Chapter 2 Section 4.1. Header Edit Requirements (ELN )

Transcription

1 TRICARE Encounter Data (TED) Chapter 2 Section 4.1 Revision: ELEMENT NAME: HEADER TYPE INDICAT (0-001) V HEADER TYPE INDICAT MUST = 0 BATCH HEADER (USED ON ALL PROVIDER BATCHES, AND F INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN NON-ADMIN CLAIM RATE ELIGIBLE TED RECDS) 5 VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE 9 BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECDS) R IF HEADER TYPE INDICAT = 5 VOUCHER HEADER NON-ADMIN CLAIM RATE-ELIGIBLE R 6 VOUCHER HEADER ADMIN CLAIM RATE-ELIGIBLE 9 BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECDS) THEN BATCH/VOUCHER IDENTIFIER MUST = 5 INSTITUTIONAL/NON-INSTITUTIONAL (BATCH/ VOUCHER) IF CONTRACT NUMBER = H D-0001 THEN BYPASS THIS EDIT ELSE IF HEADER TYPE INDICAT = 5 VOUCHER HEADER NON-ADMIN CLAIM RATE-ELIGIBLE 6 VOUCHER HEADER ADMIN CLAIM RATE-ELIGIBLE AND TYPE OF SUBMISSION B ADJUSTMENT TO NON-TED RECD (HCSR) DATA E COMPLETE CANCELLATION OF NON-TED RECD (HCSR) DATA THEN ADJUSTMENT KEY MUST = 5 VOUCHER R IF HEADER TYPE INDICAT = 0 BATCH HEADER (USED ON ALL PROVIDER, PRICING BATCHES, AND F INSTITUTIONAL/NON- INSTITUTIONAL AT-RISK NON-ADMIN CLAIM RATE ELIGIBLE TED RECDS) IF THE FIRST POSITION OF EACH BATCH/VOUCHER HEADER RECD IS NOT A 0, 5, 6, 9. THEN THE ENTIRE BATCH/VOUCHER WILL BE REJECTED. 1

2 9 BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL AT-RISK ADMIN CLAIM RATE ELIGIBLE RED RECDS) AND TYPE OF SUBMISSION B ADJUSTMENT TO NON-TED RECD (HCSR) DATA E COMPLETE CANCELLATION OF NON-TED RECD (HCSR) DATA AND BATCH/VOUCHER IDENTIFIER = 5 INSTITUTIONAL/NON-INSTITUTIONAL THEN ADJUSTMENT KEY MUST = 0 BATCH R IF HEADER TYPE INDICAT = 5 VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE AND TYPE OF SUBMISSION = D COMPLETE DENIAL R HEADER TYPE INDICAT (0-001) (Continued) THEN AMOUNT INTEREST PAYMENT MUST = ZERO O ZERO PAYMENT TED RECD DUE TO 100% OHI AND F INSTITUTIONAL RECDS AMOUNT PAID BY GOVERNMENT CONTRACT (TOTAL) MUST = ZERO F NON-INSTITUTIONAL RECDS THE TOTAL OF ALL OCCURRENCES/LINE ITEMS OF AMOUNT PAID BY GOVERNMENT CONTRACT BY PROCEDURE CODE MUST = ZERO IF DRG NUMBER IS NOT BLANK TYPE OF INSTITUTION = 70 HHA THEN BYPASS THIS EDIT ELSE IF FILING DATE IS 03/01/2012 AND FREQUENCY CODE ON ANY INSTITUTIONAL RECD = 3 INTERIM-INTERIM 4 INTERIM-FINAL THEN HEADER TYPE INDICAT MUST = 0 BATCH HEADER (USED ON ALL PROVIDER BATCHES, AND F INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN NON-ADMIN CLAIM RATE ELIGIBLE TED RECDS) 5 VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE IF THE FIRST POSITION OF EACH BATCH/VOUCHER HEADER RECD IS NOT A 0, 5, 6, 9. THEN THE ENTIRE BATCH/VOUCHER WILL BE REJECTED. 2

3 CONTRACT NUMBER (0-010) V MUST BE A VALID VALUE FOUND ON THE DHA DATABASE R IF CONTRACT NUMBER = H C-0003 TPHARM HT D-0002 TPHARM AND BATCH/VOUCHER INDICAT = 5 INSTITUTIONAL/NON-INSTITUTIONAL THEN ALL OCCURRENCES OF RECD TYPE INDICAT MUST = 2 NON-INSTITUTIONAL AND ALL OCCURRENCES OF TYPE OF SERVICE (POSITION 2) MUST = M MOP ALL OCCURRENCES OF TYPE OF SERVICE (POSITION 2) MUST = B RETAIL PHARMACY ELEMENT NAME: BATCH/VOUCHER IDENTIFIER (0-015) V MUST = 3 PROVIDER 5 INSTITUTIONAL/NON-INSTITUTIONAL R IF BATCH/VOUCHER IDENTIFIER = 5 INSTITUTIONAL/NON-INSTITUTIONAL THEN RECD TYPE (F EVERY TED RECD IN THE BATCH/VOUCHER) MUST = 1 INSTITUTIONAL 2 NON-INSTITUTIONAL R IF BATCH/VOUCHER IDENTIFIER = 3 PROVIDER THEN RECD TYPE (F EVERY TED RECD IN THE BATCH/VOUCHER) MUST = 3 PROVIDER NOTE: IF THIS EDIT FAILS F ANY TED RECD, THE ENTIRE BATCH/VOUCHER FAILS. 3

4 BATCH/VOUCHER NUMBER (0-020) NONE R IF BATCH/VOUCHER IDENTIFIER = 5 INSTITUTIONAL/NON-INSTITUTIONAL AND BATCH/VOUCHER RESUBMISSION NUMBER > 0 THEN CONTRACT IDENTIFIER MUST BE A UNIQUE (KEY) COMBINATION OF CONTRACT NUMBER, BATCH/ VOUCHER IDENTIFIER AND BATCH/VOUCHER NUMBER R IF BATCH/VOUCHER IDENTIFIER = 5 INSTITUTIONAL/NON-INSTITUTIONAL AND BATCH/VOUCHER RESUBMISSION NUMBER > 0 THEN BATCH/VOUCHER NUMBER AND HEADER TYPE INDICAT MUST BE ON THE DHA DATABASE R IF HEADER TYPE INDICAT = 0 BATCH HEADER (USED ON ALL PROVIDER, PRICING BATCHES, AND F INSTITUTIONAL/NON- INSTITUTIONAL FINANCIALLY UNDERWRITTEN NON- ADMIN CLAIM RATE ELIGIBLE TED RECDS) 5 VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE 9 BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECDS) AND BATCH/VOUCHER RESUBMISSION NUMBER = 0 THEN BATCH/VOUCHER NUMBER MUST NOT EXIST ON THE DHA DATABASE AND CONTRACT IDENTIFIER MUST BE A UNIQUE (KEY) COMBINATION OF CONTRACT NUMBER, BATCH/ VOUCHER IDENTIFIER AND BATCH/VOUCHER NUMBER WITHIN THIS DHA PROCESSING CYCLE R IF HEADER TYPE INDICAT = 0 BATCH HEADER (USED ON ALL PROVIDER, PRICING BATCHES, AND F INSTITUTIONAL/NON- INSTITUTIONAL FINANCIALLY UNDERWRITTEN NON- ADMIN CLAIM RATE ELIGIBLE TED RECDS) 5 VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE 9 BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECDS) AND BATCH/VOUCHER RESUBMISSION NUMBER > 0 THEN CONTRACT IDENTIFIER MUST BE A UNIQUE (KEY) COMBINATION OF CONTRACT NUMBER, BATCH/ VOUCHER IDENTIFIER AND BATCH/VOUCHER NUMBER WITHIN THIS DHA PROCESSING CYCLE. 4

5 ELEMENT NAME: BATCH/VOUCHER ASAP ACCOUNT NUMBER (0-025) V MUST BE ALPHANUMERIC R IF HEADER TYPE INDICAT = 0 BATCH HEADER (USED ON ALL PROVIDER BATCHES, AND F INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN NON-ADMIN CLAIM RATE ELIGIBLE TED RECDS) 9 BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECDS) THEN BATCH/VOUCHER ASAP ACCOUNT NUMBER MUST BE ZERO R IF HEADER TYPE INDICAT = 5 VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE AND BATCH/VOUCHER RESUBMISSION NUMBER = ZERO THEN ASAP ACCOUNT NUMBER MUST BE VALID 1 AND ACTIVE 2 F THE CONTRACT NUMBER ON THE TED BATCH/VOUCHER RECD R IF CONTRACT NUMBER = H (TDEFIC) THEN BYPASS THIS EDIT ELSE IF HCDP PLAN COVERAGE CODE = 000 NO HEALTH CARE COVERAGE PLAN 121 CHCBP STANDARD - INDIVIDUAL COVERAGE 122 CHCBP EXTRA - FAMILY COVERAGE 401 TRS TIER 1 MEMBER-ONLY 402 TRS TIER 1 MEMBER AND FAMILY 403 TOBACCO CESSATION DEMONSTRATION PROGRAM 404 WEIGHT MANAGEMENT DEMONSTRATION PROGRAM 405 TRS TIER 2 MEMBER-ONLY 406 TRS TIER 2 MEMBER AND FAMILY 407 TRS TIER 3 MEMBER-ONLY 408 TRS TIER 3 MEMBER AND FAMILY 409 TRS SURVIV CONTINUING INDIVIDUAL COVERAGE 410 TRS SURVIV CONTINUING FAMILY COVERAGE 411 TRS SURVIV NEW INDIVIDUAL COVERAGE 412 TRS SURVIV NEW FAMILY COVERAGE 413 TRS MEMBER-ONLY COVERAGE 414 TRS MEMBER AND FAMILY COVERAGE 418 TRR MEMBER-ONLY COVERAGE 2 DEFINED IN THE TRICARE OPERATIONS MANUAL (TOM), CHAPTER 3. IF CONTRACT REQUIRES THE ABILITY TO SUBMIT INITIAL SUBMISSIONS ON A CLOSED BATCH/VOUCHER CLIN/ASAP ACCOUNT, THEN CONTACT DHA, CRM F INSTRUCTIONS ON HOW TO PROCEED. 5

6 BATCH/VOUCHER ASAP ACCOUNT NUMBER (0-025) (Continued) 419 TRR MEMBER AND FAMILY COVERAGE 420 TRR SURVIV INDIVIDUAL COVERAGE 421 TRR SURVIV FAMILY COVERAGE 422 TYA TRICARE STANDARD F ADFMs 423 TYA TRICARE STANDARD F RETIRED AND MOH FAMILY MEMBERS 424 TYA TRS 425 TYA TRR 426 TYA PRIME F ADFMs 427 TY TPR F ADFMs 428 TYA PRIME F RETIRED AND MOH FAMILY MEMBERS 429 TYA TRICARE OVERSEAS PRIME F ADFMs 430 TYA TRICARE OVERSEAS PRIME REMOTE F ADFMs ENROLLMENT/HEALTH PLAN CODE = Y CHCBP STANDARD - INDIVIDUAL COVERAGE AA SN SR CHCBP EXTRA - FAMILY COVERAGE SHCP - NON-MTF/eMSM REFERRED CARE SHCP - MTF/eMSM REFERRED CARE SPECIAL PROCESSING CODE = AN SHCP - NON-MTF/eMSM REFERRED CARE AR DC DE MM PV SHCP - MTF/eMSM REFERRED CARE DCPE-DVA TDRL PHYSICAL EXAM MMPCMHP RETAIL PHARMACY F DVA HCC MEMBER CATEGY CODE = A ACTIVE DUTY G J N S T V Y NATIONAL GUARD ACTIVE > 30 DAYS; AGR CODE A-H ACADEMY STUDENT, NOT OCS NATIONAL GUARD NOT ACTIVE < 31 DAYS RESERVE MEMBER ACTIVE > 30 DAYS FEIGN MILITARY RESERVE MEMBER NOT ACTIVE < 31 DAYS SERVICE AFFILIATES (ROTC, MERCHANT MARINE) AND HCC MEMBER RELATIONSHIP CODE = A SELF THEN BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER APPROPRIATION TYPE FOUND IN CAMS MUST TF TRUST/ACCRUAL FUND ELSE IF OGP TYPE CODE = A MEDICARE PART A C MEDICARE PART A & B 2 DEFINED IN THE TRICARE OPERATIONS MANUAL (TOM), CHAPTER 3. IF CONTRACT REQUIRES THE ABILITY TO SUBMIT INITIAL SUBMISSIONS ON A CLOSED BATCH/VOUCHER CLIN/ASAP ACCOUNT, THEN CONTACT DHA, CRM F INSTRUCTIONS ON HOW TO PROCEED. 6

7 BATCH/VOUCHER ASAP ACCOUNT NUMBER (0-025) (Continued) I L MEDICARE PART A & D MEDICARE PART A, B AND D AND OGP BEGIN REASON CODE N NOT ELIGIBLE F MEDICARE AND HCDP PLAN COVERAGE CODE = 004 DIRECT CARE F SURVIVS OF ACTIVE DUTY DECEASED SPONSS 005 TRICARE STANDARD F SURVIVS OF ACTIVE DUTY DECEASED SPONSS 016 DIRECT CARE F SURVIVS OF GUARD/RESERVE DECEASED SPONSS 017 TRICARE STANDARD F SURVIVS OF GUARD/ RESERVE DECEASED SPONSS 021 TFL F SURVIVS OF ACTIVE DUTY DECEASED SPONSS 023 TFL F SURVIVS OF GUARD/RESERVE DECEASED SPONSS 110 TRICARE PRIME F INDIVIDUAL COVERAGE F SURVIVS OF ACTIVE DUTY DECEASED SPONSS 111 TRICARE PRIME FAMILY COVERAGE F SURVIVS OF ACTIVE DUTY DECEASED SPONSS 114 TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE F SURVIVS OF ACTIVE DUTY DECEASED SPONSS 115 TRICARE USFHP DIRECT CARE FAMILY COVERAGE F SURVIVS OF ACTIVE DUTY DECEASED SPONSS 136 TRICARE PRIME INDIVIDUAL COVERAGE F SURVIVS OF GUARD/RESERVE DECEASED SPONSS 137 TRICARE PRIME FAMILY COVERAGE F SURVIVS OF GUARD/RESERVE DECEASED SPONSS 138 TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE F SURVIVS OF GUARD/RESERVE DECEASED SPONSS 139 TRICARE USFHP DIRECT CARE FAMILY COVERAGE F SURVIVS OF GUARD/RESERVE DECEASED SPONSS 143 TRICARE PLUS COVERAGE F SURVIVS OF ACTIVE DUTY DECEASED SPONSS 144 TRICARE PLUS WITH CHC COVERAGE F SURVIVS OF ACTIVE DUTY DECEASED SPONSS 148 TRICARE PLUS COVERAGE F SURVIVS OF GUARD/ RESERVE DECEASED SPONSS 2 DEFINED IN THE TRICARE OPERATIONS MANUAL (TOM), CHAPTER 3. IF CONTRACT REQUIRES THE ABILITY TO SUBMIT INITIAL SUBMISSIONS ON A CLOSED BATCH/VOUCHER CLIN/ASAP ACCOUNT, THEN CONTACT DHA, CRM F INSTRUCTIONS ON HOW TO PROCEED. 7

8 R BATCH/VOUCHER ASAP ACCOUNT NUMBER (0-025) (Continued) 149 TRICARE PLUS COVERAGE WITH CHC COVERAGE F SURVIVS OF GUARD/RESERVE DECEASED SPONSS 151 TRICARE PLUS COVERAGE F SURVIVS OF GUARD/ RESERVE DECEASED SPONSS HCC MEMBER CATEGY CODE = F FMER MEMBER H R W MOH RECIPIENT RETIRED FMER SPOUSE THEN BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER APPROPRIATION TYPE FOUND IN CAMS MUST = TF TRUST/ACCRUAL FUND ELSE BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER APPROPRIATION TYPE FOUND IN CAMS MUST TF TRUST/ACCRUAL FUND IF ANY OCCURRENCE OF TYPE OF SUBMISSION = B ADJUSTMENT TO NON-TED RECD (HCSR) DATA BATCH/VOUCHER RESUBMISSION NUMBER > 00 E COMPLETE CANCELLATION OF NON-TED RECD (HCSR) DATA HEADER TYPE INDICAT MUST = 0 BATCH HEADER (USED ON ALL PROVIDER BATCHES, AND F INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN NON-ADMIN CLAIM RATE ELIGIBLE TED RECDS) THEN BYPASS THIS EDIT ELSE IF BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN CAMS = TD TRICARE DOMESTIC AND CONTRACT NUMBER = T3 NTH 9 BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECDS) AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) ADMISSION DATE (INSTITUTIONAL) START OF CONTRACT CONTRACT NUMBER = T3 SOUTH AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) ADMISSION DATE (INSTITUTIONAL) START OF CONTRACT CONTRACT NUMBER = T3 WEST AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) ADMISSION DATE (INSTITUTIONAL) START OF CONTRACT CONTRACT NUMBER = T2017 EAST AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) ADMISSION DATE (INSTITUTIONAL) BEGIN DATE OF OLDEST OPEN OPTION PERIOD 2 DEFINED IN THE TRICARE OPERATIONS MANUAL (TOM), CHAPTER 3. IF CONTRACT REQUIRES THE ABILITY TO SUBMIT INITIAL SUBMISSIONS ON A CLOSED BATCH/VOUCHER CLIN/ASAP ACCOUNT, THEN CONTACT DHA, CRM F INSTRUCTIONS ON HOW TO PROCEED. 8

9 BATCH/VOUCHER ASAP ACCOUNT NUMBER (0-025) (Continued) CONTRACT NUMBER = T2017 WEST AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) ADMISSION DATE (INSTITUTIONAL) BEGIN DATE OF OLDEST OPEN OPTION PERIOD THEN SPECIAL PROCESSING CODE SHCP - NON-MTF/eMSM REFERRED CARE MUST = AN ENROLLMENT/HEALTH PLAN CODE MUST = AP AR AS AU CL CM CT LD L2 SN SR ABA PILOT SHCP - MTF/eMSM REFERRED CARE COMPREHENSIVE AUTISM CARE DEMONSTRATION AUTISM DEMONSTRATION CLINICAL TRIALS INDIVIDUAL CASE MANAGEMENT CUSTODIAL CARE LDTs DEMONSTRATION NON-FDA APPROVED LDTs DEMONSTRATION SHCP - NON-MTF/eMSM REFERRED CARE SHCP - MTF/eMSM REFERRED CARE HCDP PLAN COVERAGE CODE MUST = 000 CARE DLEIVIER TO INELIGIBLES 401 TRS TIER 1 MEMBER-ONLY 402 TRS TIER 1 MEMBER AND FAMILY 403 TOBACCO CESSATION DEMONTRATION PROGRAM 404 WEIGHT MANAGEMENT DEMONSTRATION PROGRAM 405 TRS TIER 2 MEMBER-ONLY 406 TRS TIER 2 MEMBER AND FAMILY 407 TRS TIER 3 MEMBER-ONLY 408 TRS TIER 3 MEMBER AND FAMILY 409 TRS SURVIV CONTINUING INDIVIDUAL COVERAGE 410 TRS SURVIV CONTINUING FAMILY COVERAGE 411 TRS SURVIV NEW INDIVIDUAL COVERAGE 412 TRS SURVIV NEW FAMILY COVERAGE 413 TRS MEMBER-ONLY COVERAGE 414 TRS MEMBER AND FAMILY COVERAGE 418 TRR MEMBER-ONLY COVERAGE 419 TRR MEMBER AND FAMILY COVERAGE 420 TRR SURVIV INDIVIDUAL COVERAGE 421 TRR SURVIV FAMILY COVERAGE 422 TYA TRICARE STANDARD F ADSMs 2 DEFINED IN THE TRICARE OPERATIONS MANUAL (TOM), CHAPTER 3. IF CONTRACT REQUIRES THE ABILITY TO SUBMIT INITIAL SUBMISSIONS ON A CLOSED BATCH/VOUCHER CLIN/ASAP ACCOUNT, THEN CONTACT DHA, CRM F INSTRUCTIONS ON HOW TO PROCEED. 9

10 R BATCH/VOUCHER ASAP ACCOUNT NUMBER (0-025) (Continued) PATIENT ZIP CODE IS IN ALASKA PCM DMIS-ID STATE = ALASKA 423 TYA TRICARE STANDARD F RETIRED AND MOH FAMILY MEMBERS 424 TYA TRS 425 TYA TRR 426 TYA PRIME F ADFMs 427 TYA TPR F ADFMs HCC MEMBER CATEGY CODE MUST = A ACTIVE DUTY 428 TYA PRIME F RETIRED AND MOH FAMILY MEMBERS 429 TYA TRICARE OVERSEAS PRIME F ADFMs 430 TYA TRICARE OVERSEAS PRIME REMOTE F ADFMs 999 UNVERIFIED NEWBN G J N S T V Z NATIONAL GUARD > 30 DAYS ACADEMY STUDENT NATIONAL GUARD < 30 DAYS RESERVE > 30 DAYS FEIGN MILITARY MEMBER RESERVE < 30 DAYS UNKNOWN AND HCC MEMBER RELATIONSHIP CODE MUST = A SELF Z UNKNOWN IF ANY OCCURRENCE OF TYPE OF SUBMISSION = B ADJUSTMENT TO NON-TED RECD (HCSR) DATA THEN BYPASS THIS EDIT E COMPLETE CANCELLATION OF NON-TED RECD (HCSR) DATA ELSE IF BATCH/VOUCHER CLIN/ASAP TRICARE CIVILIAN PRIME ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN CAMS = TC THEN ENROLLMENT CODE/HEALTH PLAN CODE MUST = U TRICARE PRIME CIVILIAN PCM AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) ADMISSION DATE (INSTITUTIONAL) START DATE OF HEALTH CARE DELIVERY F THE CONTRACT NUMBER R IF ANY OCCURRENCE OF TYPE OF SUBMISSION = B ADJUSTMENT TO NON-TED RECD (HCSR) DATA 2 DEFINED IN THE TRICARE OPERATIONS MANUAL (TOM), CHAPTER 3. IF CONTRACT REQUIRES THE ABILITY TO SUBMIT INITIAL SUBMISSIONS ON A CLOSED BATCH/VOUCHER CLIN/ASAP ACCOUNT, THEN CONTACT DHA, CRM F INSTRUCTIONS ON HOW TO PROCEED. 10

11 THEN BYPASS THIS EDIT BATCH/VOUCHER ASAP ACCOUNT NUMBER (0-025) (Continued) E COMPLETE CANCELLATION OF NON-TED RECD (HCSR) DATA ELSE IF BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN CAMS = TN TRICARE NON-CIVILIAN PRIME THEN ENROLLMENT CODE/HEALTH PLAN CODE MUST = T TRICARE STANDARD PROGRAM V Z WF TRICARE EXTRA TRICARE PRIME, MTF/eMSM/PCM TRICARE PRIME REMOTE ADFM AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) ADMISSION DATE (INSTITUTIONAL) START DATE OF HEALTH CARE DELIVERY F THE CONTRACT NUMBER R IF HEADER TYPE INDICAT = 5 VOUCHER HEADER NON-ADMIN CLAIM RATE-ELIGIBLE AND POSITION 1 THRU 4 OF THE CLIN/ASAP NUMBER = MIPR THEN ALL OCCURRENCES OF TYPE OF SERVICE (POSITION 2) MUST = M MOP R IF HEADER TYPE INDICAT = 5 VOUCHER HEADER NON-ADMIN CLAIM RATE-ELIGIBLE AND TYPE OF SERVICE (POSITION 2) = M MOP THEN POSITION 1 THRU 4 OF THE CLIN/ASAP NUMBER MUST = MIPR R IF HEADER TYPE INDICAT = 5 VOUCHER HEADER NON-ADMIN CLAIM RATE-ELIGIBLE AND CONTRACT NUMBER = H C-0003 TPHARM HT D-0002 TPHARM AND POSITION 1 THRU 4 OF THE CLIN/ASAP NUMBER MIPR THEN ALL OCCURRENCES OF TYPE OF SERVICE (POSITION 2) MUST = B RETAIL PHARMACY R IF HCDP PLAN COVERAGE CODE = 018 TFL F RETIRED SPONSS AND FAMILY MEMBERS AND MOH 020 TFL F TRANSITIONAL SURVIVS OF ACTIVE DUTY DECEASED SPONSS 021 TFL F SURVIVS OF ACTIVE DUTY DECEASED SPONSS 022 TFL F TRANSITIONAL SURVIVS OF GUARD/ RESERVE DECEASED SPONSS 023 TFL F SURVIVS OF GUARD/RESERVE DECEASED SPONSS 2 DEFINED IN THE TRICARE OPERATIONS MANUAL (TOM), CHAPTER 3. IF CONTRACT REQUIRES THE ABILITY TO SUBMIT INITIAL SUBMISSIONS ON A CLOSED BATCH/VOUCHER CLIN/ASAP ACCOUNT, THEN CONTACT DHA, CRM F INSTRUCTIONS ON HOW TO PROCEED. 11

12 BATCH/VOUCHER ASAP ACCOUNT NUMBER (0-025) (Continued) 029 TFL F MEDICALLY RETIRED SPONSS AND FAMILY MEMBERS AND TYPE OF SUBMISSION = I INITIAL SUBMISSION R RESUBMISSION THEN OGP TYPE CODE MUST N NO MEDICARE V CHAMPVA AND OGP BEGIN REASON CODE MUST N NOT ELIGIBLE F MEDICARE W NOT APPLICABLE 2 DEFINED IN THE TRICARE OPERATIONS MANUAL (TOM), CHAPTER 3. IF CONTRACT REQUIRES THE ABILITY TO SUBMIT INITIAL SUBMISSIONS ON A CLOSED BATCH/VOUCHER CLIN/ASAP ACCOUNT, THEN CONTACT DHA, CRM F INSTRUCTIONS ON HOW TO PROCEED. ELEMENT NAME: BATCH/VOUCHER DATE (0-030) V MUST BE A VALID JULIAN DATE AND CANNOT BE > DHA CURRENT SYSTEM DATE V BATCH/VOUCHER DATE MUST BE CONTRACT BEGIN DATE 1 AND BATCH/VOUCHER DATE MUST BE CONTRACT END DATE R IF HEADER TYPE INDICAT = 5 VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE AND BATCH/VOUCHER RESUBMISSION NUMBER = 00 AND BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN CAMS = TD TRICARE DOMESTIC TF TT TRICARE FEIGN TRICARE TARGET AND TYPE OF SUBMISSION = D COMPLETE DENIAL I O R INITIAL SUBMISSION ZERO PAYMENT WITH 100% OHI/TPL RESUBMISSION THEN BATCH/VOUCHER DATE IN HEADER MUST BE EQUAL TO WITHIN ASAP BEGIN AND END DATES ON THE DHA DATABASE R IF HEADER TYPE INDICAT = 5 VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE THEN BATCH/VOUCHER DATE IN HEADER MUST NOT BE LESS THAN THE ASAP BEGIN DATE ON THE DHA DATABASE R IF BATCH/VOUCHER RESUBMISSION NUMBER = 00 THEN BATCH/VOUCHER DATE MUST 09/29/XXXX 1 CONTRACT DATES ON THE DHA DATABASE. THESE DATES ARE TAKEN FROM THE DHA CONTRACTS. 12

13 R BATCH/VOUCHER DATE (0-030) (Continued) 09/30/XXXX UNLESS BATCH/VOUCHER IDENTIFIER = 3 PROVIDER (BATCH ONLY) IF BATCH/VOUCHER RESUBMISSION NUMBER = 00 AND TRANSMISSION FILE RECEIVED TIME/DATE STAMP > 10:00 AM 09/28/(CURRENT YEAR) AND BATCH/VOUCHER IDENTIFIER = 5 INSTITUTIONAL/NON-INSTITUTIONAL (BATCH/ VOUCHER) THEN BATCH/VOUCHER DATE MUST NOT BE < 10/01/(CURRENT YEAR) R IF HEADER TYPE INDICAT = 5 VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE AND BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN CAMS = TC TRICARE CIVILIAN PRIME TN TRICARE NON-CIVILIAN PRIME THEN BEGIN DATE OF CARE (NON-INSTITUTIONAL) ADMISSION DATE (INSTITUTIONAL) MUST BE EQUAL TO WITHIN ASAP BEGIN AND END DATES ON THE DHA DATABASE 1 CONTRACT DATES ON THE DHA DATABASE. THESE DATES ARE TAKEN FROM THE DHA CONTRACTS. ELEMENT NAME: BATCH/VOUCHER SEQUENCE NUMBER (0-035) V MUST BE NUMERIC AND > ZERO. NONE ELEMENT NAME: BATCH/VOUCHER RESUBMISSION NUMBER (0-040) V MUST BE NUMERIC AND IF BATCH/VOUCHER IDENTIFIER = 5 INSTITUTIONAL/NON-INSTITUTIONAL THEN MUST BE 1 GREATER THAN THE PRI SUBMISSION NUMBER UNDER THE SAME CONTRACT IDENTIFIER 1. NONE 13

14 TOTAL NUMBER OF RECDS (0-045) V V MUST BE NUMERIC. MUST EQUAL NUMBER OF TED RECDS IN THE BATCH/VOUCHER V TOTAL RECDS MUST > R IF BATCH/VOUCHER IDENTIFIER = 5 INSTITUTIONAL/NON-INSTITUTIONAL AND BATCH/VOUCHER RESUBMISSION NUMBER > ZERO THEN NUMBER OF RECDS IN THE BATCH/VOUCHER MUST = NUMBER OUTSTANDING RECDS 1. ELEMENT NAME: TOTAL AMOUNT PAID (0-050) V MUST BE NUMERIC R IF BATCH/VOUCHER IDENTIFIER = 5 INSTITUTIONAL/NON-INSTITUTIONAL THEN TOTAL AMOUNT PAID MUST = THE ACCUMULATED TOTAL OF AMOUNTS PAID BY GOVERNMENT CONTRACT AND AMOUNT OF INTEREST PAYMENT F ALL TED RECDS IN THE BATCH/VOUCHER R IF BATCH/VOUCHER IDENTIFIER = 3 PROVIDER R 2 THEN TOTAL AMOUNT PAID MUST EQUAL ZERO. IF POSITION 1 THRU 4 OF THE CLIN/ASAP NUMBER = MIPR AND BATCH/VOUCHER DATE 07/14/2011 THEN BYPASS THIS EDIT ELSE IF HEADER TYPE INDICAT = 5 VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE AND BATCH/VOUCHER IDENTIFIER = 5 INSTITUTIONAL/NON-INSTITUTIONAL AND BATCH/VOUCHER RESUBMISSION NUMBER > ZERO THEN TOTAL AMOUNT PAID MUST BE EQUAL TO THE VOUCHER BALANCE 1. 1 DHA DATABASE (EXCLUDES CONTRACT NUMBER MDA C-0013 (TMOP)). 2 ALL TMOP BATCH/VOUCHERS WITH A MIPR CLIN/ASAP NUMBER AND BATCH/VOUCHER DATE 07/14/2011 WILL BYPASS THIS EDIT. ELEMENT NAME: INITIAL TRANSMISSION DATE (DHA DERIVED) (0-055) NONE NONE 14

15 ELEMENT NAME: DHA BATCH/VOUCHER PROCESSING DATE (DHA DERIVED) (0-060) NONE NONE ELEMENT NAME: FUND ACCOUNTING (0-065) V R R 3 MUST BE NUMERIC. IF POSITION 1 THRU 4 OF THE BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER = MIPR AND BATCH/VOUCHER DATE 07/14/2011 AND HEADER TYPE INDICAT = 5 VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE AND BATCH/VOUCHER IDENTIFIER = 5 INSTITUTIONAL/NON-INSTITUTIONAL AND BATCH/VOUCHER RESUBMISSION NUMBER > ZERO THEN THE FUND ACCOUNTING MUST BE EQUAL TO THE VOUCHER BALANCE 1. IF POSITION 1 THRU 4 OF THE BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER = MIPR AND BATCH/VOUCHER DATE 07/14/2011 THEN THE FUND ACCOUNTING MUST = THE ACCUMULATED TOTAL OF AMOUNT ALLOWED BY PROCEDURE CODE F ALL TED RECDS IN THIS VOUCHER. 2 THIS EDIT IS PERFMED F ALL MAIL DER BATCH/VOUCHERS ONLY. 3 THIS EDIT IS PERFMED F TPHARM MAIL DER BATCH/VOUCHERS. - END - 15

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