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TRICARE Systems Manual 7950.3-M, April 1, 2015
TRICARE Encounter Data (TED)
Chapter 2
Section 5.2
Institutional Edit Requirements (ELN 100 - 199)
Revision:  C-28, August 28, 2019
ELEMENT NAME:  PERSON SEX (PATIENT) (1-100)
VALIDITY EDITS
1-100-01V
PERSON SEX (PATIENT) MUST =
F
FEMALE OR
M
MALE OR
Z
UNKNOWN
Relational Edits
NONE
ELEMENT NAME:  PATIENT ZIP CODE (1-105)
1  WHEN FOREIGN COUNTRY CODES ARE SUBMITTED, THE FIRST THREE CHARACTERS WILL BE EDITED AGAINST Addendum A.
VALIDITY EDITS
1-105-01V
MUST BE NINE DIGITS OR FIVE DIGITS WITH FOUR BLANKS
MUST BE A VALID ZIP CODE (BASED ON ADMISSION DATE) IN THE GOVERNMENT PROVIDED ELECTRONIC ZIP CODE FILE OR
MUST BE A THREE CHARACTER FOREIGN COUNTRY CODE (BASED ON THE COUNTRY CODES TABLE1) FOLLOWED BY SIX BLANKS
Relational Edits
NONE
ELEMENT NAME:  ENROLLMENT/HEALTH PLAN CODE (1-110)
1  PATIENT AGE IS CALCULATED BASED ON PERSON BIRTH CALENDAR DATE (PATIENT) AND BEGIN DATE OF CARE.
VALIDITY EDITS
1-110-01V
MUST BE A VALID ENROLLMENT/HEALTH PLAN CODE (REFER TO Section 2.5).
Relational Edits
1-110-02R
IF ENROLLMENT/HEALTH PLAN CODE =
Y
CHCBP - NON-NETWORK OR
AA
CHCBP - NETWORK
THEN NO OCCURRENCE OF SPECIAL PROCESSING CODE CAN =
CL
CLINICAL TRIALS OR
PF
ECHO
1-110-06R
IF ENROLLMENT/HEALTH PLAN CODE =
SN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
SO
SHCP - NON-TRICARE ELIGIBLE OR
SR
SHCP - MTF/eMSM REFERRED CARE OR
ST
SHCP - TRICARE ELIGIBLE
THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
AN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
AR
SHCP - MTF/eMSM REFERRED CARE OR
CE
SHCP - CCEP OR
SC
SHCP - NON-TRICARE ELIGIBLE OR
SE
SHCP - TRICARE ELIGIBLE OR
SM
SHCP - EMERGENCY
1-110-09R
•  TFL CLAIMS: THE BEGIN DATE OF CARE MUST BE ≥ 10/01/2001.
WHEN BEGIN DATE OF CARE IS < 10/01/2001, THE OCCURRENCE/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
AND TYPE OF INSTITUTION ≠
10
GENERAL MEDICAL AND SURGICAL
THEN BEGIN DATE OF CARE MUST BE ≥ 10/01/2001
AND AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
FF
TFL (FIRST PAYOR-NOT A MEDICARE BENEFIT) OR
FG
TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) OR
FS
TFL (SECOND PAYOR)
ELSE IF BEGIN DATE OF CARE IS < 10/01/2001
THEN ADJUSTMENT/DENIAL REASON CODE FOR THAT DETAILED OCCURRENCE/LINE ITEM (EXCEPT FOR LINE CONTAINING REVENUE CODE 0001) 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 O
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 NEWBORN 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
1-110-10R
•  TFL CLAIMS: THE BEGIN DATE OF CARE MUST BE ≥ 10/01/2001
UNLESS THE BENEFICIARY IS AN INPATIENT AND THE ADMISSION DATE WAS PRIOR TO 10/01/2001, TFL WILL PAY FOR THE ENTIRE HOSPITAL STAY.
IF ENROLLMENT/HEALTH PLAN CODE =
FE
TFL - NETWORK OR
FS
TFL - NON-NETWORK
AND TYPE OF INSTITUTION =
10
GENERAL MEDICAL AND SURGICAL
THEN END DATE OF CARE ≥ 10/01/2001
AND AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
FF
TFL (FIRST PAYOR-NOT A MEDICARE BENEFIT) OR
FG
TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) OR
FS
TFL (SECOND PAYOR)
1-110-12R
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 PAYOR-NOT A MEDICARE BENEFIT) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
T
MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
RS
MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-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 (1-111)
VALIDITY EDITS
1-111-01V
MUST BE A VALID HCDP PLAN COVERAGE CODE LISTED IN Addendum L.
1-111-02V
IF FILING DATE ≥ 09/01/2007
AND HCDP PLAN COVERAGE CODE =
109
TRICARE USFHP DIRECT CARE COVERAGE FOR ADFMs 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
118
TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE FOR RETIRED SPONSORS AND FAMILY MEMBERS OR
119
TRICARE USFHP DIRECT CARE FAMILY COVERAGE FOR RETIRED SPONSORS AND FAMILY MEMBERS OR
133
TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE FOR TRANSITIONAL SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
138
TRICARE USFHP DIRECT CARE INDIVUDUAL COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
139
TRICARE USFHP DIRECT CARE FAMILY COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
316
USFHP PRIME - SPONSOR AND FAMILY MEMBERS (PRESENTATION ONLY)
THEN AMOUNT ALLOWED (TOTAL) MUST = ZERO
Relational Edits
1-111-01R
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 - MTF/eMSM REFERRED CARE
TV
TRICARE SELECT
1-111-02R
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
1-111-03R
IF HCDP PLAN COVERAGE CODE =
417
TCSRC
THEN ENROLLMENT/HEALTH PLAN CODE MUST =
X
FOREIGN SERVICE MEMBER OR
SR
SHCP - MTF/eMSM REFERRED CARE
ELEMENT NAME:  REGION INDICATOR (1-112)
VALIDITY EDITS
1-112-01V
MUST BE VALID REGION INDICATOR (REFER TO Section 2.8).
1-112-02V
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:  PCM LOCATION DMIS-ID (ENROLLMENT) CODE (1-115)
VALIDITY EDITS
1-115-01V
MUST BE A VALID FOUR DIGIT PCM LOCATION DMIS-ID.
1-115-03V
IF FILING DATE ≥ 09/01/2007
AND PCM LOCATION DMIS-ID =
0190
JOHNS HOPKINS MEDICAL SERVICES CORPORATION OR
0191
BRIGHTON MARINE OR
0192
CHRISTUS HEALTH/ST JOHN’S OR
0193
ST VINCENTS CATHOLIC MEDICAL CENTERS OF NY OR
0194
PACIFIC MEDICAL CLINICS OR
0196
CHRISTUS HEALTH/ST JOSEPH’S OR
0197
CHRISTUS HEALTH/ST MARY’S OR
0198
MARTIN’S POINT HEALTH CARE OR
0199
FAIRVIEW HEALTH SYSTEM
THEN AMOUNT ALLOWED (TOTAL) MUST = ZERO
Relational Edits
NONE
ELEMENT NAME:  AMOUNT BILLED (TOTAL) (1-120)
VALIDITY EDITS
1-120-01V
MUST BE NUMERIC.
Relational Edits
1-120-01R
IF TYPE OF SUBMISSION =
A
ADJUSTMENT OR
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL OR
I
INITIAL SUBMISSION OR
O
ZERO PAYMENT WITH 100% OHI/TPL OR
R
RESUBMISSION
THEN AMOUNT BILLED (TOTAL) MUST BE > ZERO
UNLESS ANY OCCURRENCE/LINE ITEM REVENUE CODE = 0022, 0023, OR 0024
AND AMOUNT ALLOWED (TOTAL) = ZERO
1-120-02R
AMOUNT BILLED (TOTAL) MUST = TOTAL CHARGE BY REVENUE CODE FOR REVENUE CODE 0001
ELEMENT NAME:  AMOUNT ALLOWED (TOTAL) (1-125)
VALIDITY EDITS
1-125-01V
MUST BE NUMERIC.
Relational Edits
1-125-01R
IF TYPE OF SUBMISSION =
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL
THEN AMOUNT ALLOWED (TOTAL) MUST = ZERO
AND ALL OCCURRENCES/LINE ITEMS (EXCLUDING REVENUE CODE 0001) MUST CONTAIN A DENIAL CODE LISTED IN Addendum G, Figure 2.G-1 OR Figure 2.G-2.
1-125-02R
IF ALL DETAIL ADJUSTMENT/DENIAL REASON CODES CONTAIN A DENIAL CODE (REFER TO Addendum G, Figure 2.G-1 OR Figure 2.G-2).
AND TYPE OF SUBMISSION =
B
ADJUSTMENT NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
THEN AMOUNT ALLOWED (TOTAL) MUST BE ≤ ZERO
1-125-03R
IF TYPE OF SUBMISSION =
A
ADJUSTMENT OR
I
INITIAL SUBMISSION OR
O
ZERO PAYMENT WITH 100% OHI/TPL OR
R
RESUBMISSION
THEN AMOUNT ALLOWED (TOTAL) MUST BE > ZERO
1-125-04R
IF AMOUNT ALLOWED (TOTAL) = ZERO
THEN AMOUNT PAID BY GOVERNMENT CONTRACTOR (TOTAL) MUST = ZERO
UNLESS TYPE OF SUBMISSION =
B
ADJUSTMENT NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
ELEMENT NAME:  AMOUNT PAID BY OTHER HEALTH INSURANCE (1-130)
VALIDITY EDITS
1-130-01V
MUST BE NUMERIC.
Relational Edits
1-130-01R
IF TYPE OF SUBMISSION =
A
ADJUSTMENT OR
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL OR
I
INITIAL SUBMISSION OR
O
ZERO PAYMENT WITH 100% OHI/TPL OR
R
RESUBMISSION
THEN AMOUNT OF OTHER HEALTH INSURANCE MUST BE ≥ ZERO
1-130-03R
IF AMOUNT PAID BY OTHER HEALTH INSURANCE > ZERO
AND AMOUNT ALLOWED (TOTAL) > ZERO
AND AMOUNT PAID BY GOVERNMENT CONTRACTOR (TOTAL) = ZERO
AND DATE ADJUSTMENT IDENTIFIER = ZEROES
THEN TYPE OF SUBMISSION MUST =
O
ZERO PAYMENT TED RECORD DUE TO 100% OHI
UNLESS THE AMOUNT PATIENT COST-SHARE = THE AMOUNT ALLOWED (TOTAL)
ELEMENT NAME:  OTHER GOVERNMENT PROGRAM (OGP) TYPE CODE (1-131)
VALIDITY EDITS
1-131-01V
MUST BE A VALID OGP TYPE CODE LISTING IN Section 2.6.
Relational Edits
1-131-01R
IF OGP TYPE CODE =
V
CHAMPVA
THEN TYPE OF SUBMISSION MUST =
C
COMPLETE CANCELLATION OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
ELEMENT NAME:  OTHER GOVERNMENT PROGRAM (OGP) BEGIN REASON CODE (1-132)
VALIDITY EDITS
1-132-01V
MUST BE A VALID OGP BEGIN REASON CODE LISTING IN Section 2.6.
Relational Edits
NONE
ELEMENT NAME:  AMOUNT PATIENT COST-SHARE (1-135)
VALIDITY EDITS
1-135-01V
MUST BE NUMERIC.
Relational Edits
1-135-01R
IF TYPE OF SUBMISSION =
A
ADJUSTMENT OR
I
INITIAL SUBMISSION OR
O
ZERO PAYMENT WITH 100% OHI/TPL OR
R
RESUBMISSION
THEN AMOUNT PATIENT COST-SHARE MUST BE ≥ ZERO
1-135-02R
IF TYPE OF SUBMISSION =
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL
THEN AMOUNT PATIENT COST-SHARE MUST BE = ZERO
ELEMENT NAME:  HEALTH CARE COVERAGE (HCC) COPAYMENT FACTOR CODE (1-136)
VALIDITY EDITS
1-136-01V
MUST BE A VALID HCC COPAYMENT FACTOR CODE LISTING IN Section 2.5.
Relational Edits
NONE
ELEMENT NAME:  AMOUNT PAID BY GOVERNMENT CONTRACTOR (TOTAL) (1-140)
VALIDITY EDITS
1-140-01V
MUST BE NUMERIC.
Relational Edits
1-140-01R
IF TYPE OF SUBMISSION =
A
ADJUSTMENT OR
I
INITIAL SUBMISSION OR
R
RESUBMISSION
THEN AMOUNT PAID BY GOVERNMENT CONTRACTOR (TOTAL) MUST BE ≥ ZERO
1-140-02R
IF TYPE OF SUBMISSION =
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL OR
O
ZERO PAYMENT WITH 100% OHI/TPL
THEN AMOUNT PAID BY GOVERNMENT CONTRACTOR (TOTAL) MUST = ZERO
ELEMENT NAME:  AMOUNT INTEREST PAYMENT (1-145)
1  REDUCTIONS IN INTEREST MUST BE PROCESSED USING SAME REASON CODE AS PAYMENT TO ENSURE DHA ACCOUNTING SYSTEM PROCESSES TRANSACTION CORRECTLY.
VALIDITY EDITS
1-145-01V
MUST BE NUMERIC.
Relational Edits
1-145-01R
IF TYPE OF SUBMISSION =
A
ADJUSTMENT OR
C
COMPLETE CANCELLATION OR
I
INITIAL SUBMISSION OR
O
ZERO PAYMENT WITH 100% OHI/TPL OR
R
RESUBMISSION
THEN AMOUNT INTEREST PAYMENT MUST BE ≥ ZERO
1-145-02R
IF TRANSACTION RECORD AMOUNT INTEREST PAYMENT ≠ ZERO
THEN TRANSACTION RECORD REASON FOR INTEREST PAYMENT MUST =
A
CLAIMS PENDED AT GOVERNMENT DIRECTION (TERMINATED 07/08/2019) OR
B
CLAIMS REQUIRING GOVERNMENT INTERVENTION OR
C
CLAIMS REQUIRING DEVELOPMENT FOR POTENTIAL TPL (TERMINATED 07/08/2019) OR
D
CLAIMS REQUIRING AN ACTION/INTERFACE WITH ANOTHER PRIME CONTRACTOR (TERMINATED 07/08/2019) OR
E
CLAIMS RETAINED BY THE CONTRACTOR THAT DO NOT FALL INTO ONE OF THE ABOVE CATEGORIES (TERMINATED 07/08/2019) OR
F
10 USC 1095c(a)(2) INTEREST PAYMENT (THE CONTRACTOR IS FISCALLY REPONSIBILE FOR ANY INTEREST) (EFFECTIVE DATE 07/09/2019) OR
G
10 USC 1095c(a)(2) INTEREST PAYMENT (THE GOVERNMENT IS FISCALLY REPONSIBILE FOR ANY INTEREST) (EFFECTIVE DATE 07/09/2019)
1-145-04R
IF TYPE OF SUBMISSION =
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL
THEN AMOUNT INTEREST PAYMENT MUST BE = ZERO
1-145-05R
IF TRANSACTION RECORD AMOUNT INTEREST PAYMENT < ZERO AND REASON FOR INTEREST PAYMENT =
F
10 USC 1095c(a)(2) INTEREST PAYMENT (THE CONTRACTOR IS FISCALLY REPONSIBILE FOR ANY INTEREST) (EFFECTIVE DATE 07/09/2019) OR
G
10 USC 1095c(a)(2) INTEREST PAYMENT (THE GOVERNMENT IS FISCALLY REPONSIBILE FOR ANY INTEREST) (EFFECTIVE DATE 07/09/2019)
THEN TRANSACTION RECORD REASON FOR INTEREST PAYMENT MUST = REASON FOR INTEREST PAYMENT FOUND ON DATABASE1
ELEMENT NAME:  REASON FOR INTEREST PAYMENT (1-150)
VALIDITY EDITS
1-150-01V
MUST BE A VALID REASON FOR INTEREST PAYMENT CODE (BASED ON BEGIN DATE OF CARE) (REFER TO Section 2.8).
AND THE BEGIN DATE OF CARE MUST BE ON OR AFTER THE CARE EFFECTIVE DATE AND ON OR BEFORE THE CARE TERMINATION DATE
Relational Edits
1-150-01R
IF TRANSACTION RECORD REASON FOR INTEREST PAYMENT =
A
CLAIMS PENDED AT GOVERNMENT DIRECTION (TERMINATED 07/08/2019) OR
B
CLAIMS REQUIRING GOVERNMENT INTERVENTION OR
C
CLAIMS REQUIRING DEVELOPMENT FOR POTENTIAL TPL (TERMINATED 07/08/2019) OR
D
CLAIMS REQUIRING AN ACTION/INTERFACE WITH ANOTHER PRIME CONTRACTOR (TERMINATED 07/08/2019) OR
E
CLAIMS RETAINED BY THE CONTRACTOR THAT DO NOT FALL INTO ONE OF THE ABOVE CATEGORIES (TERMINATED 07/08/2019) OR
F
10 USC 1095c(a)(2) INTEREST PAYMENT (THE CONTRACTOR IS FISCALLY REPONSIBILE FOR ANY INTEREST) (EFFECTIVE DATE 07/09/2019) OR
G
10 USC 1095c(a)(2) INTEREST PAYMENT (THE GOVERNMENT IS FISCALLY REPONSIBILE FOR ANY INTEREST) (EFFECTIVE 07/09/2019)
THEN TRANSACTION RECORD AMOUNT INTEREST PAYMENT MUST ≠ ZERO
ELEMENT NAME:  OVERRIDE CODE (1-160)
VALIDITY EDITS
1-160-01V
OCCURRENCE NUMBER 1--MUST BE A VALID OVERRIDE CODE (REFER TO Section 2.6).
1-160-02V
OCCURRENCE NUMBER 2--MUST BE A VALID OVERRIDE CODE (REFER TO Section 2.6).
1-160-03V
OCCURRENCE NUMBER 3--MUST BE A VALID OVERRIDE CODE (REFER TO Section 2.6).
1-160-04V
A VALUE CANNOT BE CODED MORE THAN ONCE (EXCEPT BLANK).
1-160-05V
ALL OCCURRENCES OF OVERRIDE CODE MUST BE BLANK FILLED FOLLOWING THE FIRST OCCURRENCE OF A BLANK FILLED OVERRIDE CODE.
Relational Edits
1-160-13R
IF ANY OCCURRENCE OF OVERRIDE CODE =
NC
NON-CERTIFIED PROVIDER (DOES NOT INCLUDE SANCTIONED/SUSPENDED PROVIDERS)
THEN ANY OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
AD
FOREIGN ACTIVE DUTY CLAIMS OR
AN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
AR
SHCP - MTF/eMSM REFERRED CARE OR
CE
SHCP - CCEP OR
EU
EMERGENCY SERVICES RENDERED BY AN UNAUTHORIZED PROVIDER OR
GU
SERVICE MEMBER ENROLLED IN TPR OR
MN
TSP - NETWORK OR
MS
TSP - NON-NETWORK OR
SC
SHCP - NON-TRICARE ELIGIBLE OR
SE
SHCP - TRICARE ELIGIBLE OR
SM
SHCP - EMERGENCY
OR ENROLLMENT/HEALTH PLAN CODE MUST =
SN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
SR
SHCP - MTF/eMSM REFERRED CARE
ELEMENT NAME:  TYPE OF SUBMISSION (1-165)
VALIDITY EDITS
1-165-01V
VALUE MUST BE A VALID TYPE OF SUBMISSION.
1-165-02V
IF TYPE OF SUBMISSION =
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
THEN ADJUSTMENT KEY CANNOT =
0
BATCH OR
5
VOUCHER
1-165-03V
IF TYPE OF SUBMISSION =
A
ADJUSTMENT OR
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
C
COMPLETE CANCELLATION OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
THEN MATCH MUST BE FOUND ON THE DHA DATABASE
AND TYPE OF SUBMISSION ON THE EXISTING DHA DATABASE RECORD ≠
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
UNLESS THE RECORD HAS PROVISIONAL ERRORS
1-165-04V
IF TYPE OF SUBMISSION =
D
COMPLETE DENIAL OR
I
INITIAL SUBMISSION OR
O
ZERO PAYMENT WITH 100% OHI/TPL OR
R
RESUBMISSION
THEN A TED RECORD MUST NOT BE PRESENT ON THE DATABASE WITH THE SAME TRI.
Relational Edits
1-165-01R
IF TYPE OF SUBMISSION =
O
ZERO PAYMENT WITH 100% OHI/TPL
THEN THE AMOUNT OF OHI MUST BE > ZERO
AND AMOUNT ALLOWED (TOTAL) MUST BE > ZERO
AND AMOUNT PAID BY GOVERNMENT CONTRACTOR (TOTAL) MUST BE = ZERO
1-165-02R
IF ALL OCCURRENCES/LINE ITEMS (EXCLUDING REVENUE CODE 0001) CONTAIN AN ADJUSTMENT/DENIAL REASON CODE LISTED IN Addendum G, Figure 2.G-1)
THEN TYPE OF SUBMISSION MUST =
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
1-165-04R
IF BATCH/VOUCHER RESUBMISSION NUMBER = ZERO FOR THIS BATCH OR VOUCHER
THEN TYPE OF SUBMISSION MUST ≠
R
RESUBMISSION
1-165-05R
IF BATCH/VOUCHER RESUBMISSION NUMBER > ZERO FOR THIS BATCH OR VOUCHER
THEN TYPE OF SUBMISSION MUST BE ≠
I
INITIAL TED RECORD SUBMISSION
1-165-06R
IF TYPE OF SUBMISSION =
I
INITIAL SUBMISSION OR
R
RESUBMISSION
AND TYPE OF INSTITUTION ≠
70
HHA OR
71
SNF
AND SPECIAL PROCESSING CODE ≠
11
HOSPICE
THEN AMOUNT BILLED (TOTAL), AMOUNT ALLOWED (TOTAL), COVERED DAYS, AND TOTAL CHARGE BY REVENUE CODE MUST BE > 0.
1-165-07R
IF TYPE OF SUBMISSION =
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
THEN BEGIN DATE OF CARE MUST BE < 10/01/2010
ELEMENT NAME:  CA/NAS NUMBER (1-170)
1  CATCHMENT AREA DETERMINATION IS BASED ON ADMISSION DATE.
2  MTF/eMSM IS A 40 MILES CATCHMENT AREA.
VALIDITY EDITS
1-170-01V
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 ADMISSION DATE 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 PAYOR-NOT A MEDICARE BENEFIT) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
T
MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
AN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
AR
SHCP - MTF/eMSM REFERRED CARE OR
CE
SHCP - CCEP OR
PF
ECHO OR
RS
MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-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, MTF/eMSM/PCM OR
AA
CHCBP - NETWORK OR
BB
TSP OR
FE
TFL - NETWORK OR
FS
TFL - NON-NETWORK OR
SN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
SR
SHCP - MTF/eMSM 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 =
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.
1-170-02R
IF CA/NAS EXCEPTION REASON IS NOT BLANK
THEN CA/NAS NUMBER MUST = BLANK
1-170-03R
IF CA/NAS EXCEPTION REASON = BLANK
AND PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) =
290-316 (MENTAL HEALTH, ICD-9-CM)
AND PATIENT ZIP CODE IS IN AN MTF/eMSM2 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
1-170-04R
IF CA/NAS NUMBER IS CODED
THEN CA/NAS EXCEPTION REASON MUST = BLANK
ELEMENT NAME:  CA/NAS REASON FOR ISSUANCE (1-175)
VALIDITY EDITS
1-175-01V
IF BEGIN DATE OF CARE ≥ 03/28/2013
THEN CA/NAS REASON FOR ISSUANCE MUST BE BLANK
ELSE VALUE MUST BE A VALID CA/NAS REASON OF ISSUANCE OR BLANK.
Relational Edits
1-175-02R
IF CA/NAS NUMBER IS BLANK
THEN CA/NAS REASON FOR ISSUANCE MUST = BLANK.
ELEMENT NAME:  CA/NAS EXCEPTION REASON (1-180)
1  CATCHMENT AREA DETERMINATION IS BASED ON ADMISSION DATE.
2  MTF/eMSM IS A 40 MILES CATCHMENT AREA.
VALIDITY EDITS
1-180-01V
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 CODE OR BLANK (REFER TO Section 2.4).
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 ADMISSION DATE 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 PAYOR-NOT A MEDICARE BENEFIT) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
T
MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
AN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
AR
SHCP - MTF/eMSM REFERRED CARE OR
CE
SHCP - CCEP OR
PF
ECHO OR
RS
MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-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, MTF/eMSM/PCM OR
AA
CHCBP - NETWORK OR
BB
TSP OR
FE
TFL - NETWORK OR
FS
TFL - NON-NETWORK OR
SN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
SR
SHCP - MTF/eMSM 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 =
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.
1-180-03R
IF PATIENT ZIP CODE IS IN AN MTF/eMSM2 CATCHMENT AREA1
AND PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) =
290-316 (MENTAL HEALTH, ICD-9-CM)
AND CA/NAS NUMBER IS NOT CODED
AND BEGIN DATE OF CARE IS < 03/28/2013
THEN CA/NAS EXCEPTION REASON MUST BE CODED
1-180-07R
IF CA/NAS EXCEPTION REASON =
5
RTC
AND PATIENT ZIP CODE IS IN AN MTF/eMSM2 CATCHMENT AREA1
THEN TYPE OF INSTITUTION =
72
RTC
1-180-08R
IF CA/NAS EXCEPTION REASON =
S
HHA PPS
THEN TYPE OF INSTITUTION MUST =
70
HHA
AND ONE OCCURRENCE OF REVENUE CODE MUST =
0023
HHA PPS
ELEMENT NAME:  SPECIAL PROCESSING CODE (1-185)
1  PATIENT AGE IS CALCULATED BASED ON PERSON BIRTH CALENDAR DATE (PATIENT) AND CARE DATES.
VALIDITY EDITS
1-185-01V
OCCURRENCE NUMBER 1--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8).
1-185-02V
OCCURRENCE NUMBER 2--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8).
1-185-03V
OCCURRENCE NUMBER 3--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8).
1-185-04V
OCCURRENCE NUMBER 4--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8).
1-185-05V
A VALUE CANNOT BE CODED MORE THAN ONCE (EXCEPT BLANK).
1-185-06V
ALL OCCURRENCES OF SPECIAL PROCESSING CODE MUST BE BLANK FILLED FOLLOWING THE FIRST OCCURRENCE OF A BLANK FILLED SPECIAL PROCESSING CODE.
1-185-07V
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
AN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
AR
SHCP - MTF/eMSM REFERRED CARE
THEN BEGIN DATE OF CARE MUST BE < 06/01/2004
1-185-08V
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
1-185-10V
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
1-185-11V
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
1-185-14V
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
ST
SPECIALIZED TREATMENT
THEN BEGIN DATE OF CARE MUST BE < 10/01/2004
Relational Edits
1-185-08R
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, MTF/eMSM/PCM OR
WF
TPR FOR ENROLLED ADFM RESIDING WITH A TPR ELIGIBLE SERVICE MEMBER OR
XF
FOREIGN ADFM
1-185-14R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
AN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
AR
SHCP - MTF/eMSM 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 =
SR
SHCP - MTF/eMSM REFERRED CARE OR
SN
SHCP - NON-MTF/eMSM REFERRED CARE OR
SO
SHCP - NON-TRICARE ELIGIBLE OR
ST
SHCP - TRICARE ELIGIBLE
1-185-32R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
E
HHC/CM DEMO (AFTER 03/15/1999, GRANDFATHERED INTO THE ICMP)
THEN BEGIN DATE OF CARE IS ≥ 03/15/1999
AND AT LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
CM
ICMP
1-185-34R
•  TFL CLAIMS: THE BEGIN DATE OF CARE MUST BE ≥ 10/01/2001.
IF BEGIN DATE OF CARE IS < 10/01/2001, THE LINE ITEMS MUST CONTAIN AN ADJUSTMENT/DENIAL REASON CODE LISTED IN THIS EDIT.
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
FF
TFL (FIRST PAYOR-NOT A MEDICARE BENEFIT) OR
FG
TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) OR
FS
TFL (SECOND PAYOR)
AND TYPE OF INSTITUTION ≠
10
GENERAL MEDICAL AND SURGICAL
THEN BEGIN DATE OF CARE MUST BE ≥ 10/01/2001
AND ENROLLMENT/HEALTH PLAN CODE MUST =
FE
TFL - NETWORK OR
FS
TFL - NON-NETWORK
ELSE IF BEGIN DATE OF CARE IS < 10/01/2001
THEN ADJUSTMENT/DENIAL REASON CODE FOR THAT DETAILED LINE ITEM (EXCEPT LINE CONTAINING REVENUE CODE 0001) 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
1-185-35R
•  TFL CLAIMS: THE BEGIN DATE OF CARE MUST BE ≥ 10/01/2001
UNLESS THE BENEFICIARY IS AN INPATIENT AND THE ADMISSION DATE WAS PRIOR TO 10/01/2001, TFL WILL PAY FOR THE ENTIRE HOSPITAL STAY.
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
FF
TFL (FIRST PAYOR-NOT A MEDICARE BENEFIT) OR
FG
TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, I.E., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) OR
FS
TFL (SECOND PAYOR)
AND TYPE OF INSTITUTION =
10
GENERAL MEDICAL AND SURGICAL
THEN END DATE OF CARE MUST BE ≥ 10/01/2001
AND ENROLLMENT/HEALTH PLAN CODE MUST =
FE
TFL - NETWORK OR
FS
TFL - NON-NETWORK
1-185-39R
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
1-185-49R
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
1-185-50R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
49
HOSPITAL REIMBURSEMENT REDUCED BY MANUFACTURER CREDIT/REPLACEMENT OF DEVICE DURING WARRANTY PERIOD OR
50
HOSPITAL REIMBURSEMENT REDUCED BY MANUFACTURER CREDIT/RECALLED DEVICE
THEN DRG NUMBER MUST EQUAL A DRG SUBJECT TO THE REPLACEMENT DEVICE POLICY POSTED ON TRICARE’S DRG WEB PAGE AT HTTP://WWW.HEALTH.MIL/DRG.
AND IF END DATE OF CARE < 10/01/2014
THEN DATE OF ADMISSION MUST BE ≥ THE DRG EFFECTIVE DATE AND ≤ THE DRG TERMINATION DATE AS PER THE REPLACEMENT DEVICE POLICY POSTED ON TRICARE’S DRG WEB PAGE AT HTTP://WWW.HEALTH.MIL/DRG.
ELSE END DATE OF CARE MUST BE ≥ THE DRG EFFECTIVE DATE AND ≤ THE DRG TERMINATION DATE
1-185-51R
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
1-185-52R
IF BEGIN DATE OF CARE IS ≥ 01/01/2018
AND ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
R
MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NOT A MEDICARE BENEFIT) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
T
MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
RS
MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-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, MTF/eMSM/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
ELEMENT NAME:  HEALTH CARE DELIVERY PROGRAM (HCDP) SPECIAL ENTITLEMENT CODE (1-186)
VALIDITY EDITS
1-186-01V
MUST BE A VALID HCDP SPECIAL ENTITLEMENT CODE (REFER TO Section 2.5).
Relational Edits
NONE
ELEMENT NAME:  PRICING RATE CODE (1-190)
VALIDITY EDITS
1-190-01V
VALUE MUST BE A VALID INSTITUTIONAL PRICING RATE CODE.
Relational Edits
1-190-01R
IF FILING STATE/COUNTRY CODE =
MD
MARYLAND
THEN PRICING RATE CODE MUST ≠
H
TRICARE DRG REIMBURSEMENT WITH SHORT STAY OUTLIER OR
I
TRICARE DRG REIMBURSEMENT WITH COST OUTLIER OR
J
TRICARE DRG REIMBURSEMENT WITH NO OUTLIER OR
DD
DISCOUNTED DRG
1-190-02R
IF DRG NUMBER IS CODED (OTHER THAN ZERO)
THEN PRICING RATE CODE MUST =
H
TRICARE DRG REIMBURSEMENT WITH SHORT STAY OUTLIER OR
I
TRICARE DRG REIMBURSEMENT WITH COST OUTLIER OR
J
TRICARE DRG REIMBURSEMENT WITH NO OUTLIER OR
U
SHCP CLAIM OR ACTIVE DUTY MEMBER GSU CLAIM PAID OUTSIDE NORMAL LIMITS OR
V
MEDICARE REIMBURSEMENT RATE OR
DD
DISCOUNTED DRG
1-190-03R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
11
HOSPICE
THEN PRICING RATE CODE MUST =
D
DISCOUNT RATE AGREEMENT OR
P
PER DIEM RATE AGREEMENT OR
U
SHCP CLAIM OR ACTIVE DUTY MEMBER GSU CLAIM PAID OUTSIDE NORMAL LIMITS OR
V
MEDICARE REIMBURSEMENT RATE
UNLESS TYPE OF SUBMISSION =
D
COMPLETE DENIAL
OR AMOUNT ALLOWED (TOTAL) = ZERO
1-190-04R
IF PRICING RATE CODE =
V
MEDICARE REIMBURSEMENT RATE
THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
T
MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND EARLIEST BEGIN DATE OF CARE ≥ 10/01/2001 OR
FS
TFL (SECOND PAYOR) OR
MN
TSP - NON-NETWORK OR
MS
TSP - NETWORK
OR TYPE OF INSTITUTION =
70
HHA OR
76
SNF
1-190-05R
IF PRICING RATE CODE =
U
SHCP CLAIM OR ACTIVE DUTY MEMBER TPR CLAIM PAID OUTSIDE NORMAL LIMITS
THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
AN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
AR
SHCP - MTF/eMSM 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-MTF/eMSM-REFERRED CARE OR
SR
SHCP - MTF/eMSM REFERRED CARE
1-190-06R
IF ANY OCCURRENCE OF REVENUE CODE =
0022
SNF - PPS
THEN PRICING RATE CODE MUST =
D
DISCOUNT RATE AGREEMENT OR
V
MEDICARE REIMBURSEMENT RATE
UNLESS AMOUNT ALLOWED (TOTAL) = ZERO
1-190-07R
IF ANY OCCURRENCE OF REVENUE CODE =
0023
HHA PPS
THEN PRICING RATE CODE MUST =
D
DISCOUNT RATE AGREEMENT OR
V
MEDICARE REIMBURSEMENT RATE
UNLESS AMOUNT ALLOWED (TOTAL) = ZERO
1-190-08R
IF PRICING RATE CODE =
CA
CAH REIMBURSEMENT
THEN ADMISSION DATE MUST BE ≥ 12/01/2009
UNLESS PROVIDER STATE OR COUNTRY CODE =
AK
ALASKA
THEN ADMISSION DATE MUST BE ≥ 07/01/2007
1-190-09R
IF PRICING RATE CODE =
CR
CCR
THEN ADMISSION DATE MUST BE ≥ 01/01/2014.
1-190-10R
IF PRICING RATE CODE =
CA
CAH REIMBURSEMENT
AND ADMISSION DATE ≥ 01/01/2014.
THEN TYPE OF INSTITUTION MUST =
93
CAH
ELEMENT NAME:  PROVIDER STATE OR COUNTRY CODE (1-195)
1  “CORRESPONDING RECORD” ON PROVIDER FILE IS BASED ON INSTITUTIONAL TAXPAYER NUMBER, PROVIDER SUB-IDENTIFIER, PROVIDER ZIP CODE, AND TYPE OF INSTITUTION. THIS IS ONLY DETERMINED ONCE A PROVIDER MATCH HAS BEEN OBTAINED (1-200-02R).
VALIDITY EDITS
1-195-01V
VALUE MUST BE A VALID STATE OR COUNTRY CODE (REFER TO Addendums A OR B).
Relational Edits
1-195-01R
PROVIDER STATE/COUNTRY CODE MUST MATCH THE CORRESPONDING RECORD1 IN THE PROVIDER FILE.
UNLESS AMOUNT ALLOWED (TOTAL) ≤ ZERO
OR ADJUSTMENT/DENIAL REASON CODE =
38
SERVICES NOT PROVIDED OR AUTHORIZED BY DESIGNATED (NETWORK) PROVIDERS OR
52
THE REFERRING/PRESCRIBING/RENDERING PROVIDER IS NOT ELIGIBLE TO REFER/PRESCRIBE/ORDER/PERFORM THE SERVICE BILLED OR
B7
THIS PROVIDER WAS NOT CERTIFIED/ELIGIBLE TO BE PAID FOR THIS PROCEDURE/SERVICE ON THIS DATE OF SERVICE
OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
T
MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001
FG
TFL (FIRST PAYOR - NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICAL BENEFITS HAVE BEEN EXHAUSTED) OR
FS
TFL (SECOND PAYOR) OR
RS
MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR - NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) AND BEGIN DATE OF CARE ≥ 10/01/2001
THEN DO NOT CHECK FOR MATCH ON PROVIDER FILE
- END -

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