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