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TRICARE Systems Manual 7950.3-M, April 1, 2015
TRICARE Encounter Data (TED)
Chapter 2
Section 5.5
Institutional Edit Requirements (ELN 400 - 499)
Revision:  
ELEMENT NAME:  ADJUSTMENT/DENIAL REASON CODE (1-400)
VALIDITY EDITS
1-400-01V
VALUE MUST BE A VALID ADJUSTMENT/DENIAL REASON CODE (REFER TO Addendum G) OR BLANK.
Relational Edits
1-400-01R
IF AMOUNT ALLOWED (TOTAL) = ZERO
THEN ALL OCCURRENCES/LINE ITEMS (EXCLUDING REVENUE CODE 0001) MUST CONTAIN AN ADJUSTMENT/DENIAL REASON CODE (REFER TO Addendum G, Figure 2.G-1 OR Figure 2.G-2)
UNLESS TYPE OF SUBMISSION =
B
ADJUSTMENT OF NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
1-400-02R
IF TYPE OF SUBMISSION =
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL
THEN ALL OCCURRENCES/LINE ITEMS (EXCLUDING REVENUE CODE 0001) MUST CONTAIN AN ADJUSTMENT/DENIAL REASON CODE (REFER TO Addendum G, Figure 2.G-1 OR Figure 2.G-2)
1-400-03R
IF FREQUENCY CODE =
1
ADMIT THROUGH DISCHARGE
AND PRICING RATE CODE =
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
THEN NO OCCURRENCE OF ADJUSTMENT/DENIAL REASON MAY =
135
CLAIM DENIED. INTERIM BILLS CANNOT BE PROCESSED
1-400-04R
IF PRICING RATE CODE =
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
AND REVENUE CODE = 0901, 0914-0918, 096X-098X (PROFESSIONAL SERVICES), OR 081X (ORGAN ACQUISITION)
THEN ADJUSTMENT/DENIAL REASON CODE MUST BE A CODE LISTED IN Addendum G, Figure 2.G-1 OR Figure 2.G-2.
1-400-05R
IF ANY OCCURRENCE OF ADJUSTMENT/DENIAL REASON CODE =
135
CLAIM DENIED. INTERIM BILLS CANNOT BE PROCESSED
THEN ALL OCCURRENCES/LINE ITEMS (EXCLUDING REVENUE CODE 0001) MUST BE DENIED (ADJUSTMENT/DENIAL REASON CODE MUST BE A CODE LISTED IN Addendum G, Figure 2.G-1 OR Figure 2.G-2).
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