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TRICARE Systems Manual 7950.3-M, April 1, 2015
TRICARE Encounter Data (TED)
Chapter 2
Section 6.3
Non-Institutional Edit Requirements (ELN 200 - 299)
Revision:  C-21, January 31, 2019
ELEMENT NAME:  AMOUNT PATIENT COST-SHARE (2-200)
VALIDITY EDITS
2-200-01V
MUST BE NUMERIC.
Relational Edits
2-200-00R
TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT PATIENT COST-SHARE FOR THIS TED RECORD EXCEEDS DHA LIMIT OF $1,000,000.00.
2-200-01R
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
2-200-02R
IF TYPE OF SUBMISSION =
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL
THEN AMOUNT PATIENT COST-SHARE MUST BE = ZERO
2-200-03R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
DE
TDRL PHYSICAL EXAMS
THEN AMOUNT PATIENT COST-SHARE MUST BE = ZERO
ELEMENT NAME:  HEALTH CARE COVERAGE (HCC) COPAYMENT FACTOR CODE (2-201)
VALIDITY EDITS
2-201-01V
MUST BE A VALID HCC COPAYMENT FACTOR CODE LISTED IN Section 2.5.
Relational Edits
NONE
ELEMENT NAME:  AMOUNT PAID BY GOVERNMENT CONTRACTOR BY PROCEDURE CODE (2-205)
VALIDITY EDITS
2-205-01V
MUST BE NUMERIC.
Relational Edits
2-205-00R
TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT PAID BY GOVERNMENT CONTRACTOR BY PROCEDURE CODE FOR THIS TED RECORD EXCEEDS DHA LIMIT OF $1,000,000.00.
2-205-01R
IF TYPE OF SUBMISSION =
A
ADJUSTMENT OR
I
INITIAL SUBMISSION OR
O
ZERO PAYMENT WITH 100% OHI/TPL OR
R
RESUBMISSION
THEN AMOUNT PAID BY GOVERNMENT CONTRACTOR BY PROCEDURE CODE MUST BE ≥ ZERO
2-205-02R
IF TYPE OF SUBMISSION =
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL
THEN AMOUNT PAID BY GOVERNMENT CONTRACTOR BY PROCEDURE CODE MUST BE = ZERO
ELEMENT NAME:  ADJUSTMENT/DENIAL REASON CODE (2-220)
VALIDITY EDITS
2-220-01V
VALUE MUST BE A VALID ADJUSTMENT/DENIAL REASON CODE (REFER TO Addendum G).
Relational Edits
2-220-01R
IF TYPE OF SUBMISSION =
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL
THEN ALL OCCURRENCES/LINE ITEMS MUST CONTAIN AN ADJUSTMENT/DENIAL REASON CODE LISTED IN Addendum G, Figure 2.G-1 OR Figure 2.G-2
2-220-02R
IF ADJUSTMENT/DENIAL REASON CODE IS A DENIAL REASON CODE LISTED IN Addendum G, Figure 2.G-1, FOR THAT OCCURRENCE/LINE ITEM
AND 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 ALLOWED BY PROCEDURE CODE MUST = ZERO
2-220-03R
IF TYPE OF SUBMISSION =
B
ADJUSTMENT TO NON-TED (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
AND ADJUSTMENT/DENIAL REASON CODE IS A DENIAL REASON CODE LISTED IN Addendum G, Figure 2.G-1, FOR THAT OCCURRENCE/LINE ITEM
THEN AMOUNT ALLOWED BY PROCEDURE CODE MUST BE ≤ ZERO
ELEMENT NAME:  PROVIDER INDIVIDUAL NPI NUMBER (TYPE 1) (2-225)
VALIDITY EDITS
2-225-01V
MUST BE ALL BLANKS OR 10 DIGITS (MUST NOT BE ALL ZEROES)
2-225-02V
IF PROVIDER INDIVIDUAL NPI NUMBER IS ALL DIGITS
THEN THE CHECK DIGIT (POSITION 10 OF THE PROVIDER ORGANIZATIONAL NPI NUMBER) MUST EQUAL THE VALUE COMPUTED USING LUHN FORMULA FOR MODULES 10 “DOUBLE-ADD-DOUBLE” CHECK DIGIT ALGORITHM
Relational Edits
NONE
ELEMENT NAME:  PROVIDER ORGANIZATIONAL NPI NUMBER (TYPE 2) (2-230)
VALIDITY EDITS
2-230-01V
MUST BE ALL BLANKS OR 10 DIGITS (MUST NOT BE ALL ZEROES)
2-230-02V
IF PROVIDER ORGANIZATIONAL NPI NUMBER IS ALL DIGITS
THEN THE CHECK DIGIT (POSITION 10 OF THE PROVIDER ORGANIZATIONAL NPI NUMBER) MUST EQUAL THE VALUE COMPUTED USING LUHN FORMULA FOR MODULES 10 “DOUBLE-ADD-DOUBLE” CHECK DIGIT ALGORITHM
Relational Edits
NONE
ELEMENT NAME:  PROVIDER STATE OR COUNTRY CODE (2-235)
1  “CORRESPONDING RECORD” ON PROVIDER FILE IS BASED ON NON-INSTITUTIONAL PROVIDER TAXPAYER NUMBER, PROVIDER MAJOR SPECIALTY, PROVIDER SUB-IDENTIFIER, AND PROVIDER ZIP CODE. THIS IS ONLY DETERMINED ONCE A PROVIDER MATCH HAS BEEN OBTAINED (2-240-04R).
VALIDITY EDITS
2-235-01V
VALUE MUST BE A VALID STATE (REFER TO Addendum B)
OR COUNTRY CODE (REFER TO Addendum A).
Relational Edits
2-235-01R
PROVIDER STATE/COUNTRY CODE MUST MATCH THE CORRESPONDING RECORD1 IN THE PROVIDER FILE.
UNLESS AMOUNT ALLOWED BY PROCEDURE CODE IS ≤ 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., MEDICARE 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:  PROVIDER TAXPAYER NUMBER (2-240)
1  ONLY THE FIRST FIVE DIGITS OF THE PROVIDER ZIP CODE IS USED IN THE MATCH.
VALIDITY EDITS
2-240-01V
MUST BE NUMERIC
OR (FIRST THREE POSITIONS MUST BE A VALID STATE/COUNTRY CODE
AND LAST SIX POSITIONS MUST BE NUMERIC)
OR (FIRST THREE POSITIONS MUST BE A VALID STATE/COUNTRY CODE
AND FOURTH POSITION MUST BE = A
AND LAST 5 POSITIONS MUST BE NUMERIC)
Relational Edits
NO ERROR
IF 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
THEN DO NOT CHECK FOR MATCH ON PROVIDER FILE FOR THAT PROVIDER
NO ERROR
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE FOR THAT OCCURRENCE =
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., MEDICARE 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 FOR THAT PROVIDER
NO ERROR
IF AMOUNT ALLOWED BY PROCEDURE CODE ≤ ZERO
THEN DO NOT CHECK PROVIDER FILE FOR THAT PROVIDER
NO ERROR
IF PROVIDER SPECIALTY =
172A00000X (OTHER SERVICE PROVIDERS/DRIVER) OR
344600000X (TRANSPORTATION SERVICES/TAXI)
THEN DO NOT CHECK PROVIDER FILE FOR THAT PROVIDER
2-240-02R
IF PROVIDER TAXPAYER NUMBER IS ALL NINES
THEN PROVIDER SPECIALTY MUST =
172A00000X (OTHER SERVICE PROVIDERS/DRIVER) OR
344600000X (TRANSPORTATION SERVICES/TAXI)
AND PROVIDER PARTICIPATION INDICATOR MUST =
N
NO
2-240-04R
IF ANY OCCURRENCE OF OVERRIDE CODE =
NC
NON-CERTIFIED PROVIDER
THEN THE NON-CERTIFIED PROVIDER MUST MATCH THE PROVIDER ON THE PROVIDER FILE USING THE FOLLOWING:
NON-INSTITUTIONAL PROVIDER TAXPAYER NUMBER
AND PROVIDER MAJOR SPECIALITY
AND PROVIDER ZIP CODE1
AND PROVIDER SUB-IDENTIFIER
AND ACCEPTANCE AND TERMINATION DATES MUST = ZEROES
AND PROVIDER CONTRACT AFFILIATION CODE MUST = 5 (NON-CERTIFIED PROVIDER)
IF NO OCCURRENCE OF OVERRIDE CODE =
NC
NON-CERTIFIED PROVIDER
THEN THE CERTIFIED PROVIDER MUST MATCH THE PROVIDER ON THE PROVIDER FILE USING THE FOLLOWING:
NON-INSTITUTIONAL PROVIDER TAXPAYER NUMBER
AND PROVIDER MAJOR SPECIALTY
AND PROVIDER ZIP CODE1
AND PROVIDER SUB-IDENTIFIER
ELEMENT NAME:  PROVIDER SUB-IDENTIFIER (2-245)
VALIDITY EDITS
2-245-01V
MUST BE FOUR CHARACTERS
FIRST CHARACTER ALPHANUMERIC, LAST THREE CHARACTERS NUMERIC
OR FIRST TWO CHARACTERS ALPHANUMERIC, LAST TWO CHARACTERS NUMERIC
OR ALL FOUR NUMERIC
Relational Edits
NONE
ELEMENT NAME:  PROVIDER ZIP CODE (2-250)
1  WHEN FOREIGN COUNTRY CODES ARE SUBMITTED, THE FIRST THREE CHARACTERS WILL BE EDITED AGAINST Addendum A.
VALIDITY EDITS
2-250-01V
MUST BE NINE DIGITS OR FIVE DIGITS WITH FOUR BLANKS
MUST BE A VALID ZIP CODE (BASED ON BEGIN DATE OF CARE) 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:  PROVIDER TAXONOMY (SPECIALTY) (2-255)
VALIDITY EDITS
2-255-01V
THIS FIELD MUST BE A VALID PROVIDER SPECIALTY (REFER TO HTTP://WWW.WPC-EDI.COM/REFERENCE/).
Relational Edits
2-255-03R
IF PROVIDER SPECIALTY =
333600000X (SUPPLIERS/PHARMACY)
THEN TYPE OF SERVICE (SECOND POSITION) =
B
RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
2-255-04R
IF PROVIDER SPECIALTY =
183500000X (PHARMACY SERVICE PROVIDERS/PHARMACIST)
THEN TYPE OF SERVICE (SECOND POSITION) =
M
MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
ELEMENT NAME:  PROVIDER PARTICIPATION INDICATOR (2-260)
VALIDITY EDITS
2-260-01V
MUST BE A VALID PROVIDER PARTICIPATION INDICATOR.
Relational Edits
NONE
ELEMENT NAME:  PROVIDER NETWORK STATUS INDICATOR (2-265)
VALIDITY EDITS
2-265-01V
PROVIDER NETWORK STATUS INDICATOR MUST =
1
NETWORK PROVIDER OR
2
NON-NETWORK PROVIDER
Relational Edits
NONE
ELEMENT NAME:  PHYSICIAN REFERRAL NUMBER (2-270)
VALIDITY EDITS
2-270-01V
MUST BE ALL BLANKS
OR 9 CHARACTERS (INCLUDING IMBEDDED BLANKS)
OR 13 CHARACTERS (INCLUDING IMBEDDED BLANKS)
OR 10 CHARACTERS
2-270-02V
IF PHYSICIAN REFERRAL NUMBERS IS 10 CHARACTERS
THEN THE 10 CHARACTERS MUST BE ALL NUMBERIC
AND THE CHECK DIGIT (POSITION 10 OF THE PHYSICIAN REFERRAL NUMBER) MUST EQUAL THE VALUE COMPUTED USING LUHN FORMULA FOR MODULES 10 “DOUBLE-ADD-DOUBLE” CHECK DIGIT ALGORITHM
Relational Edits
NONE
ELEMENT NAME:  PLACE OF SERVICE (2-275)
VALIDITY EDITS
2-275-01V
VALUE MUST BE A VALID PLACE OF SERVICE.
Relational Edits
2-275-01R
IF ADJUSTMENT/DENIAL REASON CODE IS NOT A CODE LISTED IN Addendum G, Figure 2.G-2.
THEN PLACE OF SERVICE MUST BE CONSISTENT WITH TYPE OF SERVICE, REFER TO Addendum F.
2-275-06R
IF PLACE OF SERVICE =
21
INPATIENT HOSPITAL
THEN TYPE OF SERVICE (FIRST POSITION) MUST =
I
INPATIENT
ELEMENT NAME:  TYPE OF SERVICE (2-280)
VALIDITY EDITS
2-280-01V
FIRST POSITION MUST BE = A, I, K, M, N, O, OR P.
SECOND POSITION MUST BE = 1-9; A-M.
IF FIRST POSITION = A; SECOND POSITION MUST ≠ C.
IF FIRST POSITION = P; SECOND POSITION MUST = H.
IF FIRST POSITION = N; SECOND POSITION MUST = I.
Relational Edits
2-280-07R
IF TYPE OF SERVICE (FIRST POSITION) =
A
AMBULATORY SURGERY COST-SHARED AS INPATIENT (ACTIVE DUTY DEPENDENTS ONLY) OR
M
OUTPATIENT MATERNITY COST-SHARED AS INPATIENT OR
N
OUTPATIENT COST-SHARED AS INPATIENT OR
O
OUTPATIENT, EXCLUDING M, N, OR P OR
P
OUTPATIENT PARTIAL PSYCHIATRIC HOSPITALIZATION COST-SHARED AS INPATIENT
THEN PLACE OF SERVICE CANNOT =
21
INPATIENT HOSPITAL
2-280-08R
IF TYPE OF SERVICE (SECOND POSITION) =
B
RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
THEN NATIONAL DRUG CODE MUST ≠ BLANK
UNLESS PROVIDER STATE OR COUNTRY CODE IS A FOREIGN COUNTRY CODE (Addendum A)
2-280-09R
IF TYPE OF SERVICE (SECOND POSITION) =
M
MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
THEN TYPE OF SUBMISSION MUST ≠
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
AND CA/NAS EXCEPTION REASON MUST = BLANK
AND CA/NAS NUMBER MUST = BLANK
AND CA/NAS REASON FOR ISSUANCE MUST = BLANK
AND NATIONAL DRUG CODE MUST ≠ BLANK
AND IF BEGIN DATE OF CARE < 01/01/2016
THEN PLACE OF SERVICE MUST =
19
PHARMACY
ELSE PLACE OF SERVICE MUST =
01
PHARMACY
AND PRICING RATE CODE MUST = 0
AND PROVIDER NETWORK STATUS INDICATOR MUST =
1
NETWORK PROVIDER
AND PROVIDER PARTICIPATING INDICATOR MUST =
Y
YES
AND PROVIDER SPECIALTY MUST =
183500000X (PHARMACY SERVICE PROVIDERS/PHARMACIST)
AND IF PROCEDURE CODE =
000MN
PRESCRIPTION MEDICAL NECESSITY REVIEWS OR
000PA
PRESCRIPTION PRIOR AUTHORIZATIONS
THEN AMOUNT PATIENT COST-SHARE MUST = ZERO
AND CLAIM FORM TYPE/EMC INDICATOR MUST =
J
OTHER
ELSE IF OCCURRENCE/LINE ITEM NUMBER = 002
THEN AMOUNT BILLED BY PROCEDURE CODE ON THIS LINE ITEM MUST = ZERO
AND AMOUNT PATIENT COST-SHARE ON THIS LINE ITEM MUST = ZERO
AND NUMBER OF SERVICES ON THIS LINE ITEM MUST = ZERO
ELSE CLAIM FORM TYPE/EMC INDICATOR MUST =
I
ELECTRONIC DRUG CLAIM SUBMISSION
AND NUMBER OF SERVICES = 1
2-280-10R
IF TYPE OF SERVICE (SECOND POSITION) =
B
RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS OR
M
MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
THEN REGION INDICATOR MUST = BLANK
UNLESS PROVIDER STATE OR COUNTRY CODE IS A FOREIGN COUNTRY CODE (Addendum A)
2-280-11R
IF TYPE OF SERVICE (SECOND POSITION) =
M
MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
AND OCCURRENCE/LINE ITEM COUNT = 002
THEN PROCEDURE CODE MUST =
99070
SUPPLIES
2-280-12R
IF TYPE OF SERVICE (SECOND POSITION) =
G
DENTAL
THEN PROCEDURE CODE ≠ 00100 - 09999
2-280-13R
IF TYPE OF SERVICE (SECOND POSITION) =
B
RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS OR
M
MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
AND CLAIM FORM TYPE/EMC INDICATOR =
J
OTHER
THEN PROCEDURE CODE MUST =
000MN
PRESCRIPTION MEDICAL NECESSITY REVIEWS OR
000PA
PRESCRIPTION PRIOR AUTHORIZATIONS
ELEMENT NAME:  HEALTH CARE COVERAGE (HCC) MEMBER CATEGORY CODE (2-285)
VALIDITY EDITS
2-285-01V
MUST BE A VALID HCC MEMBER CATEGORY CODE (REFER TO Section 2.5)
Relational Edits
2-285-01R
IF HCC MEMBER RELATIONSHIP CODE =
A
SELF
THEN HCC MEMBER CATEGORY MUST ≠
A
ACTIVE DUTY OR
G
NATIONAL GUARD MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
J
ACADEMY STUDENT OR
N
NATIONAL GUARD (NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS) OR
S
RESERVE MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
T
FOREIGN MILITARY MEMBER OR
V
RESERVE MEMBER (NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS)
UNLESS ENROLLMENT/HEALTH PLAN CODE =
W
TPR SERVICE MEMBER - USA OR
X
FOREIGN SERVICE MEMBER OR
Y
CHCBP - NON-NETWORK OR
AA
CHCBP - NETWORK OR
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 OR
SU
SHCP - REFERRAL DESIGNATION UNKNOWN OR
WA
TPR FOREIGN SERVICE MEMBER
OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
SC
SHCP - NON-TRICARE ELIGIBLE OR
SE
SHCP - TRICARE ELIGIBLE OR
SM
SHCP - EMERGENCY
OR 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
2-285-02R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
PF
ECHO
THEN HHC MEMBER CATEGORY CODE MUST =
A
ACTIVE DUTY OR
G
NATIONAL GUARD MEMBER (MOBILIZED OR ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
J
ACADEMY STUDENT OR
P
TAMP MEMBER OR
S
RESERVE MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE)
2-285-03R
IF TYPE OF SERVICE (FIRST POSITION) =
A
AMBULATORY SURGERY COST-SHARED AS INPATIENT
THEN HCC MEMBER CATEGORY CODE MUST =
A
ACTIVE DUTY OR
G
NATIONAL GUARD MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
J
ACADEMY STUDENT OR
N
NATIONAL GUARD MEMBER (NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS) OR
P
TAMP MEMBER OR
S
RESERVE MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
T
FOREIGN MILITARY MEMBER OR
V
RESERVE MEMBER (NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS) OR
Z
UNKNOWN
UNLESS AMOUNT ALLOWED BY PROCEDURE CODE = 0
2-285-04R
IF 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 FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
205
TDP INDIVIDUAL COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
206
TDP FAMILY COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPNSORS OR
212
TDP INDIVIDUAL COVERAGE FOR SURVIVORS OF SELECTED RESERVE (SelRes) DECEASED SPONSORS OR
213
TDP FAMILY COVERAGE FOR SURVIVORS OF SELECTED RESERVE (SelRes) DECEASED SPONSORS OR
306
TRICARE SELECT - RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR
345
TRICARE PLUS - DIRECT CARE ONLY (PRESENTATION LAYER) OR
346
TRICARE PLUS OR
409
RESERVE SELECT SURVIVOR CONTINUING WITH INDIVIDUAL COVERAGE OR
410
RESERVE SELECT SURVIVOR CONTINUING WITH FAMILY COVERAGE OR
411
RESERVE SELECT SURVIVOR NEW INDIVIDUAL COVERAGE OR
412
RESERVE SELECT SURVIVOR NEW FAMILY COVERAGE
OR ENROLLMENT/HEALTH PLAN CODE =
AS
TRICARE SELECT - ACTIVE DUTY SURVIVORS OR
GS
TRICARE SELECT - GUARD/RESERVE SURVIVORS
OR AMOUNT ALLOWED BY PROCEDURE CODE = 0
THEN BYPASS THIS EDIT
ELSE IF TYPE OF SERVICE (SECOND POSITION) =
C
AMBULATORY SURGERY
THEN HCC MEMBER CATEGORY CODE MUST =
D
DISABLED AMERICAN VETERAN OR
F
FORMER MEMBER OR
H
MOH RECIPIENT OR
R
RETIRED OR
W
FORMER SPOUSE OR
Z
UNKNOWN
2-285-05R
IF HCC MEMBER CATEGORY CODE =
T
FOREIGN MILITARY MEMBER
THEN ONE OCCURRENCE OF OVERRIDE CODE =
M
NATO
ELEMENT NAME:  PAY GRADE CODE (SPONSOR) (2-291)
VALIDITY EDITS
2-291-01V
MUST BE A VALID PAY GRADE CODE (SPONSOR) (REFER TO Section 2.7)
Relational Edits
NONE
ELEMENT NAME:  PAY PLAN CODE (SPONSOR) (2-292)
VALIDITY EDITS
2-292-01V
MUST BE A VALID PAY PLAN CODE (SPONSOR) (REFER TO Addendum K)
Relational Edits
NONE
ELEMENT NAME:  HEALTH CARE COVERAGE (HCC) MEMBER RELATIONSHIP CODE (2-295)
1  PATIENT AGE IS CALCULATED BASED ON PERSON BIRTH CALENDAR DATE (PATIENT) AND BEGIN CARE DATE.
VALIDITY EDITS
2-295-01V
MUST BE A VALID HCC MEMBER RELATIONSHIP CODE (REFER TO Section 2.5)
Relational Edits
2-295-06R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
PF
ECHO
THEN HCC MEMBER RELATIONSHIP CODE MUST =
A
SELF OR
B
SPOUSE OR
C
CHILD OR STEPCHILD OR
D
PRE-ADOPTIVE CHILD OR
E
WARD (COURT ORDERED) OR
G
SURVIVING SPOUSE
2-295-07R
IF TYPE OF SERVICE (FIRST POSITION) =
A
AMBULATORY SURGERY COST-SHARED AS INPATIENT
THEN HCC MEMBER RELATIONSHIP CODE MUST =
A
SELF OR
B
SPOUSE OR
C
CHILD OR STEPCHILD OR
D
PRE-ADOPTIVE CHILD OR
E
WARD (COURT ORDERED) OR
G
SURVIVING SPOUSE OR
Z
UNKNOWN
AND HCC MEMBER CATEGORY CODE ≠
W
FORMER SPOUSE
UNLESS ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
SC
SHCP - NON-TRICARE ELIGIBLE
2-295-10R
IF HCC MEMBER CATEGORY CODE =
T
FOREIGN MILITARY MEMBER
AND HCC MEMBER RELATIONSHIP CODE =
A
SELF
THEN ANY OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
AN
SHCP - NON-REFERRED CARE OR
AR
SHCP - MTF/eMSM REFERRED CARE OR
SC
SHCP - NON-TRICARE ELIGIBLE OR
SM
SHCP - EMERGENCY
OR ENROLLMENT/HEALTH PLAN CODE MUST =
SN
SHCP - NON-MTF/eMSM REFERRED OR
SO
SHCP - NON-TRICARE ELIGIBLE OR
SR
SHCP - REFERRED OR
SU
SHCP - REFERRAL DESIGNATION UNKNOWN
UNLESS AMOUNT ALLOWED BY PROCEDURE CODE = ZERO
THEN BYPASS THIS EDIT
- END -

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