 10/01/(CURRENT YEAR)
0-030-05R	IF HEADER TYPE INDICATOR =	5	VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR
		6	VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE
	AND BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 =	TC	TRICARE CIVILIAN PRIME OR
		TN	TRICARE NON-CIVILIAN PRIME
	THEN BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) MUST BE EQUAL TO OR WITHIN ASAP BEGIN AND END DATES ON THE DHA DATABASE

ELEMENT NAME: BATCH/VOUCHER SEQUENCE NUMBER (0-035)
VALIDITY EDITS
0-035-01V	MUST BE NUMERIC AND > ZERO.
Relational Edits
	NONE

ELEMENT NAME: BATCH/VOUCHER RESUBMISSION NUMBER (0-040)
1 CONTRACT IDENTIFIER: A UNIQUE (KEY) COMBINATION OF CONTRACT NUMBER, BATCH/VOUCHER IDENTIFIER AND BATCH/VOUCHER NUMBER.
VALIDITY EDITS
0-040-01V	MUST BE NUMERIC
	AND IF BATCH/VOUCHER IDENTIFIER =	5	INSTITUTIONAL/NON-INSTITUTIONAL
	THEN MUST BE 1 GREATER THAN THE PRIOR SUBMISSION NUMBER UNDER THE SAME CONTRACT IDENTIFIER1.
Relational Edits
	NONE

ELEMENT NAME: TOTAL NUMBER OF RECORDS (0-045)
1 CONTRACT INFORMATION PROVIDED TO THE TED FROM THE DHA ACCOUNTING SYSTEM VIA ‘CORAMS’ FILE.
VALIDITY EDITS
0-045-01V	MUST BE NUMERIC.
0-045-02V	MUST EQUAL NUMBER OF TED RECORDS IN THE BATCH/VOUCHER.
0-045-03V	TOTAL RECORDS MUST > 0
Relational Edits
0-045-01R	IF BATCH/VOUCHER IDENTIFIER =	5	INSTITUTIONAL/NON-INSTITUTIONAL
	AND BATCH/VOUCHER RESUBMISSION NUMBER > ZERO
	THEN NUMBER OF RECORDS IN THE BATCH/VOUCHER MUST = NUMBER OUTSTANDING RECORDS1.

ELEMENT NAME: TOTAL AMOUNT PAID (0-050)
1 DHA DATABASE CONTRACT INFORMATION PROVIDED TO THE TED FROM THE DHA ACCOUNTING SYSTEM VIA ‘CORAMS’ FILE.
VALIDITY EDITS
0-050-01V	MUST BE NUMERIC.
Relational Edits
0-050-01R	IF BATCH/VOUCHER IDENTIFIER =	5	INSTITUTIONAL/NON-INSTITUTIONAL
	THEN TOTAL AMOUNT PAID MUST = THE ACCUMULATED TOTAL OF AMOUNTS PAID BY GOVERNMENT CONTRACTOR AND AMOUNT OF INTEREST PAYMENT FOR ALL TED RECORDS IN THE BATCH/VOUCHER.
0-050-02R	IF BATCH/VOUCHER IDENTIFIER =	3	PROVIDER
	THEN TOTAL AMOUNT PAID MUST EQUAL ZERO.
0-050-03R	IF BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 =	TM	TRICARE MAIL ORDER PHARMACY
	THEN BYPASS THIS EDIT
	ELSE IF HEADER TYPE INDICATOR =	5	VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR
		6	VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE
	AND BATCH/VOUCHER IDENTIFIER =	5	INSTITUTIONAL/NON-INSTITUTIONAL
	AND BATCH/VOUCHER RESUBMISSION NUMBER > ZERO
	THEN TOTAL AMOUNT PAID MUST BE EQUAL TO THE VOUCHER BALANCE1.

ELEMENT NAME: INITIAL TRANSMISSION DATE (DHA DERIVED) (0-055)
VALIDITY EDITS
	NONE
Relational Edits
	NONE

ELEMENT NAME: DHA BATCH/VOUCHER PROCESSING DATE (DHA DERIVED) (0-060)
VALIDITY EDITS
	NONE
Relational Edits
	NONE

ELEMENT NAME: FUND ACCOUNTING (0-065)
1 DHA DATABASE: CONTRACT INFORMATION PROVIDED TO THE TED FROM THE DHA ACCOUNTING SYSTEM VIA ‘CORAMS’ FILE.
VALIDITY EDITS
0-065-01V	MUST BE NUMERIC.
Relational Edits
0-065-02R	IF BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 =	TM	TRICARE MAIL ORDER PHARMACY
	AND HEADER TYPE INDICATOR =	5	VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR
		6	VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE
	AND BATCH/VOUCHER IDENTIFIER =	5	INSTITUTIONAL/NON-INSTITUTIONAL
	AND BATCH/VOUCHER RESUBMISSION NUMBER > ZERO
	THEN THE FUND ACCOUNTING MUST BE EQUAL TO THE VOUCHER BALANCE1.
0-065-03R	IF POSITION 1 THRU 4 OF THE BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER = MIPR
	AND BATCH/VOUCHER DATE ≥ 07/14/2011
	THEN THE FUND ACCOUNTING MUST = THE ACCUMULATED TOTAL OF AMOUNT ALLOWED BY PROCEDURE CODE FOR ALL TED RECORDS IN THIS VOUCHER.

- END -

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.