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TRICARE Systems Manual 7950.3-M, April 1, 2015
TRICARE Encounter Data (TED)
Chapter 2
Section 7.2
Provider Edit Requirements (ELN 100 - 199)
Revision:  
ELEMENT NAME:  AMERICAN HOSPITAL ASSOCIATION ID NUMBER (3-100)
VALIDITY EDITS
3-100-01V
MUST BE LEFT JUSTIFIED AND BLANK FILLED
OR BLANK.
Relational Edits
3-100-01R
IF INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR =
N
NON-INSTITUTIONAL
THEN AMERICAN HOSPITAL ASSOCIATION (AHA) ID NUMBER MUST= BLANK.
ELEMENT NAME:  AHA MULTI-HOSPITAL SYSTEM CODE (3-105)
VALIDITY EDITS
3-105-01V
MUST BE NUMERIC OR BLANK.
Relational Edits
3-105-01R
IF INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR =
N
NON-INSTITUTIONAL
THEN AHA MULTI-SYSTEM CODE MUST = BLANK.
ELEMENT NAME:  MEDICARE NUMBER (3-110)
VALIDITY EDITS
3-110-01V
FIRST TWO DIGITS MUST BE VALID MEDICARE STATE CODE, IF PRESENT (REFER TO Addendum B, Figure 2.B-2)
THIRD DIGIT MUST BE ONE OF THE FOLLOWING MEDICARE TYPE OF INSTITUTION CODES: S, T, U, W, Y, Z, 0, 1, 2, 3, 4, 5, 6, 7, 8, 9
DIGITS FOUR THROUGH SIX MUST BE NUMERIC
Relational Edits
3-110-01R
IF PROVIDER STATE/COUNTRY CODE (THIRD POSITION) IS NOT BLANK
AND PROVIDER STATE/COUNTRY CODE ≠
PRI
PUERTO RICO
THEN MEDICARE NUMBER MUST = BLANK.
3-110-02R
IF INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR =
N
NON-INSTITUTIONAL
THEN MEDICARE NUMBER MUST = BLANK.
3-110-03R
IF DRG EXEMPT/NON-EXEMPT INDICATOR =
N
DRG NON-EXEMPT
THEN MEDICARE NUMBER CANNOT = BLANK.
ELEMENT NAME:  PROVIDER ACCEPTANCE DATE (3-115)
VALIDITY EDITS
3-115-01V
MUST BE A VALID GREGORIAN DATE OR ALL ZEROES AND CANNOT BE > DHA CURRENT SYSTEM DATE.
Relational Edits
3-115-01R
PROVIDER TERMINATION DATE ≥ PROVIDER ACCEPTANCE DATE
OR PROVIDER TERMINATION DATE = ZEROES
3-115-02R
IF PROVIDER ACCEPTANCE DATE = ZEROES
THEN PROVIDER TERMINATION DATE MUST = ZEROES
ELEMENT NAME:  PROVIDER TERMINATION DATE (3-120)
VALIDITY EDITS
3-120-01V
MUST BE A VALID GREGORIAN DATE OR ALL ZEROES.
Relational Edits
3-120-01R
PROVIDER ACCEPTANCE DATE ≤ PROVIDER TERMINATION DATE
ELEMENT NAME:  RURAL/URBAN INDICATOR (3-125)
VALIDITY EDITS
3-125-01V
MUST BE A VALID RURAL/URBAN INDICATOR.
Relational Edits
3-125-01R
IF THIRD POSITION OF PROVIDER STATE/COUNTRY CODE IS NOT BLANK
AND PROVIDER STATE/COUNTRY CODE ≠
PRI
PUERTO RICO
THEN RURAL/URBAN INDICATOR MUST = BLANK.
3-125-02R
IF DRG EXEMPT/NON-EXEMPT INDICATOR =
C
DRG NON-EXEMPT/CONTRACTOR REIMBURSEMENT ARRANGEMENT OR
N
DRG NON-EXEMPT
AND INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR =
I
INSTITUTIONAL
THEN RURAL/URBAN INDICATOR MUST =
L
LARGE URBAN OR
R
RURAL OR
U
URBAN
ELSE RURAL/URBAN INDICTOR MUST = BLANK
ELEMENT NAME:  IDME RATIO (3-130)
VALIDITY EDITS
3-130-01V
MUST BE NUMERIC.
Relational Edits
3-130-01R
IF INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR =
N
NON-INSTITUTIONAL
THEN IDME RATIO MUST = ZEROES.
ELEMENT NAME:  IDME RATIO EFFECTIVE DATE (3-135)
VALIDITY EDITS
3-135-01V
MUST BE A VALID GREGORIAN DATE OR ALL ZEROES.
Relational Edits
3-135-01R
IF IDME RATIO = ZEROES
THEN IDME RATIO EFFECTIVE DATE MUST = ZEROES
ELEMENT NAME:  AREA WAGE INDEX (3-140)
VALIDITY EDITS
3-140-01V
MUST BE NUMERIC.
Relational Edits
3-140-01R
IF INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR =
N
NON-INSTITUTIONAL
THEN AREA WAGE INDEX MUST = ZEROES.
3-140-02R
IF DRG EXEMPT/NON-EXEMPT INDICATOR =
N
DRG NON-EXEMPT
THEN AREA WAGE INDEX MUST ≠ ZEROES.
ELEMENT NAME:  AREA WAGE INDEX EFFECTIVE DATE (3-145)
VALIDITY EDITS
3-145-01V
MUST BE A VALID GREGORIAN DATE OR ALL ZEROES AND CANNOT BE > DHA CURRENT SYSTEM DATE.
Relational Edits
3-145-01R
IF AREA WAGE INDEX = ZEROES
THEN EFFECTIVE DATE MUST = ZEROES
ELEMENT NAME:  DRG EXEMPT/NON-EXEMPT INDICATOR (3-150)
VALIDITY EDITS
3-150-01V
MUST BE A VALID DRG EXEMPT/NON-EXEMPT INDICATOR
Relational Edits
3-150-01R
IF INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR =
N
NON-INSTITUTIONAL
THEN DRG EXEMPT/NON-EXEMPT INDICATOR MUST BE BLANK.
3-150-02R
IF INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR =
I
INSTITUTIONAL
THEN DRG EXEMPT/NON-EXEMPT INDICATOR MUST NOT = BLANK.
3-150-03R
IF THIRD POSITION OF PROVIDER STATE/COUNTRY CODE IS NOT BLANK
AND PROVIDER STATE/COUNTRY CODE ≠
PRI
PUERTO RICO
AND INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR =
I
INSTITUTIONAL
THEN DRG INDICATOR MUST =
E
DRG EXEMPT
3-150-04R
IF INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR =
I
INSTITUTIONAL
AND PROVIDER STATE/COUNTRY CODE =
MD
MARYLAND
THEN DRG EXEMPT/NON-EXEMPT INDICATOR MUST =
E
DRG EXEMPT
3-150-05R
IF DRG EXEMPT/NON-EXEMPT INDICATOR =
C
DRG NON-EXEMPT/CONTRACTED REIMBURSEMENT ARRANGEMENT OR
N
DRG NON-EXEMPT
AND INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR =
I
INSTITUTIONAL
THEN PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION MUST = DRG NON-EXEMPT TYPE OF INSTITUTION (REFER TO Addendum D).
ELEMENT NAME:  DRG EXEMPT/NON-EXEMPT EFFECTIVE DATE (3-155)
VALIDITY EDITS
3-155-01V
MUST BE A VALID GREGORIAN DATE OR ALL ZEROES AND CANNOT BE > DHA CURRENT SYSTEM DATE.
Relational Edits
3-155-01R
IF DRG EXEMPT/NON-EXEMPT INDICATOR = BLANK
THEN DRG EXEMPT/NON-EXEMPT EFFECTIVE DATE MUST = ZEROES
ELEMENT NAME:  TRANSACTION CODE (3-160)
VALIDITY EDITS
3-160-01V
TRANSACTION CODE MUST =
A
ADD A RECORD OR
I
INACTIVATE A RECORD OR
M
MODIFY A RECORD
Relational Edits
3-160-01R
IF TRANSACTION CODE =
A
ADD A RECORD
AND INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR =
I
INSTITUTIONAL
THEN PROVIDER TAXPAYER NUMBER
AND PROVIDER SUB-IDENTIFIER
AND ZIP CODE (FIRST FIVE DIGITS)
AND PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION MUST NOT ALREADY EXIST ON THE PROVIDER FILE.
3-160-02R
IF TRANSACTION CODE =
A
ADD A RECORD
AND IF INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR =
N
NON-INSTITUTIONAL
THEN PROVIDER TAXPAYER NUMBER
AND PROVIDER SUB-IDENTIFIER
AND ZIP CODE (FIRST FIVE DIGITS)
MUST NOT ALREADY EXIST ON THE PROVIDER FILE.
3-160-03R
IF TRANSACTION CODE =
A
ADD A RECORD
AND INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR =
N
NON-INSTITUTIONAL
AND THE PROVIDER TAXPAYER NUMBER
AND ZIP CODE (FIRST FIVE DIGITS) ARE THE SAME AS AN EXISTING RECORD ON THE PROVIDER FILE,
AND THE FIRST CHARACTER OF THE PROVIDER SUB-IDENTIFIER IS ALPHABETIC, FOLLOWED BY A NUMBER OTHER THAN 001
THEN THE FIRST CHARACTER OF THE PROVIDER SUB-IDENTIFIER MUST MATCH AN EXISTING SUB-IDENTIFIER (WHICH ENDS IN 001) FOR THIS TAXPAYER NUMBER AND ZIP CODE (FIRST FIVE DIGITS) ON THE PROVIDER FILE. THIS LEADING ALPHA PREFIX MUST BE FOLLOWED BY THREE UNIQUE NUMERIC DIGITS
OR THE FIRST TWO CHARACTERS OF THE PROVIDER SUB-IDENTIFIER ARE ALPHABETIC, FOLLOWED BY A NUMBER OTHER THAN 01.
THEN THE FIRST TWO CHARACTERS OF THE PROVIDER SUB-IDENTIFIER MUST MATCH AN EXISTING SUB-IDENTIFIER (WHICH ENDS IN ‘01’) FOR THIS TAXPAYER NUMBER AND ZIP CODE ON THE PROVIDER FILE. THE ALPHA PREFIX MUST BE FOLLOWED BY TWO UNIQUE NUMERIC DIGITS.
3-160-06R
IF TRANSACTION CODE =
I
INACTIVATE A RECORD OR
M
MODIFY A RECORD
AND INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR =
I
INSTITUTIONAL
THEN AN ACTIVE PROVIDER RECORD MUST EXIST ON THE PROVIDER FILE FOR THE SAME PROVIDER TAXPAYER NUMBER, PROVIDER SUB-IDENTIFIER, PROVIDER ZIP CODE, AND PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION. (IN THE CASE OF FOREIGN COUNTRY, ZIP WILL BE BLANK; ANY DUPLICATES ADDED WILL HAVE TO BE ASSIGNED ANOTHER PROVIDER TAXPAYER NUMBER.)
3-160-07R
IF TRANSACTION CODE =
I
INACTIVATE A RECORD OR
M
MODIFY A RECORD
AND INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR =
N
NON-INSTITUTIONAL
THEN AN ACTIVE PROVIDER RECORD MUST EXIST ON THE PROVIDER FILE FOR THE SAME PROVIDER TAXPAYER NUMBER, PROVIDER SUB-IDENTIFIER, AND PROVIDER ZIP CODE (FIRST FIVE DIGITS).
3-160-08R
IF TRANSACTION CODE =
I
INACTIVATE A RECORD
AND INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR =
N
NON-INSTITUTIONAL
AND THE FIRST CHARACTER OF THE PROVIDER SUB-IDENTIFIER IS ALPHABETIC FOLLOWED BY 001 OR THE FIRST TWO CHARACTERS OF THE PROVIDER SUB-IDENTIFIER IS ALPHABETIC FOLLOWED BY 01.
THEN ALL ASSOCIATED RECORDS USING THE SAME PROVIDER TAXPAYER NUMBER AND PROVIDER ZIP CODE (FIRST FIVE DIGITS) AND THE SAME ONE OR TWO CHARACTER ALPHA PREFIX OF THE SUB-IDENTIFIER AND DIFFERENT NUMERIC SUFFIX OF THE SUB-IDENTIFIER MUST ALSO BE INACTIVATED.
ELEMENT NAME:  RECORD EFFECTIVE DATE (3-165)
VALIDITY EDITS
3-165-01V
MUST BE A VALID GREGORIAN DATE AND CANNOT BE > DHA CURRENT SYSTEM DATE.
Relational Edits
NONE
- END -

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