VALIDITY
EDITS
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2-160-01V1
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FOR FILING DATE PRIOR TO 01/01/2005,
VALUE MUST BE A VALID PROCEDURE CODE
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AND PROCEDURE
CODE MUST MATCH ONE OF THE RECORDS IN THE PROCEDURE CODE DATABASE
USING THE FOLLOWING DATE LOGIC:
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FOR TYPE OF SUBMISSION =
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D
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COMPLETE DENIAL OR
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I
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INITIAL TED RECORD SUBMISSION OR
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O
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ZERO PAYMENT WITH 100% OHI/TPL OR
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R
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RESUBMISSION OF AN INITIAL
TED RECORD (TYPE OF SUBMISSION WAS I) THAT WAS REJECTED
DUE TO ERRORS
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THE DATE TED RECORD PROCESSED
TO COMPLETION MUST BE ON OR AFTER THE PROCESSING EFFECTIVE DATE AND BEFORE
THE PROCESSING TERMINATION DATE
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AND THE BEGIN
DATE OF CARE MUST BE ON OR AFTER THE CARE EFFECTIVE
DATE AND BEFORE THE CARE TERMINATION DATE
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FOR TYPE OF SUBMISSION =
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A
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ADJUSTMENT TO TED RECORD DATA OR
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B
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ADJUSTMENT TO NON-TED RECORD
(HCSR) DATA OR
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C
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COMPLETE CANCELLATION OR
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E
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COMPLETE CANCELLATION OF NON-TED
RECORD (HCSR) DATA
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THE DATE TED RECORD PROCESSED
TO COMPLETION MUST BE ON OR AFTER THE PROCESSING EFFECTIVE DATE
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AND THE BEGIN
DATE OF CARE MUST BE ON OR AFTER THE CARE EFFECTIVE
DATE AND BEFORE THE CARE TERMINATION DATE
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2-160-02V1
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FOR FILING DATE ON OR AFTER
01/01/2005 VALUE MUST BE A VALID PROCEDURE CODE
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AND PROCEDURE
CODE MUST MATCH ONE OF THE RECORDS IN THE PROCEDURE CODE REFERENCE
TABLE USING THE FOLLOWING DATE LOGIC:
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BEGIN DATE OF CARE MUST BE
ON OR AFTER THE PROCEDURE CODE CARE EFFECTIVE DATE AND NOT
LATER THAN THE PROCEDURE CODE CARE TERMINATION DATE.
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Relational
Edits
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2-160-01R2
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IF ON THE MATCHING RECORD THE
PROCEDURE CODE DATABASE GOVERNMENT PAY CODE = N
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THEN AMOUNT ALLOWED
BY PROCEDURE CODE MUST BE ≤ ZERO
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UNLESS ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
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T
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MEDICARE/TRICARE DUAL ENTITLEMENT
(SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
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AD
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FOREIGN ACTIVE DUTY CLAIMS
(EFFECTIVE
06/30/1996) OR
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AN
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SHCP - NON-MTF/eMSM-REFERRED
CARE OR
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AR
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SHCP - MTF/eMSM REFERRED CARE OR
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BF
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BREASTFEEDING SUPPORT DEMONSTRATION OR
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CB
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CHILDBIRTH SUPPORT DEMONSTRATION OR
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CE
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SHCP - CCEP OR
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CL
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CLINICAL TRIALS OR
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CP
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CANCER CLINICAL TRIALS OR
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DB
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DIGITAL BREAST TOMOSYNTHESIS OR
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FS
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TFL (SECOND PAYOR) OR
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GU
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SERVICE MEMBER ENROLLED IN
TPR OR
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LD
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LDTs DEMONSTRATION OR
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L2
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FDA NON-APPROVED
LDTs DEMONSTRATION OR
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MC
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PLATELET RICH PLASMA INJECTIONS
FOR THE TREATMENT OF MUSCULOSKELETON CONDITIONS OR
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MN
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TSP - NETWORK OR
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MS
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TSP - NON-NETWORK OR
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RD
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RARE DISEASES OR
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SC
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SHCP - NON-TRICARE ELIGIBLE OR
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SE
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SHCP - TRICARE ELIGIBLE OR
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SM
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SHCP - EMERGENCY
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OR ENROLLMENT/HEALTH
PLAN CODE =
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X
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FOREIGN SERVICE MEMBER OR
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SN
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SHCP - NON-MTF/eMSM-REFERRED
CARE OR
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SR
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SHCP - MTF/eMSM REFERRED CARE OR
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WA
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TPR - FOREIGN SERVICE MEMBER
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OR ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
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AS
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COMPREHENSIVE AUTISM CARE DEMONSTRATION
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AND PROCEDURE
CODE = 0359T, 0360T, 0361T, 0364T, 0365T, 0368T, 0369T, 0370T, T1023,
97151, 97153, 97155, 97156, 97157, 97158, 99366, OR 99368
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OR ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
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AT
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AFL TREATMENTS
FOR SYMPTOMATIC BURNS AND SCARS
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AND PROCEDURE
CODE = 0479T OR 0480T
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OR FILING DATE
< 11/05/2011
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AND FILING STATE
COUNTRY CODE = A FOREIGN COUNTRY CODE (REFER TO Addendum A)
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2-160-05R
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IF PROCEDURE CODE = A0100,
A0110, A0120, A0130, A0140, A0170, E0170 - E0172, E0241- E0245,
E0273, E0625, E0701, L3215 - L3219, L3221 - L3223, L3230, L3250
- L3255, L3257, L3265, L3500, L3510, L3520, L3630, S8940, S9122
- S9124, V5281 - V5290, OR 99082
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AND AMOUNT ALLOWED
BY PROCEDURE CODE > ZERO
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THEN ONE OCCURRENCE
OF SPECIAL PROCESSING CODE MUST =
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PF
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ECHO
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UNLESS ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
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AD
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FOREIGN ACTIVE DUTY CLAIMS
(EFFECTIVE
06/30/1996) OR
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AN
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SHCP - NON-MTF/eMSM-REFERRED
CARE OR
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AR
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SHCP - MTF/eMSM REFERRED CARE OR
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CE
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SHCP - CCEP OR
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GU
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SERVICE MEMBER ENROLLED IN
TPR OR
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MN
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TSP - NETWORK OR
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MS
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TSP - NON-NETWORK OR
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SC
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SHCP - NON-TRICARE ELIGIBLE OR
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SE
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SHCP - TRICARE ELIGIBLE OR
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SM
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SHCP - EMERGENCY
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OR ENROLLMENT/HEALTH
PLAN CODE =
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X
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FOREIGN SERVICE MEMBER OR
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SN
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SHCP - NON-MTF/eMSM-REFERRED
CARE OR
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SR
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SHCP - MTF/eMSM REFERRED CARE OR
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WA
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TPR - FOREIGN SERVICE MEMBER
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2-160-06R
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IF TYPE OF SERVICE (FIRST POSITION)
=
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I
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INPATIENT
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THEN PROCEDURE
CODE MUST NOT BE FOR OUTPATIENT ONLY CARE (REFER TO Addendum E, Figure 2.E-1.
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2-160-08R
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IF PROCEDURE CODE =
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98800
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FOR DRUGS OR
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00MN
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PRESCRIPTION MEDICAL NECESSITY
REVIEWS OR
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00PA
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PRESCRIPTION PRIOR AUTHORIZATIONS
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THEN TYPE OF SERVICE
(SECOND POSITION) MUST =
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B
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RETAIL DRUGS, SUPPLIES, PRESCRIPTION, AUTHORIZATIONS,
AND REVIEWS OR
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M
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MOP DRUGS, SUPPLIES, PRESCRIPTION, AUTHORIZATIONS,
AND REVIEWS
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AND NATIONAL DRUG
CODE MUST ≠ BLANK
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UNLESS PROVIDER
STATE OR COUNTRY CODE IS A FOREIGN COUNTRY CODE ( Addendum A)
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2-160-11R
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IF PROCEDURE CODE = S5108 OR 99080
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THEN ONE OCCURRENCE
OF SPECIAL PROCESSING CODE MUST =
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AP
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ABA PILOT OR
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AU
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AUTISM DEMONSTRATION OR
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BA
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ABA (INTERIM BENEFIT)
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UNLESS ADJUSTMENT/DENIAL
REASON CODE FOR THAT OCCURRENCE/LINE ITEM IS A CODE LISTED IN Addendum G, Figure 2.G-1 OR Figure 2.G-2.
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OR ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
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AN
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SHCP - NON-MTF/eMSM-REFERRED
CARE OR
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AR
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SHCP - MTF/eMSM REFERRED CARE OR
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CE
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SHCP - CCEP OR
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GU
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SERVICE MEMBER ENROLLED IN
TPR OR
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MN
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TSP - NETWORK OR
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MS
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TSP - NON-NETWORK OR
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SC
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SHCP - NON-TRICARE ELIGIBLE OR
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SE
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SHCP - TRICARE ELIGIBLE OR
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SM
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SHCP - EMERGENCY
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OR ENROLLMENT/HEALTH
PLAN CODE =
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X
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FOREIGN SERVICE MEMBER OR
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SN
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SHCP - NON-MTF/eMSM-REFERRED
CARE OR
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SR
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SHCP - MTF/eMSM REFERRED CARE OR
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WA
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TPR - FOREIGN SERVICE MEMBER
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2-160-12R
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IF PROCEDURE CODE = 1181F,
1450F, S5115, G8539, G8542, G9165, G9166, OR G9167
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THEN ONE OCCURRENCE
OF SPECIAL PROCESSING CODE MUST =
|
AP
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ABA PILOT
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UNLESS AMOUNT
ALLOWED BY PROCEDURE CODE ≤ ZERO.
|
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OR ANY OCCURRENCE
OF SPECIAL PROCESSING CODE =
|
AD
|
FOREIGN ACTIVE DUTY CLAIMS OR
|
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AN
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SHCP - NON-MTF/eMSM-REFERRED
CARE OR
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AR
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SHCP - MTF/eMSM REFERRED CARE OR
|
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CE
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SHCP - CCEP OR
|
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GU
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SERVICE MEMBER ENROLLED IN
TPR OR
|
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MN
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TSP - NETWORK OR
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MS
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TSP - NON-NETWORK OR
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SC
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SHCP - NON-TRICARE ELIGIBLE OR
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SE
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SHCP - TRICARE ELIGIBLE OR
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SM
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SHCP - EMERGENCY
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OR ENROLLMENT/HEALTH
PLAN CODE =
|
X
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FOREIGN SERVICE MEMBER OR
|
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SN
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SHCP - NON-MTF/eMSM-REFERRED
CARE OR
|
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SR
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SHCP - MTF/eMSM REFERRED CARE OR
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WA
|
TPR - FOREIGN SERVICE MEMBER
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