Military Health System

Three (3) signed numeric digits.

Number of procedures performed/services or supplies rendered for medical, dental, and mental health care.

N/A

Identical procedures must be combined when performed by the same provider, with the same charge for each, and within the same calendar month, provided the reason for allowance/denial is the same for each charge and combining procedures does not conflict with other TED record requirements (i.e., Number of Services field size). For ambulance services, allergy testing, DME rental, or POV mileage for ECHO, enter 01 for each service regardless of number of units or mileage. When multiple units are used in a single Episode Of Care (EOC), such as one box of twelve syringes, code only one (1) supply or service. Allowed prescription drugs must be combined separately from disallowed prescription drugs. Report the number of prescriptions (not pills or day’s supply) for prescriptions.

Three (3) numeric digits.

A unique number for each utilization/revenue data occurrence within the TED record. Occurrence/line item number must be assigned in sequential ascending order.

N/A

N/A

Two (2) alphanumeric characters.

Identifies how a service or procedure is paid under OPPS.

Services paid under some payment method other than OPPS (e.g., payment for non-implantable prosthetic and orthotic devices, DME, ambulance services, and individual professional services).

More appropriate code required for TRICARE OPPS

Inpatient services

Items or services not covered by TRICARE3

Acquisition of corneal tissue and certain CRNA services and Hepatitis B vaccines

Pass-through drugs and biologicals

Non-pass-through drugs and biologicals

Items and services packaged into APC rates

Partial hospitalization service.

Packaged services subject to separate payment based on payment criteria. See codes Q1 through Q3 listed below.

Blood and blood products

Significant procedures not subject to multiple procedure discounting.

Significant procedures subject to multiple procedure discounting.

Brachytherapy sources

Clinic or ED visits

Invalid HCPCS or invalid revenue code with blank HCPCS

Ancillary services2

Valid revenue code with blank HCPCS and no other SI assigned

TRICARE reimbursement not allowed for CPT/HCPCS code submitted

Items or services not covered by TRICARE

Hospital outpatient department services paid through a comprehensive APC

Hospital outpatient department services that may be paid through a comprehensive APC

STVX-packaged codes

T-packaged codes

Codes that may be paid through a composite APC

Conditionally packaged laboratory services

N/A

One (1) alphanumeric character.

The code that indicates the reason that the person’s period of eligibility for a non-DoD OGP began. The OGP begin reason code only applies to OGP type codes of A or B only. Download field from DEERS.

Eligible for Medicare. Eligibility began after age 65 (the person did not have enough quarters of Social Security contributions to qualify at age 65). This value applies to Medicare Part A.

Enrollment in Medicare Part B, C or D; over or under age 65. Medicare Part B can only be obtained by payment of monthly premiums. This value applies to Medicare Part B, C, or D.

Eligible for Medicare because of disability. This value applies to Medicare Part A.

Eligible for Medicare at age 65. This value applies to Medicare Part A.

Eligibility for Medicare defaulted at age 65; verification not received from Center for Medicare and Medicaid Services (CMS). Applies to Medicare Part A only.

Enrollment in Medicare Part B declined by beneficiary.

Member

Not eligible for Medicare. Under age 65 this is the default value. At age 65 this indicates eligibility could not begin because the person did not have enough quarters of Social Security contributions to qualify. This value applies to Medicare Part A.

Office of Personnel Management (OPM)

Eligible for Medicare at or after 65 because of purchase. This value applies to Medicare Part A.

Eligible for Medicare because of End Stage Renal Disease (ESRD). This value applies to Medicare Part A.

Service

United States Postal Service (USPS)

Eligible for the CHAMPVA.

Not applicable.

N/A

One (1) alphanumeric character.

The code that represents what type of OGP the person has. Download field from DEERS.

Medicare Part A

Medicare Part B

Medicare Part A & B

Federal Employees Health Benefits (FEHB) Program

Medicare Part D

Medicare Part A & D

Medicare Part B & D

Medicare Part A, B, & D

No Medicare

CHAMPVA

N/A

Six (6) alphanumeric characters.

A code which indicates that certain questionable data has been identified and approved by the contractor and the normal editing and processing rules should be bypassed for this record.

Claims retained by the contractor for development (information not available from in-house sources). (Effective 02/01/2000)

TPL claims requiring development. (Effective 02/01/2000)

Government intervention claims - pended up to 60 calendar days. (Benefit Changes, CMAC updates, etc.) (Effective 02/01/2000)

Claims requiring intervention by another contractor. (Effective 02/01/2000)

Claims pended at Government direction 60 calendar days and over. (Effective 02/01/2000)

Patient is over 65. (Terminated 06/01/2003)

Patient is a spouse under 12 years of age.

Good faith claim; payment has been made.

Patient is family member 21 years or older and over 18 for VHA (over 18 for VHA is no longer effective after 01/01/1996).

Diagnosis is maternity; patient is under 12 years of age.

Claim was filed after the filing deadline.

Diagnosis/procedure code for female; sex indicates male.

Diagnosis/procedure code for male, sex indicates female.

Patient is a former spouse under 34 years of age.

Successive admission (patient is family member of an active duty sponsor and cost-share is based on both current and prior admission). (Institutional Only)

Catastrophic loss protection limit reached, patient cost-share and deductible rules do not apply.

NATO, SSN not applicable.

Retrospective payment - Inpatient Mental Health (Institutional Only)

Reserved (to be used only with DHA authorization)

Former Spouse with Pre-Existing Condition

Person birth calendar date (patient) is not consistent with diagnosis/procedure code age restricting; procedure performed due to medical necessity.

Zip code override to be used when:

Beneficiary indemnification payment

ADFM, services provided in TRICARE Eurasia-Africa, Pacific or Latin America & Canada including the Caribbean Basin. (Effective 06/28/1996)

Newborn in mother’s room without nursery charges. (Institutional Only)

Enhanced benefit

Non-Certified Providers (does not include sanctioned/suspended providers) (Effective 08/01/2003)

Payment to Provider, Pharmacy, Entity, or Client Beneficiary temporarily suspended at direction of DHA, PI

Contractor has determined that number of services is medically necessary.

N/A