19_TCRS_Sec_J_Atch_J-9_Example_of_ADDR.pdf

Attachment J-9 Example of ADDR

TCRS HT9402-17-R-0002, Section J, Attachment J-9 Page 1 of 4

TED AUDIT DETAIL REPORT TRICARE Purchased Care COMBINED PAYMENT SAMPLE Report Run Date: 05/11/XXXX

CONTRACT NO: H94002-07-R-0002 CONTRACTOR: XXXX – ACTIVE DUTY DENTAL PROGRAM AUDIT PERIOD: OCT XX-APR XX TA200-001

NON-INSTITUTIONAL

FILING STATE/COUNTRY: Alabama PART I CLAIM ID: 111111111 B1111

(A) CLAIM INFORMATION

01A CLAIM ID (KEY): 04A DATE CLAIM PAID:

02A ADJ CODE: 05A DATE CLAIM SUBMITTED:

03A DENIAL REASON CODE:

(B) PATIENT INFORMATION

01B PNT ID: 02B PNT SSN: 03B PNT DOB:

04B PNT SEX: 05B PNT PH #:

(C) PROVIDER IDENTIFICATION

01C PROV NAME: 02C PROV GRP NAME: 03SC PROV TIN: 04C PROV SUB ID:

05C PROV TAXNMY: 06C PROV INDV NPI: 07C PROV GRP NPI: 08C PROV SPEC:

09C PROV ADDRESS: 10C ST: 11C ZIP/CNTRY CD: 12C PROV PART:

(D) REFERRAL INFORMATION

01D REFERRAL NUMBER:

(E) FINANCIAL INFORMATION

01E AMT BILLED TOT: 000000000.00 02E AMT ALLOW TOT: 000000000.00 03E AMT PAID TOT: 000000000.00

04E TPL PAYMENT: 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.

TCRS HT9402-17-R-0002, Section J, Attachment J-9 Page 2 of 4

Page: 1

TED AUDIT DETAIL REPORT TRICARE Purchased Care COMBINED PAYMENT SAMPLE Report Run Date: 05/11/XXXX

CONTRACT NO: H94002-07-R-0002 CONTRACTOR: XXXX – ACTIVE DUTY DENTAL PROGRAM AUDIT PERIOD: OCT XX-APR XX TA200-001

NON-INSTITUTIONAL

FILING STATE/COUNTRY: Alabama PART II CLAIM ID: 111111111 B1111

(I) CARE DATA

01I 02I 03I 04I 05I 06I 07I 08I 09I 10I

OCC QUADRANT ANTERIOR/ INCISAL FACIAL OCCLUSAL LINGUAL BUCCAL MESIAL DISTAL

LN POSTERIOR SURFACE SURFACE SURFACE SURFACE SURFACE SURFACE SURFACE

IND Y/N IND Y/N IND Y/N IND Y/N IND Y/N IND Y/N Y/N Y/N

(I) UTILIZATION DATA

01I 11I 12I 13I 14I 15I 16I 17I 18I 19I 20I 21I

OCC CDT CDT CD TOOTH AMT AMOUNT PTN CST APPL AMT BEG DT END DT AMT

LN CODE VER ID BILLD ALLOWED SHR DED PD CARE CARE PD OHI

001 99088 23 0000641.35 0000641.35 0000000.00 000.00 0000641.35 20040920 20040921 0000000.00 002 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

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

TCRS HT9402-17-R-0002, Section J, Attachment J-9 Page 3 of 4

TED AUDIT DETAIL REPORT TRICARE Purchased Care OCCURRENCE SAMPLE Report Run Date: 05/11/XXXX

CONTRACT NO: H94002-07-R-0002 CONTRACTOR: XXXX – ACTIVE DUTY DENTAL PROGRAM AUDIT PERIOD: OCT XX-APR XX TA200-001

NON-INSTITUTIONAL

FILING STATE/COUNTRY: Alabama PART I CLAIM ID: 111111111 B1111

(A) CLAIM INFORMATION

01A CLAIM ID (KEY): 04A DATE CLAIM PAID:

02A ADJ CODE: 05A DATE CLAIM SUBMITTED:

03A DENIAL REASON CODE:

(B) PATIENT INFORMATION

01B PNT ID: 02B PNT SSN: 03B PNT DOB:

04B PNT SEX: 05B PNT PH #:

(C) PROVIDER IDENTIFICATION

01C PROV NAME: 02C PROV GRP NAME: 03SC PROV TIN: 04C PROV SUB ID:

05C PROV TAXNMY: 06C PROV INDV NPI: 07C PROV GRP NPI: 08C PROV SPEC:

09C PROV ADDRESS: 10C ST: 11C ZIP/CNTRY CD: 12C PROV PART:

(D) REFERRAL INFORMATION

01D REFERRAL NUMBER:

(E) FINANCIAL INFORMATION

01E AMT BILLED TOT: 000000000.00 02E AMT ALLOW TOT: 000000000.00 03E AMT PAID TOT: 000000000.00

04E TPL PAYMENT: 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.

TCRS HT9402-17-R-0002, Section J, Attachment J-9 Page 4 of 4

Page: 1

TED AUDIT DETAIL REPORT TRICARE Purchased Care OCCURRENCE SAMPLE Report Run Date: 05/11/XXXX

CONTRACT NO: H94002-07-R-0002 CONTRACTOR: XXXX – ACTIVE DUTY DENTAL PROGRAM AUDIT PERIOD: OCT XX-APR XX TA200-001

NON-INSTITUTIONAL

FILING STATE/COUNTRY: Alabama PART II CLAIM ID: 111111111 B1111

(I) CARE DATA

01I 02I 03I 04I 05I 06I 07I 08I 09I 10I

OCC QUADRANT ANTERIOR/ INCISAL FACIAL OCCLUSAL LINGUAL BUCCAL MESIAL DISTAL

LN POSTERIOR SURFACE SURFACE SURFACE SURFACE SURFACE SURFACE SURFACE

IND Y/N IND Y/N IND Y/N IND Y/N IND Y/N IND Y/N Y/N Y/N

(I) UTILIZATION DATA

01I 11I 12I 13I 14I 15I 16I 17I 18I 19I 20I 21I

OCC CDT CDT CD TOOTH AMT AMOUNT PTN CST APPL AMT BEG DT END DT AMT

LN CODE VER ID BILLD ALLOWED SHR DED PD CARE CARE PD OHI

001 99088 23 0000641.35 0000641.35 0000000.00 000.00 0000641.35 20040920 20040921 0000000.00 002 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

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