VALIDITY
EDITS
|
1-185-01V
|
OCCURRENCE NUMBER 1--MUST BE
A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8).
|
1-185-02V
|
OCCURRENCE NUMBER 2--MUST BE
A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8).
|
1-185-03V
|
OCCURRENCE NUMBER 3--MUST BE
A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8).
|
1-185-04V
|
OCCURRENCE NUMBER 4--MUST BE
A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8).
|
1-185-05V
|
A VALUE CANNOT BE CODED MORE
THAN ONCE (EXCEPT BLANK).
|
1-185-06V
|
ALL OCCURRENCES OF SPECIAL
PROCESSING CODE MUST BE BLANK FILLED FOLLOWING THE FIRST OCCURRENCE
OF A BLANK FILLED SPECIAL PROCESSING CODE.
|
1-185-07V
|
IF ANY OCCURRENCE OF SPECIAL
PROCESSING CODE =
|
AN
|
SHCP - NON-MTF/MARKET-REFERRED
CARE OR
|
|
|
AR
|
SHCP - MTF/MARKET REFERRED
CARE
|
|
THEN BEGIN DATE
OF CARE MUST BE < 06/01/2004
|
1-185-08V
|
IF ANY OCCURRENCE OF SPECIAL
PROCESSING CODE =
|
GF
|
TPR FOR ELIGIBLE ADFM RESIDING
WITH A TPR ELIGIBLE SERVICE MEMBER
|
|
THEN BEGIN DATE
OF CARE MUST BE < 09/01/2002
|
1-185-10V
|
IF ANY OCCURRENCE OF SPECIAL
PROCESSING CODE =
|
MN
|
TSP - NON-NETWORK OR
|
|
|
MS
|
TSP - NETWORK
|
|
THEN BEGIN DATE
OF CARE MUST BE < 12/31/2001
|
1-185-11V
|
IF ANY OCCURRENCE OF SPECIAL
PROCESSING CODE =
|
SN
|
TSS - NON-NETWORK OR
|
|
|
SS
|
TSS - NETWORK
|
|
THEN BEGIN DATE
OF CARE MUST BE < 12/31/2002
|
1-185-14V
|
IF ANY OCCURRENCE OF SPECIAL
PROCESSING CODE =
|
ST
|
SPECIALIZED TREATMENT
|
|
THEN BEGIN DATE
OF CARE MUST BE < 10/01/2004
|
Relational
Edits
|
1-185-08R
|
IF ANY OCCURRENCE OF SPECIAL
PROCESSING CODE =
|
PO
|
TRICARE PRIME - POS
|
|
THEN ENROLLMENT/HEALTH
PLAN CODE MUST =
|
U
|
TRICARE PRIME (CIVILIAN PCM) OR
|
|
|
Z
|
TRICARE PRIME, MTF/MARKET/PCM OR
|
|
|
WF
|
TPR FOR ENROLLED ADFM RESIDING
WITH A TPR ELIGIBLE SERVICE MEMBER OR
|
|
|
XF
|
FOREIGN ADFM
|
1-185-14R
|
IF ANY OCCURRENCE OF SPECIAL
PROCESSING CODE =
|
AN
|
SHCP - NON-MTF/MARKET-REFERRED
CARE OR
|
|
|
AR
|
SHCP - MTF/MARKET REFERRED
CARE OR
|
|
|
CE
|
SHCP - CCEP OR
|
|
|
SC
|
SHCP - NON-TRICARE ELIGIBLE OR
|
|
|
SE
|
SHCP - TRICARE ELIGIBLE OR
|
|
|
SM
|
SHCP - EMERGENCY
|
|
THEN ENROLLMENT/HEALTH
PLAN CODE MUST =
|
SR
|
SHCP - MTF/MARKET REFERRED
CARE OR
|
|
|
SN
|
SHCP - NON-MTF/MARKET REFERRED
CARE OR
|
|
|
SO
|
SHCP - NON-TRICARE ELIGIBLE OR
|
|
|
ST
|
SHCP - TRICARE ELIGIBLE
|
1-185-32R
|
IF ANY OCCURRENCE OF SPECIAL
PROCESSING CODE =
|
E
|
HHC/CM DEMO (AFTER 03/15/1999,
GRANDFATHERED INTO THE ICMP)
|
|
THEN BEGIN DATE
OF CARE IS ≥ 03/15/1999
|
|
AND AT LEAST ONE
OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
|
CM
|
ICMP
|
1-185-34R
|
• TFL CLAIMS:
THE BEGIN DATE OF CARE MUST BE ≥ 10/01/2001.
IF BEGIN
DATE OF CARE IS < 10/01/2001, THE LINE ITEMS MUST CONTAIN AN
ADJUSTMENT/DENIAL REASON CODE LISTED IN THIS EDIT.
|
|
IF ANY OCCURRENCE OF SPECIAL
PROCESSING CODE =
|
FF
|
TFL (FIRST PAYER-NOT A MEDICARE
BENEFIT) OR
|
|
|
FG
|
TFL (FIRST PAYER-NO TRICARE
PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) OR
|
|
|
FS
|
TFL (SECOND PAYER)
|
|
AND TYPE OF INSTITUTION
≠
|
10
|
GENERAL MEDICAL AND SURGICAL
|
|
THEN BEGIN DATE
OF CARE MUST BE ≥ 10/01/2001
|
|
AND ENROLLMENT/HEALTH
PLAN CODE MUST =
|
FE
|
TFL - NETWORK OR
|
|
|
FS
|
TFL - NON-NETWORK
|
|
ELSE IF BEGIN
DATE OF CARE IS < 10/01/2001
|
|
THEN ADJUSTMENT/DENIAL
REASON CODE FOR THAT DETAILED LINE ITEM (EXCEPT LINE CONTAINING
REVENUE CODE 0001) MUST =
|
15
|
PAYMENT ADJUSTED BECAUSE THE
SUBMITTED AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES NOT
APPLY TO THE BILLED SERVICES OR PROVIDER OR
|
|
|
26
|
EXPENSES INCURRED PRIOR TO
COVERAGE OR
|
|
|
27
|
EXPENSES INCURRED AFTER COVERAGE
TERMINATED OR
|
|
|
30
|
PAYMENT ADJUSTED BECAUSE THE
PATIENT HAS NOT MET THE REQUIRED ELIGIBILITY, SPEND DOWN, WAITING, OR RESIDENCY
REQUIREMENTS OR
|
|
|
31
|
CLAIM DENIED AS PATIENT CANNOT
BE IDENTIFIED AS OUR INSURED OR
|
|
|
32
|
OUR RECORDS INDICATE THAT THIS
DEPENDENT IS NOT AN ELIGIBLE DEPENDENT AS DEFINED OR
|
|
|
33
|
CLAIM DENIED. INSURED HAS NO
DEPENDENT COVERAGE OR
|
|
|
34
|
CLAIM DENIED. INSURED HAS NO
COVERAGE FOR NEWBORNS OR
|
|
|
62
|
PAYMENT DENIED/REDUCED FOR
ABSENCE OF, OR EXCEEDED, PRE-CERTIFICATION/AUTHORIZATION OR
|
|
|
141
|
CLAIM ADJUSTMENT BECAUSE THE
CLAIM SPANS ELIGIBLE AND INELIGIBLE PERIODS OF COVERAGE
|
1-185-35R
|
• TFL CLAIMS:
THE BEGIN DATE OF CARE MUST BE ≥ 10/01/2001
UNLESS THE
BENEFICIARY IS AN INPATIENT AND THE ADMISSION DATE WAS PRIOR TO
10/01/2001, TFL WILL PAY FOR THE ENTIRE HOSPITAL STAY.
|
|
IF ANY OCCURRENCE OF SPECIAL
PROCESSING CODE =
|
FF
|
TFL (FIRST PAYER-NOT A MEDICARE
BENEFIT) OR
|
|
|
FG
|
TFL (FIRST PAYER-NO TRICARE
PROVIDER CERTIFICATION, I.E., MEDICARE BENEFITS
HAVE BEEN EXHAUSTED) OR
|
|
|
FS
|
TFL (SECOND PAYER)
|
|
AND TYPE OF INSTITUTION
=
|
10
|
GENERAL MEDICAL AND SURGICAL
|
|
THEN END DATE
OF CARE MUST BE ≥ 10/01/2001
|
|
AND ENROLLMENT/HEALTH
PLAN CODE MUST =
|
FE
|
TFL - NETWORK OR
|
|
|
FS
|
TFL - NON-NETWORK
|
1-185-39R
|
IF ANY OCCURRENCE OF SPECIAL
PROCESSING CODE =
|
PF
|
ECHO
|
|
THEN HCDP PLAN
COVERAGE CODE MUST ≠
|
305
|
TRICARE SELECT - RETIRED SPONSORS
AND FAMILY MEMBERS OR
|
|
|
306
|
TRICARE SELECT - RESERVE SELECT
SPONSORS AND FAMILY MEMBERS OR
|
|
|
307
|
TRICARE SELECT - RETIRED RESERVE
SPONSORS AND FAMILY MEMBERS OR
|
|
|
401
|
TRS TIER 1 MEMBER-ONLY COVERAGE
(CONTINGENCY OPERATIONS) OR
|
|
|
402
|
TRS TIER 1 MEMBER AND FAMILY
COVERAGE (CONTINGENCY OPERATIONS) OR
|
|
|
405
|
TRS TIER 2 MEMBER-ONLY COVERAGE
(CERTIFIED QUALIFICATIONS) OR
|
|
|
406
|
TRS TIER 2 MEMBER AND FAMILY
COVERAGE (CERTIFIED QUALIFICATIONS) OR
|
|
|
407
|
TRS TIER 3 MEMBER-ONLY COVERAGE
(SERVICE AGREEMENT) OR
|
|
|
408
|
TRS TIER 3 MEMBER AND FAMILY
COVERAGE (SERVICE AGREEMENT) OR
|
|
|
409
|
TRS SURVIVOR CONTINUING WITH
INDIVIDUAL COVERAGE OR
|
|
|
410
|
TRS SURVIVOR CONTINUING WITH
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
|
|
|
418
|
TRR MEMBER-ONLY COVERAGE OR
|
|
|
419
|
TRR MEMBER AND FAMILY COVERAGE OR
|
|
|
420
|
TRR SURVIVOR INDIVIDUAL COVERAGE OR
|
|
|
421
|
TRR SURVIVOR FAMILY COVERAGE
|
1-185-49R
|
IF ANY OCCURRENCE OF SPECIAL
PROCESSING CODE =
|
AU
|
AUTISM DEMONSTRATION
|
|
THEN BEGIN DATE
OF CARE MUST BE ≥ 03/15/2008
|
|
AND AT LEAST ONE
OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
|
PF
|
ECHO
|
|
AND PATIENT AGE1 MUST
BE ≥ 18 MONTHS
|
1-185-50R
|
IF ANY OCCURRENCE OF SPECIAL
PROCESSING CODE =
|
49
|
HOSPITAL REIMBURSEMENT REDUCED
BY MANUFACTURER CREDIT/REPLACEMENT OF DEVICE DURING WARRANTY PERIOD OR
|
|
|
50
|
HOSPITAL REIMBURSEMENT REDUCED
BY MANUFACTURER CREDIT/RECALLED DEVICE
|
|
THEN DRG NUMBER
MUST EQUAL A DRG SUBJECT TO THE REPLACEMENT DEVICE POLICY POSTED
ON TRICARE’S DRG WEB PAGE AT HTTP://WWW.HEALTH.MIL/DRG.
|
|
AND IF END DATE
OF CARE < 10/01/2014
|
|
THEN DATE OF ADMISSION
MUST BE ≥ THE DRG EFFECTIVE DATE AND ≤ THE DRG TERMINATION DATE
AS PER THE REPLACEMENT DEVICE POLICY POSTED ON TRICARE’S DRG WEB
PAGE AT HTTP://WWW.HEALTH.MIL/DRG.
|
|
ELSE END DATE
OF CARE MUST BE ≥ THE DRG EFFECTIVE DATE AND ≤ THE DRG TERMINATION
DATE
|
1-185-51R
|
IF ANY OCCURRENCE OF SPECIAL
PROCESSING CODE =
|
PH
|
PHILIPPINES DEMONSTRATION PROJECT
|
|
THEN BEGIN DATE
OF CARE MUST BE ≥ 01/01/2013
|
|
AND HCDP PLAN
COVERAGE CODE MUST =
|
003
|
TRICARE STANDARD FOR ADFMs OR
|
|
|
005
|
TRICARE STANDARD SURVIVORS
OF ACTIVE DUTY DECEASED SPONSORS OR
|
|
|
007
|
TRICARE STANDARD TRANSITIONAL
ASSISTANCE SPONSORS AND FAMILY MEMBERS OR
|
|
|
009
|
TRICARE STANDARD RETIRED AND
MOH SPONSORS AND FAMILY MEMBERS OR
|
|
|
010
|
TRICARE STANDARD TRANSITIONAL
SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
|
|
|
015
|
TRICARE STANDARD TRANSITIONAL
SURVIVORS OF NG/RESERVE DECEASED SPONSORS OR
|
|
|
017
|
TRICARE STANDARD SURVIVORS
OF NG/RESERVE DECEASED SPONSORS OR
|
|
|
018
|
TFL RETIRED SPONSORS AND FAMILY
MEMBERS AND MOH OR
|
|
|
020
|
TFL TRANSITIONAL SURVIVORS
OF ACTIVE DUTY DECEASED SPONSORS OR
|
|
|
021
|
TFL SURVIVORS OF ACTIVE DUTY
DECEASED SPONSORS OR
|
|
|
022
|
TFL TRANSITIONAL SURVIVORS
OF NG/RESERVE DECEASED SPONSORS OR
|
|
|
023
|
TFL SURVIVORS OF NG/RESERVE
DECEASED SPONSORS OR
|
|
|
028
|
TRICARE STANDARD FOR MEDICALLY
RETIRED SPONSORS AND FAMILY MEMBERS OR
|
|
|
029
|
TFL FOR MEDICALLY RETIRED SPONSORS
AND FAMILY MEMBERS OR
|
|
|
303
|
TRICARE SELECT - ADFMs OR
|
|
|
304
|
TRICARE SELECT - TAMP SPONSORS
AND FAMILY MEMBERS OR
|
|
|
305
|
TRICARE SELECT - RETIRED SPONSORS
AND FAMILY MEMBERS 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
|
|
|
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
|
|
|
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 STANDARD FOR ADFMs OR
|
|
|
423
|
TYA STANDARD FOR RETIRED AND
MOH FAMILY MEMBERS OR
|
|
|
424
|
TYA RESERVE SELECT OR
|
|
|
425
|
TYA RETIRED RESERVE OR
|
|
|
999
|
UNVERIFIED NEWBORN
|
|
OR ENROLLMENT/HEALTH
PLAN CODE =
|
AS
|
TRICARE SELECT - ACTIVE DUTY
SURVIVORS OR
|
|
|
AT
|
TRICARE SELECT - ACTIVE DUTY
TRANSITIONAL SURVIVORS OR
|
|
|
GS
|
TRICARE SELECT - GUARD/RESERVE
SURVIVORSOR
|
|
|
GT
|
TRICARE SELECT - GUARD/RESERVE
TRANSITIONAL SURVIVORS
|
|
AND PATIENT ZIP
CODE MUST =
|
PHL
|
PHILIPPINES
|
|
AND PROVIDER STATE OR COUNTRY
CODE MUST =
|
PHL
|
PHILIPPINES
|
1-185-52R
|
IF BEGIN DATE OF CARE IS ≥
01/01/2018
|
|
AND ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
|
R
|
MEDICARE/TRICARE DUAL ENTITLEMENT
(FIRST PAYER-NOT A MEDICARE BENEFIT) AND BEGIN DATE OF CARE ≥
10/01/2001 OR
|
|
|
T
|
MEDICARE/TRICARE DUAL ENTITLEMENT
(SECOND PAYER) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
|
|
|
RS
|
MEDICARE/TRICARE DUAL ENTITLEMENT
(FIRST PAYER-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS
HAVE BEEN EXHAUSTED) AND BEGIN DATE OF CARE ≥ 10/01/2001
|
|
THEN ENROLLMENT/HEALTH
PLAN CODE MUST =
|
U
|
TRICARE PRIME, CIVILIAN CARE OR
|
|
|
Z
|
TRICARE PRIME, MTF/MARKET/PCM OR
|
|
|
ME
|
MEDICARE/TRICARE DUAL ELIGIBLE
UNDER 65/NETWORK OR
|
|
|
MS
|
MEDICARE/TRICARE DUAL ELIGIBLE
UNDER 65/NON-NETWORK OR
|
|
|
WF
|
TPR FOR ENROLLMENT ADFM RESIDING
WITH A TPR ELIGIBLE SERVICE MEMBER
|