18_TCRS_Sec_J_Atch_J-8_Example_of_TADR.pdf

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Section J Attachment J-8

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TRICARE Purchased Care Report Run Date: 01/11/XXXX

TED AUDIT DETAIL REPORT

COMBINED PAYMENT SAMPLE

CONTRACTOR: XXXX - North Region CONTRACT NO: MDA9999999999 AUDIT PERIOD: OCT XX-DEC XX TA200-001

INSTITUTIONAL

TED ID: 111111111 B1111 1111111 FILING STATE/COUNTRY: Alaska PART I

Attachment J-8 Example of TADR

TCRS HT9402-17-R-0002, Section J, Attachment J-8

(A) CLAIM / PROCESSING INFORMATION

01A FIL DT 1111111 04A SUB TYPE : A 07A OVERRIDE lOA CA/NAS EXCEP 13A REC-TYPE: 1

02A FIL ST AK 05A DTD ADJ ID 20099999 08A CLM FRM TYP F 11A CA/NAS # 15A PRICE RT CD :J

03A SEQ NO B1111 06A PTC DT 20099999 09A SP PROC CD : v 12A CA/NAS RSN CD

(B) PATIENT/SPONSOR INFORMATION

OlB PNT NAME JOHN H. SMITH 02B PNT ID: 123456789 04B PNT SEX : M 06B SP ID 987654321 08B PAY GD 06 lOB HCC RELAT : E 03B PNT DOB: 19999999 05B PNT ZIP: 20748 07B SP BOS : A 09B HCC MBR R 11B ENRL PLAN z

12B HCDP PLAN CD: 13B HCDP SPEC CD: 14B PCM DMIS ID: 15B HCC COPAY CD:

(C) PROVIDER INFORMATION

OlC TAX ID 999999999 03C NTWK IND 2 05C ZIP 995082932 07C PROV ORG NPI #:1234567890

02C SUB ID 0015 04C ST/CNTRY AK 06C TYPE INST: 10 08C PART ID : Y

(D) ADMISSION/DISCHARGE INFORMATION

OlD ADM DATE: 20080725 030 ADM SOURCE: 7 050 BGN DOC: 20080725 07D FREQ

020 ADM TYPE: 1 04D PTNT STAT : 01 06D END DOC: 20080730 08D COVD DAYS: 5

(E) DIAGNOSIS/TREATMENT PROCEDURE INFORMATION

OlE ADM OX 81321 06E SEC DX-4: 920 11E SEC DX-9 14E PRN OP PROC: 7674 19E SEC PROC-5: 24E SEC PROC-10:

02E PRN DX 81321 07E SEC DX-5: 5258 12E SEC DX-10 15E SEC PROC-1 7677 20E SEC PROC-6: 25E SEC PROC-11:

03E SEC DX-1: 8024 08E SEC DX-6: 13E SEC DX-11 16E SEC PROC-2 7902 21E SEC PROC-7:

04E SEC DX-2: 8028 09E SEC DX-7: 17E SEC PROC-3 22E SEC PROC-8: 26E DRG NUMBER : 233

05E SEC DX-3: 9571 lOE SEC DX-8: 18E SEC PROC-4 23E SEC PROC-9: 27E HIPPS CODE:

(G) FINANCIAL INFORMATION

OlG AMT BILL TOT : 000029821.00 03G AMT PD OHI 000000000.00 05G AMT GOV CNT PAID TOT : 000013530.44

02G AMT ALLOW TOT: 000013585.44 04G PNT COST SHARE: 000000055.00 06G AMT NTWRK DISCOUNT: 000000000.00

FOR OFFICIAL USE ONLY

THIS INFORMATION IS PROTECTED BY THE PRIVACY ACT OF 1974 AND SUBJECT TO THE HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996, THE DEPARTMENT OF HEALTH AND HUMAN SERVICES PRIVACY RULE IN REGARD TO THAT ACT, AND THE DOD 6025.18R,DOD HEALTH INFORMATION PRIVACY REGULATION

TED AUDIT DETAIL REPORT

COMBINED PAYMENT SAMPLE

CONTRACTOR: XXXX - North Region CONTRACT NO: MDA9999999999 AUDIT PERIOD: OCT XX-DEC XX TA200-001

INSTITUTIONAL

TED ID: 111111111 B1111 1111111 PART II FILING STATE/COUNTRY: Alaska

Attachment J-8 Example of TADR

TCRS HT9402-17-R-0002, Section J, Attachment J-8

FOR OFFICIAL USE ONLY

THIS INFORMATION IS PROTECTED BY THE PRIVACY ACT OF 1974 AND SUBJECT TO THE HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996, THE DEPARTMENT OF HEALTH AND HUMAN SERVICES PRIVACY RULE IN REGARD TO THAT ACT, AND THE DOD 6025.18R,DOD HEALTH INFORMATION PRIVACY REGULATION.

Page: 2

**** ADDITIONAL AUDIT INFORMATION ****

PATIENT ZIP CODE, STATE, CITY - 20748, MD, TEMPLE HILLS

STATUS= A MTF= WALTER REED ARMY MEDICAL @ 12 MILES

ADM DX 81321 - CL FX RADIUS SHAFT

PRIN DX 81321 - CL FX RADIUS SHAFT

SEC DX-1 8024 - CLSD FX MALAR/MAXILLARY

SEC DX-2 8028 - CLSD FX FACIAL BONE NEC

SEC DX-3 9571 - INJURY TO NERVE NEC

SEC DX-4 920 - CONTUSION HEAD X EYE

SEC DX-5 5258 - DENTAL DISORDER NEC

PRN OP PROC 7674 - OPEN RED MAXILLARY FX

SEC PROC-1 7677 - OPEN RED ALVEOLAR FX

SEC PROC-2 7902 - CLSD FX RED RADIUS/ULNA

*CURRENT* PROV TIN: 999999999 SUB ID: 0015 MEDICARE #: 000000 NTWK IND: 2 I/N IND: I

NAME: ALASKA REGIONAL HOSPITAL

ADDRESS: 2801 DEBARR RD ANCHORAGE AK 995082932

BILLING ADDRESS: PO BOX 409790 ATLANTA 303849790

TYP INST: 10 TRAN CD: M EFF DATE: 20061128

ACCEPT DATE: 19670101

TERM DATE: 00000000

DRG EXEMPT IND: N DRG EFFECT DATE: 19871001

WAGE-INDEX: 1.0000 WAGE EFFECT DATE: 20041001

RURAL/URBAN CODE: U

IDME-RATIO: 0.0000 IDME EFFECT DATE: 00000000

*HISTORY* PROV TIN: 999999999 SUB ID: 0015 MEDICARE #: 000000 NTWK IND: 2 I/N IND: I

NAME: ALASKA REGIONAL HOSPITAL

ADDRESS: 2801 DEBARR RD ANCHORAGE AK 995082932

BILLING ADDRESS: PO BOX 409790 ATLANTA 303849790

TYP INST: 10 TRAN CD: M EFF DATE: 20060824

ACCEPT DATE: 19670101

TERM DATE: 00000000

DRG EXEMPT IND: N DRG EFFECT DATE: 19871001

WAGE-INDEX: 1.0000 WAGE EFFECT DATE: 20041001

RURAL/URBAN CODE: U

IDME-RATIO: 0.0000 IDME EFFECT DATE: 00000000

*MORE HISTORY EXISTS*

TED AUDIT DETAIL REPORT

COMBINED PAYMENT SAMPLE

CONTRACTOR: XXXX - North Region CONTRACT NO: MDA9999999999 AUDIT PERIOD: OCT XX-DEC XX TA200-001

INSTITUTIONAL

TED ID: 111111111 81111 1111111 FILING STATE/COUNTRY: Alaska PART III

Attachment J-8 Example of TADR

TCRS HT9402-17-R-0002, Section J, Attachment J-8

FOR OFFICIAL USE ONLY

THIS INFORMATION IS PROTECTED BY THE PRIVACY ACT OF 1974 AND SUBJECT TO THE HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996, THE DEPARTMENT OF HEALTH AND HUMAN SERVICES PRIVACY RULE IN REGARD TO THAT ACT, AND THE DOD 6025.18R,DOD HEALTH INFORMATION PRIVACY REGULATION.

Page: 3

(H) REVENUE DATA 14A OCCURRENCE COUNT: 19

07H occ

OlH

REVENUE

02H

UNITS OF

03H

TOTAL

04H

ADJ/DNL

05H

OGP TYPE

06H

OGP BEG

LN CODE SERVICE CHARGE CODE CD RSN CD

001 0001 0 0029821.00 002 0123 5 0004965.00 003 0250 16 0001104.00 004 0255 0000236.00 005 0258 14 0001092.00 006 0259 2 0000181.00 007 0270 14 0000829.00 008 0272 11 0001224.00 009 0301 6 0001375.00 010 0305 0000224.00 011 0320 9 0001941.00 012 0324 1 0000188.00 013 0350 2 0001512.00 014 0351 2 0002736.00 015 0352 2 0002599.00 016 0360 4 0003712.00 017 0370 8 0001586.00 018 0450 3 0001779.00 12 019 0710 6 0002538.00

TED AUDIT DETAIL REPORT

COMBINED PAYMENT SAMPLE

CONTRACTOR: XXXX - North Region CONTRACT NO: MDA9999999999 AUDIT PERIOD: OCT XX-DEC XX TA200-001

NON-INSTITUTIONAL

Attachment J-8 Example of TADR

TCRS HT9402-17-R-0002, Section J, Attachment J-8

FILING STATE/COUNTRY: Alabama

(A) CLAIM / PROCESSING INFORMATION

01A FIL DT 1111111 04A SUB TYPE A

02A FIL ST AL 05A DTD ADJ ID 00000000

03A SEQ NO B1111 06A PTC DT 20081001

(B) PATIENT/SPONSOR INFORMATION

018 PNT NAME JOHN P. SMITH

02B PNT ID 123456789 048 PNT SEX M

038 PNT DOB 19771099 05B PNT ZIP 36701

PART I

07A OVERRIDE 13A REC-TYPE: 2

08A CLM FRM TYP : G

06B SP ID 999999999 08B PCM DMIS ID:

07B SP BOS N

TED ID: 111111111 B1111 1111111

(F) DIAGNOSIS INFORMATION

01F PRIN DX : 6072 03F SEC DX-2: 4019 05F SEC DX-4: 07F SEC DX-6: 09 SEC DX-8 11 SEC DX-10

02F SEC DX-1: 60789 04F SEC DX-3: 06F SEC DX-5: 08F SEC DX-7: 10 SEC DX-9 12 SEC DX-11

(G) FINANCIAL INFORMATION

OlG AMT BILL TOT : 000004489.28 04G PNT COST SHARE : 000000000.00 06G AMT NETWORK DISCOUNT: 000000000.00

02G AMT ALLOW TOT: 000004176.85 05G AMT GOV CNT PAID TOT : 000004176.85

FOR OFFICIAL USE ONLY

THIS INFORMATION IS PROTECTED BY THE PRIVACY ACT OF 1974 AND SUBJECT TO THE HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996, THE DEPARTMENT OF HEALTH AND HUMAN SERVICES PRIVACY RULE IN REGARD TO THAT ACT, AND THE DOD 6025.18R,DOD HEALTH INFORMATION PRIVACY REGULATION.

Page: 4

TED AUDIT DETAIL REPORT

COMBINED PAYMENT SAMPLE

CONTRACTOR: XXXX - North Region CONTRACT NO: MDA9999999999 AUDIT PERIOD: OCT XX-DEC XX TA200-001

NON-INSTITUTIONAL

TED ID: 111111111 Bllll 1111111 FILING STATE/COUNTRY: Alabama PART II

Attachment J-8 Example of TADR

TCRS HT9402-17-R-0002, Section J, Attachment J-8

FOR OFFICIAL USE ONLY

THIS INFORMATION IS PROTECTED BY THE PRIVACY ACT OF 1974 AND SUBJECT TO THE HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996, THE DEPARTMENT OF HEALTH AND HUMAN SERVICES PRIVACY RULE IN REGARD TO THAT ACT, AND THE DOD 6025.18R,DOD HEALTH INFORMATION PRIVACY REGULATION.

Page: 2

**** ADDITIONAL AUDIT INFORMATION

PATIENT ZIP CODE, STATE, CITY - 36701, AL, SELMA

STATUS= MTF= ALABAMA, AL @ 0 MILES

PRIN DX 6072 - INFLAM DISORD PENIS NEC

SEC DX-1 60789 - PENILE DISORDER NEC

SEC DX-2 4019 - HYPERTENSION NOS

*CURRENT* PROV TIN: 999888774 SUB ID: 0000 NTWK IND: 2 I/N IND: N

NAME: VAUGHAN REGIONAL MEDICAL CTR MAJ SPEC: 282NOOOOOX TRAN CD: M EFF DATE: 20050616

ADDRESS: 1015 MED CENTER PKWY SELMA AL 367016515 ACCEPT DATE: 20011001

BILLING ADDRESS: 1015 MEDICAL CENTER PKWY PARKW SELMA AL 367016748 TERM DATE: 00000000

*HISTORY* PROV TIN: 999888774 SUB ID: 0000 NTWK IND: 2 I/N IND: N

NAME: VAUGHAN REGIONAL MEDICAL CTR

ADDRESS: 1015 MED CENTER PKWY SELMA AL 367016515

MAJ SPEC: 282NOOOOOX TRAN CD: M EFF DATE: 20041115

ACCEPT DATE: 20011001

BILLING ADDRESS: 1015 MEDICAL CENTER PARKWAY PA SELMA AL 36701 TERM DATE: 00000000

*MORE HISTORY EXISTS*

*CURRENT* PROV TIN: 999888774 SUB ID: 0000 NTWK IND: 2 I/N IND: N

NAME: VAUGHAN REGI ONAL MEDICAL CTR MAJ SPEC: 282NOOOOOX TRAN CD: M EFF DATE: 20050616

ADDRESS: 1015 MED CEN TER PKWY SELMA AL 367016515 ACCEPT DATE: 20011001

BILLING ADDRESS: 1015 MEDICAL CENTER PKWY PARKW SELMA AL 367016748 TERM DATE: 00000000

*HISTORY* PROV TIN: 999888774 SUB ID: 0000 NTWK IND: 2 I/N IND: N

NAME: VAUGHAN REGIONAL MEDICAL CTR MAJ SPEC: 282NOOOOOX TRAN CD: M EFF DATE: 20041115

ADDRESS: 1015 MED CENTER PKWY SELMA AL 367016515 ACCEPT DATE: 20011001

BILLING ADDRESS: 1015 MEDICAL CENTER PARKWAY PA SELMA AL 36701 TERM DATE: 00000000

TED AUDIT DETAIL REPORT

COMBINED PAYMENT SAMPLE

CONTRACTOR: XXXX - North Region AUDIT PERIOD: OCT XX-DEC XX TA200-001 CONTRACT NO: MDA9999999999

NON-INSTITUTIONAL

TED ID: 111111111 Bllll 1111111 FILING STATE/COUNTRY: Alabama PART III

Attachment J-8 Example of TADR

TCRS HT9402-17-R-0002, Section J, Attachment J-8

07I 08I 09I 10I 11I occ TAX SUB NTWK ST/CNTY

FOR OFFICIAL USE ONLY

THIS INFORMATION IS PROTECTED BY THE PRIVACY ACT OF 1974 AND SUBJECT TO THE HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996, THE DEPARTMENT OF HEALTH AND HUMAN SERVICES PRIVACY RULE IN REGARD TO THAT ACT, AND THE DOD 6025.18R,DOD HEALTH INFORMATION PRIVACY REGULATION.

Page: 6

(I) PATIENT/SPONSOR INFORMATION BY PROCEDURE

Oli

PAY GD

02I

HCC RELAT

03I

HCC MBR

04I

ENRL PLAN

OSI

HCDP PLAN

CD

06I

HCDP

SPC CD

HCC

COPAY CD

05 A A SN

05 A A SN

05 A A SN

05 A A SN

05 A A SN

05 A A SN

05 A A SN

05 A A SN

05 A A SN

05 A A SN

05 A A SN

05 A A SN

05 A A SN

05 A A SN

05 A A SN

05 A A SN

(I) PROVIDER INFORMATION BY PROCEDURE

LN ID ID IND

12I

ZIP

13I

PROV

SPC CD

14I

INDV NPI

NUMBER (1)

lSI

ORG NPI

NUMBER (2)

16I

PART IND

42I

REF

NUMBER

001 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y

002 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 003 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 004 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 005 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 006 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 007 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 008 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 009 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 010 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 011 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 012 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 013 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 014 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 015 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 016 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y

TED AUDIT DETAIL REPORT

COMBINED PAYMENT SAMPLE

CONTRACTOR: XXXX - North Region AUDIT PERIOD: OCT XX-DEC XXCONTRACT NO: MDA9999999999 TA200-001

NON-INSTITUTIONAL

Attachment J-8 Example of TADR

TCRS HT9402-17-R-0002, Section J, Attachment J-8

FOR OFFICIAL USE ONLY

THIS INFORMATION IS PROTECTED BY THE PRIVACY ACT OF 1974 AND SUBJECT TO THE HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996, THE DEPARTMENT OF HEALTH AND HUMAN SERVICES PRIVACY RULE IN REGARD TO THAT ACT, AND THE DOD 6025.18R,DOD HEALTH INFORMATION PRIVACY REGULATION.

Page: 7

FILING STATE/COUNTRY: Alabama PART III TED ID: 111111111 B1111 1111111

(I) CLAIMS INFORMATION BY PROCEDURE 14A OCCURRENCE COUNT: 16

07I occ

17I

SP PROC

lSI

CA/NAS

19I

CA/NAS #

20I

CA/NAS

21I

PRICE

22I

PLA

23I

TYP

24I

PROC

25I

AD/DL

26I

OGP

27I

OGP BGN

28I

NDC

LN CD EXCP RSN CD RT CD SVC SRV CD MOD RSN CD TYPE CD RSN CD

001 SE 4 22 01

002 SE 4 22 01

003 SE 4 22 01

004 SE 4 22 01

005 SE A 22 05 TC

006 SE A 22 05 TC

007 SE A 22 05 TC

008 SE A 22 05 TC

009 SE A 22 05 TC

010 SE 4 22 02

011 SE A 22 05

012 SE A 22 05

013 SE 4 22 02

014 SE 4 22 07

015 SE 4 22 01

016 SE 4 22 01

(I) UTILIZATION DATA BY PROCEDURE

07I 29I occ PROC

30I

NBR

31I

AMT

32I

AMOUNT

33I

PTN CST

34I

APPL

35I

AMT GOV

36I

BGN

37I

END

38I

AMT

39I

APC

40I

OPPS

41I

AMNT NTWRK

LN CODE SERV BILLD ALLOWED SHR DED CNT PD DOC DOC PD OHI CD ST CD DISCOUNT

001 99088 23 0000641.35 0000641.35 0000000.00 000.00 0000641.35 20040920 20040921 0000000.00 A1111 A 0000000.0 002 99088 3 0000228.00 0000228.00 0000000.00 000.00 0000228.00 20040920 20040921 0000000.00 003 99070 23 0000451.98 0000451.98 0000000.00 000.00 0000451.98 20040920 20040921 0000000.00 004 99070 7 0000069.20 0000069.20 0000000.00 000.00 0000069.20 20040920 20040921 0000000.00 005 80048 1 0000089.00 0000010.48 0000000.00 000.00 0000010.48 20040920 20040921 0000000.00 006 85025 1 0000053.75 0000009.62 0000000.00 000.00 0000009.62 20040920 20040921 0000000.00 007 85610 1 0000036.75 0000004.86 0000000.00 000.00 0000004.86 20040920 20040921 0000000.00 008 85730 1 0000049.50 0000007.42 0000000.00 000.00 0000007.42 20040920 20040921 0000000.00 009 87070 1 0000049.50 0000010.66 0000000.00 000.00 0000010.66 20040920 20040921 0000000.00 010 36415 1 0000010.25 0000010.25 0000000.00 000.00 0000010.25 20040920 20040921 0000000.00 011 87076 1 0000044.50 0000010.00 0000000.00 000.00 0000010.00 20040920 20040921 0000000.00 012 87184 1 0000051.00 0000008.53 0000000.00 000.00 0000008.53 20040920 20040921 0000000.00 013 10060 1 0001461.00 0001461.00 0000000.00 000.00 0001461.00 20040920 20040921 0000000.00 014 00400 1 0000226.25 0000226.25 0000000.00 000.00 0000226.25 20040920 20040921 0000000.00 015 90596 1 0000592.25 0000592.25 0000000.00 000.00 0000592.25 20040920 20040921 0000000.00 016 99218 18 0000435.00 0000435.00 0000000.00 000.00 0000435.00 20040920 20040920 0000000.00

TED AUDIT DETAIL REPORT

OCCURRENCE SAMPLE

CONTRACTOR: XXXX - North Region CONTRACT NO: MDA9999999999 AUDIT PERIOD: OCT XX-DEC XX TA200-001

Attachment J-8 Example of TADR

TCRS HT9402-17-R-0002, Section J, Attachment J-8

FILING STATE/COUNTRY: Alaska PART I

INSTITUTIONAL

TED ID: 111111111 B1111 1111111

(A) CLAIM / PROCESSING INFORMATION

01A FIL DT 1111111 04A SUB TYPE A 07A OVERRIDE lOA CA/NAS EXCEP 13A REC-TYPE: 1

02A FIL ST AK 05A DTD ADJ ID 20099999 08A CLM FRM TYP F llA CA/NAS # 15A PRICE RT CD :J

03A SEQ NO B1111 06A PTC DT 20099999 09A SP PROC CD : v 12A CA/NAS RSN CD

(B) PATIENT/SPONSOR INFORMATION

01B PNT NAME JOHN H. SMITH

02B PNT ID: 123456789 04B PNT SEX : M 06B SP ID 987654321 08B PAY GD 06 lOB HCC RELAT : E

03B PNT DOB: 19999999 05B PNT ZIP: 20748 07B SP BOS : A 09B HCC MBR : R llB ENRL PLAN : Z

12B HCDP PLAN CD: 13B HCDP SPEC CD: 14B PCM DMIS ID: 15B HCC COPAY CD:

(C) PROVIDER INFORMATION

OlC TAX ID 999999999 03C NTWK IND 2 05C ZIP 995082932 07C PROV ORG NPI #:1234567890

02C SUB ID 0015 04C ST/CNTRY AK 06C TYPE INST: 10 08C PART ID : Y

(D) ADMISSION/DISCHARGE INFORMATION

OlD ADM DATE: 20080725 03D ADM SOURCE: 7 05D BGN DOC: 20080725 07D FREQ 1

02D ADM TYPE: 1 04D PTNT STAT : 01 06D END DOC: 20080730 08D COVD DAYS: 5

(E) DIAGNOSIS/TREATMENT PROCEDURE INFORMATION

OlE ADM DX 81321 06E SEC DX-4: 920 llE SEC DX-9 14E PRN OP PROC: 7674 19E SEC PROC-5: 24E SEC PROC-10:

02E PRN DX 81321 07E SEC DX-5: 5258 12E SEC DX-10 15E SEC PROC-1 7677 20E SEC PROC-6: 25E SEC PROC-11:

03E SEC DX-1: 8024 08E SEC DX-6: 13E SEC DX-11 16E SEC PROC-2 7902 21E SEC PROC-7:

04E SEC DX-2: 8028 09E SEC DX-7: 17E SEC PROC-3 22E SEC PROC-8: 26E DRG NUMBER : 233

05E SEC DX-3: 9571 10E SEC DX-8: 18E SEC PROC-4 23E SEC PROC-9: 27E HIPPS CODE:

(G) FINANCIAL INFORMATION

OlG AMT BILL TOT : 000029821.00 03G AMT PD OHI 000000000.00 05G AMT GOV CNT PAID TOT : 000013530.44

02G AMT ALLOW TOT: 000013585.44 04G PNT COST SHARE: 000000055.00 06G AMT NTWRK DISCOUNT: 000000000.00

FOR OFFICIAL USE ONLY

THIS INFORMATION IS PROTECTED BY THE PRIVACY ACT OF 1974 AND SUBJECT TO THE HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996, THE DEPARTMENT OF HEALTH AND HUMAN SERVICES PRIVACY RULE IN REGARD TO THAT ACT, AND THE DOD 6025.18R,DOD HEALTH INFORMATION PRIVACY REGULATION.

Page: 8

Attachment J-8 Example of TADR

TCRS HT9402-17-R-0002, Section J, Attachment J-8

FOR OFFICIAL USE ONLY

THIS INFORMATION IS PROTECTED BY THE PRIVACY ACT OF 1974 AND SUBJECT TO THE HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996, THE DEPARTMENT OF HEALTH AND HUMAN SERVICES PRIVACY RULE IN REGARD TO THAT ACT, AND THE DOD 6025.18R,DOD HEALTH INFORMATION PRIVACY REGULATION.

Page: 9

CONTRACT NO: MDA9999999999

TED AUDIT DETAIL REPORT

OCCURRENCE SAMPLE

CONTRACTOR: XXXX - North Region AUDIT PERIOD: OCT XX-DEC XX

TRICARE Purchased Care Report Run Date: 01/11/XXXX

TA200-001

FILING STATE/COUNTRY: Alaska PART II

INSTITUTIONAL

TED ID: 111111111 B1111 1111111

**** ADDITIONAL AUDIT INFORMATION ****

PATIENT ZIP CODE, STATE, CITY - 20748, MD, TEMPLE HILLS

STATUS= A MTF= WALTER REED ARMY MEDICAL @ 12 MILES

ADM DX 81321 - CL FX RADIUS SHAFT

PRIN DX 81321 - CL FX RADIUS SHAFT

SEC DX-1 8024 - CLSD FX MALAR/MAXILLARY

SEC DX-2 8028 - CLSD FX FACIAL BONE NEC

SEC DX-3 9571 - INJURY TO NERVE NEC

SEC DX-4 920 - CONTUSION HEAD X EYE

SEC DX-5 5258 - DENTAL DISORDER NEC

PRN OP PROC 7674 - OPEN RED MAXILLARY FX

SEC PROC-1 7677 - OPEN RED ALVEOLAR FX

SEC PROC-2 7902 - CLSD FX RED RADIUS/ULNA

*CURRENT* PROV TIN: 999999999 SUB ID: 0015 MEDICARE #: 000000 NTWK IND: 2 I/N IND: I

NAME: ALASKA REGIONAL HOSPITAL

ADDRESS: 2801 DEBARR RD ANCHORAGE AK 995082932

BILLING ADDRESS: PO BOX 409790 ATLANTA 303849790

TYP INST: 10 TRAN CD: M EFF DATE: 20061128

ACCEPT DATE: 19670101

TERM DATE: 00000000

DRG EXEMPT IND: N DRG EFFECT DATE: 19871001

WAGE-INDEX: 1.0000 WAGE EFFECT DATE: 20041001

RURAL/URBAN CODE: U

IDME-RATIO: 0.0000 IDME EFFECT DATE: 00000000

*HISTORY* PROV TIN: 999999999 SUB ID: 0015 MEDICARE #: 000000 NTWK IND: 2 I/N IND: I

NAME: ALASKA REGIONAL HOSPITAL

ADDRESS: 2801 DEBARR RD ANCHORAGE AK 995082932

BILLING ADDRESS: PO BOX 409790 ATLANTA 303849790

TYP INST: 10 TRAN CD: M EFF DATE: 20060824

ACCEPT DATE: 19670101

TERM DATE: 00000000

DRG EXEMPT IND: N

WAGE-INDEX: 1.0000

DRG EFFECT DATE: 19871001

WAGE EFFECT DATE: 20041001

RURAL/URBAN CODE: U

IDME-RATIO: 0.0000 IDME EFFECT DATE: 00000000

*MORE HISTORY EXISTS*

TED AUDIT DETAIL REPORT

OCCURRENCE SAMPLE

CONTRACTOR: XXXX - North Region AUDIT PERIOD: OCT XX-DEC XXCONTRACT NO: MDA9999999999 TA200-001

Attachment J-8 Example of TADR

TCRS HT9402-17-R-0002, Section J, Attachment J-8

FOR OFFICIAL USE ONLY

THIS INFORMATION IS PROTECTED BY THE PRIVACY ACT OF 1974 AND SUBJECT TO THE HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996, THE DEPARTMENT OF HEALTH AND HUMAN SERVICES PRIVACY RULE IN REGARD TO THAT ACT, AND THE DOD 6025.18R,DOD HEALTH INFORMATION PRIVACY REGULATION.

Page: 1 0

FILING STATE/COUNTRY: Alaska

(H) REVENUE DATA 14A OCCURRENCE COUNT: 19

PART III

INSTITUTIONAL

TED ID: 111111111 B1111 1111111

07H ace

01H

REVENUE

02H

UNITS OF

03H

TOTAL

04H

ADJ/DNL

05H

OGP TYPE

06H

OGP BEG

LN CODE SERVICE CHARGE CODE CD RSN CD

001 0001 0 0029821.00 002 0123 5 0004965.00 003 0250 16 0001104.00 004 0255 1 0000236.00 005 0258 14 0001092.00 006 0259 2 0000181.00 007 0270 14 0000829.00 008 0272 11 .0001224.00 009 0301 6 0001375.00 010 0305 1 0000224.00 011 0320 9 0001941.00 012 0324 1 0000188.00 013 0350 2 0001512.00 014 0351 2 0002736.00 015 0352 2 0002599.00 016 0360 4 0003712.00 017 0370 8 0001586.00 018 0450 3 0001779.00 12 019 0710 6 0002538.00

TED AUDIT DETAIL REPORT

OCCURRENCE SAMPLE

CONTRACTOR: XXXX - North Region CONTRACT NO: MDA9999999999 AUDIT PERIOD: OCT XX-DEC XX TA200-001

Attachment J-8 Example of TADR

TCRS HT9402-17-R-0002, Section J, Attachment J-8

FILING STATE/COUNTRY: Alabama

(A) CLAIM / PROCESSING INFORMATION

01A FIL DT 1111111 04A SUB TYPE A

02A FIL ST AL 05A DTD ADJ ID 00000000

03A SEQ NO B1111 06A PTC DT 20081001

(B) PATIENT/SPONSOR INFORMATION

01B PNT NAME JOHN P. SMITH

02B PNT ID 123456789 04B PNT SEX M

03B PNT DOB 19771099 05B PNT ZIP 36701

PART I

07A OVERRIDE 13A REC-TYPE: 2

08A CLM FRM TYP : G

06B SP ID 999999999 08B PCM DMIS ID:

07B SP BOS N

NON-INSTITUTIONAL

TED ID: 111111111 B1111 1111111

(F) DIAGNOSIS INFORMATION

01F PRIN DX : 6072 03F SEC DX-2: 4019 05F SEC DX-4: 07F SEC DX-6: 09 SEC DX-8 11 SEC DX-10

02F SEC DX-1: 60789 04F SEC DX-3: 06F SEC DX-5: 08F SEC DX-7: 10 SEC DX-9 12 SEC DX-11

(G) FINANCIAL INFORMATION

01G AMT BILL TOT : 000004489.28 04G PNT COST SHARE : 000000000.00 06G AMT NETWORK DISCOUNT: 000000000.00

02G AMT ALLOW TOT: 000004176.85 05G AMT GOV CNT PAID TOT : 000004176.85

FOR OFFICIAL USE ONLY

THIS INFORMATION IS PROTECTED BY THE PRIVACY ACT OF 1974 AND SUBJECT TO THE HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996, THE DEPARTMENT OF HEALTH AND HUMAN SERVICES PRIVACY RULE IN REGARD TO THAT ACT, AND THE DOD 6025.18R,DOD HEALTH INFORMATION PRIVACY REGULATION.

Page: 11

TED AUDIT DETAIL REPORT

OCCURRENCE SAMPLE

CONTRACTOR: XXXX - North Region CONTRACT NO: MDA9999999999 AUDIT PERIOD: OCT XX-DEC XX TA200-001

NON-INSTITUTIONAL

TED ID: 111111111 Bllll 1111111 FILING STATE/COUNTRY: Alabama PART II

Attachment J-8 Example of TADR

TCRS HT9402-17-R-0002, Section J, Attachment J-8

FOR OFFICIAL USE ONLY

THIS INFORMATION IS PROTECTED BY THE PRIVACY ACT OF 1974 AND SUBJECT TO THE HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996, THE DEPARTMENT OF HEALTH AND HUMAN SERVICES PRIVACY RULE IN REGARD TO THAT ACT, AND THE DOD 6025.18R,DOD HEALTH INFORMATION PRIVACY REGULATION.

Page: 12

**** ADDITIONAL AUDIT INFORMATION

PATIENT ZIP CODE, STATE, CITY - 36701, AL, SELMA

STATUS= MTF= ALABAMA, AL @ 0 MILES

PRIN DX

SEC DX-1

SEC DX-2

60789

- INFLAM DISORD PENIS NEC

- PENILE DISORDER NEC

- HYPERTENSION NOS

*CURRENT* PROV TIN: 999888774 SUB ID: 0000 NTWK IND: 2 I/N IND: N

NAME: VAUGHAN REGIONAL MEDICAL CTR MAJ SPEC: 282NOOOOOX TRAN CD: M EFF DATE: 20050616

ADDRESS: 1015 MED CENTER PKWY SELMA AL 367016515 ACCEPT DATE: 20011001

BILLING ADDRESS: 1015 MEDICAL CENTER PKWY PARKW SELMA AL 367016748 TERM DATE: 00000000

*HISTORY* PROV TIN: 999888774 SUB ID: 0000 NTWK IND: 2 I/N IND: N

NAME: VAUGHAN REGIONAL MEDICAL CTR

ADDRESS: 1015 MED CENTER PKWY SELMA AL 367016515

MAJ SPEC: 282NOOOOOX TRAN CD: M EFF DATE: 20041115

ACCEPT DATE: 20011001

BILLING ADDRESS: 1015 MEDICAL CENTER PARKWAY PA SELMA AL 36701 TERM DATE: 00000000

*MORE HISTORY EXISTS*

*CURRENT* PROV TIN: 999888774

NAME: VAUGHAN REGI

SUB ID: 0000

ONAL MEDICAL CTR MAJ SPEC: 282NOOOOOX

NTWK IND: 2

TRAN CD: M

I/N IND: N

EFF DATE: 20050616

ADDRESS: 1015 MED CENTER PKWY SELMA AL 367016515 ACCEPT DATE: 20011001

BILLING ADDRESS: 1015 MEDICAL CENTER PKWY PARKW SELMA AL 367016748 TERM DATE: 00000000

*HISTORY* PROV TIN: 999888774 SUB ID: 0000 NTWK IND: 2 I/N IND: N

NAME: VAUGHAN REGIONAL MEDICAL CTR MAJ SPEC: 282NOOOOOX TRAN CD: M EFF DATE: 20041115

ADDRESS: 1015 MED CENTER PKWY SELMA AL 367016515 ACCEPT DATE: 20011001

BILLING ADDRESS: 1015 MEDICAL CENTER PARKWAY PA SELMA AL 36701 TERM DATE: 00000000

TED AUDIT DETAIL REPORT

OCCURRENCE SAMPLE

CONTRACTOR: XXXX - North Region AUDIT PERIOD: OCT XX-DEC XXCONTRACT NO: MDA9999999999 TA200-001

NON-INSTITUTIONAL

TED ID: 111111111 Bllll 1111111 PART III FILING STATE/COUNTRY: Alabama

Attachment J-8 Example of TADR

TCRS HT9402-17-R-0002, Section J, Attachment J-8

13I 14I lSI 16I 42I

PROV INDV NPI ORG NPI PART IND REF

FOR OFFICIAL USE ONLY

THIS INFORMATION IS PROTECTED BY THE PRIVACY ACT OF 1974 AND SUBJECT TO THE HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996, THE DEPARTMENT OF HEALTH AND HUMAN SERVICES PRIVACY RULE IN REGARD TO THAT ACT, AND THE DOD 6025.18R,DOD HEALTH INFORMATION PRIVACY REGULATION.

Page: 13

(I) PATIENT/SPONSOR INFORMATION BY PROCEDURE

Oli

PAY GD

02I

HCC RELAT

03I

HCC MBR

04I

ENRL PLAN

OSI

HCDP PLAN

CD

06I

HCDP

SPC CD

43I

HCC

COPAY CD

OS A A SN

OS A A SN

OS A A SN

OS

OS

A A

A A

SN

SN

OS

OS

A A

A A

SN

SN

OS

OS

OS

A A A

A A A

SN

SN

SN

OS A A SN

OS

OS

OS

A A A

A A A

SN

SN

SN

OS

OS

A A

A A

SN

SN

(I) PROVIDER INFORMATION BY PROCEDURE

07I ace

OBI

TAX

09I

SUB

lOI

NTWK

lli

ST/CNTY

12I

ZIP

LN ID ID IND SPC CD NUMBER (1) NUMBER (2) NUMBER

001 621864231 0000 2 AL 367016S1S 282NOOOOOX 0000000000 0000000000 y 002 621864231 0000 2 AL 367016SlS 282NOOOOOX 0000000000 0000000000 y 003 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 004 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y oos 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 006 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 007 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 008 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 009 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 010 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 011 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 012 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 013 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 014 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y 015 621864231 0000 2 AL 36701651S 282NOOOOOX 0000000000 0000000000 y 016 621864231 0000 2 AL 367016515 282NOOOOOX 0000000000 0000000000 y

TED AUDIT DETAIL REPORT

OCCURRENCE SAMPLE

CONTRACTOR: XXXX - North Region AUDIT PERIOD: OCT XX-DEC XX TA200-001 CONTRACT NO: MDA9999999999

NON-INSTITUTIONAL

Attachment J-8 Example of TADR

TCRS HT9402-17-R-0002, Section J, Attachment J-8

FOR OFFICIAL USE ONLY

THIS INFORMATION IS PROTECTED BY THE PRIVACY ACT OF 1974 AND SUBJECT TO THE HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996, THE DEPARTMENT OF HEALTH AND HUMAN SERVICES PRIVACY RULE IN REGARD TO THAT ACT, AND THE DOD 6025.18R,DOD HEALTH INFORMATION PRIVACY REGULATION.

Page: 14

FILING STATE/COUNTRY: Alabama PART III TED ID: 111111111 B1111 1111111

(I) CLAIMS INFORMATION BY PROCEDURE 14A OCCURRENCE COUNT: 16

07I occ

17I

SP PROC

lSI

CA/NAS

19I

CA/NAS #

20I

CA/NAS

21I

PRICE

22I

PLA

23I

TYP

24I

PROC

2SI

AD/DL

26I

OGP

27I

OGP BGN

28I

NDC

LN CD EXCP RSN CD RT CD SVC SRV CD MOD RSN CD TYPE CD RSN CD

001 SE 4 22 01

002 SE 4 22 01

003 SE 4 22 01

004 SE 4 22 01

oos SE A 22 OS TC

006 SE A 22 OS TC

007 SE A 22 05 TC

008 SE A 22 05 TC

009 SE A 22 05 TC

010 SE 4 22 02

011 SE A 22 OS

012 SE A 22 OS

013 SE 4 22 02

014 SE 4 22 07

OlS SE 4 22 01

016 SE 4 22 01

(I) UTILIZATION DATA BY PROCEDURE

07I 29I occ PROC

30I

NBR

31!

AMT

32I

AMOUNT

33I

PTN CST

34I

APPL

3SI

AMT GOV

36I

BGN

37I

END

38I

AMT

39I

APC

40I

OPPS

41I

AMNT NTWRK

LN CODE SERV BILLD ALLOWED SHR DED CNT PD DOC DOC PD OHI CD ST CD DISCOUNT

001 99088 23 0000641.35 0000641.3S 0000000.00 000.00 0000641.3S 20040920 20040921 0000000.00 A1111 A 0000000.0 002 99088 3 0000228.00 0000228.00 0000000.00 000.00 0000228.00 20040920 20040921 0000000.00 003 99070 23 0000451.98 0000451.98 0000000.00 000.00 0000451.98 20040920 20040921 0000000.00 004 99070 7 0000069.20 0000069.20 0000000.00 000.00 0000069.20 20040920 20040921 0000000.00 oos 80048 1 0000089.00 0000010.48 0000000.00 000.00 0000010.48 20040920 20040921 0000000.00 006 8S02S 1 0000053.7S 0000009.62 0000000.00 000.00 0000009.62 20040920 20040921 0000000.00 007 8S610 1 0000036.75 0000004.86 0000000.00 000.00 0000004.86 20040920 20040921 0000000.00 008 85730 1 0000049.SO 0000007.42 0000000.00 000.00 0000007.42 20040920 20040921 0000000.00 009 87070 1 0000049.SO 0000010.66 0000000.00 000.00 0000010.66 20040920 20040921 0000000.00 010 36415 1 0000010.25 0000010.25 0000000.00 000.00 0000010.2S 20040920 20040921 0000000.00 011 87076 1 0000044.SO 0000010.00 0000000.00 000.00 0000010.00 20040920 20040921 0000000.00 012 87184 1 0000051.00 0000008.53 0000000.00 000.00 0000008.S3 20040920 20040921 0000000.00 013 10060 1 0001461.00 0001461.00 0000000.00 000.00 0001461.00 20040920 20040921 0000000.00 014 00400 1 0000226.25 0000226.25 0000000.00 000.00 0000226.2S 20040920 20040921 0000000.00 015 90S96 1 0000592.2S 0000592.25 0000000.00 000.00 OOOOS92.2S 20040920 20040921 0000000.00 016 99218 18 0000435.00 0000435.00 0000000.00 000.00 0000435.00 20040920 20040920 0000000.00

File details come from the government source that posted it. Updated .