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TRICARE Systems Manual 7950.3-M, April 1, 2015
TRICARE Encounter Data (TED)
Chapter 2
Section 6.2
Non-Institutional Edit Requirements (ELN 100 - 199)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-36, April 15, 2020
ELEMENT NAME:  TYPE OF SUBMISSION (2-100)
VALIDITY EDITS
2-100-01V
VALUE MUST BE A VALID TYPE OF SUBMISSION.
2-100-02V
IF TYPE OF SUBMISSION =
B
ADJUSTMENT OF NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
THEN ADJUSTMENT KEY CANNOT =
0
BATCH OR
5
VOUCHER
AND REGION INDICATOR MUST = BLANK
2-100-03V
IF TYPE OF SUBMISSION =
A
ADJUSTMENT OR
B
ADJUSTMENT OF NON-TED RECORD (HCSR) DATA OR
C
COMPLETE CANCELLATION OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
THEN A 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 NON-TED RECORD (HCSR) DATA
UNLESS THE RECORD HAS PROVISIONAL ERRORS
2-100-04V
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
2-100-01R
IF TYPE OF SUBMISSION =
O
ZERO PAYMENT WITH 100% OHI/TPL
THEN THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT OF OHI MUST BE > ZERO.
AND THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT ALLOWED BY PROCEDURE CODE MUST BE > ZERO.
AND THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT PAID BY GOVERNMENT CONTRACTOR BY PROCEDURE CODE MUST = ZERO.
2-100-02R
IF ALL OCCURRENCES/LINE ITEMS ARE DENIED (REFER TO 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
2-100-04R
IF RESUBMISSION NUMBER = ZERO FOR THIS BATCH OR VOUCHER
THEN TYPE OF SUBMISSION MUST ≠
R
RESUBMISSION
2-100-05R
IF RESUBMISSION NUMBER > ZERO FOR THIS BATCH OR VOUCHER
THEN TYPE OF SUBMISSION MUST ≠
I
INITIAL TED RECORD SUBMISSION
2-100-06R
IF TYPE OF SUBMISSION =
I
INITIAL SUBMISSION OR
R
RESUBMISSION
THEN THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT BILLED BY PROCEDURE CODE, AND THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT ALLOWED BY PROCEDURE CODE MUST BE > 0.
2-100-07R
IF TYPE OF SUBMISSION =
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HSCR) DATA
THEN BEGIN DATE OF CARE MUST BE < 10/01/2010
2-100-09R
IF TYPE OF SUBMISSION =
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
THEN TYPE OF SERVICE (SECOND POSITION) MUST ≠
M
MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
2-100-10R
IF THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT PAID BY OTHER HEALTH INSURANCE > 0
AND THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT ALLOWED (TOTAL) BY PROCEDURE CODE > 0
AND THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT PAID BY GOVERNMENT CONTRACTOR BY PROCEDURE CODE = 0
AND DATE ADJUSTMENT IDENTIFIED = ZEROES
THEN TYPE OF SUBMISSION MUST =
O
ZERO PAYMENT TED RECORD DUE TO 100% OHI
UNLESS THE SUM OF THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT PATIENT COST-SHARE AND THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT APPLIED TOWARD DEDUCTIBLE ≥ THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT ALLOWED BY PROCEDURE CODE
ELEMENT NAME:  CLAIM FORM TYPE/EMC INDICATOR (2-105)
VALIDITY EDITS
2-105-01V
MUST BE A VALID CLAIM FORM TYPE/EMC INDICATOR.
Relational Edits
2-105-01R
IF CLAIM FORM TYPE/EMC INDICATOR =
I
ELECTRONIC DRUG CLAIM SUBMISSION
THEN TYPE OF SERVICE (SECOND POSITION) MUST =
B
RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS OR
M
MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
2-105-02R
IF CLAIM FORM TYPE/EMC INDICATOR =
J
OTHER
AND TYPE OF SERVICE SECOND POSITION =
B
RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS OR
M
MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
THEN PROCEDURE CODE MUST =
000MN
PRESCRIPTION MEDICAL NECESSITY REVIEWS OR
000PA
PRESCRIPTION PRIOR AUTHORIZATIONS
UNLESS PROVIDER STATE OR COUNTRY CODE IS A FOREIGN COUNTRY CODE (Addendum A)
ELEMENT NAME:  ADMINISTRATIVE CLIN (2-108)
VALIDITY EDITS
2-108-01V
MUST BE BLANKS.
Relational Edits
REFER TO Section 8.1.
ELEMENT NAME:  PCM LOCATION DMIS-ID (ENROLLMENT) CODE (2-110)
VALIDITY EDITS
2-110-01V
MUST BE A VALID FOUR DIGIT DMIS-ID CODE.
2-110-03V
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
0194
CHRISTUS HEALTH/ST MARY’S OR
0198
MARTIN’S POINT HEALTH CARE OR
0199
FAIRVIEW HEALTH SYSTEM
THEN THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT ALLOWED BY PROCEDURE CODE MUST = ZERO
Relational Edits
NONE
ELEMENT NAME:  AMOUNT INTEREST PAYMENT (2-112)
1  REDUCTIONS IN INTEREST MUST BE PROCESSED USING SAME REASON CODE AS PAYMENT TO ENSURE DHA ACCOUNTING SYSTEM PROCESSES TRANSACTION CORRECTLY.
VALIDITY EDITS
2-112-01V
MUST BE NUMERIC
Relational Edits
2-112-01R
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
2-112-02R
IF TYPE OF SUBMISSION =
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL
THEN AMOUNT INTEREST PAYMENT MUST = ZERO
2-112-03R
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 (TERMINATED 07/08/2019) 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)
2-112-04R
IF TRANSACTION RECORD AMOUNT INTEREST PAYMENT < ZERO AND REASON FOR INTEREST PAYMENT =
F
10 USC 1095c(a)(2) INTEREST PAYMENT (THE CONTRACTOR IS FISCALLY RESPONSIBLE FOR ANY INTEREST) (EFFECTIVE DATE 07/09/2019) OR
G
10 USC 1095c(a)(2) INTEREST PAYMENT (THE GOVERNMENT IS FISCALLY RESPONSIBLE 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 (2-113)
VALIDITY EDITS
2-113-01V
MUST BE A VALID REASON FOR INTEREST PAYMENT CODE (BASED ON BEGIN DATE OF CARE) (REFER TO Section 2.8).
AND AT LEAST ONE OCCURRENCE OF BEGIN DATE OF CARE MUST BE ON OR AFTER THE CARE EFFECTIVE DATE AND ON OR BEFORE THE CARE TERMINATION DATE
Relational Edits
2-113-01R
IF TRANSACTION RECORD REASON FOR INTEREST PAYMENT =
A
CLAIMS PENDED AT GOVERNMENT DIRECTION (TERMINATED 07/08/2019) OR
B
CLAIMS REQUIRING GOVERNMENT INTERVENTION (TERMINATED 07/08/2019) 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)
THEN TRANSACTION RECORD AMOUNT INTEREST PAYMENT MUST ≠ ZERO
ELEMENT NAME:  ICD VERSION (2-114)
VALIDITY EDITS
2-114-01V
VALUE MUST BE A VALID ICD VERSION
Relational Edits
NO ERROR
IF THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT ALLOWED BY PROCEDURE CODE = ZERO
2-114-01R
IF ICD VERSION =
9
ICD-9
THEN END DATE OF CARE OF EACH LINE ITEM MUST BE < 10/01/2015.
2-114-02R
IF ICD VERSION =
0
ICD-10
THEN BEGIN DATE OF CARE OF EACH LINE ITEM MUST BE ON OR AFTER ≥ 10/01/2015.
ELEMENT NAME:  PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (2-115)
VALIDITY EDITS
2-115-01V
IF FILING DATE IS PRIOR TO 10/01/2004
THEN VALUE IN POSITIONS 1-7 MUST BE A VALID ICD DIAGNOSIS CODE, EXCLUDING E000.0-E999.1
2-115-02V
IF FILING DATE IS ON OR AFTER 10/01/2004
THEN VALUE IN POSITIONS 1-7 MUST BE A VALID ICD DIAGNOSIS CODE, EXCLUDING E000.0-E999.1 (ICD-9-CM) AND V00-Y99.9 (ICD-10-CM)
AND FOR AT LEAST ONE LINE ITEM
EITHER BEGIN DATE OF CARE MUST BE ON OR AFTER THE DIAGNOSIS EFFECTIVE DATE AND NOT LATER THAN THE DIAGNOSIS TERMINATION DATE ON THE ICD DIAGNOSIS REFERENCE TABLE
OR END DATE OF CARE MUST BE ON OR AFTER THE DIAGNOSIS EFFECTIVE DATE AND NOT LATER THAN THE DIAGNOSIS TERMINATION DATE ON THE ICD DIAGNOSIS REFERENCE TABLE
2-115-03V
POA INDICATOR (POSITION 8 OF THE PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR) MUST BE A VALID VALUE.
Relational Edits
2-115-01R
IF PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) IS FOR FEMALE
AND PERSON SEX (PATIENT) IS MALE
THEN AT LEAST ONE OVERRIDE CODE MUST =
G
DIAGNOSIS/PROCEDURAL CODE FOR FEMALE: SEX INDICATES MALE
2-115-02R
IF PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) IS FOR MALE
AND PERSON SEX (PATIENT) IS FEMALE
THEN AT LEAST ONE OVERRIDE CODE MUST =
H
DIAGNOSIS/PROCEDURAL CODE FOR MALE: SEX INDICATES FEMALE
2-115-06R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
PF
ECHO
THEN PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) CANNOT =
799.9
ICD-9-CM OR
R69
ICD-10-CM OR
R99
ICD-10-CM
UNLESS TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT ALLOWED BY PROCEDURE CODE = ZERO
OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
1
MEDICAID
ELEMENT NAME:  SECONDARY TREATMENT DIAGNOSIS/POA INDICATOR OCCURRENCES 1 - 24 (2-116 THROUGH 2-138, 2-340)
1  XXX EQUALS ELN (116 THROUGH 138, 2-340) FOR EACH OCCURRENCE OF SECONDARY TREATMENT DIAGNOSIS/POA INDICATOR.
VALIDITY EDITS
2-XXX-01V1
IF FILING DATE IS PRIOR TO 10/01/2004
THEN VALUE IN POSITIONS 1-7 MUST BE A VALID ICD DIAGNOSIS CODE OR BLANK FILLED.
2-XXX-02V1
IF FILING DATE IS ON OR AFTER 10/01/2004
THEN VALUE IN POSITIONS 1-7 MUST BE A VALID ICD DIAGNOSIS CODE OR BLANK FILLED.
AND BEGIN DATE OF CARE MUST BE ON OR AFTER THE DIAGNOSIS EFFECTIVE DATE AND NOT LATER THAN THE DIAGNOSIS TERMINATION DATE ON THE ICD DIAGNOSIS REFERENCE TABLE
OR END DATE OF CARE MUST BE ON OR AFTER THE DIAGNOSIS EFFECTIVE DATE AND NOT LATER THAN THE DIAGNOSIS TERMINATION DATE ON THE ICD DIAGNOSIS REFERENCE TABLE
2-XXX-03V1
ALL OCCURRENCES OF SECONDARY TREATMENT DIAGNOSIS/POA INDICATOR MUST BE BLANK FILLED FOLLOWING THE FIRST OCCURRENCE OF A BLANK FILLED SECONDARY TREATMENT DIAGNOSIS/POA INDICATOR
2-XXX-04V
POA INDICATOR (POSITION 8 OF THE PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR) MUST BE A VALID VALUE.
Relational Edits
2-XXX-01R1
IF ANY SECONDARY TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) IS FOR FEMALE
AND PERSON SEX (PATIENT) IS MALE
THEN AT LEAST ONE OVERRIDE CODE MUST =
G
DIAGNOSIS/PROCEDURAL CODE FOR FEMALE: SEX INDICATES MALE
2-XXX-02R1
IF ANY SECONDARY TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) IS FOR MALE
AND PERSON SEX (PATIENT) IS FEMALE
THEN AT LEAST ONE OVERRIDE CODE MUST =
H
DIAGNOSIS/PROCEDURAL CODE FOR MALE: SEX INDICATES FEMALE
ELEMENT NAME:  TED RECORD CORRECTION INDICATOR (2-139)
VALIDITY EDITS
2-139-01V
VALUE MUST BE BLANK.
Relational Edits
NONE
ELEMENT NAME:  TOTAL OCCURRENCE/LINE ITEM COUNT (2-140)
VALIDITY EDITS
2-140-01V
VALUE MUST BE IN RANGE: 001-099
AND MUST EQUAL THE PHYSICAL COUNT OF THE DETAIL OCCURRENCE/LINE ITEM ON THE TED RECORD.
2-140-02V
IF TYPE OF SUBMISSION =
A
ADJUSTMENT OR
B
ADJUSTMENT OF NON-TED RECORD (HCSR) DATA OR
C
COMPLETE CANCELLATION OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
THEN TOTAL OCCURRENCE/LINE ITEM COUNT MUST BE ≥ TOTAL OCCURRENCE/LINE ITEM COUNT FROM DHA DATABASE
Relational Edits
NONE
ELEMENT NAME:  ADJUSTMENT SEQUENCE NUMBER (2-141)1
1  BYPASS ALL 2-141 EDITS FOR CONTRACT NUMBERS MDA906-02-C-0013 (TMOP), MDA906-03-C-0019 (TRRx), MDA906-03-C-0009 (WEST), MDA906-03-C-0010 (SOUTH), MDA906-03-C-0011 (NORTH), AND MDA906-03-C-0015 (TDEFIC).
VALIDITY EDITS
2-141-01V
MUST BE NUMERIC.
Relational Edits
2-141-01R
IF TYPE OF SUBMISSION =
D
COMPLETE DENIAL OR
I
INITIAL SUBMISSION OR
O
ZERO PAYMENT WITH 100% OHI/TPL OR
R
RESUBMISSION
THEN ADJUSTMENT SEQUENCE NUMBER MUST = 000 (ZEROES)
2-141-02R
IF TYPE OF SUBMISSION =
A
ADJUSTMENT OR
C
COMPLETE CANCELLATION
THEN ADJUSTMENT SEQUENCE NUMBER MUST BE ONE GREATER THAN THE CURRENT VALUE IN THE TED DATABASE
2-141-03R
IF TYPE OF SUBMISSION =
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
THEN ADJUSTMENT SEQUENCE NUMBER MUST = 000 (ZEROES)
ELEMENT NAME:  OCCURRENCE/LINE ITEM NUMBER (2-145)
VALIDITY EDITS
2-145-01V
EACH VALUE MUST BE NUMERIC AND NOT EQUAL TO ZERO.
2-145-02V
OCCURRENCE/LINE ITEM NUMBER MUST BE CODED FOR EACH NUMBER OF OCCURRENCES SPECIFIED BY THE TOTAL OCCURRENCE/LINE ITEM COUNT.
2-145-03V
OCCURRENCE/LINE ITEM NUMBER MUST BE REPORTED IN ASCENDING CONSECUTIVE ORDER.
Relational Edits
NONE
ELEMENT NAME:  BEGIN DATE OF CARE (2-150)
1  “AUTHORIZED” RECORD ON PROVIDER FILE IS BASED ON NON-INSTITUTIONAL PROVIDER TAXPAYER NUMBER, PROVIDER SUB-IDENTIFIER, PROVIDER MAJOR SPECIALTY, PROVIDER ZIP CODE, AND PROVIDER ACCEPTANCE AND TERMINATION DATES. THIS IS ONLY DETERMINED ONCE A PROVIDER MATCH HAS BEEN OBTAINED (2-240-04R).
VALIDITY EDITS
2-150-01V
MUST BE A VALID GREGORIAN DATE AND CANNOT BE > DHA CURRENT SYSTEM DATE.
2-150-02V
CANNOT BE MORE THAN 10 YEARS PRIOR TO DHA CURRENT SYSTEM DATE.
2-150-03V
BEGIN DATE OF CARE MUST BE ≤ END DATE OF CARE.
Relational Edits
2-150-01R
BEGIN DATE OF CARE MUST BE ≤ END DATE OF CARE.
2-150-02R
BEGIN DATE OF CARE MUST BE ≤ FILING DATE.
2-150-03R
BEGIN DATE OF CARE MUST BE ≤ DATE TED RECORD PROCESSED TO COMPLETION.
2-150-04R
BEGIN DATE OF CARE MUST BE ≥ PERSON BIRTH CALENDAR DATE (PATIENT).
2-150-05R
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 BEGIN DATE OF CARE MUST BE ≤ DATE ADJUSTMENT IDENTIFIED.
2-150-06R
PROVIDER MUST BE “AUTHORIZED”1 ON PROVIDER FILE FOR EACH BEGIN DATE OF CARE
UNLESS AMOUNT ALLOWED BY PROCEDURE CODE ≤ ZERO
OR ADJUSTMENT/DENIAL REASON CODE FOR THAT OCCURRENCE/LINE ITEM =
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 PROVIDER SPECIALTY =
172A00000X (OTHER SERVICE PROVIDER/DRIVERS) OR
344600000X (TRANSPORTATION SERVICES/TAXI)
OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
T
MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
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 PROVIDER FILE
ELEMENT NAME:  END DATE OF CARE (2-155)
1  “AUTHORIZED” RECORD ON PROVIDER FILE IS BASED ON NON-INSTITUTIONAL PROVIDER TAXPAYER NUMBER, PROVIDER SUB-IDENTIFIER, PROVIDER MAJOR SPECIALTY, PROVIDER ZIP CODE, AND PROVIDER ACCEPTANCE AND TERMINATION DATES. THIS IS ONLY DETERMINED ONCE A PROVIDER MATCH HAS BEEN OBTAINED (2-240-04R).
VALIDITY EDITS
2-155-01V
MUST BE A VALID GREGORIAN DATE AND CANNOT BE > DHA CURRENT SYSTEM DATE.
2-155-02V
CANNOT BE MORE THAN 10 YEARS PRIOR TO DHA CURRENT SYSTEM DATE.
2-155-03V
END DATE OF CARE MUST BE > OR EQUAL TO BEGIN DATE OF CARE.
Relational Edits
2-155-02R
END DATE OF CARE MUST BE ≤ FILING DATE.
2-155-03R
END DATE OF CARE MUST BE ≤ DATE TED RECORD PROCESSED TO COMPLETION.
2-155-04R
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 END DATE OF CARE MUST BE ≤ DATE ADJUSTMENT IDENTIFIED.
2-155-05R
PROVIDER MUST BE “AUTHORIZED”1 ON PROVIDER FILE FOR EACH END DATE OF CARE
UNLESS AMOUNT ALLOWED BY PROCEDURE CODE ≤ ZERO
OR ADJUSTMENT/DENIAL REASON CODE FOR THAT OCCURRENCE/LINE ITEM =
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 PROVIDER SPECIALTY =
172A00000X (OTHER SERVICE PROVIDER/DRIVERS) OR
344600000X (TRANSPORTATION SERVICES/TAXI)
OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
T
MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
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 PROVIDER FILE
2-155-06R
END DATE OF CARE MUST BE IN THE SAME FISCAL YEAR AS THE BEGIN DATE OF CARE
ELEMENT NAME:  PROCEDURE CODE (2-160)
1  PROCEDURE CODE RECORD MATCH MADE IN 2-160-01V OR 2-160-02V WILL BE USED IN EDIT 2-160-01R.
2  BYPASS EDIT 2-160-01R IF RECORD FAILS EDIT 2-160-01V OR 2-160-02V.
VALIDITY EDITS
2-160-01V1
FOR FILING DATE PRIOR TO 01/01/2005, VALUE MUST BE A VALID PROCEDURE CODE
AND PROCEDURE CODE MUST MATCH ONE OF THE RECORDS IN THE PROCEDURE CODE DATABASE USING THE FOLLOWING DATE LOGIC:
FOR TYPE OF SUBMISSION =
D
COMPLETE DENIAL OR
I
INITIAL TED RECORD SUBMISSION OR
O
ZERO PAYMENT WITH 100% OHI/TPL OR
R
RESUBMISSION OF AN INITIAL TED RECORD (TYPE OF SUBMISSION WAS I) THAT WAS REJECTED DUE TO ERRORS
THE DATE TED RECORD PROCESSED TO COMPLETION MUST BE ON OR AFTER THE PROCESSING EFFECTIVE DATE AND BEFORE THE PROCESSING TERMINATION DATE
AND THE BEGIN DATE OF CARE MUST BE ON OR AFTER THE CARE EFFECTIVE DATE AND BEFORE THE CARE TERMINATION DATE
FOR TYPE OF SUBMISSION =
A
ADJUSTMENT TO TED RECORD DATA OR
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
C
COMPLETE CANCELLATION OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
THE DATE TED RECORD PROCESSED TO COMPLETION MUST BE ON OR AFTER THE PROCESSING EFFECTIVE DATE
AND THE BEGIN DATE OF CARE MUST BE ON OR AFTER THE CARE EFFECTIVE DATE AND BEFORE THE CARE TERMINATION DATE
2-160-02V1
FOR FILING DATE ON OR AFTER 01/01/2005 VALUE MUST BE A VALID PROCEDURE CODE
AND PROCEDURE CODE MUST MATCH ONE OF THE RECORDS IN THE PROCEDURE CODE REFERENCE TABLE USING THE FOLLOWING DATE LOGIC:
BEGIN DATE OF CARE MUST BE ON OR AFTER THE PROCEDURE CODE CARE EFFECTIVE DATE AND NOT LATER THAN THE PROCEDURE CODE CARE TERMINATION DATE.
Relational Edits
2-160-01R2
IF ON THE MATCHING RECORD THE PROCEDURE CODE DATABASE GOVERNMENT PAY CODE = N
THEN AMOUNT ALLOWED BY PROCEDURE CODE MUST BE ≤ ZERO
UNLESS ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
T
MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
AD
FOREIGN ACTIVE DUTY CLAIMS (EFFECTIVE 06/30/1996) OR
AN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
AR
SHCP - MTF/eMSM REFERRED CARE OR
CE
SHCP - CCEP OR
CL
CLINICAL TRIALS OR
CP
CANCER CLINICAL TRIALS OR
DB
DIGITAL BREAST TOMOSYNTHESIS OR
FS
TFL (SECOND PAYOR) OR
GU
SERVICE MEMBER ENROLLED IN TPR OR
LD
LDTs DEMONSTRATION OR
L2
NON-FDA APPROVED LDTs DEMONSTRATION OR
MC
PLATELET RICH PLASMA INJECTIONS FOR THE TREATMENT OF MUSCULOSKELETON CONDITIONS OR
MN
TSP - NETWORK OR
MS
TSP - NON-NETWORK OR
RD
RARE DISEASES OR
SC
SHCP - NON-TRICARE ELIGIBLE OR
SE
SHCP - TRICARE ELIGIBLE OR
SM
SHCP - EMERGENCY
OR ENROLLMENT/HEALTH PLAN CODE =
X
FOREIGN SERVICE MEMBER OR
SN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
SR
SHCP - MTF/eMSM REFERRED CARE OR
WA
TPR - FOREIGN SERVICE MEMBER
OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
AS
COMPREHENSIVE AUTISM CARE DEMONSTRATION
AND PROCEDURE CODE = 0359T, 0360T, 0361T, 0364T, 0365T, 0368T, 0369T, 0370T, T1023, 97151, 97153, 97155, OR 97156
OR FILING DATE < 11/05/2011
AND FILING STATE COUNTRY CODE = A FOREIGN COUNTRY CODE (REFER TO Addendum A)
2-160-05R
IF PROCEDURE CODE = A0100, A0110, A0120, A0130, A0140, A0170, E0170 - E0172, E0241- E0245, E0273, E0625, E0701, L3215 - L3219, L3221 - L3223, L3230, L3250 - L3255, L3257, L3265, L3500, L3510, L3520, L3630, S8940, S9122 - S9124, V5281 - V5290, OR 99082
AND AMOUNT ALLOWED BY PROCEDURE CODE > ZERO
THEN ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
PF
ECHO
UNLESS ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
AD
FOREIGN ACTIVE DUTY CLAIMS (EFFECTIVE 06/30/1996) OR
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
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 =
X
FOREIGN SERVICE MEMBER OR
SN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
SR
SHCP - MTF/eMSM REFERRED CARE OR
WA
TPR - FOREIGN SERVICE MEMBER
2-160-06R
IF TYPE OF SERVICE (FIRST POSITION) =
I
INPATIENT
THEN PROCEDURE CODE MUST NOT BE FOR OUTPATIENT ONLY CARE (REFER TO Addendum E, Figure 2.E-1.
2-160-08R
IF PROCEDURE CODE =
98800
FOR DRUGS OR
00MN
PRESCRIPTION MEDICAL NECESSITY REVIEWS OR
00PA
PRESCRIPTION PRIOR AUTHORIZATIONS
THEN TYPE OF SERVICE (SECOND POSITION) MUST =
B
RETAIL DRUGS, SUPPLIES, PRESCRIPTION, AUTHORIZATIONS, AND REVIEWS OR
M
MOP DRUGS, SUPPLIES, PRESCRIPTION, AUTHORIZATIONS, AND REVIEWS
AND NATIONAL DRUG CODE MUST ≠ BLANK
UNLESS PROVIDER STATE OR COUNTRY CODE IS A FOREIGN COUNTRY CODE (Addendum A)
2-160-11R
IF PROCEDURE CODE = S5108 OR 99080
THEN ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
AP
ABA PILOT OR
AU
AUTISM DEMONSTRATION OR
BA
ABA (INTERIM BENEFIT)
UNLESS ADJUSTMENT/DENIAL REASON CODE FOR THAT OCCURRENCE/LINE ITEM IS A CODE LISTED IN Addendum G, Figure 2.G-1 OR Figure 2.G-2.
OR 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
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 =
X
FOREIGN SERVICE MEMBER OR
SN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
SR
SHCP - MTF/eMSM REFERRED CARE OR
WA
TPR - FOREIGN SERVICE MEMBER
2-160-12R
IF PROCEDURE CODE = 1181F, 1450F, S5115, G8539, G8542, G9165, G9166, OR G9167
THEN ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
AP
ABA PILOT
UNLESS AMOUNT ALLOWED BY PROCEDURE CODE ≤ ZERO.
OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
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
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 =
X
FOREIGN SERVICE MEMBER OR
SN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
SR
SHCP - MTF/eMSM REFERRED CARE OR
WA
TPR - FOREIGN SERVICE MEMBER
ELEMENT NAME:  PROCEDURE CODE MODIFIER (2-165)
VALIDITY EDITS
2-165-01V
MUST BE A VALID PROCEDURE CODE MODIFIER AS DEFINED IN Section 2.7.
Relational Edits
NONE
ELEMENT NAME:  NATIONAL DRUG CODE (2-170)
VALIDITY EDITS
2-170-01V
MUST BE A VALID NATIONAL DRUG CODE OR BLANK
Relational Edits
2-170-01R
IF NATIONAL DRUG CODE = BLANK
THEN TYPE OF SERVICE (SECOND POSITION) MUST ≠
B
RETAIL DRUGS, SUPPLIES, PRESCRIPTION, AUTHORIZATIONS, AND REVIEWS OR
M
MOP DRUGS, SUPPLIES, PRESCRIPTION, AUTHORIZATIONS, AND REVIEWS
AND PROCEDURE CODE MUST ≠
98800
FOR DRUGS
UNLESS PROVIDER STATE OR COUNTRY CODE IS A FOREIGN COUNTRY CODE (Addendum A)
2-170-02R
IF NATIONAL DRUG CODE ≠ BLANK
THEN TYPE OF SERVICE (SECOND POSITION) MUST =
B
RETAIL DRUGS, SUPPLIES, PRESCRIPTION, AUTHORIZATIONS, AND REVIEWS OR
M
MOP DRUGS, SUPPLIES, PRESCRIPTION, AUTHORIZATIONS, AND REVIEWS
AND PROCEDURE CODE MUST =
98800
FOR DRUGS OR
99070
FOR SUPPLIES OR
000MN
PRESCRIPTION MEDICAL NECESSITY REVIEWS OR
000PA
PRESCRIPTION PRIOR AUTHORIZATIONS
ELEMENT NAME:  NUMBER OF SERVICES (2-175)
1  EDITS 2-175-02R, 2-175-03R, 2-175-04R, AND 2-175-06R ARE ONLY EXECUTED FOR FILING DATES < 02/01/2010.
2  EDIT 2-175-07R IS ONLY EXECUTED FOR FILING DATES ≥ 02/01/2010. PROCEDURE CODE RECORD MATCH MADE IN 2-160-01V OR 2-160-02V WILL BE USED IN EDIT 2-175-07R. BYPASS EDIT 2-175-07R IF RECORD FAILS EDIT 2-160-01V OR 2-160-02V.
3  TO DETERMINE MAXIMUM NUMBER OF SERVICES REFER TO THE MAXIMUM NUMBER OF SERVICES CODE LIST AT HTTP://HEALTH.MIL/MILITARY-HEALTH-TOPICS/BUSINESS-SUPPORT/RATES-AND-REIMBURSEMENT.
VALIDITY EDITS
2-175-01V
MUST BE NUMERIC.
Relational Edits
2-175-01R
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 NUMBER OF SERVICES FOR EACH OCCURRENCE MUST BE > ZERO
UNLESS TYPE OF SERVICE (SECOND POSITION) =
M
MOP DRUGS, SUPPLIES, PRESCRIPTION, AUTHORIZATIONS, AND REVIEWS
AND OCCURRENCE/LINE ITEM NUMBER = 002
THEN NUMBER OF SERVICES ON THIS LINE ITEM MUST = ZERO
2-175-02R1
•  SURGERY PROCEDURE CODES
IF AMOUNT ALLOWED BY PROCEDURE CODE > ZERO
AND PROCEDURE CODE = 10000-36399 OR 36800-69999 (SURGERY)
THEN NUMBER OF SERVICES PER PROCEDURE CODE ON A LINE ITEM CANNOT EXCEED 10 PER DAY
UNLESS PROCEDURE CODE = 11201, 11721, 13102, 13122, 13133, 13153, 15001, 15003, 15101, 15201, 15221, 15241, 15261, 15301, 15321, 15331, 15341, 15343, 15361, 15366, 15401, 15421, 15431, 17003, 17004, 17110, 17111, OR 17310
OR ANY OCCURRENCE OF OVERRIDE CODE =
NS
CONTRACTOR HAS DETERMINED THE NUMBER OF SERVICES IS MEDICALLY NECESSARY
2-175-03R1
•  E/M PROCEDURE CODES
IF AMOUNT ALLOWED BY PROCEDURE CODE > ZERO
AND PROCEDURE CODE =
99201-99205 (OFFICE VISITS - NEW PATIENTS) OR
99211-99215 (OFFICE VISITS - ESTABLISHED PATIENTS) OR
99217 (DISCHARGE SERVICES) OR
99221-99233 (HOSPITAL CARE PER DAY) OR
99234-99236 (OBSERVATION OR INPATIENT CARE SERVICES) OR
99238-99239 (HOSPITAL DISCHARGE SERVICES) OR
99241-99245 (OFFICE CONSULTATIONS) OR
99251-99255 (INITIAL INPATIENT CONSULTATIONS) OR
99261-99263 (FOLLOW-UP INPATIENT CONSULTATIONS) OR
99271-99275 (CONFIRMATORY CONSULTATIONS) OR
99281-99285 (EMERGENCY DEPARTMENT VISIT) OR
99291 (CRITICAL CARE) (NOTE: CODE 99292 EXCLUDED BECAUSE UTILIZED TO REPORT FOR EACH ADDITIONAL 15 MINUTES OF CARE) OR
99295-99298 (NEONATAL INTENSIVE CARE) OR
99301-99315 (NURSING FACILITY CHARGES) OR
99321-99333 (DOMICILIARY, REST HOME, OR CUSTODIAL CARE SERVICES) OR
99341-99350 (HOME SERVICES) OR
99354 (PROLONGED SERVICES) (NOTE: CODE 99355 EXCLUDED BECAUSE UTILIZED TO REPORT FOR EACH ADDITIONAL 30 MINUTES OF CARE) OR
99356 (PROLONGED SERVICES) (NOTE: CODE 99357 EXCLUDED BECAUSE UTILIZED TO REPORT FOR EACH ADDITIONAL 30 MINUTES OF CARE) OR
99361-99373 (CASE MANAGEMENT SERVICES) OR
99374-99380 (CARE PLAN OVERSIGHT) OR
99381-99429 (PREVENTIVE MEDICINE SERVICES) OR
99431-99440 (NEWBORN CARE) OR
99450-99456 (SPECIAL EVALUATION AND MANAGEMENT SERVICES)
THEN NUMBER OF SERVICES PER PROCEDURE CODE ON A LINE ITEM CANNOT EXCEED THREE PER DAY
UNLESS ANY OCCURRENCE OF OVERRIDE CODE =
NS
CONTRACTOR HAS DETERMINED THAT NUMBER OF SERVICES IS MEDICALLY NECESSARY
2-175-04R1
•  MEDICAL PROCEDURE CODES
IF AMOUNT ALLOWED BY PROCEDURE CODE > ZERO
AND PROCEDURE CODE =
99500-99512 (HOME HEALTH VISIT) OR
99551-99568 (HOME INFUSION PER DIEM CODES)
THEN NUMBER OF SERVICES PER PROCEDURE CODE ON A LINE ITEM CANNOT EXCEED THREE PER DAY
UNLESS ANY OCCURRENCE OF OVERRIDE CODE =
NS
CONTRACTOR HAS DETERMINED THAT NUMBER OF SERVICES IS MEDICALLY NECESSARY
2-175-06R1
•  VACCINES (VACCINE PRODUCT ONLY) PROCEDURE CODES
IF AMOUNT ALLOWED BY PROCEDURE CODE > ZERO
AND PROCEDURE CODE =
90476-90479 (VACCINES, TOXOIDS)
THEN NUMBER OF SERVICES PER PROCEDURE CODE ON A LINE ITEM CANNOT EXCEED THREE PER DAY
UNLESS ANY OCCURRENCE OF OVERRIDE CODE =
NS
CONTRACTOR HAS DETERMINED THAT NUMBER OF SERVICES IS MEDICALLY NECESSARY
2-175-07R2
IF AMOUNT ALLOWED BY PROCEDURE CODE = ZERO
OR PRICING RATE CODE =
P1
OPPS OR
P2
OPPS WITH COST OUTLIER OR
P3
OPPS WITH DISCOUNT OR
P5
HOSPITAL-BASED PARTIAL HOSPITALIZATION PAID AS OPPS
OR NO OCCURRENCE OF SPECIAL PROCESSING CODE =
T
MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
FS
TFL (SECOND PAYOR)
THEN BYPASS THIS EDIT
ELSE NUMBER OF SERVICES CANNOT EXCEED THE MAXIMUM ALLOWED NUMBER OF SERVICES PER DAY FOR THE PROCEDURE CODE ON THIS LINE ITEM3 (BEGIN DATE OF CARE MUST BE ON OR AFTER THE MAXIMUM NUMBER OF SERVICES TABLE EFFECTIVE DATE AND NOT LATER THAN THE MAXIMUM NUMBER OF SERVICES TABLE TERMINATION DATE)
UNLESS ANY OCCURRENCE OF OVERRIDE CODE =
NS
CONTRACTOR HAS DETERMINED THAT NUMBER OF SERVICES IS MEDICALLY NECESSARY
ELEMENT NAME:  AMOUNT BILLED BY PROCEDURE CODE (2-180)
VALIDITY EDITS
2-180-01V
MUST BE NUMERIC.
2-180-02V
IF CONTRACT NUMBER =
MDA906-02-C-0013 (TMOP)
THEN IF PROCEDURE CODE =
000MN
PRESCRIPTION MEDICAL NECESSITY REVIEWS OR
000PA
PRESCRIPTION PRIOR AUTHORIZATIONS
THEN AMOUNT BILLED BY PROCEDURE CODE MUST > ZERO
ELSE IF TYPE OF SUBMISSION =
C
COMPLETE CANCELLATION TO TED RECORD DATA
OR ADJUSTMENT/DENIAL REASON CODE IS A DENIAL REASON CODE LISTED IN Addendum G, Figure 2.G-1 FOR THAT OCCURRENCE/LINE ITEM
THEN AMOUNT BILLED BY PROCEDURE CODE MUST = ZERO
AND AMOUNT ALLOWED BY PROCEDURE CODE MUST = ZERO
AND AMOUNT PAID BY OHI MUST = ZERO
AND AMOUNT PAID BY GOVERNMENT CONTRACTOR BY PROCEDURE CODE MUST = ZERO
AND AMOUNT PATIENT COST-SHARE MUST = ZERO
ELSE IF OCCURRENCE/LINE ITEM NUMBER = 002
THEN AMOUNT BILLED BY PROCEDURE CODE MUST = ZERO
ELSE AMOUNT BILLED BY PROCEDURE CODE MUST BE ≥ $10.20 AND ≤ $11.48
2-180-03V
IF CONTRACT NUMBER =
MDA906-02-C-0013 (TMOP)
AND AMOUNT BILLED BY PROCEDURE CODE = ZERO
THEN TYPE OF SUBMISSION MUST =
C
COMPLETE CANCELLATION TO TED RECORD DATA
OR OCCURRENCE/LINE ITEM NUMBER MUST = 002
OR ADJUSTMENT/DENIAL REASON CODE MUST BE A DENIAL REASON CODE LISTED IN Addendum G, Figure 2.G-1 FOR THAT OCCURRENCE/LINE ITEM
Relational Edits
2-180-00R
IF TYPE OF SUBMISSION ≠
D
COMPLETE DENIAL
THEN TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT BILLED BY PROCEDURE CODE FOR THIS TED RECORD MUST NOT EXCEED DHA LIMIT OF $1,000,000.00
ELEMENT NAME:  AMOUNT ALLOWED BY PROCEDURE CODE (2-185)
VALIDITY EDITS
2-185-01V
MUST BE NUMERIC.
Relational Edits
2-185-00R
TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT ALLOWED BY PROCEDURE CODE FOR THIS TED RECORD EXCEEDS DHA LIMIT OF $1,000,000.00.
2-185-01R
IF TYPE OF SUBMISSION =
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL
THEN AMOUNT ALLOWED BY PROCEDURE CODE MUST = ZERO FOR ALL OCCURRENCES/LINE ITEMS
2-185-02R
IF PRICING RATE CODE =
b
NO SPECIAL RATE OR
D
DISCOUNT RATE OR
V
MEDICARE REIMBURSEMENT RATE
AND NO OCCURRENCE OF SPECIAL PROCESSING CODE =
T
MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
FS
TFL (SECOND PAYOR) OR
16
AMBULATORY SURGERY FACILITY CHARGE
AND TYPE OF SUBMISSION =
A
ADJUSTMENT OR
I
INITIAL SUBMISSION OR
O
ZERO PAYMENT WITH 100% OHI/TPL OR
R
RESUBMISSION
THEN AMOUNT ALLOWED BY PROCEDURE CODE MUST BE ≤ AMOUNT BILLED BY PROCEDURE CODE FOR EACH OCCURRENCE/LINE ITEM
2-185-03R
IF PRICING RATE CODE =
4
PAID AS BILLED OR
I
CLAIM AUDITING SOFTWARE-ADDED PROCEDURE, PAID AS BILLED
AND TYPE OF SUBMISSION =
A
ADJUSTMENT OR
I
INITIAL SUBMISSION OR
O
ZERO PAYMENT WITH 100% OHI/TPL OR
R
RESUBMISSION
THEN AMOUNT ALLOWED BY PROCEDURE CODE MUST BE = AMOUNT BILLED BY PROCEDURE CODE
2-185-04R
IF AMOUNT ALLOWED BY PROCEDURE CODE = ZERO
THEN ADJUSTMENT/DENIAL REASON CODE FOR THAT OCCURRENCE/LINE ITEM MUST BE A CODE LISTED IN Addendum G, Figure 2.G-1 OR Figure 2.G-2.
UNLESS TYPE OF SUBMISSION =
B
ADJUSTMENT NON-TED DATA (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
2-185-05R
IF TYPE OF SUBMISSION =
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
THEN AMOUNT ALLOWED BY PROCEDURE CODE ≤ ZERO
2-185-06R
IF AMOUNT ALLOWED BY PROCEDURE CODE > ZERO
THEN TYPE OF SUBMISSION MUST =
A
ADJUSTMENT OR
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
I
INITIAL SUBMISSION OR
O
ZERO PAYMENT WITH 100% OHI/TPL OR
R
RESUBMISSION
2-185-07R
IF AMOUNT ALLOWED BY PROCEDURE CODE = ZERO
THEN AMOUNT PAID BY GOVERNMENT CONTRACTOR BY PROCEDURE CODE MUST = ZERO
UNLESS TYPE OF SUBMISSION =
B
ADJUSTMENT NON-TED DATA (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
ELEMENT NAME:  AMOUNT PAID BY OTHER HEALTH INSURANCE (2-190)
VALIDITY EDITS
2-190-01V
MUST BE NUMERIC.
Relational Edits
2-190-00R
TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT PAID BY OTHER HEALTH INSURANCE FOR THIS TED RECORD EXCEEDS DHA LIMIT OF $1,000,000.00.
2-190-01R
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 PAID BY OTHER HEALTH INSURANCE MUST BE ≥ ZERO.
ELEMENT NAME:  OTHER GOVERNMENT PROGRAM (OGP) TYPE CODE (2-191)
VALIDITY EDITS
2-191-01V
MUST BE A VALID OGP TYPE CODE LISTING IN Section 2.6.
Relational Edits
2-191-01R
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 (2-192)
VALIDITY EDITS
2-192-01V
MUST BE A VALID OGP BEGIN REASON CODE LISTING IN Section 2.6.
Relational Edits
NONE
ELEMENT NAME:  AMOUNT APPLIED TOWARD DEDUCTIBLE (2-195)
VALIDITY EDITS
2-195-01V
MUST BE NUMERIC.
Relational Edits
2-195-00R
TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT APPLIED TOWARD DEDUCTIBLE FOR THIS TED RECORD EXCEEDS DHA LIMIT OF $1,000,000.00.
2-195-01R
IF TYPE OF SUBMISSION =
A
ADJUSTMENT OR
I
INITIAL SUBMISSION OR
O
ZERO PAYMENT WITH 100% OHI/TPL OR
R
RESUBMISSION
THEN AMOUNT APPLIED TOWARD DEDUCTIBLE MUST BE ≥ ZERO
2-195-02R
IF TYPE OF SUBMISSION =
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL
THEN AMOUNT APPLIED TOWARD DEDUCTIBLE MUST BE = ZERO
2-195-03R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
NE
OPERATION NOBLE EAGLE/OPERATION ENDURING FREEDOM DEMONSTRATION
AND BEGIN DATE OF CARE ≥ 09/14/2001 AND < 11/01/2008
AND ENROLLMENT/HEALTH PLAN CODE =
T
TRICARE STANDARD PROGRAM OR
V
TRICARE EXTRA
THEN AMOUNT APPLIED TOWARD DEDUCTIBLE MUST = ZERO
2-195-04R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
DE
TDRL PHYSICAL EXAMS OR
PF
ECHO
THEN AMOUNT APPLIED TOWARD DEDUCTIBLE MUST = ZERO
- END -

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