20_TCRS_Sec_J_Atch_J-10_DHA_Comp_Rvw_Gdlns.pdf

Attachment J-10 Compliance Review Guidelines

TCRS HT9402-17-R-0002, Section J, Attachment J-10

Department of Defense – Defense Health Agency TRICARE Claims Review Services

Compliance Review Guidelines

CHAPTER PAGE

INTRODUCTION

A. Background 1 B. Purpose 1 C. Applicability of the Claims Audit Guidelines 1

CHAPTER 1 – CLAIMS AUDIT PROCESS

A. GENERAL 2

1. Purpose 2

2. Scope 2

3. Claim Sampling 2

B. CONDUCTING THE AUDIT 2

1. Preparation 2

2. Use of the Ted Audit Detail Report (TADR) 2

3. Auditing Techniques 3

4. Medical Review Determination 3

C. POST-AUDIT REPORTS 4

1. Creating the Post-Audit Reports 4

2. Verification of the Audit Reports 4

D. ANALYSIS OF CONTRACTOR PAYMENT AND OCCURRENCE

AUDIT ERROR REPORT 4

1. Analysis of Errors 4

2. Significant Audit Findings 4

3. Monitoring Deficiencies 4

E. REBUTTALS OF AUDIT FINDINGS 5

1. Time Period 5

2. Responses to Rebuttals 5

F. CONFIDENTIALITY OF AUDIT DOCUMENTS 5

CHAPTER 2 – AUTOMATED TED AUDIT (TA) APPLICATION

A. INTRODUCTION 6

B. SCOPE OF AUTOMATED FEATURES 6

C. DESCRIPTION OF AUTOMATED FUNCTIONS 6

1. Select Claims Sample

2. Access Table 6

3. Create Claim Sampling Reports (Pre-Audit Reports) 7

4. Enter Audit Errors 7

5. Create Final Audit Reports (Post-Audit Reports) 7

6. Maintain History Data 8

CHAPTER 3 – AUDITING TED DATA ELEMENTS

A Adjustment/Denial Reason Code 9 Admission Date 9 Admission Diagnosis 9 Ambulatory Payment Classification (APC) Code 9 Amount Allowed (Total) 9 Amount Allowed Pay Procedure Code 10 Amount Applied Toward Deductible 10 Amount Billed (Total) 10 Amount Billed (by Procedure Code) 10 Amount Network Provider Discount 11 Amount Paid by Government Contractor (Total) 11 Amount Paid by Government Contractor (by Procedure) 12 Amount paid by Other Health Insurance 12 Amount Patient Cost-Share 13

B Begin Date of Care 13

C CA/NAS Exception Reason 13 CA/NAS Issuance Reason Code 14 CA/NAS Number 14 Claim Form Type/EMC Indicator 14 Covered Days 14

D Date Adjustment Identified 15 Date TED Record Processed to Completion 15 DRG Number 15

E End Date of Care 15 Enrollment/Health Plan Code 15

F Filing Date 16 Filing State/Country Code 16

Frequency Code 16

H Health Care Coverage (HCC) CoPayment Factor Code 16 Health Care Coverage (HCC) Member Category Code 17 Health Care Delivery Program (HCDP) Plan Coverage 17 Health Care Delivery Program (HCDP) Special Entitlement Code 17 HIPPS Code 17

N National Drug Code 17 Number of Services 17

O Occurrence/Line Item Number 18 OPPS Payment Status Indicator Code 18 Other Government Program (OGP) Begin Reason Code 18 Other Government Program (OGP) Type Code 18 Override Code 18

P Patient Status 19 Patient Zip Code 19 Pay Grade (Sponsor) 20 PCM Location 20 Person Birth Calendar Date (Patient) 20 Person Identifier (Sponsor) 20 Person Identifier (Patient) 20 Person Name (Patient) 21 Person Sex (Patient) 21 Physician Referral Number 21 Place of Service 21 Pricing Rate Code 21 Principal Operation/Non-Surgical Procedure Code 21 Principal Treatment Diagnosis 22 Procedure Code Number 22 Procedure Code Modifier 23 Provider Individual NPI Number (Type 1) 23 Provider Network Status Indicator 23 Provider Organizational NPI Number (Type 2) 23 Provider Participation Indicator 23

Provider Taxonomy (Specialty) 24 Provider State or Country Code 24 Provider Sub-Identifier 24 Provider Taxpayer Number 24

Provider Zip Code 25

R Record Type Indicator 25 Revenue Code 25

S Secondary Operation/Non-Surgical Procedure Code 25 Secondary Treatment Diagnosis 25 Sequence Number 26 Service Branch Classification Code 26 Source of Admission 26 Special Processing Code 26

T Total Charge by Revenue Code 26 Total Occurrence/Line Item Count 27 Type of Admission 27 Type of Institution 27 Type of Service 27 Type of Submission 28

U Units of Service by Revenue Code 28

CHAPTER 4 – ASSESSMENT OF TRICARE ENCOUNTER (TED) RECORD

OCCURRENCE, PAYMENT AND PROCEDURAL ERRORS

A. INTRODUCTION 29

B. TED RECORD OCCURRENCE ERRORS 29

1. General 29

2. Errors Specific to Data Field Category 29

3. Errors NOT Specific to Data Fields 29

a. “J” Category Error Conditions and Number of Errors

Assessed 30

b. Auditing “J” Category Errors 31

C. TED RECORD PAYMENT ERRORS 33

1. Type of Payment Errors 34

2. Assessing Payment Errors 36

3. Amount Billed for Computation of Payment Error Rates 36

D. PROCEDURAL/DOCUMENTATION ERRORS 36

E. PROCESS ERRORS 37

APPENDIX A

TED Audit Detail Record (TADR) Data Elements 39

APPENDIX B

TED Audit Error Categories 43

TCRS HT9402-17-R-0002, Section J, Attachment J-10 Page 1 of 52

INTRODUCTION

A. BACKGROUND

Claims processing services are competitively procured through TRICARE purchased-care contractors (.

Each TRICARE claims processing contractor is contractually responsible for the timely and accurate adjudication of all TRICARE claim types for a specific regional jurisdiction. Each purchased-care contractors is charged with providing or arranging for delivery of quality, timely health care services and have the responsibility for providing the timely and accurate processing of all claims received into their custody. It is the responsible of the purchased-care contractor to report detailed information for each treatment encounter transactions through the TRICARE Encounter Data (TED) records to Defense Health Agency (DHA). The TED record provides detailed information for each treatment encounter and are required for DHA health care and financial reporting to the Office of the Secretary of Defense Health Affairs (OASD-HA), DHA, Uniformed Services, TRICARE Regional Offices, Congress, other governmental entities and to the public.

B. PURPOSE OF THE CLAIMS AUDIT

The purpose of the ongoing claims audit program of DHA is to determine the accuracy of each purchased-care contractor's claims processing procedures and to determine the accuracy of TED payment record coding. The error findings are reported in terms of either payment error rates or payment record coding occurrence error rates. These error rates are important indicators of each purchased-care contractor's claims processing performance. The error rates are used to determine whether the purchased-care contractor qualifies for monetary awards or reductions in accordance with the positive and negative provisions of the purchased-care contracts. The audits also serve to identify specific areas of contractual noncompliance requiring corrective action by the purchased-care contractor and to determine if certain changes to operational and policy requirements have been implemented by each purchased-care contractor as directed by DHA.

C. APPLICABILITY OF THE CLAIMS AUDIT GUIDELINES

These guidelines are intended for the sole use by DHA Program Analysts and the TRICARE Claims Review Services (TCRS) contractor. They have been written solely for the purpose of facilitating the auditing of purchased-care contractor processed claims. They are not intended, nor should they be construed, in any way to take precedence over or contradict purchased-care contractor contractual requirements or existing TRICARE Policy, Operations, System, or Reimbursement requirements, or existing legislative, regulatory or policy directives relative to Chapter 55, Title 10 of the United States Code (USC). They are not intended to provide operational or procedural guidance for the purchased-care contractors.

Any contradictions or inconsistencies between these guidelines and the directives and contractual requirements referred to above are unintentional and are to be brought to the attention of the Chief, Improper Payment Evaluation & Transition Section, DHA.

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CHAPTER 1 – CLAIMS AUDIT PROCESS

A. General

1. Purpose. The purpose of the DHA claims audit is to determine the accuracy of institutional, and non-institutional claims payment, and to determine the accuracy of TRICARE Encounter Data (TED) payment record coding for the institutional, and non-institutional claims. The resulting payment or occurrence error rates are used to evaluation the purchased-care contractor’s performance against TMA claims processing standards under the terms of their individual contracts, and in the application of positive or negative incentive provisions of the individual purchased-care contractor’s contract. The audits are also used to identify underwritten unallowable health care costs in the Annual Health Care cost audits.

2. Scope. The audit process entails: 1) the evaluation of purchased-care contractor payment determinations based on the claim form submitted for reimbursement by the TRICARE eligible beneficiary, health care provider, the purchased-care contractors claims processing documentation, other source documents, files used by the purchased-care contractor in the adjudication process, and; 2) the evaluation of contractor TED’s payment record coding based on the above documentation, and the purchased-care contractor’s payment determination. These evaluations are made by comparing the purchased-care contractor's claims processing, and coding decisions with requirements in the TRICARE Policy Manual (TPM); the TRICARE Reimbursement Manual (TRM); the TRICARE Operations Manual (TOM); the TRICARE Systems Manual (TSM); and the individual purchased-care contracts.

3. Claim Sampling. Each purchased-care contract is audited on a quarterly, semi-annual, or annual basis depending on the purchased-care contractor’s contract requirement. Samples of each purchased-care contractor's processed claims are selected from edited TED payment record submissions received at DHA within each contract audit period. This sample selection process is automated, and begins the sequence of auditing events. See Section J, Attachment J-4, DHA Sampling Methodology, for additional information regarding DHA’s sampling methodologies.

B. Conducting the Audit

1. Preparation

a. Prior to beginning an audit, the auditor will review the Deficiency File for the individual contract he/she is to audit to become familiar with error findings from previous audits.

2. Use of the TED Audit Detail Report (TADR)

a. The primary tool during the audit is the TADR. This report is a facsimile of the TED payment record as reported by the purchased-care contractor for those claims selected for audit.

Each TEDs data field identified on the TADR is found in the TRICARE Systems Manual, Chapter 2, Sections 2.2. The data fields are identified by abbreviated name, and labeled with an alphanumeric code which is used for recording error conditions. The auditor records payment, or occurrence errors assessed on audit on this form as they are identified by highlighting, or otherwise marking the error code, or field.

Explanations of reasons for assessing errors will also be entered on the TADR in narrative form. Since these reports will be stored after the audit, care must be taken to maintain their legibility.

b. The TADR contains claims processing, patient, and sponsor information;

provider information; admission and discharge information; procedure, and diagnostic code narrative

TCRS HT9402-17-R-0002, Section J, Attachment J-10 Page 3 of 52 descriptions and utilization information; and zip code catchment area information based on the data submitted on the payment record by the purchased-care contractor to facilitate recording of errors, and eliminate some file look-ups.

3. Auditing Techniques. Specific error assessment and auditing guidelines are provided in Chapters 3, 4, and 5. Each auditor develops an approach to verify the accuracy of each purchased-care contractors payment record coding, benefit determinations during on-the-job training, and experience.

Generally, the following considerations apply to every claim audited. These are not all-inclusive, nor are any sequential order prescribed. Each auditor is expected to develop an approach which is most effective for timely and accurate results, as follows:

a. Was the claim properly executed (appropriate signatures, timely filed, valid claim form, and provider participation certification)?

b. Is the patient eligible? Is the patient enrolled in TRICARE Prime? Is the patient and sponsor information properly coded?

c. Is the provider authorized? Is the provider contracted, or not contracted? Is the provider information (provider number, zip code, specialty, capacity) and coded correctly?

d. Is the diagnosis coded properly? Is it covered?

e. Is a Preauthorization, or Care Authorization/Non-availability Statement (CA/NAS) needed? If so, is it present?

f. Are the service(s), and date(s) of service coded properly? Is each service a benefit? Is each service medically necessary? Was it provided at the appropriate level? Does it require medical review? If so, is documentation of the medical review determination present and correct?

g. Are the billed charges reported correctly? Are the allowed amounts correct?

Was other health insurance or third party liability properly considered? Is the deductible properly credited? Is the patient's cost-share correct? Is the amount of payment correct? Was payment made to the correct party?

h. Was the payment record properly prepared? Are the data fields coded correctly?

4. Medical Review Determinations. In accordance with TOM, Chapter 8, Section 6, “Pursuant to National Defense Authorization Act for Fiscal Year 2007 (NDAA FY 2007), Section 731(b)(2) where services are covered by both Medicare and TRICARE, and medical necessity documentation is required for claims processing, the contractor shall require only the documentation as specified by the Medicare Indemnity Program, for example, the Centers for Medicare, and Medicaid Services (CMS)-Certificates of Medical Necessity. No additional documentation for medical necessity is generally required if the care has been preauthorized.” However if a claim meets Medical Review Determination requirements the TCRS contractor shall use available in-house methods to review such claims. Claims involving questionable purchased-care contractor decisions regarding medical necessity and appropriateness of care issues, regardless of the dollar amounts involved, will be handled as follows if available policy guidelines are silent on the issue:

a. Consult with a Nurse Consultant or a Registered Nurse to make a determination.

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b. Based on consultation with the above individuals, a determination regarding the contractor's decision will be made for purposes of issuing the audit report timely.

C. Post-Audit Reports

1. Creating the Post-Audit Reports. After all claims for the audit period have been audited;

the auditor enters the error findings and comments into the automated TED Audit (TA) application and generates the payment error or occurrence error post-audit reports. The post-audit reports consist of the following Combined Payment or Occurrence audit reports:

a. TED Audit Summary Report TA280-001

b. TED Audit Analysis of Errors Report TA260-001

c. TED Audit Listing: TA240-001

d. TED Audit Error Report: TA220-001

e. TED Audit Error Analysis Report TA360-001

2. Verification of the Audit Reports Since the accuracy of the quarterly, semi-annual, and annual claims audit reports is essential, the following steps are critical.

a. Auditors are to verify that the payment error amounts, or occurrence errors reported on the Combined Payment, or Occurrence Audit Error Report (TA220-001) match the Under/Over payment error amount, or the number of fields and the number fields in error reported on the Combined Payment or Occurrence TED Audit Listing (TA240-001) reports. Inconsistencies which the auditor is unable to resolve are to be reported to the lead or supervisor.

b. Auditors will also compare the data reported on the Audit Errors Report with the highlighted errors contained on the TADR.

D. Analysis of Purchased-Care Contractor Payment and Occurrence Audit Error Report

1. Analysis of Errors. Following the end of the 2nd rebuttal review process, an analysis of payment and occurrence errors is prepared for each audit by the auditor. The written report provides an analysis of audit findings, and a discussion of recurring payment, or occurrence errors, any high dollar errors ascending during the audit process, and any significant audit findings. The analysis report should also include any observed inconsistency in the TRICARE direction provided in TRICARE Policy, Reimbursement, Operation or System manuals.

2. Significant Audit Findings. Payment and occurrence error findings are considered significant deficiencies when they represent high volume errors, high dollar amount errors, or errors which by their nature have the potential for rarely occurring. Also significant are those findings which indicate a purchased-care contractor has failed to implement or has incorrectly implemented a contractual requirement, e.g., TRICARE Policy/ Reimbursement/ Operations/ Systems Manual changes, or which indicate other substantive processing problems, e.g., EOBs sent to minors, incorrect coding of TED records based on claims information provided on audit..

3. Monitoring Deficiencies. Prior to beginning an audit, the auditors will review each purchased-care contractor's error report file for those findings to be monitored.

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E. Rebuttals of Audit Findings

1. Time Period. Generally purchased-care contractors have 45 calendar days following receipt of the audit reports to submit rebuttal comments directly to the TCRS contractor, or notify the TCRS COR, that no rebuttal will be submitted.

2. Responses to Rebuttals:

a. Responses must be clear, concise, and self-explanatory, addressing each issue raised by the purchased-care contractor. In most cases, it will be necessary to reiterate the issue or question in order that those reviewing, and concurring in the reply will fully understand the response.

This is especially important in those cases where the auditor is sustaining the original determination, or removing errors for reasons other that those cited in the purchased-care contractor's rebuttal. Appropriate references, e.g., TRICARE Operations, Policy, Reimbursement, or Systems Manuals are to be cited whenever possible.

b. Responses are to be in a format which addresses the claim number, beneficiary name, claim type, disputed errors, contractor rebuttal position, auditor position after consideration, errors removed, upheld, or any additional errors assessed.

F. Confidentiality of Audit Documents. All TRICARE claims, and claim documentation used in the claims audit are subject to the provisions of the Privacy Act of 1974, HIPAA Privacy Rule of 2002, and all DoD Privacy requirements since they contain information of a personal nature on each beneficiary.

Due to the confidential nature of the information, each auditor is responsible for safeguarding these documents as follows:

1. Health Insurance Portability and Accountability Act (Security and Privacy Rule), and Privacy Act. The auditor,, shall comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements, specifically, the administrative simplification provisions of the law, and the associated rules and regulations published by the Secretary, Health and Human Services (HHS), the DoD Health Information Privacy Regulation (DoD 6025.18-R), the HIPAA Security Compliance Memorandum (HA Policy 60-010), the Security Standards for the Protection of Electronic Protected Health Information and the requirements of the TOM, Chapter 19 and the TSM, Chapter 1

2. While auditors are away from their work area for any extended time, such as leave, or after duty hours, all claims and audit documentation are too secured.

3. For a brief period of absence, such as a break, lunch or meeting, all documents are to be covered, or placed in such a way so that they are not visible to a casual observer.

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CHAPTER 2 - AUTOMATED TED AUDIT (TA) APPLICATION

A. Introduction. This chapter describes the objectives, and features of the automated TED Audit (TA) application, and provides an overview of the auditor's interface with this application. The objective of the TA application is to facilitate; enhance the accuracy and timely completion of the audits; and production of audit reports through automation of the claims audit functions as follows:

1. Error collection

2. Production of audit reports

3. Audit error summary reports

B. Scope of Automated Features

1. The TA application contains batch as well as online processing. The batch portion of the system is responsible for extracting, determining sample sizes, pulling statistically valid random samples, and loading TED sampled records into the TA database. Various audit reports are produced during the batch process. In addition to the full sample set, the batch system also produces a five percent sub sample for ‘in-house’ auditing. The TA online system interfaces with the preloaded TA database; serves as an interface to the auditors, allowing them to recall, and resolve various audit errors.

2. The TA application interfaces with the TRICARE Encounter Data (TED) Operation Data Store (ODS) to make a random selection of claims. During this selection process, the system also interfaces with various files, and DHA Reference (RF) tables to provide narrative descriptions of procedure and diagnosis codes, catchment area information based on zip codes, provider information, and pricing data.

3. Selected claim and error data is collected, and maintained on the TA databases. These databases are then used to produce claims sampling, and detail reports used by the auditors to audit each claim. After the claims have been audited, the application provides for automated collection of errors through on-line entry of payment, and coding errors by the auditor to the claim audit database. The audit cycles are concluded with automated generation of final audit reports, and subsequently, rebuttal reports from claim, and error data maintained on the audit databases. The audit databases retain claim, and error data for each audit cycle for the current and previous audit. This historical data allows for future creation of special post-audit reports for trend analysis, and summary reporting.

C. Description of Automated Functions. The automated function is designed to interface directly with the audit database to provide required data. A brief narrative description of the functions follows:

1. Select Claim Sample. The application is designed to provide an automated capability for selecting a random sample of claims to be audited. The claims are selected from edited TED record submissions that pass the edit levels at DHA each audit cycle.

2. Access Tables. Tables maintained in the audit database are available on-line during the processing of claim sampling reports.

a. Three tables maintained on the audit database are available for online access, and updating. They are:

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(1) Error Code Table - A table containing audit error codes.

(2) Auditor ID Table. A table used to identify individuals having authorized access to the automated application.

b. The RF tables used by the application are available for online access by the auditors. These RF tables are maintained, and updated by either DHA or from input tapes received at DHA from the purchased-care contractor. They are:

(1) Procedure Information

(2) Pricing Information

(3) Catchment Area Zip Codes

(4) Provider Information

(5) Catastrophic Cap and Deductible Information

3. Create Claim Sampling Reports (pre-audit reports). This process creates reports based on claims selected for each contract each audit cycle. They are:

a. TED Audit Detail Report (TADR). Report #TA200-001, is produced for each claim selected for audit. These reports contain detail claim data to be audited, all error codes with narrative definition that were identified by the claim audit system edits, table information extracted for the detail claim data, and the auditor error code applicable for each element in the claim.

b. TED ICN (Individual Claim Number) Listing Report. Report #TA160-001, contains TED claim numbers for all claims selected for audit within a contract for the audit period. These reports are used to request the hard copy claims, and supporting documentation from the Health Care Delivery purchased-care contractor.

4. Enter Audit Errors. This is a process of entering audit errors, payment error amounts, or auditor comments to the claim audit database either during, or upon completion of the audit of the hardcopy claims and payment records.

5. Create Final Audit Reports (post-audit reports). After all claims have been audited, and audit errors have been entered in the TA application, an auditor may request creation of a final audit report or a rebuttal report. Final reports are then produced for the specified contract number, and audit period from the data maintained on the claim audit database. The final reports are:

a. TED Audit Summary Report: Report #TA280-001 provides the total number of errors for each claim type, total dollar amounts of payment errors and error rates.

b. TED Audit Analysis of Errors Report: Report #TA260-001 provides the number of errors assessed for each error type and category.

c. TED Audit Listing: Report #TA240-001 provides a summary listing of payment and occurrence errors by ICN number.

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d. TED Audit Error Report: Report #TA220-001 provides a report of all errors assessed by claim number and the auditor’s comments (if any). This report is not produced when rebuttal reports are generated.

e. TED Audit Error Code Analysis Report: Report TA340-01 provides an analysis of the number and percentage an error code was assessed during the current audit process and historically, the number and percentage an error code has been assessed.

6. Maintain History Data. The audit database is updated with each sample selection and as each audit is entered. The database contains audit data for the current quarter and previous quarters for each contract. This allows for recovery of audit data for any audit period maintained in the history files.

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CHAPTER 3 - AUDITING TED DATA ELEMENTS

This chapter provides special guidance for auditing the data on the TRICARE Encounter Data (TED) Record. The names of the fields are arranged in alphabetical order with the corresponding TED Audit Detail Report (TADR) audit code following the name of each field. The discussion of payment errors under each data field is intended to provide the auditor with an indication of the types of payment errors that may be related to a particular data field. Chapter 4 provides more information on determining errors, and Appendix B lists all the audit codes related to the various data fields and types of errors.

ADJUSTMENT/DENIAL REASON CODE. (04H on institution record, 25I on non-institution record).

This field identifies the reason for nonpayment of services or adjustment of the detail line item. It is required if services are not allowed. BLANK filled if not applicable.

Payment Error: Claims denied or allowed in error are payment errors.

ADMISSION DATE (01D for institution record). Reports the date the patient was first admitted to the institution for that episode of care. The admission date is found in UB-92 Form Locator 17 and in Form Locator 12 of the UB-04. This is required information.

Payment Error: None.

ADMISSION DIAGNOSIS (01E on institution record). This field represents the ICD-9-CM code to identify diagnosis under which the patient was admitted to the institution. The code must be the most detailed subcategory or sub-classification. All zeros are not permitted. The admitting diagnosis can be found in UB-92 Form Locator 76 and Form Locator 69-71 of the UB-04. This is required information.

Payment Error: A payment error may be assessed when the admitting diagnosis does not substantiate an emergency admission and an NAS is required but absent.

AMBULATORY PAYMENT CLASSIFICATION (APC) CODE (39I on non-institution record). Is the grouping that categorizes outpatient visits according to the clinical characteristics, the typical resource use, and the costs associated with the diagnosis and the procedures performed when paid under the Outpatient Prospective Payment System (OPPS). This is required information.

AMOUNT ALLOWED (Total) (02G on both institution and non-institution record). Is the amount allowed on the institutional record as reported by the purchased-care contractor, and is the total amount allowed for all authorized services on the TED Record. If the complete TED Record is denied (Type of Submission "D") this amount must be zero. This data is required unless a unique health care plan allows only partial submission of the financial data. The Total Amount Allowed reported on the non-institutional TADR is a DHA derived data field and is the accumulative amount allowed by procedure code. This is required information.

Payment Error: The following conditions may constitute payment errors:

1. Incorrect determination of allowable charge (billed, DRG calculation or per diem) on any service/procedure causing error in total amount allowed.

2. Omission of a billed charge may cause error in allowable amount.

3. Inclusion of extra charges not shown on claim may cause error in allowable amount.

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AMOUNT ALLOWED BY PROCEDURE CODE (32I on non-institution record). Is the total amount allowed for this (these) service(s)/supply(ies). The amount allowed is determined based on prevailing rate, conversion amount, billed amount, negotiated rates, or manual pricing. Zeros are to be entered if a claim is denied. This is required information.

For Mail Order Pharmacy (MOP) records under the TRICARE Pharmacy Program (TPHARM) contract the AMOUNT ALLOWED BY PROCEDURE CODE is the acquisition cost of the drug or supply.

Payment Error: The following conditions may represent payment errors:

1. Incorrect determination of allowable charge due to incorrect procedure code, number of services, billed amount, etc.

2. Incorrect pricing methodology used.

AMOUNT APPLIED TOWARD DEDUCTIBLE (34I on non-institution record). This is that portion of the amount allowed which is applied toward the person or family deductible for the fiscal year for the services reported on the occurrence/line item. This is required information.

Payment Error: The following conditions may represent payment errors:

1. Claim or portion of claim not applied to deductible resulting in excess payment. The amount of the excess payment is the payment error amount.

2. Claim or portion of claim applied to deductible in error regardless of whether the claim is paid or denied. The amount of the deductible which is the government's cost-share is the payment error amount.

3. Failure to apply other health insurance payment to deductible. The amount which should be applied to the deductible is the payment error amount.

AMOUNT BILLED (TOTAL) (01G on both institution and non-institution record). This data field represents the amount billed total field is reported by the purchased-care contractor on the institutional TED record and is derived by DHA on the non-institutional TADR. This field reports the total amount billed for all reported services. The amount billed must be the sum of all total charges per revenue codes on the institutional record and the sum of all total charges per procedure code on the non-institutional TED record. This is required information.

Payment Error: The following conditions may constitute payment errors:

1. Incorrect calculation of total itemized charges.

2. Portion of charges omitted.

3. Inclusion of charges not shown on claim or itemization.

AMOUNT BILLED BY PROCEDURE CODE (31I on non-institution record). This data field represents the amount billed by the provider for this (these) service(s)/ supply (ies). Combining charges for the same procedures having the same billed charges under the contractor's operation is optional with the contractor

TCRS HT9402-17-R-0002, Section J, Attachment J-10 Page 11 of 52 if the same action is taken with all. The option to combine like services shall be applied to those services rendered the same calendar month.

If a lump charge is billed on the claim for several procedures, the contractor must develop for a breakdown of charges unless the billing is for outpatient care from a hospital. This is a required field.

For MOP records under the TPHARM contract the AMOUNT BILLED BY PROCEDURE CODE on the first occurrence/line item must be the acquisition cost of the drug or supply. It must be $0.00 on the second occurrence/line item.

Payment Error: The following may result in payment errors:

1. Amount entered for a distinct service differs from the amount on the claim form or itemized bill.

2. Incorrect aggregate total entered for multiple services on one line.

3. Charges not separated (lump amount) for several different procedures processed without adequate documentation or breakdown of charges.

4. Charges not billed on the claim, but appearing on other insurance EOB/worksheet entered as part of the claim.

5. Combined charges that spans two pricing profiles.

AMOUNT NETWORK PROVIDER DISCOUNT (06G on institution record, 41I on non-institution record). This data field represents the amount of network provider discount for all services reported on the TED record. The amount will be the difference between the network provider’s negotiated or discounted rate and the DRG amount, the mental health per diem, or any other TRICARE payment determined through a DHA-approved reimbursement methodology. This field represents the amount of network provider discount for service(s) on this occurrence/line item. The amount will be the difference between the network provider’s negotiated or discounted rate and the CMAC, prevailing charge, billed charges or any other TRICARE payment determined through a DHA-approved reimbursement methodology.

The AMOUNT NETWORK PROVIDER DISCOUNT is applicable to the North, South, and West Region contracts only. Excludes claims when TRICARE is secondary payer and the OHI has made payment(s).

AMOUNT PAID BY GOVERNMENT CONTRACTOR (TOTAL) (05G on both the institution, and non-institution record). This data field is the portion of total amount allowed that was paid by government contractor for the services reported on the TED record. The field reflects the total amount paid regardless of a provider’s financial arrangement with the contractor, i.e., "withhold amounts'. The Amount Paid by Government Contractor as reported on the non-institutional TADR is a DHA derived data field, and is the accumulative amount paid by procedure code.

The amount paid is determined as follows:

1. If other insurance is involved, the TRICARE payment is calculated using the three step computation contained in the TRM.

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2. If other insurance is involved and the claim is for inpatient hospital care from a nonexempt DRG provider, the TRICARE payment will be calculated as described in the TRM.

Payment Error: The following may constitute payment errors:

1. Amount of payment is incorrect.

2. Non-payable claim paid and vice versa.

3. Payment made to wrong provider.

4. Payment duplicates payment on previous claim.

AMOUNT PAID BY GOVERNMENT CONTRACTOR BY PROCEDURE CODE (35I on non-institution record). Is the portion of amount allowed that was paid by government contractor for all services on this line item as reported on the non-institutional TED record. The field reflects the total amount paid regardless of a provider’s financial arrangement with the contractor, i.e., "withhold amounts'.

This is required data on the non-institutional records.

For MOP records, the AMOUNT PAID BY GOVERNMENT CONTRACTOR BY PROCEDURE CODE must be the acquisition cost of the drug or supply minus the AMOUNT PATIENT COST- SHARE. It must be only the acquisition cost of the drug or supply on the second occurrence/line item.

The amount due is determined as follows:

1. If no other insurance is involved, the amount will be the allowed amount per line item less deductible and patient cost-share.

2. If other insurance is involved, the TRICARE payment is calculated using the three step computation contained in the TRM.

3. If other insurance is involved and the claim is for inpatient hospital care from a nonexempt DRG provider, the TRICARE payment will be calculated as described in the TRM.

Payment Error: The following may constitute payment errors:

1. Amount of payment is incorrect.

2. Non-payable claim paid and vice versa.

3. Payment made to wrong provider.

4. Payment duplicates payment on previous claim.

AMOUNT PAID BY OTHER HEALTH INSURANCE (OHI) (03G on institution record, 38I on non-institution record). This data field is on both the institutional and non-institutional TED record. The total amount paid by other health insurance (OHI) includes third party liability (TPL) for all services on the institutional record, and service(s) on each line item on the non-institutional record. Any inpatient/ institutional claim that have a diagnosis code in the ICD-9-CM diagnosis code range of 800-999.9

TCRS HT9402-17-R-0002, Section J, Attachment J-10 Page 13 of 52 regardless of the dollar value, and any outpatient/non-institutional claim within the same ICD-9CM diagnosis code range with a billed charge of $500 or more, are considered potential TPL claims. This is required information.

Payment Error: Any claim that falls within the diagnosis, and billed charge parameters where no OHI development or information is included may result in a payment error.

AMOUNT PATIENT COST-SHARE (04G on institution record, 33I on non-institution record). For institutional TED records this field represents the total amount of money the beneficiary is responsible for paying in connection with covered services, other than any disallowed amounts. For non-institutional TED records this field represents the total amount of money the beneficiary is responsible for paying in connection with covered services, other than the annual fiscal year deductible and any disallowed amounts for services reported on this occurrence/line item. This is required information.

Payment Error: The following may result in payment errors:

1. Incorrect determination of the allowed amount.

2. Incorrect application of the outpatient deductible.

3. Incorrect Health Care Coverage (HCC) Member Category.

4. Incorrect Type of Service, e.g., inpatient verses outpatient.

BEGIN DATE OF CARE (05D on institution record, 36I on non-institution record). This is the earliest date of care reported on the institutional TED record. If the record has a Frequency Code of ‘3’ Interim, or ‘4’ Final, the BEGIN DATE OF CARE must match (plus or minus 1 day) the ENDING DATE OF CARE on the previous TED Record submitted. For non-institutional TED records this field represents the earliest beginning date of the provider’s service for this procedure. This is required information.

Payment Error: The following may constitute payment errors:

1. Date of service is past the claims filing deadline and no waiver has been granted by the contractor.

2. Beneficiary is ineligible on correct date of care. (Refer to the TRM for the effects of ineligibility on DRG priced claims.)

3. Inclusive dates of care overlap two fiscal years, which results in incorrect deductible.

4. Date of service is past the claims filing deadline and no waiver has been granted by the managed care contractor.

5. Beneficiary is ineligible on date of care.

6. Provider is not authorized for date of care.

CA/NAS EXCEPTION REASON (10A on institution record, 18I non-institution record). This field describes the reason for bypassing the requirement of a CA (Care Authorization) /NAS (Non-Availability Statement). All contractors are required to process for CA/NAS for inpatient mental health (MH) care.

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When no CA/NAS exceptions apply to inpatient MH care, or beneficiaries residing within the catchment area, the field must be blank. The field must also be blank if the beneficiary resides outside a catchment area. Reference: TPM for additional information.

Payment Error: The following situations may result in payment errors:

1. Beneficiary zip code indicates CA/NAS is required, no exception reasons apply and CA/NAS Statement is not with claim.

2. CA/NAS Exception Reason coded when none apply and payment made based on exception code.

CA/NAS ISSUANCE REASON CODE (12A for institution record, 20I for non-institution record). The CA/NAS Reason For Issuance indicates why the care was not or cannot be provided by a MTF.

Download from DEERS. This is required information if available.

CA/NAS NUMBER (11A for institution record, 19I for non-institution record). This field represents the unique number assigned by the Military Treatment Facility (MTF) when issuing the CA/NAS. Care authorization is also issued by the MTF. Download from DEERS. This data field must be BLANK if the record contains treatment data exempt from CA/NAS requirement or services are denied for lack of CA/NAS. The CA/NAS number represents the following information:

1. The first 4 digits are the Data Management information System (DMIS) facility identifier.

2. The next 8 digits represent the date the form is issued and is in YYYYMMDD format.

3. The final 3 digits are the facility sequence number.

Payment Error: If the CA/NAS number does not correspond to the inpatient admission for this TED Record a payment error may be assessed.

CLAIM FORM TYPE/EMC INDICATOR (08A on both the institution and non-institution record). This field represents the code associated with the primary claim form submitted. For MOP prescriptions this data element must be “I”, for MOP and Retail Pharmacy Prior Authorizations and Medical Necessity Reviews, this data element must be “J”. This is a required field.

COVERED DAYS (08D on institution record). This data field represents the number of hospital days authorized by the contractor. More specifically, the number of hospital days where there was any allowance by the contractor. For admit through discharge statement, enter the number of hospital days where there was any allowance by the contractor. For initial, interim or final statements enter the number of allowed days in the period covered by the TED record. The day of admission is to be counted as a hospital day. The day of discharge is NOT to be counted as a hospital day. This is a required field.

Example of determination of interim/final bill hospital days:

Initial Billing - Admitted March 10 Billing is through March 31. Number of days = 22.

Interim Billing - First date is April 1 Billing is through April 30. Number of days = 30.

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Final Statement - First date is May 1.

Discharge date is May 21. Number of days = 20.

Payment Error: Incorrect calculation of hospital days resulting in incorrect allowance of room charges or erroneous calculation of patient cost-share may be assessed payment errors.

DATE ADJUSTMENT IDENTIFIED (05A on both the institution and non-institution record). This field represents the date the contractor determined an adjustment or cancellation TED record was required.

The data field must be “Zero” filled if the TED record is an initial submission. This is required information

DATE TED RECORD PROCESSED TO COMPLETION (06A on both the institution and non-institution record). This field represents the date the contractor processed the claim/treatment encounter data to completion. This is when all services and supplies on the claim have been adjudicated, payment has been determined, deductible has been applied, checks and EOBs have been prepared for mailing, and payment/deductible/denial has been posted to history, and the TED Record(s). This date does not change for resubmissions unless previously coded in error. This is required information.

DRG NUMBER (26E on institution record). This data field identifies the Diagnosis Related Group (DRG) determined for this care on an institutional record. This is required if the TED record is processed under the TRICARE DRG reimbursement methodology. The auditor will verify the TED record entry with the 3M Health Systems Information (HIS) DRG Grouper program on the personal computer.

Payment Error: The following may constitute payment errors:

1. Payment based on erroneous DRG number.

2. DRG reimbursement for number exempt from DRG payment.

3. Erroneous outlier determinations.

4. DRG payment based on erroneous weighing factors.

END DATE OF CARE (06D on institution record, 37I on non-institution record). For institutional records this data field represents the latest date of care reported on this TED record, for non-institutional the data field represents the latest date of care for this procedure. This is required information.

Payment Error: The following may constitute payment errors:

1. Date of service is past the claims filing deadline, and no waiver has been granted by the contractor.

2. Beneficiary is ineligible on date of care.

3. Inclusive dates of care overlap two fiscal years, which adversely affects the deductible.

ENROLLMENT/HEALTH PLAN CODE (11B on the institution record, 04I on the non-institution record). This field indicates whether the patient is enrolled with the contractor (Prime), or not (non- Prime), or if the care was received under the Standard TRICARE Program, or a special care program.

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Enrollment/Health Plan Code ‘U’ shall be used for CONUS (Continental United States) and also for TRICARE Overseas Program (TOP) Prime enrollees. This is required information which must be entered.

Payment Error: A payment error exists if the contractor processed the claim under the incorrect enrollment status which resulted in an overpayment or underpayment.

FILING DATE (01A on both the institution and non-institution record). This is the date the request for payment of services rendered was received by the contractor for processing. This field is part of the Internal Control Number group composed of the Filing Date, Filing State/Country Code, and Sequence Number. Generally, the date entered by the contractor is not questioned unless there is evidence that it is incorrect, e.g., the date is earlier than a date of service on the claim, or the claim is a reprocessing of a previously denied claim and has not been assigned a new claim number. This is required data.

Payment Error: If the filing date is earlier than the date of services on the claim, a payment error may exist if the contractor paid for services not yet rendered.

FILING STATE/COUNTRY CODE (02A on both the institution and non-institution record). This data field represents the State or Country where the primary care was provided. This field is part of the Internal Control Number group composed of the Filing Date, Filing State/Country Code, and Sequence Number. State code will consist of two (2) alphanumeric characters while the foreign countries will consist of three (3) alphanumeric characters. This information is required.

Payment Error: Claims processed for care provided outside the contractor’s contractual jurisdiction would result in a payment error.

FREQUENCY CODE (07D on institution record) This is data field describes the frequency of billing from the institution. All TED Records for interim (interim or final) statement must be submitted as an adjustment using the same TRI (TED Record Indicator) as the initial submission. The frequency information can be found at Form Locator 4 on the UP-92 and UB-04 claim forms.

The Initial, Interim, and Final TED Records, when used, must be submitted in correct sequence. If the patient is transferred and the care is processed under DRG rules, the Code ‘1’ must be used; all other transfers must use Code ‘1’ or ‘4’ as appropriate. This is required information.

Payment Error: A non-qualifying interim claim processed for payment under the DRG pricing methodology may result in a payment error.

HEALTH CARE COVERAGE (HCC) COPAYMENT FACTOR CODE (15B on institution record, 43I on non-institution record). This field represents the code used to identify for each insured in managed care the category of co-payment, and deductible they must pay based on external forces for a particular health care coverage period. Actual rates depend on Health Care Delivery Program (HCDP) Plan Coverage Code. Information is downloaded by the purchased-care contractor from DEERS. This is a required field.

If person not on DEERS but claim is payable (i.e., government liability), the data field must be reported as ‘Z’.

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HEALTH CARE COVERAGE (HCC) MEMBER CATEGORY CODE (09B on the institution record, 02I on the non-institution record). This data field represents the member’s category code during the Health Care Coverage period as verified through DEERS. This is required information.

HEALTH CARE COVERAGE (HCC) MEMBER RELATIONSHIP CODE (10B on both the intuition and non-institution record) This data field defines the members relationship code for the Health Care Coverage period as verified through DEERS. If person not on DEERS but claim is payable (i.e., government liability), the data field must report ‘Z’. This is required information.

Payment Error: The following may result in payment errors:

1. Payment based on incorrect relationship of former spouse (H), (I), or (J),

2. Payment made when the HCC member category code is active duty and relationship is spouse verses self.

HEALTH CARE DELIVERY PROGRAM (HCDP) PLAN COVERAGE (12B on institution record, 05I on non-institution record). This data field represents the plan coverage a family member or sponsor has within the HCDP type as verified by the purchased-care contractor through DEERS.