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/MARKET REFERRED
CARE OR
|
|
|
SR
|
SHCP - MTF/MARKET REFERRED
CARE
|
|
OR SPECIAL PROCESSING
CODE =
|
AN
|
SHCP - NON-MTF/MARKET REFERRED
CARE OR
|
|
|
AR
|
SHCP - MTF/MARKET 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
|
|
|
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
|
|
|
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
CALENDAR DAYS; AGR CODE A-H OR
|
|
|
J
|
ACADEMY STUDENT, NOT OCS OR
|
|
|
N
|
NATIONAL GUARD NOT ACTIVE OR <
31 CALENDAR DAYS OR
|
|
|
S
|
RESERVE MEMBER ACTIVE > 30
CALENDAR DAYS OR
|
|
|
T
|
FOREIGN MILITARY OR
|
|
|
V
|
RESERVE MEMBER NOT ACTIVE OR <
31 CALENDAR 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
|
DC FOR SURVIVORS OF ACTIVE
DUTY DECEASED SPONSORS OR
|
|
|
005
|
TRICARE STANDARD FOR SURVIVORS
OF ACTIVE DUTY DECEASED SPONSORS OR
|
|
|
016
|
DC 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 DC INDIVIDUAL
COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
|
|
|
115
|
TRICARE USFHP DC 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 DC INDIVIDUAL
COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
|
|
|
139
|
TRICARE USFHP DC 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 OCCURRENCE) MUST =
|
AN
|
SHCP - NON-MTF/MARKET REFERRED
CARE OR
|
|
|
AP
|
ABA PILOT OR
|
|
|
AR
|
SHCP - MTF/MARKET 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
|
|
|
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
|
|
|
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
|
|
|
G1
|
GOOD FAITH PAYMENT DEBT TRANSFER3 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
|
|
|
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/MARKET REFERRED
CARE OR
|
|
|
SR
|
SHCP - MTF/MARKET 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 CALENDAR
DAYS OR
|
|
|
J
|
ACADEMY STUDENT OR
|
|
|
N
|
NATIONAL GUARD < 30 CALENDAR
DAYS OR
|
|
|
S
|
RESERVE > 30 CALENDAR DAYS OR
|
|
|
T
|
FOREIGN MILITARY MEMBER OR
|
|
|
V
|
RESERVE < 30 CALENDAR 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/MARKET/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
|
TMOP
|
|
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
OCCURRENCE OF TYPE OF SERVICE (POSITION 2) =
|
M
|
MOP
|
|
THEN BATCH/VOUCHER
CLIN/ASP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 MUST
=
|
TM
|
TMOP
|
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
|
TRRx
|
|
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
|