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TRICARE Systems Manual 7950.3-M, April 1, 2015
TRICARE Encounter Data (TED)
Chapter 2
Section 1.2
Data Reporting - Provider File Record Submission
Revision:  
1.0  General
1.1  Contractor Submission of TRICARE Encounter Provider Records (TEPRV) Requirements
1.1.1  Electronic Media Submission
Contractors are required to submit TEPRV Records (except for TRICARE For Life (TFL) second payor) via electronic media to the Defense Health Agency (DHA) for each provider who rendered care to TRICARE beneficiaries.
1.1.2  Record Content
Required Information for each Health Care Provider:
•  A Unique Provider ID Number (PROVIDER TAXPAYER NUMBER).
•  Name.
•  Address.
•  Medical Specialty
•  Authorization Period.
•  Denied services and TRICARE Encounter Data (TED) record cancellations will be excluded from the TEPRV check.
•  The TEPRV must be present on the Provider File at DHA prior to reporting associated TED records.
•  The data will be used by DHA to track services rendered by each provider.
1.2  Accountability For TEPRVs
The contractor having contractual authority for provider certification in a given region has accountability for the TEPRVs for providers in that region and is responsible for ensuring these TEPRVs pass the DHA edits and for performing all maintenance transactions. This responsibility extends to those TEPRVs submitted in support of claims processing by another contractor with the exception of pharmacy TEPRVs which can be submitted by any contractor.
1.3  Data Submission
The contractor must provide a separate record for each provider who renders care to a TRICARE beneficiary.
1.3.1  The Initial Load Of The Provider Information
1.3.1.1  The initial load of the Provider information must be submitted following the rules listed below. Every effort must be made to ensure that duplicate Provider records are not submitted and that only active Provider records are submitted.
1.3.1.2  For non-institutional providers, multiple records will be required when more than one provider is billing under the same PROVIDER TAXPAYER NUMBER (e.g., clinics). In this case, the PROVIDER ZIP CODE and PROVIDER SUB-IDENTIFIER must be used to identify unique providers. Refer to these elements for further instructions.
1.3.2  Transition Of Future Provider Information Between Contractors
The transition of future provider information between contractors must retain the provider record key information. For institutional providers the record key is: PROVIDER TAXPAYER NUMBER, PROVIDER ZIP CODE, and PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION. For non-institutional providers the record key is: PROVIDER TAXPAYER NUMBER, PROVIDER ZIP CODE, and PROVIDER SUB-IDENTIFIER.
1.3.3  Inactive Providers
When the contractor removes a provider from their active provider files (e.g., due to long periods of inactivity), a TEPRV must be submitted to TRICARE as a modify Transaction Code with a Provider Termination Date reflecting when the Provider was removed from the contractor’s files.
1.4  Institutional Providers that are Part of a Multi-Hospital Chain
1.4.1  Providers must be identified within the PROVIDER TAXPAYER NUMBER by the zip code.
1.4.2  In addition, multiple records will be required for institutional providers with both DRG-exempt and DRG-non-exempt units under the same PROVIDER TAXPAYER NUMBER.
1.4.3  These are to be identified by the PROVIDER SPECIALTY/TYPE OF INSTITUTION. Only one DRG-non-exempt TYPE OF INSTITUTION will be allowed per PROVIDER TAXPAYER NUMBER and zip code, while multiple DRG-exempt types of facility will be allowed.
1.4.4  No duplicates within the PROVIDER TAXPAYER NUMBER, PROVIDER ZIP CODE, and PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION will be allowed.
1.5  Institution Provides Outpatient Care
1.5.1  Additional TEPRVs must be reported to DHA. For outpatient services (e.g., ambulatory surgery in hospital, emergency room, hospital services), submit a TEPRV with PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION = FACILITY CHARGES (refer to edit 3-160-05R) and INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR = N.
1.5.2  If the institution has a clinic associated with it, additional TEPRVs must be reported to DHA using the PROVIDER SUB-IDENTIFIER in the same manner as a stand alone clinic.
2.0  Provider File Record Maintenance
The Provider File is a dynamic file where records can be added, modified, or inactivated when a change is required.
2.1  File Submission
2.1.1  The contractor must submit TEPRVs indicating the type of change and updated information.
2.1.2   TEPRVs will be submitted on an as needed basis.
2.1.3  Each group of TEPRVs must be preceded by a batch header record that identifies the subsequent records as provider transaction records.
2.2  Add Transactions
2.2.1  The TRANSACTION CODE must be A.
2.2.2   All required data elements must be included.
2.2.3  An ADD cannot be made for institutional providers if the PROVIDER TAXPAYER NUMBER, PROVIDER SUB-IDENTIFIER, PROVIDER ZIP CODE, and PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION are already on file.
2.2.4  An ADD for non-institutional providers cannot be made if the PROVIDER TAXPAYER NUMBER, PROVIDER ZIP CODE and PROVIDER SUB-IDENTIFIER are already on file.
2.3  Modify Transactions
2.3.1  The TRANSACTION CODE must be M.
2.3.2  All required data elements must be included.
2.3.3  The MODIFY is used to make changes to an existing provider record, such as a termination of authorization or reauthorization.
2.3.4  A MODIFY will replace the previous record with a new record. Records being replaced will be held in history. Multiple periods of authorization will be stored on the DHA master provider file.
2.3.5  For institutional providers, a MODIFY will not be accepted if the PROVIDER TAXPAYER NUMBER, PROVIDER SUB-IDENTIFIER, PROVIDER ZIP CODE, and PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION are not already on the file.
2.3.6  For non-institutional providers, a MODIFY will not be accepted if the PROVIDER TAXPAYER NUMBER, PROVIDER ZIP CODE and PROVIDER SUB-IDENTIFIER are not already on the file.
2.4  Inactivate Transactions
The TRANSACTION CODE must be I.
2.4.1  Institutional Providers
The INACTIVATE process is to be used when there is an error on the PROVIDER TAXPAYER NUMBER, PROVIDER SUB-IDENTIFIER, PROVIDER ZIP CODE, or PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION data elements.
2.4.2  Non-Institutional Providers
2.4.2.1  The INACTIVATE process is used when there is an error on either the PROVIDER TAXPAYER NUMBER, PROVIDER ZIP CODE, or the PROVIDER SUB-IDENTIFIER data elements.
2.4.2.2  To correct an error on these data elements, the incorrect record must be inactivated and the correct record added using two separate transactions.
2.4.2.3  When correcting an error on these data elements for a clinic, all provider records associated with the clinic must also be inactivated. This process also applies when replacing a record containing a contractor Assigned Provider Number (APN) with a record containing the actual Provider Taxpayer Number.
3.0  Resubmission of Provider Batches and Provider Records
3.1  Batches that fail any edits at the header record level will be rejected and returned to the contractor for correction. Header level rejections require the resubmission of the entire batch with the appropriate data corrections. The RESUBMISSION NUMBER must not be incremented from what was reported on the prior submission.
3.2  TEPRVs that fail any edits will be rejected and returned to the contractor for correction and resubmission in a new batch.
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