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TRICARE Systems Manual 7950.3-M, April 1, 2015
TRICARE Encounter Data (TED)
Chapter 2
Section 4.1
Header Edit Requirements (ELN 000 - 099)
Revision:  C-39, September 8, 2020
ELEMENT NAME:  HEADER TYPE INDICATOR (0-001)
1  IF THE FIRST POSITION OF EACH BATCH/VOUCHER HEADER RECORD IS NOT A 0, 5, 6, OR 9. THEN THE ENTIRE BATCH/VOUCHER WILL BE REJECTED.
2  IDHA DATABASE: CONTRACT INFOMATION PROVIDED TO THE TED FROM THE DHA ACCOUNTING SYSTEM VIA ‘CORAMS’ FILE.
VALIDITY EDITS
0-001-01V1
HEADER TYPE INDICATOR MUST =
0
BATCH HEADER (USED ON ALL PROVIDER BATCHES, AND FOR INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN NON-ADMIN CLAIM RATE ELIGIBLE TED RECORDS) OR
5
VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR
6
VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE OR
9
BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECORDS)
Relational Edits
0-001-01R
IF HEADER TYPE INDICATOR =
5
VOUCHER HEADER NON-ADMIN CLAIM RATE-ELIGIBLE OR
6
VOUCHER HEADER ADMIN CLAIM RATE-ELIGIBLE OR
9
BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECORDS)
THEN BATCH/VOUCHER IDENTIFIER
MUST =
5
INSTITUTIONAL/NON-INSTITUTIONAL (BATCH/VOUCHER)
0-001-02R
IF CONTRACT NUMBER = H94002-10-D-0001
THEN BYPASS THIS EDIT
ELSE IF HEADER TYPE INDICATOR =
5
VOUCHER HEADER NON-ADMIN CLAIM RATE-ELIGIBLE OR
6
VOUCHER HEADER ADMIN CLAIM RATE-ELIGIBLE
AND TYPE OF SUBMISSION ≠
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
THEN ADJUSTMENT KEY MUST =
5
VOUCHER
0-001-03R
IF HEADER TYPE INDICATOR =
0
BATCH HEADER (USED ON ALL PROVIDER, PRICING BATCHES, AND FOR INSTITUTIONAL/NON-INSTITUTIONAL AT-RISK NON-ADMIN CLAIM RATE ELIGIBLE TED RECORDS) OR
9
BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL AT-RISK ADMIN CLAIM RATE ELIGIBLE TED RECORDS)
AND TYPE OF SUBMISSION ≠
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
AND BATCH/VOUCHER IDENTIFIER =
5
INSTITUTIONAL/NON-INSTITUTIONAL
THEN ADJUSTMENT KEY MUST =
0
BATCH
0-001-04R
IF HEADER TYPE INDICATOR =
5
VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR
6
VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE
AND TYPE OF SUBMISSION =
D
COMPLETE DENIAL OR
O
ZERO PAYMENT TED RECORD DUE TO 100% OHI
THEN AMOUNT INTEREST PAYMENT MUST = ZERO
AND FOR INSTITUTIONAL RECORDS AMOUNT PAID BY GOVERNMENT CONTRACTOR (TOTAL) MUST = ZERO
FOR NON-INSTITUTIONAL RECORDS THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT PAID BY GOVERNMENT CONTRACTOR BY PROCEDURE CODE MUST = ZERO
0-001-05R
IF DRG NUMBER IS NOT BLANK OR
TYPE OF INSTITUTION =
70
HHA
THEN BYPASS THIS EDIT
ELSE IF FILING DATE IS ≥ 03/01/2012
AND FREQUENCY CODE ON ANY INSTITUTIONAL RECORD =
3
INTERIM-INTERIM OR
4
INTERIM-FINAL
THEN HEADER TYPE INDICATOR MUST =
0
BATCH HEADER (USED ON ALL PROVIDER BATCHES, AND FOR INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN NON-ADMIN CLAIM RATE ELIGIBLE TED RECORDS) OR
5
VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE
0-001-06R
IF HEADER TYPE INDICATOR =
6
VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE OR
9
BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECORDS)
THEN AN ADMINISTRATIVE CLIN MUST BE FOUND IN DHA DATABASE2
ELEMENT NAME:  CONTRACT NUMBER (0-010)
1  DHA DATABASE: CONTRACT INFORMATION PROVIDED TO THE TED FROM THE DHA ACCOUNTING SYSTEM VIA ‘CORAMS’ FILE.
VALIDITY EDITS
0-010-01V
MUST BE A VALID VALUE FOUND ON THE DHA DATABASE1.
Relational Edits
0-010-01R
IF CONTRACT NUMBER =
H94002-08-C-0003 TPHARM OR
HT9402-14-D-0002 TPHARM
AND BATCH/VOUCHER INDICATOR =
5
INSTITUTIONAL/NON-INSTITUTIONAL
THEN ALL OCCURRENCES OF RECORD TYPE INDICATOR MUST =
2
NON-INSTITUTIONAL
AND ALL OCCURRENCES OF TYPE OF SERVICE (POSITION 2) MUST =
M
MOP
OR ALL OCCURRENCES OF TYPE OF SERVICE (POSITION 2) MUST =
B
RETAIL PHARMACY
0-010-02R
IF CONTRACT NUMBER ≠
HT9402-14-D-0002 TPHARM OR
HT9402-16-C-0001 T17 EAST
THEN NO OCCURRENCE OF ENROLLMENT/HEALTH PLAN CODE CAN =
Y
CHCBP - NON-NETWORK - INDIVIDUAL COVERAGE OR
AA
CHCBP - NETWORK - FAMILY COVERAGE
AND NO OCCURRENCE OF HEALTH CARE PLAN COVERAGE CAN =
121
CHCBP - NON-NETWORK - INDIVIDUAL COVERAGE OR
122
CHCBP - NETWORK - FAMILY COVERAGE
ELEMENT NAME:  BATCH/VOUCHER IDENTIFIER (0-015)
NOTE: IF ANY TED RECORD FAILS A HEADER EDIT, THE ENTIRE BATCH/VOUCHER FAILS.
VALIDITY EDITS
0-015-01V
MUST =
3
PROVIDER OR
5
INSTITUTIONAL/NON-INSTITUTIONAL
Relational Edits
0-015-01R
IF BATCH/VOUCHER IDENTIFIER =
5
INSTITUTIONAL/NON-INSTITUTIONAL
THEN RECORD TYPE (FOR EVERY TED RECORD IN THE BATCH/VOUCHER) MUST =
1
INSTITUTIONAL OR
2
NON-INSTITUTIONAL
0-015-02R
IF BATCH/VOUCHER IDENTIFIER =
3
PROVIDER
THEN RECORD TYPE (FOR EVERY TED RECORD IN THE BATCH/VOUCHER) MUST =
3
PROVIDER
ELEMENT NAME:  BATCH/VOUCHER NUMBER (0-020)
1  DHADATABASE: CONTRACT INFORMATION PROVIDED TO THE TED FROM THE DHA ACCOUNTING SYSTEM VIA ‘CORAMS FILE.
2  CONTRACT IDENTIFIER: A UNIQUE (KEY) COMBINATION OF CONTRACT NUMBER, BATCH/VOUCHER IDENTIFIER AND BATCH/VOUCHER NUMBER.
VALIDITY EDITS
NONE
Relational Edits
0-020-01R
IF BATCH/VOUCHER IDENTIFIER =
5
INSTITUTIONAL/NON-INSTITUTIONAL
AND BATCH/VOUCHER RESUBMISSION NUMBER > 0
THEN CONTRACT IDENTIFIER2 MUST BE ON THE DHA DATABASE1.
0-020-02R
IF BATCH/VOUCHER IDENTIFIER =
5
INSTITUTIONAL/NON-INSTITUTIONAL
AND BATCH/VOUCHER RESUBMISSION NUMBER > 0
THEN CONTRACT NUMBER AND BATCH/VOUCHER NUMBER AND HEADER TYPE INDICATOR MUST BE ON THE DHA DATABASE.
0-020-03R
IF HEADER TYPE INDICATOR =
0
BATCH HEADER (USED ON ALL PROVIDER, PRICING BATCHES, AND FOR INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN NON-ADMIN CLAIM RATE ELIGIBLE TED RECORDS) OR
5
VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR
6
VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE OR
9
BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECORDS)
AND BATCH/VOUCHER RESUBMISSION NUMBER = 0
THEN CONTRACT NUMBER AND BATCH/VOUCHER NUMBER MUST NOT EXIST ON THE DHA DATABASE
AND CONTRACT IDENTIFIER2 MUST BE UNIQUE WITHIN THIS DHA PROCESSING CYCLE.
0-020-04R
IF HEADER TYPE INDICATOR =
0
BATCH HEADER (USED ON ALL PROVIDER, PRICING BATCHES, AND FOR INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN NON-ADMIN CLAIM RATE ELIGIBLE TED RECORDS) OR
5
VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR
6
VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE OR
9
BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECORDS)
AND BATCH/VOUCHER RESUBMISSION NUMBER > 0
THEN CONTRACT IDENTIFIER2 MUST BE UNIQUE WITHIN THIS DHA PROCESSING CYCLE.
ELEMENT NAME:  BATCH/VOUCHER ASAP ACCOUNT NUMBER (0-025)
1  DHA DATABASE: CONTRACT INFORMATION PROVIDED TO THE TED FROM THE DHA ACCOUNTING SYSTEM VIA ‘CORAMS’ FILE.
2  DEFINED IN THE TRICARE OPERATIONS MANUAL (TOM), Chapter 3. IF CONTRACTOR REQUIRES THE ABILITY TO SUBMIT ‘INITIAL SUBMISSIONS’ ON A CLOSED BATCH/VOUCHER CLIN/ASAP ACCOUNT, THEN CONTACT DHA, CRM FOR INSTRUCTIONS ON HOW TO PROCEED.
3  THIS CODE SHALL ONLY BE USED BY THE REGIONAL CONTRACTORS WHEN TRANSFERRING UNDERWRITTEN DEBT CREATED BY GOOD FAITH PAYMENTS TO NON-UNDERWRITTEN DEBT IN ACCORDANCE WITH THE TOM, Chapter 10, Section 3, paragraph 6.7.1.
VALIDITY EDITS
0-025-01V
MUST BE ALPHANUMERIC.
Relational Edits
0-025-01R
IF HEADER TYPE INDICATOR =
0
BATCH HEADER (USED ON ALL PROVIDER BATCHES, AND FOR INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN NON-ADMIN CLAIM RATE ELIGIBLE TED RECORDS) OR
9
BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECORDS)
THEN BATCH/VOUCHER ASAP ACCOUNT NUMBER MUST BE ALL ZEROS.
0-025-02R
IF HEADER TYPE INDICATOR =
5
VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR
6
VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE
AND BATCH/VOUCHER RESUBMISSION NUMBER = ZERO
THEN ASAP ACCOUNT NUMBER FOUND ON THE DHA DATABASE1 MUST BE VALID AND ACTIVE2 FOR THE CONTRACT NUMBER ON THE TED BATCH/VOUCHER RECORD.
0-025-05R
IF BATCH/VOUCHER RESUBMISSION NUMBER > 00
OR HEADER TYPE INDICATOR =
0
BATCH HEADER (USED ON ALL PROVIDER, PRICING BATCHES, AND FOR INSTITUTIONAL/NON-INSTITUTIONAL AT-RISK NON-ADMIN CLAIM RATE ELIGIBLE TED RECORDS) OR
9
BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL AT-RISK ADMIN CLAIM RATE ELIGIBLE TED RECORDS)
THEN BYPASS THIS EDIT
ELSE IF HCDP PLAN COVERAGE CODE =
000
NO HEALTH CARE COVERAGE PLAN OR
121
CHCBP - NON-NETWORK - INDIVIDUAL COVERAGE OR
122
CHCBP - NETWORK - FAMILY COVERAGE 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
330
TRICARE PRIME - YOUNG ADULT ACTIVE DUTY/TAMP OR
331
TRICARE PRIME - YOUNG ADULT RETIRED OR
332
TPR - YOUNG ADULT ACTIVE DUTY OR
401
TRS TIER 1 MEMBER-ONLY OR
402
TRS TIER 1 MEMBER AND FAMILY OR
403
TOBACCO CESSATION DEMONSTRATION PROGRAM OR
404
WEIGHT MANAGEMENT DEMONSTRATION PROGRAM OR
405
TRS TIER 2 MEMBER-ONLY OR
406
TRS TIER 2 MEMBER AND FAMILY OR
407
TRS TIER 3 MEMBER-ONLY OR
408
TRS TIER 3 MEMBER AND FAMILY 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
417
TRANSITIONAL CARE FOR SERVICE-RELATED CONDITIONS (TCSRC) 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 TRICARE STANDARD FOR ADFMs OR
423
TYA TRICARE STANDARD FOR RETIRED AND MOH FAMILY MEMBERS OR
424
TYA TRS OR
425
TYA TRR OR
426
TYA PRIME FOR ADFMs OR
427
TYA TPR FOR ADFMs OR
428
TYA PRIME FOR RETIRED AND MOH FAMILY MEMBERS OR
429
TYA TRICARE OVERSEAS PRIME FOR ADFMs OR
430
TYA TRICARE OVERSEAS PRIME REMOTE FOR ADFMs
OR ENROLLMENT/HEALTH PLAN CODE =
Y
CHCBP - NON-NETWORK - INDIVIDUAL COVERAGE OR
AA
CHCBP - NETWORK - FAMILY COVERAGE OR
SN
SHCP - NON-MTF/eMSM REFERRED CARE OR
SR
SHCP - MTF/eMSM REFERRED CARE
OR SPECIAL PROCESSING CODE =
AN
SHCP - NON-MTF/eMSM REFERRED CARE OR
AR
SHCP - MTF/eMSM REFERRED CARE OR
A2
ACO PILOT FOR PART A SERVICES RENDERED BY KP CONTRACTED PROVIDERS OR
A3
ACO PILOT FOR PART A SERVICES RENDERED BY NON-KP PROVIDERS OR
B2
ACO PILOT FOR PART B SERVICES RENDERED BY KP CONTRACTED PROVIDERS OR
B3
ACO PILOT FOR PART B SERVICES RENDERED BY NON-KP PROVIDERS OR
DC
DCPE-DVA/VHA OR
DE
TDRL PHYSICAL EXAM OR
D2
ACO PILOT FOR PART B SERVICES RENDERED BY NON-KP PHARMACIES OR
MM
MMPCMHP OR
PV
RETAIL PHARMACY FOR DVA/VHA
OR HCC MEMBER CATEGORY CODE =
A
ACTIVE DUTY OR
G
NATIONAL GUARD ACTIVE > 30 DAYS; AGR CODE A-H OR
J
ACADEMY STUDENT, NOT OCS OR
N
NATIONAL GUARD NOT ACTIVE OR < 31 DAYS OR
S
RESERVE MEMBER ACTIVE > 30 DAYS OR
T
FOREIGN MILITARY OR
V
RESERVE MEMBER NOT ACTIVE OR < 31 DAYS OR
Y
SERVICE AFFILIATES (ROTC, MERCHANT MARINE)
AND HCC MEMBER RELATIONSHIP CODE =
A
SELF
THEN BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER APPROPRIATION TYPE FOUND IN DHA DATABASE1 MUST ≠
TF
TRUST/ACCRUAL FUND
ELSE IF OGP TYPE CODE =
A
MEDICARE PART A OR
C
MEDICARE PART A & B OR
I
MEDICARE PART A & D OR
L
MEDICARE PART A, B AND D
AND OGP BEGIN REASON CODE ≠
N
NOT ELIGIBLE FOR MEDICARE
AND HCDP PLAN COVERAGE CODE =
004
DIRECT CARE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
005
TRICARE STANDARD FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
016
DIRECT CARE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
017
TRICARE STANDARD FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
021
TFL FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
023
TFL FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
110
TRICARE PRIME FOR INDIVIDUAL COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
111
TRICARE PRIME FAMILY COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
114
TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
115
TRICARE USFHP DIRECT CARE FAMILY COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
136
TRICARE PRIME INDIVIDUAL COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
137
TRICARE PRIME FAMILY COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
138
TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
139
TRICARE USFHP DIRECT CARE FAMILY COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
143
TRICARE PLUS COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
144
TRICARE PLUS WITH CHC COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
148
TRICARE PLUS COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
149
TRICARE PLUS COVERAGE WITH CHC COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
151
TRICARE PLUS COVERAGE FOR TRANSITIONAL SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS
OR ENROLLMENT/HEALTH PLAN CODE =
AS
TRICARE SELECT - ACTIVE DUTY SURVIVORS OR
GS
TRICARE SELECT - GUARD/RESERVE SURVIVORS
OR HCC MEMBER CATEGORY CODE =
F
FORMER MEMBER OR
H
MOH RECIPIENT OR
R
RETIRED OR
W
FORMER SPOUSE
THEN BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER APPROPRIATION TYPE FOUND IN DHA DATABASE1 MUST =
TF
TRUST/ACCRUAL FUND
ELSE BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER APPROPRIATION TYPE FOUND IN DHA DATABASE1 MUST ≠
TF
TRUST/ACCRUAL FUND
0-025-08R
IF ANY OCCURRENCE OF TYPE OF SUBMISSION =
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
OR BATCH/VOUCHER RESUBMISSION NUMBER > 00
OR HEADER TYPE INDICATOR =
0
BATCH HEADER (USED ON ALL PROVIDER BATCHES, AND FOR INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN NON-ADMIN CLAIM RATE ELIGIBLE TED RECORDS) OR
9
BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECORDS)
THEN BYPASS THIS EDIT
ELSE IF BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 =
TD
TRICARE DOMESTIC
AND CONTRACT NUMBER =
T3 NORTH
AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) ≥ START OF CONTRACT
OR CONTRACT NUMBER =
T3 SOUTH
AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) ≥ START OF CONTRACT
OR CONTRACT NUMBER =
T3 WEST
AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) ≥ START OF CONTRACT
OR CONTRACT NUMBER =
T2017 EAST
AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) ≥ BEGIN DATE OF OLDEST OPEN OPTION PERIOD
OR CONTRACT NUMBER =
T2017 WEST
AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) ≥ BEGIN DATE OF OLDEST OPEN OPTION PERIOD
THEN SPECIAL PROCESSING CODE (ANY OCCURRANCE) MUST =
AN
SHCP - NON-MTF/eMSM REFERRED CARE OR
AP
ABA PILOT OR
AR
SHCP - MTF/eMSM REFERRED CARE OR
AS
COMPREHENSIVE AUTISM CARE DEMONSTRATION OR
AU
AUTISM DEMONSTRATION OR
A2
ACO PILOT FOR PART A SERVICES RENDERED BY KP CONTRACTED PROVIDERS OR
A3
ACO PILOT FOR PART A SERVICES RENDERED BY NON-KP PROVIDERS OR
B2
ACO PILOT FOR PART B SERVICES RENDERED BY KP CONTRACTED PROVIDERS OR
B3
ACO PILOT FOR PART B SERVICES RENDERED BY NON-KP PROVIDERS OR
CE
SHCP - CCEP OR
CL
CLINICAL TRIALS OR
CM
INDIVIDUAL CASE MANAGEMENT OR
CT
CUSTODIAL CARE OR
DC
DCPE-DVA/VHA OR
DE
TDRL PHYSICAL EXAM OR
D2
ACO PILOT FOR PART B SERVICES RENDERED BY NON-KP PHARMACIES OR
GU
SERVICE MEMBER ENROLLED IN TPR OR
G1
GOOD FAITH PAYMENT DEBT TRANSFER3 OR
G2
GOOD FAITH PAYMENT OR
HH
HHVBP OR
LD
LDTs DEMONSTRATION OR
L2
NON-FDA APPROVED LDTs DEMONSTRATION OR
MC
PLATELET RICH PLASMA INJECTIONS FOR THE TREATMENT OF MUSCULOSKELETAL CONDITIONS (EFFECTIVE 10/01/2019) OR
PC
PROVISIONAL COVERAGE FOR EMERGING SERVICES AND SUPPLIES OR
PV
RETAIL PHARMACY FOR DVA/VHA OR
RB
RESPITE BENEFIT OR
SC
SHCP - NON-TRICARE ELIGIBLE OR
SE
SHCP - TRICARE ELIGIBLE OR
SM
SHCP - EMERGENCY
OR ENROLLMENT/HEALTH PLAN CODE MUST =
Y
CHCBP - NON-NETWORK - INDIVIDUAL COVERAGE OR
AA
CHCBP - NETWORK - FAMILY COVERAGE OR
SN
SHCP - NON-MTF/eMSM REFERRED CARE OR
SR
SHCP - MTF/eMSM REFERRED CARE
OR HCDP PLAN COVERAGE CODE MUST =
000
CARE DELIVERED TO INELIGIBLES OR
121
CHCBP - NON-NETWORK - INDIVIDUAL COVERAGE OR
122
CHCBP - NETWORK - FAMILY COVERAGE 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
330
TRICARE PRIME - YOUNG ADULT ACTIVE DUTY/TAMP OR
331
TRICARE PRIME - YOUNG ADULT RETIRED OR
332
TPR - YOUNG ADULT ACTIVE DUTY OR
401
TRS TIER 1 MEMBER-ONLY OR
402
TRS TIER 1 MEMBER AND FAMILY OR
403
TOBACCO CESSATION DEMONSTRATION PROGRAM OR
404
WEIGHT MANAGEMENT DEMONSTRATION PROGRAM OR
405
TRS TIER 2 MEMBER-ONLY OR
406
TRS TIER 2 MEMBER AND FAMILY OR
407
TRS TIER 3 MEMBER-ONLY OR
408
TRS TIER 3 MEMBER AND FAMILY 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
417
TRANSITIONAL CARE FOR SERVICE-RELATED CONDITIONS (TCSRC) 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 TRICARE STANDARD FOR ADSMs OR
423
TYA TRICARE STANDARD FOR RETIRED AND MOH FAMILY MEMBERS OR
424
TYA TRS OR
425
TYA TRR OR
426
TYA PRIME FOR ADFMs OR
427
TYA TPR FOR ADFMs OR
428
TYA PRIME FOR RETIRED AND MOH FAMILY MEMBERS OR
429
TYA TRICARE OVERSEAS PRIME FOR ADFMs OR
430
TYA TRICARE OVERSEAS PRIME REMOTE FOR ADFMs OR
999
UNVERIFIED NEWBORN
OR PATIENT ZIP CODE IS IN ALASKA
OR PCM DMIS-ID MUST =
0005
BASSETT ACH-FT. WAINWRIGHT OR
0006
3rd MED GRP-ELMENDORF OR
0130
USCG CLINIC KODIAK OR
0202
AHC-GREELY OR
0203
354th MED GRP-EIELSON OR
0204
TMC FT. RICHARDSON OR
0417
USCG CLINIC KETCHIKAN OR
1340
AF-C-673RD FLT MED-ELMENDORF OR
6033
KAMISH CLINIC-FT. WAINWRIGHT OR
6083
PREVENTIVE MEDICINE- BASSETT OR
7044
USCG CLINIC JUNEAU OR
7047
USCG CLINIC SITKA
OR HCC MEMBER CATEGORY CODE MUST =
A
ACTIVE DUTY OR
G
NATIONAL GUARD > 30 DAYS OR
J
ACADEMY STUDENT OR
N
NATIONAL GUARD < 30 DAYS OR
S
RESERVE > 30 DAYS OR
T
FOREIGN MILITARY MEMBER OR
V
RESERVE < 30 DAYS OR
Z
UNKNOWN
AND HCC MEMBER RELATIONSHIP CODE MUST =
A
SELF OR
Z
UNKNOWN
0-025-09R
IF ANY OCCURRENCE OF TYPE OF SUBMISSION =
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
THEN BYPASS THIS EDIT
ELSE IF BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 =
TC
TRICARE CIVILIAN PRIME
THEN ENROLLMENT/HEALTH PLAN CODE MUST =
U
TRICARE PRIME CIVILIAN PCM
AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) ≥ START DATE OF HEALTH CARE DELIVERY FOR THE CONTRACT NUMBER.
0-025-10R
IF ANY OCCURRENCE OF TYPE OF SUBMISSION =
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
THEN BYPASS THIS EDIT
ELSE IF BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 =
TN
TRICARE NON-CIVILIAN PRIME
THEN ENROLLMENT/HEALTH PLAN CODE MUST =
T
TRICARE STANDARD PROGRAM OR
V
TRICARE EXTRA OR
Z
TRICARE PRIME, MTF/eMSM/PCM OR
WF
TRICARE PRIME REMOTE ADFM
AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) ≥ START DATE OF HEALTH CARE DELIVERY FOR THE CONTRACT NUMBER.
0-025-11R
IF HEADER TYPE INDICATOR =
5
VOUCHER HEADER NON-ADMIN CLAIM RATE-ELIGIBLE OR
6
VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE
AND BATCH/VOUCHER CLIN/ASP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 =
TM
TRICARE MAIL ORDER PHARMACY
THEN THE FIRST OCCURRENCE OF TYPE OF SERVICE (POSITION 2) MUST =
M
MOP
0-025-12R
IF HEADER TYPE INDICATOR =
5
VOUCHER HEADER NON-ADMIN CLAIM RATE-ELIGIBLE OR
6
VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE
AND THE FIRST OCCURRANCE OF TYPE OF SERVICE (POSITION 2) =
M
MOP
THEN BATCH/VOUCHER CLIN/ASP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 MUST =
TM
TRICARE MAIL ORDER PHARMACY
0-025-13R
IF HEADER TYPE INDICATOR =
5
VOUCHER HEADER NON-ADMIN CLAIM RATE-ELIGIBLE OR
6
VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE
AND BATCH/VOUCHER CLIN/ASP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 =
TR
TRICARE RETAIL PHARMACY
THEN THE FIRST OCCURRENCE OF TYPE OF SERVICE (POSITION 2) MUST =
B
RETAIL PHARMACY
0-025-14R
IF HCDP PLAN COVERAGE CODE =
018
TFL FOR RETIRED SPONSORS AND FAMILY MEMBERS AND MOH OR
020
TFL FOR TRANSITIONAL SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
021
TFL FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
022
TFL FOR TRANSITIONAL SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
023
TFL FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
029
TFL FOR MEDICALLY RETIRED SPONSORS AND FAMILY MEMBERS
AND TYPE OF SUBMISSION =
I
INITIAL SUBMISSION OR
R
RESUBMISSION
THEN OGP TYPE CODE MUST ≠
N
NO MEDICARE OR
V
CHAMPVA
AND OGP BEGIN REASON CODE MUST ≠
N
NOT ELIGIBLE FOR MEDICARE OR
W
NOT APPLICABLE
ELEMENT NAME:  BATCH/VOUCHER DATE (0-030)
1  DHA DATABASE: CONTRACT INFORMATION PROVIDED TO THE TED FROM THE DHA ACCOUNTING SYSTEM VIA ‘CORAMS’ FILE.
VALIDITY EDITS
0-030-01V
MUST BE A VALID JULIAN DATE AND CANNOT BE > DHA CURRENT SYSTEM DATE.
0-030-02V
BATCH/VOUCHER DATE MUST BE ≥ CONTRACT BEGIN DATE1
AND BATCH/VOUCHER DATE MUST BE ≤ CONTRACT END DATE1
Relational Edits
0-030-01R
IF HEADER TYPE INDICATOR =
5
VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR
6
VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE
AND BATCH/VOUCHER RESUBMISSION NUMBER =
00
AND BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 =
TD
TRICARE DOMESTIC OR
TF
TRICARE FOREIGN OR
TT
TRICARE TARGET
AND TYPE OF SUBMISSION =
D
COMPLETE DENIAL OR
I
INITIAL SUBMISSION OR
O
ZERO PAYMENT WITH 100% OHI/TPL OR
R
RESUBMISSION
THEN BATCH/VOUCHER DATE IN HEADER MUST BE EQUAL TO OR WITHIN ASAP BEGIN AND END DATES ON THE DHA DATABASE.
0-030-02R
IF HEADER TYPE INDICATOR =
5
VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR
6
VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE
THEN BATCH/VOUCHER DATE IN HEADER MUST NOT BE LESS THAN THE ASAP BEGIN DATE ON THE DHA DATABASE.
0-030-03R
IF BATCH/VOUCHER RESUBMISSION NUMBER =
00
THEN BATCH/VOUCHER DATE MUST ≠
09/29/XXXX OR
09/30/XXXX
UNLESS BATCH/VOUCHER IDENTIFIER =
3
PROVIDER (BATCH ONLY)
0-030-04R
IF BATCH/VOUCHER RESUBMISSION NUMBER =
00
AND TRANSMISSION FILE RECEIVED TIME/DATE STAMP > 10:00 AM 09/28/(CURRENT YEAR)
AND BATCH/VOUCHER IDENTIFIER =
5
INSTITUTIONAL/NON-INSTITUTIONAL (BATCH/VOUCHER)
THEN BATCH/VOUCHER DATE MUST NOT BE < 10/01/(CURRENT YEAR)
0-030-05R
IF HEADER TYPE INDICATOR =
5
VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR
6
VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE
AND BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 =
TC
TRICARE CIVILIAN PRIME OR
TN
TRICARE NON-CIVILIAN PRIME
THEN BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) MUST BE EQUAL TO OR WITHIN ASAP BEGIN AND END DATES ON THE DHA DATABASE
ELEMENT NAME:  BATCH/VOUCHER SEQUENCE NUMBER (0-035)
VALIDITY EDITS
0-035-01V
MUST BE NUMERIC AND > ZERO.
Relational Edits
NONE
ELEMENT NAME:  BATCH/VOUCHER RESUBMISSION NUMBER (0-040)
1  CONTRACT IDENTIFIER: A UNIQUE (KEY) COMBINATION OF CONTRACT NUMBER, BATCH/VOUCHER IDENTIFIER AND BATCH/VOUCHER NUMBER.
VALIDITY EDITS
0-040-01V
MUST BE NUMERIC
AND IF BATCH/VOUCHER IDENTIFIER =
5
INSTITUTIONAL/NON-INSTITUTIONAL
THEN MUST BE 1 GREATER THAN THE PRIOR SUBMISSION NUMBER UNDER THE SAME CONTRACT IDENTIFIER1.
Relational Edits
NONE
ELEMENT NAME:  TOTAL NUMBER OF RECORDS (0-045)
1  CONTRACT INFORMATION PROVIDED TO THE TED FROM THE DHA ACCOUNTING SYSTEM VIA ‘CORAMS’ FILE.
VALIDITY EDITS
0-045-01V
MUST BE NUMERIC.
0-045-02V
MUST EQUAL NUMBER OF TED RECORDS IN THE BATCH/VOUCHER.
0-045-03V
TOTAL RECORDS MUST > 0
Relational Edits
0-045-01R
IF BATCH/VOUCHER IDENTIFIER =
5
INSTITUTIONAL/NON-INSTITUTIONAL
AND BATCH/VOUCHER RESUBMISSION NUMBER > ZERO
THEN NUMBER OF RECORDS IN THE BATCH/VOUCHER MUST = NUMBER OUTSTANDING RECORDS1.
ELEMENT NAME:  TOTAL AMOUNT PAID (0-050)
1  DHA DATABASE CONTRACT INFORMATION PROVIDED TO THE TED FROM THE DHA ACCOUNTING SYSTEM VIA ‘CORAMS’ FILE.
VALIDITY EDITS
0-050-01V
MUST BE NUMERIC.
Relational Edits
0-050-01R
IF BATCH/VOUCHER IDENTIFIER =
5
INSTITUTIONAL/NON-INSTITUTIONAL
THEN TOTAL AMOUNT PAID MUST = THE ACCUMULATED TOTAL OF AMOUNTS PAID BY GOVERNMENT CONTRACTOR AND AMOUNT OF INTEREST PAYMENT FOR ALL TED RECORDS IN THE BATCH/VOUCHER.
0-050-02R
IF BATCH/VOUCHER IDENTIFIER =
3
PROVIDER
THEN TOTAL AMOUNT PAID MUST EQUAL ZERO.
0-050-03R
IF BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 =
TM
TRICARE MAIL ORDER PHARMACY
THEN BYPASS THIS EDIT
ELSE IF HEADER TYPE INDICATOR =
5
VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR
6
VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE
AND BATCH/VOUCHER IDENTIFIER =
5
INSTITUTIONAL/NON-INSTITUTIONAL
AND BATCH/VOUCHER RESUBMISSION NUMBER > ZERO
THEN TOTAL AMOUNT PAID MUST BE EQUAL TO THE VOUCHER BALANCE1.
ELEMENT NAME:  INITIAL TRANSMISSION DATE (DHA DERIVED) (0-055)
VALIDITY EDITS
NONE
Relational Edits
NONE
ELEMENT NAME:  DHA BATCH/VOUCHER PROCESSING DATE (DHA DERIVED) (0-060)
VALIDITY EDITS
NONE
Relational Edits
NONE
ELEMENT NAME:  FUND ACCOUNTING (0-065)
1  DHA DATABASE: CONTRACT INFORMATION PROVIDED TO THE TED FROM THE DHA ACCOUNTING SYSTEM VIA ‘CORAMS’ FILE.
VALIDITY EDITS
0-065-01V
MUST BE NUMERIC.
Relational Edits
0-065-02R
IF BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN DHA DATABASE1 =
TM
TRICARE MAIL ORDER PHARMACY
AND HEADER TYPE INDICATOR =
5
VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR
6
VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE
AND BATCH/VOUCHER IDENTIFIER =
5
INSTITUTIONAL/NON-INSTITUTIONAL
AND BATCH/VOUCHER RESUBMISSION NUMBER > ZERO
THEN THE FUND ACCOUNTING MUST BE EQUAL TO THE VOUCHER BALANCE1.
0-065-03R
IF POSITION 1 THRU 4 OF THE BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER = MIPR
AND BATCH/VOUCHER DATE ≥ 07/14/2011
THEN THE FUND ACCOUNTING MUST = THE ACCUMULATED TOTAL OF AMOUNT ALLOWED BY PROCEDURE CODE FOR ALL TED RECORDS IN THIS VOUCHER.
- END -

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