17_TCRS_Sec_J_Atch_J-7_ADDP_MDR_Data_File.pdf

Attachment J-7 ADDP MDR Data Elements

ADDP Data Elements File

TCRS HT9402-17-R-0002, Section J, Attachment J-7 Page 1 of 5

Data File Requirements:

1. File Content: Monthly data feeds, reflecting previous month's claim activity and provider data feeds.

2. Format: Fixed Length and in order listed below for claims and providers.

3. Contractor will submit the data the 1st and 15th of each month.

4. Method of Delivery to Government: ADDP files will be sent to the MHS Data Repository (MDR) via Secure File Transfer Protocol (SFTP), to a fixed IP address provided by the Government, in accordance with the Interface Control Document (ICD) (see C.21.3).

Description of ADDP Claims Data File Elements:

Field Name (logical name)

Field Length

Position Data Type Value Range

Functional Description

ADSM Last Name 35 1-35 Alphabetic None Last name of Active Duty Service Member ADSM First Name 25 36-60 Alphabetic Nona First name of Active Duty Service Member ADSM Middle Name 25 61-85 Alphabetic None Middle name of Active Duty Service Member ADSM Social Security Number

9 86-94 Alpha-numeric

None Social Security Number (SSN) of Active Duty· Service Member

ADSM Gender 1 95 Alphabetic F, M, X Service member's sex code. Coded as follows: F Female M Male X Unknown

ADSM Birth Date 8 96-103 Date None Service member's birth date. Format YYYYMMDD.

DEERS ID 14 104-117 Alpha-numeric None The Identifier assigned by Defense Enrollment

Eligibility Reporting System (DEERS) that Is used to represent a patient within a Department of Defense Electronic Data Interchange (DoD EDI_PN.)

ADSM Branch of Service .

1 118 Alphabetic A,C,F, H. M,N, 0, 1,2, 3,4,6

A code that represents the branch of service with which the Active Duty Service Member is affiliated. A Army C Coast Guard F Air Force H Commissioned Corps of the Public Health

Service M Marine Corps N Navy 0 Commissioned Corps of the National

Oceanographic and Atmospheric Administration (NOAA)

1 2 3 4 6 Foreign Services Component 1 119 Alphabetic D,R A code that represents if the ADSM is within reach of a

DTF or Is Ina remote location(not within reach of a

DTF).

D DTF area R Remote

ADSM Phone Number 14 120-133 Alpha-numeric

None The home telephone number of the Active Duty Service Member

Performing Provider Number

9 134-142 Alpha-numeric

None A unique number assigned to an Individual o,r organization which performs health care services.

Provider Tax ID 9 143-151 Alpha numeric

None The Taxpayer Identification Number (TIN) of the provider.

National Provider ID (NPI) - Individual

14 152-165 Alpha-numeric

None National Provider ID (NPI) number of the provider rendering dental services.

National Provider ID (NPI) - Group

14 166-179 Alpha- None National Provider ID (NPI) number of the provider rendering dental services. numeric

TCRS HT9402-17-R-0002, Section J, Attachment J-7 Page 2 of 5

Field Length

Position Data Type Value Range

Functional Description

Performing Provider Zip

5 180-184 Alpha-numeric

None The business address Zip code of the provider.

Performing Provider Specialty

3 185-187 Alpha-numeric

None Code describing the provider's specialty.

Performing Provider Specialty- HIPAA Taxonomy

10 188-197 Alpha-numeric

None A unique alphanumeric code structured into three distinct levels Including provider type, classification, and area of specialization.

Provider Network Status 1 198 Alpha-numeric

1, 2, 3 Indicates whether or not the provider Is a network or non-network provider.

1 Network provider 2 Non-network provider 3 Not eligible

Provider Suffix 3 199-201 Alphabetic None The Professional Degree which a doctor receives upon graduation from a college or university (ex:

DDS, DMD.)

Claim Number 13 202-214 Alpha-numeric

None The unique number for the claim.

Claim Line-Item Number

4 215-218 Numeric 0000-

The line number of a particular service on the bill.

Claim Rejection Reason

5 219-223 Alpha-numeric

None The reason for the rejection of the claim.

Line-Item Rejection Reason

5 224-228 Alpha-numeric

None The reason for the rejection of the line-item within the claim.

Benefit Category 6 229-234 Alpha-numeric

ASURG

ANES

CIO

CONSUL

DDIAG

Identifies the general benefit category of the service provided.

ASURG Assistant surgery ANES Anesthesia CIO Crowns, Inlays, and Ontays

DGENL

DORAL

DPREV

DPROS

MORAL

MREST

ORTHO

PERIO

SURG

CONSUL Consultation DDIAG Dental Diagnostic DGENL Dental General Services DORAL Dental Oral Surgery DPREV Dental Preventive DPROS Dental Prosthetic MORAL Medical/Surgical Oral Surgery MREST Minor Restorative ORTHO Orthodontic PERIO Periodontics

SURG Surgery Date of Service 8 235-242 Date None The date that dental services were first provided for this claim. Format: YYYYMMDD.

End Date of Service 8 243-250 Date None

The last dale that dental services were provided for this claim. Format: YYYYMMDD.

Claim Receipt Dale 8 251-258 Date None The date that the claim was received for payment.

Format: YYYYMMDD.

Claim Paid Date 8 259-266 Date None The date that the claim was paid. Formal:

YYYYMMDD.

Claim Finalized Date 8 267-274 Date · None The date that the claim was adjudicated and payment decisions made. Formal: YYYYMMDD.

Date of Last Exam 8 275-282 Date None The date of the patient's last dental examination.

Format: YYYYMMDD.

CDT Procedure Code 5 283-287 Alpha-numeric

None Current Denial Terminology (CDT) procedure code for the service.

CDT Version 2 288-289 Alpha-numeric

None The CDT version that was used to determine the procedure code.

Adjustment Reason 2 290-291 Alpha-numeric

None Code identifying the reason for non-payment of services or adjustment of the detail line item.

TCRS HT9402-17-R-0002, Section J, Attachment J-7 Page 3 of 5

Field

Length Position Data Type Value

Range Functional Description

Adjustment Code 1 292 Alphabetic A, B, C, O,E,F, G,H,l,J

Indicates the adjustment made to claim.

A Additional payment B History change

· c Refund reprocess D Cancel Refund E Transfer funds F Utilization transfer/original (intraplan) G Utilization transfer/secondary (intraplan) H Administrative I Refund J Product line transfer (interface claim).

Tooth Number 2 293-294 Alpha-numeric

None The tooth entered on the pricing grid on the Claim Adjudication screen.

Anterior/Posterior indicator

1 295 Alpha-numeric

Indicates anterior or posterior location.

Buccal Surface Indicator

1 296 Alphabetic N,Y Indicates buccal surface. Coded as follows:

N No y Yes

Distal Surface 1 297 Alphabetic N,Y Indicates distal surface. Coded as follows:

N No y Yes

Facial Surface Indicator

1 298 Alphabetic N,Y Indicates facial surface. Coded as follows:

N No y Yes

Incisal Surface Indicator

1 299 Alphabetic N,Y Indicates incisal surface. Coded as follows:

N No y Yes

Lingual Surface Indicator

1 300 Alphabetic N,Y Indicates lingual surface. Coded as follows:

N No y Yes

Mesial Surface 1 301 Alphabetic N,Y Indicates mesial surface. Coded as follows:

N No y Yes

Occlusal Surface Indicator

1 302 Alphabetic N,Y Indicates occlusal surface. Coded as follows:

N No y Yes

Quadrant (Mouth Area Code)

2 · 303-304 Alpha-numeric

None Identifies the quadrant of dental care.

Provider Charge 9 (6,2) 305-313 Numeric None The amount charged by the provider for services, by line item. Format: "dddddd. cc"

Allowed Amount 9 (6,2) 314-322 Numeric None The amount allowed under the plan for the specified services, by line item. Format: "dddddd.cc”

Approved Amount 9 (6,2) 323-331 Numeric None The approved amount that the plan would pay towards the dental services, by line item. Format:

"dddddd.cc"

Other Carrier Payment 9 (6,2) 332-340 Numeric None Payments made by Other Health Insurance (OHI) towards the Provider Charges, by line item Format:

"dddddd.cc”·

Third Party Liability

(TPL)

9 (6,2) 341 349 Numeric None The amount paid by Third Party Liability (TPL) plan carriers towards the Provider Charges, by line item.

Format: "dddddd.cc"

Prior Placement Date 8 350-357 Date None The date of prior placement. Format: YYYYMMDD.

Replacement Reason

1 358 Alpha-numeric

1,2,3,4 The replacement code representing the reason a specific crown, prosthesis, inlay or onlay is to be replaced.

1 Lost 2 Broken 3 Accident 4 No longer serviceable

TCRS HT9402-17-R-0002, Section J, Attachment J-7 Page 4 of 5

(logical name)

Field Length

Position Data Type Value Range

Functional Description

Oral Health Initiative Indicator

1 359 Alpha-numeric

N,Y A code indicating If this service Is part of an Oral Health Initiative.

N No y Yes

Dental Readiness Classification

1 360 Alpha-numeric;

1. 2. 3 A code representing the AOSM's dental readiness by claim.

1 No dental treatment needed 2 Minor dental treatment needed 3 Urgent or emergent dental care required

Referral Number 16 361-376 Alpha-numeric

A unique referral number associated with the claim.

Authorization Number

16 377-392 Alpha-numeric

A unique authorization number associated with the claim.

DMIS Code 4 393-396 Numeric A code representing a particular Dental Treatment Facility.

MMSO Residual Claims Indicator

1 397 Alpha-numeric

Indicates that this is a residual claim.

Special Processing Arrangement (SPA)

2 398-399 Alpha AT,RT A code that represents if the claim was processed as a DTF Referred or Remote ADSM, Code AT DTF Referred RT Remote ADSM

Government Charged Amount

9 (6,2) 400-408 Numeric None The allowed amount paid by the Government to the Contractor for the specified services, by line Item.

Format: "dddddd.cc".

Diabetic Indicator 3 409-411 Numeric 250 The claim form will report If the ADSM Is diabetic.

Pregnancy Indicator 3 412-414 Alpha-numeric V22 The claim form will report if the ADSM is pregnant.

Health Care Delivery Program (HCDP) Plan Coverage Code

3 415-417 Numeric 025

The code that represents the plan coverage a sponsor has within a HCDP type.

025 - Direct Care Dental for Active Duty Sponsors 026

- Direct care Dental for Active Duty Foreign

Military 232 - Remote ADDP for sponsors enrolled In

TRICARE Prime Remote 233 - Remote ADDP for sponsors not eligible for

TRICARE Prime Remote 234 - Remote ADDP - Automatic Enrollment

234.

HealthCare Coverage (HCC) Member Category

1 418 Alpha A,G,J, P,S,T

The member category code during the HCC period. A- Active Duty G- National Guard member (mobilized or on active duty for 31 days or more) Early ID Alert Status.

J - Academy student (does not include Officer

Candidate School or Merchant Marine Academy)

P - Transitional Assistance Management Program member

S - Reserve member (mobilized or on active duty for 31 days or more) Early ID Alert Status

T – Foreign military member

Code

Remote Authorization

1 419 Alpha-numeric

1, 2, 3 A code representing remote authorizations by line Item:

1 Approved 2 Disapproved 3 Authorized care not completed

TCRS HT9402-17-R-0002, Section J, Attachment J-7 Page 5 of 5

Description of ADDP Provider Data File Elements:

Field Length

Position Data Type Value Range

Functional Description - Baseline Definitions.

Provider Tax Identifier 9 1-9 Alpha-numeric

None _The taxpayer Identification Number (TIN} of the provider.

Provider Identifier 9 10-18 Alpha-numeric

None A unique number assigned to an individual or organization which performs health care services.

Individual Provider Name

53 19-71 Alpha-numeric

None The text name of the individual provider.

Group Name 53 72-124 Alpha-numeric

None The text name of the dental group {if service was performed by a provider who is part of a group).

Provider Specialty 3 125-127 Alpha-numeric

None Code describing the provider's specialty.

HIPAA Provider Taxonomy

10 128-137 Alpha-numeric

None A unique alphanumeric code structured Into three distinct levels Including provider type, classification, and area of specialization.

Provider SSN 9 138-146 Alpha-numeric

None Social Security Number (SSN) of the dental provider.

Provider Network Status 1 147 Alpha-numeric

1,2 Indicates whether or not the provider Is a network or non-network provider (at the date of service).

1 Network provider 2 Non-network provider

Provider Telephone Number

10 148-157 Alpha-numeric

None Business telephone number of the provider.

Provider Street Address Line 1

36 158-193 Alpha-numeric

None Provider's business street address line 1.

Provider Street Address Line 2

36 194- 29 Alpha-numeric

None Provider's business street address line 2.

State 2 230-231 Alpha-numeric

None Provider's business state code.

Provider Zip Code 9 232-240 Alpha-numeric

None Provider's business zip code.

Country Code 3 241-243 Alpha-numeric

None Provider's business country code.

National Provider Identifier (NPI) Individual ----

14 244-257 Alpha-numeric

None National Provider ID (NPI) number of the provider.

National Provider Identifier (NPI) Group

14 258-271 Alpha-numeric

None National Provider ID (NPI) number of the provider.

Reserved For Future Use

11 272-282 Alpha-numeric

None Placeholder for future requirements.