TRICARE Manuals - Display Chap 2 Sect 6.4 (Change 7, Jul 24, 2024)

TRICARE Encounter Data (TED)

Chapter 2

Section 6.4

Non-Institutional Edit Requirements (ELN 300 - 399)

Revision: C-4, May 30, 2024

ELEMENT NAME: ENROLLMENT/HEALTH PLAN CODE (2-300)
1 PATIENT AGE IS CALCULATED BASED ON PERSON BIRTH CALENDAR DATE (PATIENT) AND CARE DATES.
VALIDITY EDITS
2-300-01V	MUST BE A VALID ENROLLMENT/HEALTH PLAN CODE (REFER TO Section 2.5)
Relational Edits
2-300-02R	IF ENROLLMENT/HEALTH PLAN CODE =	Y	CHCBP - NON-NETWORK OR
		AA	CHCBP - NETWORK
	OR HCDP PLAN COVERAGE CODE =	121	CHCBP - NON-NETWORK INDIVIDUAL COVERAGE OR
		122	CHCBP - NETWORK FAMILY COVERAGE
	THEN NO OCCURRENCE OF SPECIAL PROCESSING CODE =	BF	BREASTFEEDING SUPPORT DEMONSTRATION OR
		CB	CHILDBIRTH SUPPORT DEMONSTRATION OR
		CL	CLINICAL TRIALS OR
		PF	ECHO
2-300-07R	IF ENROLLMENT/HEALTH PLAN CODE =	SN	SHCP - NON-MARKET/MTF-REFERRED CARE OR
		SO	SHCP - NON-TRICARE ELIGIBLE OR
		SR	SHCP - MARKET/MTF-REFERRED CARE OR
		ST	SHCP - TRICARE ELIGIBLE
	THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	AN	SHCP -NON-MARKET/MTF-REFERRED CARE OR
		AR	SHCP - MARKET/MTF-REFERRED CARE OR
		CE	SHCP - CCEP OR
		SC	SHCP - NON-TRICARE ELIGIBLE OR
		SE	SHCP - TRICARE ELIGIBLE OR
		SM	SHCP - EMERGENCY
2-300-10R	IF ENROLLMENT/HEALTH PLAN CODE =	PS	TSRx
	THEN TYPE OF SERVICE (SECOND POSITION) MUST =	B	RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS OR
		M	MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
2-300-11R	IF ENROLLMENT/HEALTH PLAN CODE =	PS	TSRx
	THEN NATIONAL DRUG CODE CANNOT BE BLANK.
	UNLESS AMOUNT ALLOWED BY PROCEDURE CODE FOR THAT OCCURRENCE/LINE ITEM = ZERO
	OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	1	MEDICAID
	OR PROVIDER STATE OR COUNTRY CODE IS FOREIGN COUNTRY CODE (Addendum A)
2-300-12R	• TFL CLAIMS: THE BEGIN DATE OF CARE MUST BE ≥ 10/01/2001. FOR EACH LINE ITEM WHERE BEGIN DATE OF CARE IS < 10/01/2001, THE LINE ITEM MUST CONTAIN AN ADJUSTMENT/DENIAL REASON CODE LISTED IN THIS EDIT.
	IF ENROLLMENT/HEALTH PLAN CODE =	FE	TFL - NETWORK OR
		FS	TFL - NON-NETWORK
	THEN BEGIN DATE OF CARE MUST BE ≥ 10/01/2001
	AND AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	FF	TFL (FIRST PAYER-NOT A MEDICARE BENEFIT) OR
		FG	TFL (FIRST PAYER-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICAL BENEFITS HAVE BEEN EXHAUSTED) OR
		FS	TFL (SECOND PAYER)
	ELSE IF BEGIN DATE OF CARE IS < 10/01/2001 (FOR THAT DETAILED LINE ITEM)
	THEN ADJUSTMENT/DENIAL REASON CODE FOR THAT DETAIL OCCURRENCE 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
2-300-15R	IF ENROLLMENT/HEALTH PLAN CODE =	SU	SCHP - REFERRAL DESIGNATION UNKNOWN
	THEN TYPE OF SERVICE (SECOND POSITION) MUST =	B	RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS OR
		M	MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
2-300-16R	IF ENROLLMENT/HEALTH PLAN CODE =	SU	SCHP - REFERRAL DESIGNATION UNKNOWN
	THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	SC	SHCP - NON-TRICARE ELIGIBLE OR
		SE	SHCP - TRICARE ELIGIBLE
2-300-17R	• FOR MOP ONLY: FOR TSRx, THE PATIENT MUST BE 64 YEARS AND 8 MONTHS OR GREATER. IF THE PATIENT IS LESS THAN THIS AGE, THE LINE ITEM MUST CONTAIN AN ADJUSTMENT/DENIAL REASON CODE LISTED IN THIS EDIT.
	IF ENROLLMENT/HEALTH PLAN CODE =	PS	TSRx
	AND TYPE OF SERVICE (SECOND POSITION) =	M	MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
	THEN PATIENT AGE1 MUST BE ≥ 64 YEARS AND 8 MONTHS
	ELSE IF PATIENT AGE1 < 64 YEARS AND 8 MONTHS
	THEN ADJUSTMENT/DENIAL REASON CODE FOR THAT DETAIL OCCURRENCE 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
2-300-18R	IF ENROLLMENT/HEALTH PLAN CODE =	X	FOREIGN SERVICE MEMBER
	THEN HCC MEMBER RELATIONSHIP CODE MUST =	A	SELF OR
		T	FOREIGN MILITARY MEMBER
	AND HCC MEMBER CATEGORY CODE MUST =	A	ACTIVE DUTY OR
		G	NATIONAL GUARD MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 CALENDAR DAYS OR MORE) OR
		J	ACADEMY STUDENT OR
		N	NATIONAL GUARD (NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 CALENDAR DAYS OR LESS) OR
		S	RESERVE MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 CALENDAR DAYS OR MORE) OR
		V	RESERVE MEMBER (NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 CALENDAR DAYS OR LESS)
2-300-19R	IF BEGIN DATE OF CARE IS ≥ 01/01/2018
	AND ENROLLMENT/HEALTH PLAN CODE =	ME	MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NETWORK OR
		MS	MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NON-NETWORK
	THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	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

ELEMENT NAME: HEALTH CARE DELIVERY PROGRAM (HCDP) PLAN COVERAGE CODE (2-301)
VALIDITY EDITS
2-301-01V	MUST BE A VALID HCDP PLAN COVERAGE CODE LISTED IN Addendum L.
2-301-02V	IF FILING DATE ≥ 09/01/2007
	AND HCDP PLAN COVERAGE CODE =	109	TRICARE USFHP DC COVERAGE FOR ADFMs 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
		118	TRICARE USFHP DC INDIVIDUAL COVERAGE FOR RETIRED SPONSORS AND FAMILY MEMBERS OR
		119	TRICARE USFHP DC FAMILY COVERAGE FOR RETIRED SPONSORS AND FAMILY MEMBERS OR
		133	TRICARE USFHP DC INDIVIDUAL COVERAGE FOR TRANSITIONAL SURVIVORS OR ACTIVE DUTY 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
		316	USFHP PRIME - SPONSOR AND FAMILY MEMBERS (PRESENTATION ONLY)
	THEN THE TOTAL OF ALL OCCURRENCES/LINEITEMS OF AMOUNT ALLOWED BY PROCEDURE CODES MUST = ZERO
2-301-03R	IF HCDP PLAN COVERAGE CODE =	417	TCSRC
	THEN ENROLLMENT/HEALTH PLAN CODE MUST =	X	FOREIGN SERVICE MEMBER OR
		SR	SHCP - MARKET/MTF-REFERRED CARE
Relational Edits
2-301-01R	IF HCDP PLAN COVERAGE CODE =	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	TRICARE RETIRED RESERVE (TRR) MEMBER-ONLY COVERAGE OR
		419	TRR MEMBER AND FAMILY COVERAGE OR
		420	TRR SURVIVOR INDIVIDUAL COVERAGE OR
		421	TRR SURVIVOR FAMILY COVERAGE
	THEN ENROLLMENT/HEALTH PLAN CODE MUST =	T	TRICARE STANDARD OR
		V	TRICARE EXTRA OR
		FE	TFL - NETWORK OR
		FS	TFL - NON-NETWORK OR
		ME	MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NETWORK OR
		MS	MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NON NETWORK OR
		PS	TSRx OR
		SR	SHCP - MARKET/MTF-REFERRED CARE OR
		TV	TRICARE SELECT
2-301-02R	IF HCDP PLAN COVERAGE CODE =	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
	THEN NO OCCURRENCE OF SPECIAL PROCESSING CODE CAN =	PF	ECHO

ELEMENT NAME: REGION INDICATOR (2-303)
VALIDITY EDITS
2-303-01V	MUST BE A VALID REGION INDICATOR (REFER TO Section 2.8)
2-303-02V	IF TYPE OF SUBMISSION ≠	B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
	AND REGION INDICATOR =	NC	NORTH CONTRACT OR
		OC	OVERSEAS CONTRACT OR
		SC	SOUTH CONTRACT OR
		WC	WEST CONTRACT OR
		E7	EAST CONTRACT 2017 OR
		W7	WEST CONTRACT 2017
	THEN ADJUSTMENT KEY MUST =	0	BATCH OR
		5	VOUCHER
Relational Edits
	NONE

ELEMENT NAME: SPECIAL PROCESSING CODE (2-305)
1 PATIENT AGE IS CALCULATED BASED ON PERSON BIRTH CALENDAR DATE (PATIENT) AND CARE DATES. 2 DHA DATABASE: CONTRACT INFORMATION PROVIDED TO THE TED SYSTEM FROM THE DHA ACCOUNTING SYSTEM VIA ‘CORAMS’ FILE.
VALIDITY EDITS
2-305-01V	OCCURRENCE NUMBER 1--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8) AND BEGIN DATE OF CARE MUST BE ON OR AFTER THE SPECIAL PROCESSING EFFECTIVE DATE AND NO LATER THAN THE SPECIAL PROCESSING TERMINATION DATE (REFER TO Section 2.8).
2-305-02V	OCCURRENCE NUMBER 2--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8) AND BEGIN DATE OF CARE MUST BE ON OR AFTER THE SPECIAL PROCESSING EFFECTIVE DATE AND NO LATER THAN THE SPECIAL PROCESSING TERMINATION DATE (REFER TO Section 2.8).
2-305-03V	OCCURRENCE NUMBER 3--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8) AND BEGIN DATE OF CARE MUST BE ON OR AFTER THE SPECIAL PROCESSING EFFECTIVE DATE AND NO LATER THAN THE SPECIAL PROCESSING TERMINATION DATE (REFER TO Section 2.8).
2-305-04V	OCCURRENCE NUMBER 4--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8) AND BEGIN DATE OF CARE MUST BE ON OR AFTER THE SPECIAL PROCESSING EFFECTIVE DATE AND NO LATER THAN THE SPECIAL PROCESSING TERMINATION DATE (REFER TO Section 2.8).
2-305-05V	A VALUE CANNOT BE CODED MORE THAN ONCE (EXCEPT BLANK).
2-305-06V	ALL OCCURRENCES OF SPECIAL PROCESSING CODE MUST BE BLANK FILLED FOLLOWING THE FIRST OCCURRENCE OF A BLANK FILLED SPECIAL PROCESSING CODE.
2-305-07V	• SHCP - MARKET/MTF-REFERRED/NON-REFERRED
	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	AN	SHCP - NON-MARKET/MTF-REFERRED CARE OR
		AR	SHCP - MARKET/MTF-REFERRED CARE
	THEN BEGIN DATE OF CARE MUST BE < 06/01/2004
2-305-08V	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
2-305-10V	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
2-305-11V	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
2-305-14V	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	ST	SPECIALIZED TREATMENT
	THEN BEGIN DATE OF CARE MUST BE < 10/01/2004
Relational Edits
2-305-02R	IF CA/NAS EXCEPTION REASON =	6	RESOURCE SHARING
	THEN AT LEAST ONE SPECIAL PROCESSING CODE MUST =	S	RESOURCE SHARING - EXTERNAL
2-305-08R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	PF	ECHO
	THEN NO OCCURRENCE OF SPECIAL PROCESSING CODE =	6	HHC OR
		A	PARTNERSHIP PROGRAM OR
		E	HHC/CM DEMO (AFTER 03/15/1999, GRANDFATHERED INTO THE ICMP) OR
		S	RESOURCE SHARING - EXTERNAL OR
		CM	ICMP OR
		CT	CCTP OR
		RI	RESOURCE SHARING - INTERNAL
2-305-12R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	U	BRAC MEDICARE PHARMACY
	THEN TYPE OF SERVICE (SECOND POSITION) MUST =	B	RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
	AND BEGIN DATE OF CARE MUST BE < 04/01/2001
2-305-13R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	16	AMBULATORY SURGERY FACILITY CHARGE
	THEN PRICING RATE CODE MUST =	0	PRICING NOT APPLICABLE (DENIED SERVICE/SUPPLIES AND ALLOWED DRUGS) OR
		1	PRICED MANUALLY OR
		C	AMBULATORY SURGERY FACILITY PAYMENT RATE OR
		D	DISCOUNTED AMBULATORY SURGERY - FACILITY PAYMENT RATE OR
		E	AMBULATORY SURGERY-PAID AS BILLED OR
		P	CLAIM AUDITING SOFTWARE-ADDED PROCEDURE, AMBULATORY SURGERY-FACILITY PAYMENT RATE OR
		Q	CLAIM AUDITING SOFTWARE-ADDED PROCEDURE, DISCOUNTED AMBULATORY SURGERY-FACILITY PAYMENT RATE OR
		R	CLAIM AUDITING SOFTWARE-ADDED PROCEDURE, AMBULATORY SURGERY-PAID AS BILLED OR
		V	MEDICARE REIMBURSEMENT RATE OR
		CA	CAH REIMBURSEMENT OR
		P1	OPPS OR
		P2	OPPS WITH COST OUTLIER OR
		P3	OPPS WITH DISCOUNT
2-305-14R	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, MARKET/MTF/PCM OR
		WF	TPR FOR ENROLLED ADFM RESIDING WITH A TPR ELIGIBLE SERVICE MEMBER OR
		XF	FOREIGN ADFM
2-305-22R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	AN	SHCP - NON-MARKET/MTF-REFERRED CARE OR
		AR	SHCP - MARKET/MTF-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 =	SN	SHCP - NON-MARKET/MTF-REFERRED CARE OR
		SO	SHCP - NON-TRICARE ELIGIBLE OR
		SR	SHCP - MARKET/MTF-REFERRED CARE OR
		ST	SHCP - TRICARE ELIGIBLE OR
		SU	SHCP - REFERRAL DESIGNATION UNKNOWN
2-305-24R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	E	HHC/CM DEMO (AFTER 03/15/1999, GRANDFATHERED INTO THE ICMP)
	THEN BEGIN DATE OF CARE MUST BE ≥ 03/15/1999
	AND AT LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	CM	ICMP
2-305-26R	• TFL CLAIMS: THE BEGIN DATE OF CARE MUST BE ≥ 10/01/2001.
	IF AMOUNT ALLOWED BY PROCEDURE CODE IS ≤ ZERO
	THEN BYPASS THIS EDIT
	ELSE 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., MEDICAL BENEFITS HAVE BEEN EXHAUSTED) OR
		FS	TFL (SECOND PAYER)
	THEN BEGIN DATE OF CARE MUST BE ≥ 10/01/2001
	AND ENROLLMENT/HEALTH PLAN CODE MUST =	FE	TFL - NETWORK OR
		FS	TFL - NON-NETWORK
2-305-30R	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
2-305-31R	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
2-305-32R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	RB	RESPITE BENEFIT FOR ADSMS
	THEN BEGIN DATE OF CARE MUST BE ≥ 01/01/2008
	AND AT LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	SE	SHCP - TRICARE ELIGIBLE
2-305-33R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	PS	SPECIALTY PHARMACY SERVICES
	THEN TYPE OF SERVICE (SECOND POSITION) MUST =	M	MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
	AND PROCEDURE CODE MUST ≠	000MN	PRESCRIPTION MEDICAL NECESSITY REVIEWS OR
		000PA	PRESCRIPTION PRIOR AUTHORIZATIONS
2-305-34R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	PV	RETAIL PHARMACY FOR DVA/VHA BENEFICIARIES
	THEN TYPE OF SERVICE (SECOND POSITION) MUST =	B	RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
	AND PROVIDER NETWORK STATUS INDICATOR MUST =	1	NETWORK PROVIDER
	AND PROCEDURE CODE MUST ≠	000MN	PRESCRIPTION MEDICAL NECESSITY REVIEWS OR
		000PA	PRESCRIPTION PRIOR AUTHORIZATIONS
2-305-35R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	DE	TDRL PHYSICAL EXAMS
	THEN BEGIN DATE OF CARE MUST BE ≥ 03/30/2009
	AND ENROLLMENT/HEALTH PLAN CODE MUST =	SR	SHCP - MARKET/MTF-REFERRED CARE
	AND AT LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	SE	SHCP - TRICARE ELIGIBLE
2-305-36R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	EF	TRICARE RESERVE AND NATIONAL GUARD FAMILY MEMBER BENEFITS
	THEN BEGIN DATE OF CARE MUST BE ≥11/01/2009
	AND ENROLLMENT/HEALTH PLAN CODE MUST =	T	TRICARE STANDARD PROGRAM OR
		V	TRICARE EXTRA OR
		TV	TRICARE SELECT OR
		ME	MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NETWORK OR
		MS	MEDICARE/TRICARE DUAL ELIGIBILE UNDER 65/NON-NETWORK
	AND HCDP SPECIAL ENTITLEMENT CODE MUST =	02	NOBLE EAGLE PARTICIPATION SPECIAL ENTITLEMENT OR
		03	ENDURING FREEDOM PARTICIPATION SPECIAL ENTITLEMENT OR
		08	SPECIAL ENTITLEMENT FOR GUARD/RESERVE ON ACTIVE DUTY MORE THAN 30 CALENDAR DAYS (EXCLUDING AGR)
	AND AMOUNT APPLIED TOWARD DEDUCTIBLE MUST = ZERO
2-305-37R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	DC	DCPE-VHA
	THEN BEGIN DATE OF CARE MUST BE ≥ 10/01/2014
	AND AT LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	17	VHA MEDICAL PROVIDER CLAIM OR
		AD	FOREIGN ACTIVE DUTY CLAIMS
	AND ENROLLMENT/HEALTH PLAN CODE MUST =	W	TPR SERVICE MEMBER - USA OR
		X	FOREIGN SERVICE MEMBER OR
		SR	SHCP - MARKET/MTF-REFERRED CARE OR
		WA	TPR FOREIGN SERVICE MEMBER
	AND AT LEAST ONE PROCEDURE CODE MUST = 99456
	OR PRINCIPLE DIAGNOSIS CODE MUST = V68.01 OR Z02.71
2-305-38R	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
2-305-39R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	AS	COMPREHENSIVE AUTISM CARE DEMONSTRATION
	THEN PROCEDURE CODE MUST BE 0359T - 0361T, 0364T, 0365T, 0368T - 0370T, T1023, 97151, 97153, 97155 - 97158, 99366, OR 99368
2-305-40R	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, MARKET/MTF/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
2-305-41R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	LB	LBP DEMONSTRATION
	THEN BEGIN DATE OF CARE MUST BE > 01/01/2021 AND < 01/01/2024
	AND AMOUNT OF PATIENT COST SHARE MUST = ZERO
	AND AMOUNT APPLIED TO DEDUCTIBLE MUST = ZERO
	AND PROVIDER STATE/COUNTRY CODE MUST=	AZ	ARIZONA OR
		CA	CALIFORNIA OR
		CO	COLORADO OR
		FL	FLORIDA OR
		GA	GEORGIA OR
		KY	KENTUCKY OR
		NC	NORTH CAROLINA OR
		OH	OHIO OR
		TN	TENNESSEE OR
		VA	VIRGINIA
	AND PATIENT ZIP CODE MUST BE A ZIP CODE IN THE FOLLOWING STATES: AZ, CA, CO, FL, GA, KY, NC, OH, TN, OR VA
	AND PROVIDER SPECIALTY MUST NOT = 251E00000X - HHA
2-305-42r	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	NQ	PI TEMPORARILY SUSPENDED PROVIDER, PHARMACY, ENTITY, OR CLIENT BENEFICARY CLAIM IN ‘PROCESS STATUS’
	THEN BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE2 MUST=	TD	TRICARE DOMESTIC OR
		TF	TRICARE FOREIGN OR
		TM	TRICARE MAIL ORDER PHARMACY OR
		TR	TRICARE RETAIL PHARMACY
2-305-44R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	CB	CHILDBIRTH SUPPORT DEMONSTRATION
	THEN PROCEDURE CODE MUST BE 99509 OR 59899
	AND BEGIN DATE OF CARE MUST BE ≥ 01/01/2022 AND < 01/01/2027
	UNLESS CONTRACT NUMBER =	HT9402-20-D-0002 (TOP)
	THEN BEGIN DATE OF CARE MUST BE ≥ 01/01/2025 AND < 01/01/2027
2-305-45R	IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =	BF	BREASTFEEDING SUPPORT DEMONSTRATION
	THEN PROCEDURE CODE MUST BE 99401, 99402, 99403, 99404, 99411, OR 99412
	AND BEGIN DATE OF CARE MUST BE ≥ 01/01/2022 AND < 01/01/2027
	UNLESS CONTRACT NUMBER =	HT9402-20-D-0002 (TOP)
	THEN BEGIN DATE OF CARE MUST BE ≥ 01/01/2025 AND < 01/01/2027

ELEMENT NAME: HEALTH CARE DELIVERY PROGRAM (HCDP) SPECIAL ENTITLEMENT CODE (2-306)
VALIDITY EDITS
2-306-01V	MUST BE A VALID HCDP SPECIAL ENTITLEMENT CODE (REFER TO Section 2.5)
Relational Edits
	NONE

ELEMENT NAME: CA/NAS NUMBER (2-310)
1 CATCHMENT AREA DETERMINATION IS BASED ON BEGIN DATE OF CARE.
VALIDITY EDITS
2-310-01V	IF BEGIN DATE OF CARE ≥ 03/28/2013
	THEN CA/NAS NUMBER MUST BE BLANK.
	ELSE IF CA/NAS NUMBER IS NOT BLANK
	THEN MUST BE 1 TO 11 OR 1 TO 15 ALPHANUMERIC CHARACTERS.
Relational Edits
NO ERROR	IF TYPE OF SUBMISSION =	C	COMPLETE CANCELLATION OR
		D	COMPLETE DENIAL
	THEN BYPASS ALL CA/NAS NUMBER RELATIONAL EDITING.
NO ERROR	IF BEGIN DATE OF CARE IS OLDER THAN SIX YEARS
	THEN DO NOT CHECK IF ZIP CODE IS IN CATCHMENT AREA1
NO ERROR	IF 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
		AN	SHCP - NON-MARKET/MTF-REFERRED CARE OR
		AR	SHCP - MARKET/MTF-REFERRED CARE OR
		CE	SHCP - CCEP OR
		PF	ECHO
		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 OR
		SC	SHCP - NON-TRICARE ELIGIBLE OR
		SE	SHCP - TRICARE ELIGIBLE OR
		SM	SHCP - EMERGENCY OR
		ST	SPECIALIZED TREATMENT OR
		WR	MENTAL HEALTH WRAP AROUND
	THEN BYPASS ALL CA/NAS NUMBER EDITING.
NO ERROR	IF ENROLLMENT/HEALTH PLAN CODE =	U	TRICARE PRIME, CIVILIAN PCM OR
		W	TPR SERVICE MEMBER - USA OR
		X	FOREIGN SERVICE MEMBER OR
		Y	CHCBP - NON-NETWORK OR
		Z	TRICARE PRIME, MARKET/MTF/PCM OR
		AA	CHCBP - NETWORK OR
		BB	TSP OR
		FE	TFL - NETWORK OR
		FS	TFL - NON-NETWORK OR
		PS	TSRx OR
		SN	SHCP - NON-MARKET/MTF-REFERRED CARE OR
		SR	SHCP - MARKET/MTF-REFERRED CARE OR
		WF	TPR FOR ENROLLED ADFM RESIDING WITH A TPR ELIGIBLE SERVICE MEMBER
	THEN BYPASS ALL CA/NAS NUMBER EDITING.
NO ERROR	IF HCC MEMBER CATEGORY CODE =	T	FOREIGN MILITARY MEMBER
	THEN BYPASS ALL CA/NAS NUMBER EDITING.
NO ERROR	IF ANY OCCURRENCE OF ADJUSTMENT/DENIAL REASON CODE FOR THAT DETAIL OCCURRENCE =	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
	THEN BYPASS ALL CA/NAS NUMBER EDITING
NO ERROR	IF AMOUNT OF OTHER HEALTH INSURANCE PAID IS > ZERO
	THEN NO CA/NAS IS REQUIRED -- BYPASS ALL CA/NAS NUMBER EDITING.
2-310-02R	IF CA/NAS EXCEPTION REASON ≠ BLANK
	THEN CA/NAS NUMBER MUST = BLANK
2-310-03R	• MENTAL HEALTH CHECK
	IF CA/NAS EXCEPTION REASON = BLANK
	AND TYPE OF SERVICE (FIRST POSITION) =	I	INPATIENT
	AND PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) =	290-316 (MENTAL HEALTH, ICD-9-CM)
	AND PATIENT ZIP CODE IS IN MARKET/MTF CATCHMENT AREA1
	AND BEGIN DATE OF CARE IS < 03/28/2013
	THEN CA/NAS NUMBER MUST BE CODED
	UNLESS ANY OCCURRENCE OF OVERRIDE CODE =	C	GOOD FAITH PAYMENT
	THEN CA/NAS NUMBER MUST = BLANK
2-310-04R	IF CA/NAS NUMBER IS CODED
	THEN CA/NAS EXCEPTION REASON MUST = BLANK

ELEMENT NAME: CA/NAS REASON FOR ISSUANCE (2-315)
VALIDITY EDITS
2-315-01V	IF BEGIN DATE OF CARE ≥ 03/28/2013
	THEN CA/NAS REASON FOR ISSUANCE MUST BE BLANK.
	ELSE VALUE MUST A VALID CA/NAS REASON FOR ISSUANCE.
Relational Edits
2-315-02R	IF CA/NAS NUMBER = BLANK
	THEN CA/NAS REASON FOR ISSUANCE MUST = BLANK.

ELEMENT NAME: CA/NAS EXCEPTION REASON (2-320)
1 CATCHMENT AREA DETERMINATION IS BASED ON BEGIN DATE OF CARE.
VALIDITY EDITS
2-320-01V	IF BEGIN DATE OF CARE ≥ 03/28/2013
	THEN CA/NAS EXCEPTION REASON MUST BE BLANK.
	ELSE VALUE MUST BE A VALID CA/NAS EXCEPTION REASON.
Relational Edits
NO ERROR	IF TYPE OF SUBMISSION =	C	COMPLETE CANCELLATION OR
		D	COMPLETE DENIAL
	THEN BYPASS ALL CA/NAS EXCEPTION REASON EDITING.
NO ERROR	IF BEGIN DATE OF CARE IS OLDER THAN SIX YEARS
	THEN DO NOT CHECK IF ZIP CODE IS IN CATCHMENT AREA
NO ERROR	IF 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-NOT A MEDICARE BENEFIT) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
		AN	SHCP - NON-MARKET/MTF-REFERRED CARE OR
		AR	SHCP - MARKET/MTF-REFERRED CARE OR
		CE	SHCP - CCEP OR
		PF	ECHO
		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 OR
		SC	SHCP - NON-TRICARE ELIGIBLE OR
		SE	SHCP - TRICARE ELIGIBLE OR
		SM	SHCP - EMERGENCY OR
		ST	SPECIALIZED TREATMENT OR
		WR	MENTAL HEALTH WRAP AROUND
	THEN BYPASS ALL CA/NAS EXCEPTION REASON EDITING.
NO ERROR	IF ENROLLMENT/HEALTH PLAN CODE =	U	TRICARE PRIME, CIVILIAN PCM OR
		W	TPR SERVICE MEMBER - USA OR
		X	FOREIGN SERVICE MEMBER OR
		Y	CHCBP - NON-NETWORK OR
		Z	TRICARE PRIME, MARKET/MTF/PCM OR
		AA	CHCBP - NETWORK OR
		BB	TSP OR
		FE	TFL - NETWORK OR
		FS	TFL - NON-NETWORK OR
		PS	TSRx OR
		SN	SHCP - NON-MARKET/MTF-REFERRED CARE OR
		SR	SHCP - MARKET/MTF-REFERRED CARE OR
		WF	TPR FOR ENROLLED ADFM RESIDING WITH A TPR ELIGIBLE SERVICE MEMBER
	THEN BYPASS ALL CA/NAS EXCEPTION REASON EDITING.
NO ERROR	IF HCC MEMBER CATEGORY CODE =	T	FOREIGN MILITARY MEMBER
	THEN BYPASS ALL CA/NAS EXCEPTION REASON EDITING.
NO ERROR	IF ANY OCCURRENCE OF ADJUSTMENT/DENIAL REASON CODE FOR THAT DETAIL OCCURRENCE =	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
	THEN BYPASS ALL CA/NAS EXCEPTION REASON EDITING
NO ERROR	IF AMOUNT OF OTHER HEALTH INSURANCE PAID IS > ZERO
	THEN NO CA/NAS IS REQUIRED -- BYPASS ALL CA/NAS EXCEPTION REASON EDITING
2-320-04R	IF PATIENT ZIP CODE IS IN A MARKET/MTF CATCHMENT AREA1
	AND TYPE OF SERVICE (FIRST POSITION) =	I	INPATIENT
	AND PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) =	290-316	MENTAL HEALTH, ICD-9-CM
	AND CA/NAS NUMBER NOT CODED
	AND BEGIN DATE OF CARE IS < 03/28/2013
	THEN CA/NAS EXCEPTION REASON MUST BE CODED

ELEMENT NAME: PRICING RATE CODE (2-325)
VALIDITY EDITS
2-325-01V	VALUE MUST A VALID NON-INSTITUTIONAL PRICING RATE CODE.
Relational Edits
2-325-01R	IF PRICING RATE CODE =	C	AMBULATORY SURGERY FACILITY PAYMENT RATE OR
		D	DISCOUNTED AMBULATORY SURGERY FACILITY PAYMENT RATE OR
		E	AMBULATORY SURGERY-PAID AS BILLED OR
		P	CLAIM AUDITING SOFTWARE-ADDED PROCEDURE, AMBULATORY SURGERY-FACILITY PAYMENT RATE OR
		Q	CLAIM AUDITING SOFTWARE-ADDED PROCEDURE, DISCOUNTED AMBULATORY SURGERY-FACILITY PAYMENT RATE OR
		R	CLAIM AUDITING SOFTWARE-ADDED PROCEDURE, AMBULATORY SURGERY-PAID AS BILLED
	THEN ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	16	AMBULATORY SURGERY FACILITY CHARGE
2-325-02R	IF ADJUSTMENT/DENIAL REASON CODE FOR THAT OCCURRENCE/LINE ITEM IS A CODE LISTED IN Addendum G, Figure 2.G-1.
	THEN PRICING RATE CODE MUST =	0	PRICING NOT APPLICABLE (DENIED SERVICE/SUPPLIES AND ALLOWED DRUGS)
2-325-03R	IF PRICING RATE CODE FOR THAT OCCURRENCE/LINE ITEM =	0	PRICING NOT APPLICABLE (DENIED SERVICE/SUPPLIES AND ALLOWED DRUGS)
	THEN AMOUNT ALLOWED BY PROCEDURE CODE MUST = ZERO
	UNLESS TYPE OF SERVICE (SECOND POSITION) =	B	RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS OR
		M	MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
	OR TYPE OF SUBMISSION =	B	ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR)
2-325-04R	IF PRICING RATE CODE =	V	MEDICARE REIMBURSEMENT RATE
	THEN ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	16	AMBULATORY SURGERY FACILITY CHARGE OR
		T	MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYER) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
		FS	TFL (SECOND PAYER) OR
		MN	TSP - NON-NETWORK OR
		MS	TSP - NETWORK
2-325-05R	IF PRICING RATE CODE =	U	SHCP CLAIM OR ACTIVE DUTY MEMBER TPR PAID OUTSIDE NORMAL LIMITS
	THEN ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =	AR	SHCP - MARKET/MTF-REFERRED CARE OR
		AN	SHCP - NON-MARKET/MTF-REFERRED CARE OR
		CE	SHCP - CCEP OR
		GU	SERVICE MEMBER ENROLLED IN TPR OR
		SC	SHCP - NON-TRICARE ELIGIBLE OR
		SE	SHCP - TRICARE ELIGIBLE OR
		SM	SHCP - EMERGENCY
	OR ENROLLMENT/HEALTH PLAN CODE MUST =	SN	SHCP - NON-MARKET/MTF-REFERRED CARE OR
		SR	SHCP - MARKET/MTF-REFERRED CARE
2-325-06R	IF PRICING CODE =	W	PRICED OVER CMAC
	AND ENROLLMENT/HEALTH PLAN CODE =	T	TRICARE STANDARD PROGRAM
	AND AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE =	NE	OPERATION NOBLE EAGLE/OPERATION ENDURING FREEDOM DEMONSTRATION
	AND BEGIN DATE OF CARE ≥ 09/14/2001 AND < 11/01/2009
	THEN PROVIDER PARTICIPATING INDICATOR MUST =	N	NO
2-325-08R	IF PRICING RATE CODE =	P1	OPPS OR
		P2	OPPS WITH COST OUTLIER OR
		P3	OPPS WITH DISCOUNT OR
		P5	PARTIAL HOSPITALIZATION - PAID AS OPPS
	THEN APC CODE MUST ≠ BLANK
2-325-09R	IF PRICING RATE CODE =	CA	CAH REIMBURSEMENT
	THEN BEGIN DATE OF CARE MUST BE ≥ 12/01/2009
	UNLESS PROVIDER STATE OR COUNTRY CODE =	AK	ALASKA
	THEN BEGIN DATE OF CARE MUST BE ≥ 07/01/2007

ELEMENT NAME: AMBULATORY PAYMENT CLASSIFICATION (APC) CODE (2-330)
VALIDITY EDITS
2-330-01V	MUST BE A VALID APC CODE AS LISTED ON DHA’S OPPS WEBSITE AT HTTP://HEALTH.MIL/MILITARY-HEALTH-TOPICS/BUSINESS-SUPPORT/RATES-AND-REIMBURSEMENT/OUTPATIENT-PROSPECTIVE-PAYMENT-SYSTEM, BLANK, OR ALL ZEROES
	UNLESS AMOUNT ALLOWED BY PROCEDURE CODE = ZERO
Relational Edits
2-330-01R	IF APC CODE = BLANK
	THEN PRICING RATE CODE ≠	P1	OPPS OR
		P2	OPPS WITH COST OUTLIER OR
		P3	OPPS WITH DISCOUNT OR
		P5	PARTIAL HOSPITALIZATION - PAID AS OPPS

ELEMENT NAME: OPPS PAYMENT STATUS INDICATOR CODE (2-331)
VALIDITY EDITS
2-331-01V	MUST BE A VALID OPPS PAYMENT STATUS INDICATOR CODE (REFER TO Section 2.6) OR BLANK.
Relational Edits
2-331-01R	IF OPPS PAYMENT STATUS INDICATOR CODE = BLANK
	THEN APC CODE MUST = ALL ZEROES OR BLANK.

ELEMENT NAME: AMOUNT NETWORK PROVIDER DISCOUNT (2-335)
VALIDITY EDITS
2-335-01V	MUST BE NUMERIC AND ≥ ZERO
Relational Edits
2-335-01R	IF TYPE OF SUBMISSION =	B	ADJUSTMENT TO NON-TED (HCSR) DATA OR
		C	COMPLETE CANCELLATION OR
		D	COMPLETE DENIAL OR
		E	COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA OR
		O	ZERO GOVERNMENT TED RECORD DUE TO 100% OHI
	THEN AMOUNT NETWORK PROVIDER DISCOUNT MUST = ZERO
2-335-02R	IF PROVIDER NETWORK STATUS INDICATOR =	2	NON-NETWORK PROVIDER
	THEN AMOUNT NETWORK PROVIDER DISCOUNT MUST = ZERO
2-335-03R	IF REGION INDICATOR =	b	BLANK
	THEN AMOUNT NETWORK PROVIDER DISCOUNT MUST = ZERO

- END -

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