1.0
General
1.1 TED records
provide detailed information for each treatment encounter and are
required for the Defense Health Agency (DHA) health care and financial
reporting. A TED record is submitted as either an institutional
or non-institutional record.
1.1.1 Institutional
TED records usually reflect a treatment encounter created by the
formal acceptance of a hospital or other authorized institutional
provider of a TRICARE beneficiary for the purpose of occupying a
bed with the reasonable expectation that the patient will remain
on inpatient status at least 24 hours with a registration and assignment
of an inpatient number or designation. Institutional TED records
may also reflect outpatient care in a Hospice or Home Health Program.
1.1.2 Non-institutional TED records
reflect either inpatient or outpatient health care services exclusive
of inpatient institutional facility services, including institutional
care in connection with ambulatory surgery.
1.2 All elements of the TED records
must be maintained in the contractor’s claims history file. The
claims history will reflect the data submitted to the DHA on the
TED record including initial submissions, resubmissions, adjustments,
and cancellations. Claims history will also contain all data necessary
to reproduce a TED record as required by this manual and to reproduce
an Explanation Of Benefits (EOB), if required.
1.3 There are three types of TED
records:
• Initial Submission
• Adjustment/Cancellation Submission
• Resubmission
1.4 These types of records are
discussed in the following paragraphs. Complete record layouts and
data requirements by Element Locator Number (ELN) are detailed in
Sections 2.4 through
2.9. Edit criteria are detailed in
Sections 5.1 through
6.4, and
8.1.
1.5 TED records within a day’s
cycle are processed by DHA first in Processed To Completion (PTC)
Date Order, then by TYPE OF SUBMISSION (I, O, D, R first; A, B, C, E second).
2.0 Initial Submission Of TED Records
Initial submission applies
only to the first submission of a new TED record. Initial submissions
are identified by TYPE OF SUBMISSION codes I, D,
and O on the TED record.
2.1 All
data indicated as “required” in the data element definition must
be reported. If not received in the treatment encounter data, this
data must be developed.
2.2 All signed
numeric data elements on the initial submission must be reported
as positive values.
2.3 When institutional
TED records are reported for other than the complete inpatient hospital
stay, the TED records must be reported to DHA in the sequence that
the care was provided (FREQUENCY CODES, 2-Initial, 3-Interim or
4-Final). Refer to
paragraph 7.0 for requirements on submitting
interim bills for institutional claims.
3.0 Submission Of Adjustment/Cancellation
TED Records
3.1 Adjustment and cancellation
TED records correct records with claims processing errors, or update
prior data on the record with more current/accurate information.
For contracts awarded prior to July 1, 2007, adjustment records
also corrected relational errors that were provisionally accepted
on the DHA database.
3.2 Adjustments
and cancellations to complete denial or cancellation TED records
are not permitted. Denied or canceled TED records that require further
processing activity must be submitted as new, initial submissions.
3.3 All adjustments and cancellations
to TED records must be submitted using the same Adjustment Key that was
used on the original submission.
3.4 Adjustments
and cancellations to TED records are identified by TYPE OF SUBMISSION
codes A, B, C, and E on
the TED record. Adjustments and cancellations to non-TED records
must be reported using TYPE OF SUBMISSION codes B or E.
The use of the proper TYPE OF SUBMISSION code is essential for accurate
processing of adjustments.
3.5 Adjustment
and cancellation conditions include, but are not limited to, the
following:
• Error in information received
from the provider or beneficiary.
• Late submission of data from
providers.
• Error in processing by current
or prior contractor (if applicable).
• Patient liability corrections.
• Successful recoupment of monies,
or receipt of a refund from the provider, beneficiary, or third
party.
• Stale dated payment checks.
3.6 When health care is charged
to the wrong Government fund (i.e., financially underwritten vs.
non-financially underwritten) the original record must be canceled
and a new, initial TED record submitted under the correct Government
fund.
3.7 Adjustment submissions are
positive (where additional monies are being paid by the contractor), negative
(where monies are being credited back to the contractor), or statistical
(serve to correct prior information but have no impact on payment
amount).
Note: If an
adjustment to a record results in the net effect of a complete cancellation
of the TED record (i.e., where the AMOUNT ALLOWED, AMOUNT GOVERNMENT
PAY, and AMOUNT PATIENT COST-SHARE = zero, and all line items are
denied), the adjustment must be reported with TYPE OF SUBMISSION
code C or E. Refer to the examples later
in this Section for an example of a complete cancellation TED record.
An adjustment to a TED record which would change the TYPE OF SUBMISSION
from I, R, or A to O is
not allowed. The original TED record must be canceled and a new,
initial record submitted with the correct TYPE OF SUBMISSION O.
3.7.1 Adjustment and cancellation
submissions to TED records must be reported using the TED RECORD INDICATOR
(TRI) reported on the initial submission TED record, regardless
of the number of adjustments to the initial TED record. However,
an adjustment that would result in submission of a different RECORD
TYPE INDICATOR (e.g., change an institutional record, type 1, to
a non-institutional record, type 2) is not permitted. In this instance, the
initial TED record must be completely canceled (TYPE OF SUBMISSION
code C or E), and a new initial TED record submitted
with the correct RECORD TYPE INDICATOR.
3.7.2 All data
as reported on the initial TED record must be resubmitted on adjustment
and cancellation TED records except for signed numeric fields, and
those numeric fields requiring correction. Data contained within
each line item in the variable portion of the adjustment or cancellation
TED record must be reported in the same sequence, with the same
LINE ITEM NUMBER as on the initial TED record. An adjustment or
cancellation TED record can add additional detail line items, but
cannot remove previously reported line items. All signed numeric
fields and those non-signed numeric fields requiring correction
must be reported according to the following paragraphs:
3.7.2.1 All signed numeric data elements
affected by the adjustment or cancellation must reflect the difference between
what was initially reported and the correct amount.
If adjustments were made in signed numeric fields prior to the current
adjustment, these data elements must reflect the difference amounts
after combining the amounts in the initial and all prior adjustment
submissions with this submission. Those signed numeric data elements
that are unaffected by the adjustment netting process must be set
to zero.
3.7.2.2 Alphanumeric data elements
requiring correction or update must reflect the most current information
applicable to the service(s) being reported. All other alphanumeric
data elements must be reported as on the initial submission, or
if prior adjustments corrected/updated the initial data, the data
from the most recent submission must be reported.
3.7.2.3 Adjustment and complete cancellation
TED records are matched and applied to their corresponding initial
submission TED record, and any prior adjustment TED records, using
the DHA database which consists of all TED and Health Care Service
Records. The resulting “net” TED record is completely edited through
the DHA edit system as if it were an initial submission TED record.
Thus, the original and any prior adjustments must have passed all
TED edits before a new adjustment is reported.
3.7.3 Examples
Examples of adjustment and
cancellation submissions are located below. Example
paragraph 3.7.3.1 portrays
a positive adjustment, example
paragraph 3.7.3.2 portrays a negative adjustment,
example
paragraph 3.7.3.3 portrays an adjustment correcting
information without impact on payment amount, and example
paragraph 3.7.3.4 portrays
a negative adjustment resulting in a complete cancellation.
3.7.3.1
Positive
Adjustment
A TED
record was submitted by the contractor and processed by DHA with
an amount billed of $200, amount allowed of $100, and $50 applied
to the deductible. The amount allowed should have been $180 and
no monies should have been applied to the deductible. The amount
billed, however, was unchanged.
Initial
Ted Record Positive Adjustment Amounts
Initial TED Record
|
Amount Billed
|
$200.00
|
Amount Allowed
|
100.00
|
Amount to Deductible
|
50.00
|
Amount Paid (75%)
|
37.50
|
Initial
Ted Record Positive Adjustment Amounts
Adjustment TED Record
|
Amount Billed
|
0
|
Amount Allowed
|
80.00
|
Amount to Deductible
|
- 50.00
|
Amount Paid (75%)
|
97.50
|
Effect At DHA
|
Amount Billed
|
$200.00
|
Amount Allowed
|
180.00
|
Amount to Deductible
|
0
|
Amount Paid
|
135.00
|
3.7.3.2
Negative
Adjustment
A TED
record was submitted by the contractor and processed by DHA with
an amount billed of $500, an amount allowed of $500, and amount
paid by the contractor of $500. However, Other Health Insurance
(OHI) was involved and their payment of $400 was recouped. The amounts
billed and allowed were correct but the amount paid should have
been $100.
TED Record
Negative Adjustment Amounts
Initial TED Record
|
Amount Billed
|
$500.00
|
Amount Allowed
|
500.00
|
Amount to OHI
|
0
|
Amount Paid
|
500.00
|
Adjustment TED Record
|
Amount Billed
|
0
|
Amount Allowed
|
0
|
Amount to OHI
|
400.00
|
Amount Paid
|
- 400.00
|
Effect At DHA
|
Amount Billed
|
500.00
|
Amount Allowed
|
500.00
|
Amount to OHI
|
400.00
|
Amount Paid
|
100.00
|
3.7.3.3
Statistical
Adjustment
A TED
record was submitted by the contractor and processed by DHA for
a hospitalization spanning 20 bed days and $2,000 in billed charges.
Fifteen of the days were considered authorized. Subsequently, the
total number of bed days was found to be 30 and billed charges were
actually $3,000. However, the allowable days and amount paid by
the contractor remained unchanged.
TED Record
Statistical Adjustment
Initial TED Record
|
Amount Billed
|
$2,000.00
|
Amount Allowed
|
1,500.00
|
Covered Days
|
15
|
Amount Paid (75%)
|
1,125.00
|
Adjustment TED Record
|
Amount Billed
|
1,000.00
|
Amount Allowed
|
0
|
Covered Days
|
0
|
Amount Paid
|
0
|
Effect At DHA
|
Amount Billed
|
3,000.00
|
Amount Allowed
|
1,500.00
|
Covered Days
|
15
|
Amount Paid
|
1,125.00
|
3.7.3.4
Negative
Adjustment (Complete Cancellation)
A TED record was submitted
by the contractor and processed by DHA with an amount billed of
$500, allowed of $500, and amount paid by Government contractor
of $375. Subsequently, the contractor processed an adjustment to
pay in full, reporting an increase of $125 in the amount paid by
Government contractor. The contractor then determined the care was
processed in error and recouped the entire $500 payment.
TED Record
Negative Adjustment
Initial TED Record
|
Amount Billed
|
$500.00
|
Amount Allowed
|
500.00
|
Patient Cost-Share
|
125.00
|
Amount Paid
|
375.00
|
Covered Days
|
5
|
Adjustment TED Record
|
Amount Billed
|
0
|
Amount Allowed
|
0
|
Patient Cost-Share
|
- 125.00
|
Amount Paid
|
125.00
|
Covered Days
|
0
|
Effect At DHA
|
Amount Billed
|
500.00
|
Amount Allowed
|
500.00
|
Patient Cost-Share
|
0
|
Amount Paid
|
500.00
|
Covered Days
|
5
|
Cancellation TED Record
|
Amount Billed
|
0
|
Amount Allowed
|
- 500.00
|
Patient Cost-Share
|
0
|
Amount Paid
|
- 500.00
|
Covered Days
|
- 5
|
Effect At DHA
|
Amount Billed
|
500.00
|
Amount Allowed
|
0
|
Patient Cost-Share
|
0
|
Amount Paid
|
0
|
Covered Days
|
0
|
4.0 Resubmission of TED Batch/Vouchers
and TED Records
4.1 Batches/vouchers 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/voucher with the appropriate
data corrections. The BATCH/VOUCHER RESUBMISSION NUMBER must not
be incremented from what was reported on the prior submission.
4.2 Institutional and Non-Institutional
Records which fail any edits will be rejected and returned
to the contractor for correction and resubmission. All returned
records which are contained in a voucher must be returned
by the contractor at the same time and balance to the outstanding
TOTAL AMOUNT PAID and number of outstanding records for that voucher
at DHA. All returned records which are contained in a batch must
be returned by the contractor at the same time and balance to the
outstanding number of records for that batch at DHA. Upon resubmission,
the records will again be processed through the DHA editing system.
Resubmission batch/vouchers are identified by the BATCH/VOUCHER
RESUBMISSION NUMBER in the Header Record. Resubmission applies to
all Institutional and Non-Institutional TED records which have failed
to pass the DHA edits.
4.3 TED record
resubmissions must be reported using the TRI reported on the initial
or adjustment TED record, regardless of the number of times the
TED record is resubmitted.
4.4 All data
as reported on the initial or adjustment TED record must be resubmitted
except for that data changed in order to correct the error(s).
4.5 If a TED record with TYPE OF
SUBMISSION =
I (initial) is rejected, report the correction
TED record with TYPE OF SUBMISSION =
R (resubmission).
• All other rejected TED records
must retain their original TYPE OF SUBMISSION throughout the error
correction/resubmission process.
4.6 To liquidate or “clear” a voucher,
both TOTAL AMOUNT PAID and the number of outstanding TED records must
zero out. When a TED record passes editing, the TOTAL NUMBER OF
RECORDS and the TOTAL AMOUNT PAID submitted on the original voucher
are decremented on the DHA database by the corresponding amount.
A voucher “clears” when both totals reach zero and the DHA database
reflects no outstanding record or paid amounts.
4.7 To liquidate or “clear” a batch,
the number of outstanding records must zero out.
4.8 The contractor shall correct
the related monetary data to balance to the AMOUNT PAID BY GOVERNMENT CONTRACTOR
reported on the TED record if DHA edits identify that the dollar
amount on the voucher are incorrect. On institutional Ted records, do
not change the AMOUNT PAID BY THE GOVERNMENT CONTRACTOR (TOTAL). For
non-institutional TED records, do not change the AMOUNT PAID
BY THE GOVERNMENT CONTRACTOR BY PROCEDURE CODE.Correction
of the payment error will be reflected through the contractor’s
processing and subsequent submission of the adjustment/cancellation
TED record.
5.0
Assignment
of TED Records to the Accrual Fund For Foreign And Pharmacy Contractors
5.1 All contractors that are assigned
appropriation specific Automated Standard Application for Payment (ASAP)
accounts (appropriated funds and accrual funds) shall group TED
records under the correct Contract Line Item Number (CLIN)/ASAP
Account Number using the BATCH/VOUCHER ASAP ACCOUNT NUMBER VALIDATION
- ACCRUAL FUND CHECK edits in
Section 4.1.
5.2 When ASAP accounts are assigned
to a contractor, the Government will specify the appropriate fund
that the ASAP account shall be linked to. All claims grouped to
the Accrual Fund shall pass edit 0-000-05F (BATCH/VOUCHER ASAP ACCOUNT
NUMBER VALIDATION - ACCRUAL FUND CHECK). All claims that do not
group to the Accrual Fund shall be grouped to the Appropriated Fund
ASAP account.
6.0
Batch/Voucher
CLIN/ASAP Account Number Selection Criteria For Contractors
The following process is only
to be used by contractors submitting both financially underwritten
and non-financially underwritten claims to DHA.
6.1 Batches - Header Type Indicator
0 or 9
The contractor
shall zero fill the BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER (0-025)
for all data submissions sent to DHA using the Batch process (0-001).
Under the T-2017 regional contracts, batches are only used for Provider
Files.
6.2 Vouchers - Header Type Indicator
5 or 6
6.2.1 The contractor must select
one of the BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBERs assigned to them
by DHA, Contract Resource Management (CRM) in accordance with Section
G of the contract for all data submissions sent to DHA using the
Voucher process (0-001). DHA, CRM shall assign two types of BATCH/VOUCHER CLIN/ASAP
ACCOUNT NUMBERs a non-financially underwritten ASAP Account (formerly
known as not-at-risk bank accounts) that is issued on a federal
fiscal year basis and a financially underwritten CLIN Account that
is issued for each contract option period and is valid until the
CLIN is closed for TED data processing.
6.2.2 The eight
character non-financially underwritten BATCH/VOUCHER CLIN/ASAP Account
Numbers are issued based on the following format:
• Positions 1 through 4 is 1889.
• Position 5 is the fiscal year
of the ASAP Account.
• Position 6 and 7 is the Contractor
Number (contract specific two digit number assigned by DHA, CRM).
• Position 8 is 1.
6.2.3 The eight character financially
underwritten BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBERs are issued
based on the following format:
• Positions 1 through 6 are equal
to the contract CLIN/Sub-Contract Line Item (SLIN) found in Section
B of the contract (Note: if the SLIN in Section B is numeric then 00 (zero)
fill positions 5 and 6).
• Positions 7 and 8 are the contract
region: EE for East and WW for
West region.
6.2.4 The contractor
shall use the procedures outlined below in order to properly group
claims under the correct BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER.
6.2.5
Criteria
For Selecting DHA Non-Financially Underwritten ASAP Account
6.2.5.1 All non-financially underwritten
claims shall be submitted to DHA, CRM using the non-financially underwritten
ASAP Account Number with a 1 in position 8.
6.2.5.2 The contractor shall use the
non-financially underwritten ASAP Account Number for all Service member
claims and for all healthcare programs identified as non-financially
underwritten in Section H of the contract.
6.2.5.3 All ASAP Type BATCH/VOUCHER
CLIN/ASAP ACCOUNT NUMBERs assigned by DHA, CRM shall have an active date
range assigned. The BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER’s active dates
shall not cross fiscal years unless the contract is in a transition
out period. For all Initial TED data submissions (1-165 and 2-100)
the BATCH/VOUCHER Date (0-030) is the field DHA shall use when editing
for proper selection of ASAP Type BATCH/VOUCHER CLIN/ASAP ACCOUNT
NUMBER based on date. All disbursements shall be made using a currently active ASAP
Type BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER. All credits where reported
disbursements did not occur (stale dated checks, voids, etc.) shall
be credited back to the BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER originally
used to report the disbursement. All collections (credits) of funds
where the disbursement was originally reported to DHA using an ASAP
Type BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER shall be credited to
DHA using currently active BATCH/VOUCHER CLIN/ASAP
ACCOUNT NUMBER.
6.2.6 Criteria
For Selecting Financially Underwritten CLINs (excludes all claims
that meet criteria specified under
paragraph 6.2.5)
6.2.6.1 All financially underwritten
benefit payments must use the BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER
containing the DHA Benefit CLIN (positions 1 through 4 of ASAP)
contained in Section B of the contract (positions 5 and 6 is zero
filled since the CLIN is numeric).
6.2.6.2 The contractor shall be assigned
one financially underwritten CLIN per contract option period. In order
to determine the correct BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER
the contractor must determine the correct option period the claim
falls under. To determine the correct option period the BEGIN DATE
OF CARE (2-150) for non-institutional claims or ADMISSION DATE (1-265)
for institutional claims must be equal to or fall within the option
period begin and end dates.
6.2.6.3 All CLIN Type BATCH/VOUCHER
CLIN/ASAP Account Numbers assigned by DHA, CRM shall have an
active date
range assigned which shall correspond to the begin and end dates
of the CLIN. The BATCH/VOUCHER CLIN/ASAP Account Number’s
active dates
shall not cross Option Periods. The BEGIN DATE OF CARE (2-150) or ADMISSION
DATE (1-265) are the fields DHA shall use when editing for proper
selection of CLIN Type BATCH/VOUCHER. For non-institutional claims
all occurrences of BEGIN DATE OF CARE must fall within the
active date range
of the CLIN type BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER used in
the voucher header. For institutional claims the ADMISSION DATE
must fall within the
active date range of the CLIN
type BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER used in the voucher
header. See the TRICARE Operations Manual (TOM),
Chapter 8, Section 6, paragraph 9.9.
7.0
Interim
Institutional Payments
7.1 In certain cases, providers
can submit interim bills for institutional claims as a method to
facilitate cash flow. Interim-interim and interim-final TED records
with filing dates before January 1, 2011 must be submitted as an adjustment
using the same TRI as the initial submission.
7.2 Interim-interim and interim-final
TED records (FREQUENCY CODES 3 and 4)
with filing dates on or after January 1, 2011 with the exception
of interim billings reimbursed under the Diagnosis Related Group
(DRG) or Home Health Agency (HHA) payment methodology must
be submitted with a unique TRI and must be submitted on batch/vouchers
with HEADER TYPE INDICATOR 0 or 5. DRG
and HHA interim-interim and interim-final TED records will continue
to be submitted as an adjustment using the same TRI as the initial
submission.
7.3 For claims that are reimbursed
under the TRICARE DRG payment methodology please see the TRICARE Reimbursement
Manual (TRM),
Chapter 6, Section 3 for requirements on submitting
DRG interim bills.
7.4 For claims
that are reimbursed under the Home Health Agency Prospective Payment
System (HHA PPS) methodology, please see the guidelines on submitting
interim bills in the TRM,
Chapter 12, Section 6.
7.5 International Classification
of Diseases (ICD) version and Operation/Non-Surgical Procedure (OP/NSP) codes
are determined by patient discharge date. ICD, 10th Revision, Clinical
Modification, (ICD-10-CM) diagnosis and ICD-10-Procedure Coding
System (ICD-10-PCS) OP/NSP codes are appropriate for claims with
discharge dates on or after October 1, 2015 and ICD, 9th Revision,
Clinical Modification (ICD-9-CM) and ICD-9-Procedure Coding System
(ICD-9-PCS) codes are appropriate for discharge dates on or before
September 30, 2015. Since the TED record does not report discharge
date, end date of care will determine ICD version when PATIENT STATUS
indicates discharged, transferred or expired (i.e., codes 01, 02, 03).
Admission date will determine ICD version when the PATIENT STATUS
indicates the patient remains hospitalized (i.e., 30).
8.0
Process
for Reporting External Resource Sharing Encounters to DHA
The following process is to
be used by claims processors to submit data to DHA which relates
to External Resource Sharing encounters.
8.1 Special
Processing Code
For External
Resource Sharing encounters, submit a TED record which includes
SPECIAL PROCESSING CODE of S Resource Sharing - External,
for each patient encounter.
8.2 “Amount”
Field Reporting
The “amount”
fields must contain the following:
8.2.1 Amount
Billed By Procedure Code
If a Resource
Sharing provider is being reimbursed on a fee-for-service basis
with negotiated/discounted rates, report these amounts in the AMOUNT
BILLED BY PROCEDURE CODE field.
8.2.2 Amount
Allowed/Amount Allowed By Procedure Code
The AMOUNT ALLOWED BY PROCEDURE
CODE field must contain the CHAMPUS Maximum Allowable Charge (CMAC)
or negotiated/discounted rates as appropriate.
8.2.3 Amount Paid By Government Contractor
The AMOUNT PAID BY GOVERNMENT
CONTRACTOR field must equal the “lesser” of the amount allowed minus (PATIENT
COST-SHARE plus AMOUNT APPLIED TOWARD DEDUCTIBLE) or AMOUNT ALLOWED
minus amount of OHI. If the “lesser” computed amount is negative,
AMOUNT PAID BY GOVERNMENT CONTRACTOR must = $0.00.
9.0 Process for Reporting Blood
Clotting Factor Data to DHA
9.1 Blood
clotting factor reimbursement will be calculated based on the reimbursement
methodology described in the TRM. Blood clotting factor charges
will not be submitted separately from the DRG reimbursable hospital
charges but will be included on the institutional TED record.
9.2 Data Reporting
The following are data reporting
requirements specific for TED records containing blood clotting
factor charges.
• REVENUE CODE 0636 (Drugs Requiring
Detailed Coding) is to be reported for blood clotting factor.
• UNITS OF SERVICE will reflect
the number of units billed on the claim, not the number of payment
units.
• AMOUNT BILLED (TOTAL) is the
sum of all billed charges on the claim including charges for the
blood clotting factor.
• AMOUNT ALLOWED (TOTAL) is the
sum of DRG allowed amount and the allowable reimbursement for the blood
clotting factor.