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TRICARE Systems Manual 7950.3-M, April 1, 2015
TRICARE Encounter Data (TED)
Chapter 2
Section 2.6
Data Requirements - Institutional/Non-Institutional Record Data Elements (M - O)
Revision:  C-29, September 20, 2019
DATA ELEMENT DEFINITION
ELEMENT NAME:  NATIONAL DRUG CODE
Notes And Special Instructions:
1  Only required for Outpatient Drug claims. Blank fill for non-pharmacy TED records.
This data element must be present for Mail Order Pharmacy (MOP) and Retail Pharmacy.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Non-Institutional
2-170
Up to 99
Yes1
Primary Picture (Format)
Eleven (11) alphanumeric characters.
Definition
Number assigned to pharmaceutical products by the FDA.
Code/Value Specifications
N/A
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  NUMBER OF SERVICES
Notes And Special Instructions:
Number of Services should be reported as 999 for HCPCS J-codes when the actual quantity of the services on the claim form exceeds 999.
For a list of maximum number of services allowed for a procedure code per day, refer to the Maximum Number of Services by Procedure Code list on DHA’s web site at http://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement. These values conform to CMS’ Medically Unlikely Edits (MUE) program for CPT/HCPCS codes that have been assigned a limit by CMS. Any CPT/HCPCS code not assigned a limit by CMS have been assigned a limit deemed reasonable by TRICARE. The edits for MUE program are published on the CMS web site at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/NationalCorrectCodInitEd/08_MUE.asp.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Non-Institutional
2-175
Up to 99
Yes
Primary Picture (Format)
Three (3) signed numeric digits.
Definition
Number of procedures performed/services or supplies rendered for medical, dental, and mental health care.
Code/Value Specifications
N/A
Algorithm
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.
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  OCCURRENCE/LINE ITEM NUMBER
Notes And Special Instructions:
N/A
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-380
2-145
Up to 450
Up to 99
Yes
Yes
Primary Picture (Format)
Three (3) numeric digits.
Definition
A unique number for each utilization/revenue data occurrence within the TED record. Occurrence/line item number must be assigned in sequential ascending order.
Code/Value Specifications
N/A
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  OPPS PAYMENT STATUS INDICATOR CODE
Notes And Special Instructions:
1  Required on all TED records reimbursed under OPPS.
2  Effective January 1, 2015, SI of X is no longer recognized.
3  Effective January 1, 2017, SI of E is no longer recognized.
Refer to the TRM for additional information and more complete definitions of the OPPS Payment SI codes. Must be left justified and blank filled.
The list of Payment SIs For Hospital OPPS and OPPS Payment Status can be found at http://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/Outpatient-Prospective-Payment-System.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Non-Institutional
2-331
Up to 99
Yes1
Primary Picture (Format)
Two (2) alphanumeric characters.
Definition
Identifies how a service or procedure is paid under OPPS.
Code/Value Specifications
A
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).
B
More appropriate code required for TRICARE OPPS
C
Inpatient services
E
Items or services not covered by TRICARE3
F
Acquisition of corneal tissue and certain CRNA services and Hepatitis B vaccines
G
Pass-through drugs and biologicals
H
1.  Pass-through device categories.
2.  Therapeutic radiopharmaceuticals.
K
Non-pass-through drugs and biologicals
N
Items and services packaged into APC rates
P
Partial hospitalization service.
Q
Packaged services subject to separate payment based on payment criteria. See codes Q1 through Q3 listed below.
R
Blood and blood products
S
Significant procedures not subject to multiple procedure discounting.
T
Significant procedures subject to multiple procedure discounting.
U
Brachytherapy sources
V
Clinic or ED visits
W
Invalid HCPCS or invalid revenue code with blank HCPCS
X
Ancillary services2
Z
Valid revenue code with blank HCPCS and no other SI assigned
TB
TRICARE reimbursement not allowed for CPT/HCPCS code submitted
E1
Items or services not covered by TRICARE
J1
Hospital outpatient department services paid through a comprehensive APC
J2
Hospital outpatient department services that may be paid through a comprehensive APC
Q1
STVX-packaged codes
Q2
T-packaged codes
Q3
Codes that may be paid through a composite APC
Q4
Conditionally packaged laboratory services
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  OTHER GOVERNMENT PROGRAM (OGP) BEGIN REASON CODE
Notes And Special Instructions:
1  If the DEERS response does not contain an OGP BEGIN REASON CODE, report W in this field.
If person not on DEERS but claim is payable (i.e., Government liability), report W in this field.
Note:  For MOP use the data element Medicare Begin Reason Code from the DEERS inquiry/response to report this information. If the DEERS response does not contain an OGP BEGIN REASON CODE, report W in this field.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-132
2-192
1
Up to 99
Yes1
Yes1
Primary Picture (Format)
One (1) alphanumeric character.
Definition
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.
Code/Value Specifications
A
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.
B
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.
D
Eligible for Medicare because of disability. This value applies to Medicare Part A.
E
Eligible for Medicare at age 65. This value applies to Medicare Part A.
F
Eligibility for Medicare defaulted at age 65; verification not received from Center for Medicare and Medicaid Services (CMS). Applies to Medicare Part A only.
G
Enrollment in Medicare Part B declined by beneficiary.
N
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.
P
Eligible for Medicare at or after 65 because of purchase. This value applies to Medicare Part A.
R
Eligible for Medicare because of End Stage Renal Disease (ESRD). This value applies to Medicare Part A.
V
Eligible for the CHAMPVA.
W
Not applicable.
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  OTHER GOVERNMENT PROGRAM (OGP) TYPE CODE
Notes And Special Instructions:
Instructions to submit the TED OGP TYPE CODE:
1.  If the DEERS response returns only one OGP TYPE CODE segment report the DEERS OGP TYPE CODE in the TED OGP TYPE CODE; unless the DEERS response returns OGP TYPE CODE value D then report H in the TED OGP TYPE CODE.
2.  If the DEERS response returns multiple OGP TYPE CODE segments containing the values A and B report a C in the TED OGP TYPE CODE.
3.  If the DEERS response returns multiple OGP TYPE CODE segments containing the values A and D report a I in the TED OGP TYPE CODE.
4.  If the DEERS response returns multiple OGP TYPE CODE segments containing the values B and D report a J in the TED OGP TYPE CODE.
5.  If the DEERS response returns multiple OGP TYPE CODE segments containing the values A, B, and D report a L in the TED OGP TYPE CODE.
6.  If the DEERS response does not returns a OGP TYPE CODE segment report N in the TED OGP TYPE CODE.
7.  For MOP and Retail Pharmacy, the Medicare Coverage Type Code from the DEERS inquiry/response should be reported in the TED OGP TYPE CODE.
Contractors shall forward claims for beneficiaries who are age 65 or older to the TDEFIC contractor when the DEERS response shows a Health Care Delivery Plan Code of 018, 020, 021, or 022, indicating TFL or the response carries a Medicare Begin Reason Code of A, D, E, or R, indicating the patient has Medicare Part A.
Contractors shall forward claims for beneficiaries who are under 65 to the TDEFIC contractor when the DEERS response carries a Medicare Begin Reason Code indicating the patient has Medicare Part A.
On receipt of the claim, the TDEFIC contractor shall determine if a benefit exists. The forwarding regional contractors shall determine if a dual eligible benefit exists.
If person not on DEERS but claim is payable (i.e., Government liability), report N in this field.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-131
2-191
1
Up to 99
Yes
Yes
Primary Picture (Format)
One (1) alphanumeric character.
Definition
The code that represents what type of OGP the person has. Download field from DEERS.
Code/Value Specifications
A
Medicare Part A
B
Medicare Part B
C
Medicare Part A & B
H
Medicare Part D
I
Medicare Part A & D
J
Medicare Part B & D
L
Medicare Part A, B, & D
N
No Medicare
V
CHAMPVA
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
N/A
DATA ELEMENT DEFINITION
ELEMENT NAME:  OVERRIDE CODE
Notes And Special Instructions:
1  Required if override code is applicable to override DHA edit checking. Each occurrence is two characters, left justify and blank fill each. Can report 1 to 3 codes, do not duplicate.
Records/Locator Numbers
Record Name
Locator#
Occurrences
Required
Institutional
Non-Institutional
1-160
2-095
3
3
Yes1
Yes1
Primary Picture (Format)
Six (6) alphanumeric characters.
Definition
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.
Code/Value Specifications
11
Claims retained by the contractor for development (information not available from in-house sources). (Effective 02/01/2000)
12
TPL claims requiring development. (Effective 02/01/2000)
13
Government intervention claims - pended up to 60 calendar days. (Benefit Changes, CMAC updates, etc.) (Effective 02/01/2000)
14
Claims requiring intervention by another contractor. (Effective 02/01/2000)
15
Claims pended at Government direction 60 calendar days and over. (Effective 02/01/2000)
A
Patient is over 65. (Terminated 06/01/2003)
B
Patient is a spouse under 12 years of age.
C
Good faith claim; payment has been made.
D
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).
E
Diagnosis is maternity; patient is under 12 years of age.
F
Claim was filed after the filing deadline.
G
Diagnosis/procedure code for female; sex indicates male.
H
Diagnosis/procedure code for male, sex indicates female.
I
Patient is a former spouse under 34 years of age.
J
Successive admission (patient is family member of an active duty sponsor and cost-share is based on both current and prior admission). (Institutional Only)
K
Catastrophic loss protection limit reached, patient cost-share and deductible rules do not apply.
M
NATO, SSN not applicable.
N
Retrospective payment - Inpatient Mental Health (Institutional Only)
P
Reserved (to be used only with DHA authorization)
Q
Former Spouse with Pre-Existing Condition
R
Person birth calendar date (patient) is not consistent with diagnosis/procedure code age restricting; procedure performed due to medical necessity.
S
Zip code override to be used when:
1.  A beneficiary has moved out of a region and the contractor is still responsible for the care claimed; or
2.  If a beneficiary resides in a region different from the region they are enrolled in, but are within the same contract jurisdiction.
U
Beneficiary indemnification payment
V
ADFM, services provided in TRICARE Eurasia-Africa, Pacific or Latin America & Canada including the Caribbean Basin. (Effective 06/28/1996)
Y
Newborn in mother’s room without nursery charges. (Institutional Only)
Z
Enhanced benefit
NC
Non-Certified Providers (does not include sanctioned/suspended providers) (Effective 08/01/2003)
NS
Contractor has determined that number of services is medically necessary.
Algorithm
N/A
Subordinate And/Or Group Elements
Subordinate
Group
N/A
PROCESSING INFORMATION
- END -

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