Attachment_L-1b,_Detail_Level_Claims_Data_Fields.doc
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- Attached to
- TRICARE Overseas Program (TOP) 2021 Solicitation - HT940219R0001 Federal contract opportunity
- Solicitation number
- HT9402-19-R-0001
- Issued by
- Defense Health Agency
About this file
This document contains a Request for Proposal for the TRICARE Overseas Program 2021 contract. The RFP seeks proposals to provide a range of health care support services for TRICARE-eligible beneficiaries residing outside the United States, including developing provider networks, claims processing, medical management, and customer service support. The contract will be a single-award IDIQ with fixed unit prices and has a base period of one year for transition followed by up to seven one-year option periods and a potential six-month extension, for a total potential performance period of eight years and six months. Proposals are due by October 31, 2019. The RFP is issued by the Defense Health Agency on behalf of the Military Health System for the estimated $50 billion annual budget.
Section L, Attachment L-1b, Detail Level Claims Data Fields
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Attachment L-1b, Detail Level Claims Data/Data Fields
Data Package Defined – Purchased Care for TOP 2021 Data
Collected by December 16, 2018
Background
This file contains TRICARE purchased care records where acceptance date was between September 1, 2015, and August 31, 2018. Any cancelled or denied records were excluded. Records for the Continued Health Care Benefit Program (CHCBP) and Uniformed Services Family Health Plan (USFHP) programs were excluded. Also, records for Medicare Eligible Retiree Health Care Fund (MERFC) eligible beneficiaries received care in Domestic or in U.S. territories were excluded.
Definition of Foreign and Domestic
Domestic = the 50 states or the District of Columbia (DC).
Foreign = all other countries and territories (not in the 50 states and DC.) such as Puerto Rico, Guam, US Virgin Islands, American Samoa, and Northern Mariana Islands will be included as Foreign.
The TED files contain net records. Records from the TED Institutional and TED Non-Institutional datasets are included in this extraction if records processed by the TOP Contractor, regardless of location.
The sponsors’ Social Security Numbers were assigned another number to address any PHI and is consistent within all of the data. Any other unique patient identifiers, such as TED numbers, DEERS person id, and provider tax id, have been scrambled on all records. No filters have been applied to the provider database, such that it should contain all records for TRICARE providers that delivered care during fiscal years 2012 through 2018.
All files are fixed format. The record layout is provided below, along with information about the content and format of each field. Consider each field numeric unless otherwise specified. A “$” indicates a character variable, and the number indicates the length of the field.
This file does not include Volume statistics.
Completion Factors
These files are prepared from administrative data and are known to be incomplete. Records were extracted with “Acceptance Date” between calendar year September 1, 2015 and August 31, 2018. Completion Factors are not included. Note that vouchers are submitted and processed in different intervals therefore, completion factors vary for different countries.
The RFP claims data files reflect net records, with all adjustments to a claim netted into the final record, with only one "processed date" for the net record. A valid alternative completion factor would not be able to developed using the uncompleted claims data provided in this RFP data package.
Other Factors
Exchange rates have fluctuated from month-to-month over the last couple of years, some country expenditures affected more than others. Amounts in the RFP claims data files are actual amounts paid, thus reflecting impact of exchange rates to the US dollar at the time of service.
Institutional Data Files
TRICARE detail TED Institutional data, for claims with acceptance date between September 1, 2015 and August 31, 2018.
· This feed includes TED records with Fiscal year of end date of care (FY) from 2012 through 2018. Data were extracted on December 16, 2018.
· Each Institutional (TED-I Header) record represents a net TRICARE Encounter Data; each record is a hospital claim for services provided in the private sector.
Record layouts for the TRICARE institutional data are provided below. This includes a TED-I Header layout for the TED-based data. The records are fixed width. A “$” indicates a character variable, and the number indicates the length of the field.
| Field Name |
| Position |
| Length |
| Comments |
| Valid Values |
| TED Number |
| 1 |
| $24 |
| Unique key identifying the claim. Concatenation of the filing date, filing state/country code, sequence number, time stamp and adjustment key. |
Note: The TED number is scrambled for all records using a consistent algorithm across all data provided with this extraction.
| Admission Date |
| 25 |
| $8 |
| Date patient was admitted to the institution. In the case of an interim claim, the admission date should not change. |
| YYYYMMDD |
| Begin Date of Care |
| 33 |
| $8 |
| Begin date of billing period. |
| YYYYMMDD |
| End Date of Care |
| 41 |
| $8 |
| End date of billing period. |
| YYYYMMDD |
| Sponsor SSN (Scrambled) |
| 49 |
| $9 |
| Sponsor Social Security Number is scrambled for all records using a consistent algorithm across all data provided with this extraction. |
| Date of Birth |
| 58 |
| $8 |
| Birth date of patient. |
| YYYYMMDD |
| EDI_PN (Scrambled) |
| 66 |
| $10 |
| DEERS Person ID is scrambled for all records using a consistent algorithm across all data provided with this extraction. |
| Gender |
| 76 |
| $1 |
| Gender of patient/beneficiary. |
| F = Female |
M = Male Z = Unknown
| Patient Age |
| 77 |
| N3.0 |
| Age of patient. |
| Patient Zip Code |
| 80 |
| $5 |
| Patient's zip code if there is one; otherwise contains code indicating the country of residence for the patient. |
If the value in this field is not numeric, refer to "State/country codes".
| Submission Code |
| 85 |
| $1 |
| Code indicating the type of submission. |
| Submission type of last transaction |
A = Adjustment to TED record data I = Initial TED record submission O = Zero payment TED record due to 100% OHI R = Resubmission of an initial TED that was rejected due to errors
| Claim Form Type |
| 86 |
| $1 |
| Code indicating whether the claim was electronic or paper. |
| B = DD Form 2642 |
C = HCFA 1500
F = UB92
G = Electronic Inst.
H = Electronic NI J = Other
| Enrollment DMIS ID |
| 87 |
| $4 |
| Code indicating enrollment site of beneficiary at the time of service. This field will be populated whether the beneficiary is enrolled in TRICARE Prime, or TRICARE Plus. Use enrollment status to determine which program the beneficiary is enrolled to. |
| See Reference Table: DMIS ID Information. For HCSRs, this field will not generally represent the enrollment DMISID on active duty or OCONUS records. It is recommended that you use the DEERS enrollment site if you need this kind of information. For TEDs, all claims will use this field to represent the enrollment site except OCONUS, where again, DEERS enrollment site is a better choice. |
| Admitting Diagnosis |
| 91 |
| $7 |
| Diagnosis code assigned at admission. May not be the primary diagnosis. |
| FY15 and back: ICD-9-CM |
FY16 and forward: ICD-10-CM
| Principle Diagnosis |
| 98 |
| $7 |
| After study, the diagnosis code which represents the diagnosis which led to the admission. |
FY15 and back: ICD-9-CM
FY16 and forward: ICD-10-CM
| Secondary Diagnosis 1 |
| 105 |
| $7 |
| Secondary diagnosis code. If available may be coded up to 11 occurrences. |
| FY15 and back: ICD-9-CM, left aligned, no decimals (assumed after third position). |
FY16 and forward: ICD-10-CM, left aligned, no decimals (assumed after 3 third position).
| Secondary Diagnosis 2 |
| 112 |
| $7 |
| Secondary Diagnosis 3 |
| 119 |
| $7 |
| Secondary Diagnosis 4 |
| 126 |
| $7 |
| Secondary Diagnosis 5 |
| 133 |
| $7 |
| Secondary Diagnosis 6 |
| 140 |
| $7 |
| Secondary Diagnosis 7 |
| 147 |
| $7 |
| Secondary Diagnosis 8 |
| 154 |
| $7 |
| Secondary Diagnosis 9 |
| 161 |
| $7 |
| Secondary Diagnosis 10 |
| 168 |
| $7 |
| Secondary Diagnosis 11 |
| 175 |
| $7 |
| Principle Procedure |
| 182 |
| $7 |
| Principle procedure code. |
FY15 and back: ICD-9-CM left aligned, no decimals (decimal is assumed to be after the third position)
FY16 and forward: ICD-10-PCS left aligned, no decimals (ICD-10-PCS inherently have no decimals)
| Secondary Procedure 1 |
| 189 |
| $7 |
| Secondary procedure code. If available may be coded up to 11 occurrences. |
| FY15 and back: ICD-9-CM left aligned, no decimals (decimal is assumed to be after the third position) |
FY16 and forward: ICD-10-PCS left aligned, no decimals (ICD-10-PCS inherently have no decimals)
| Secondary Procedure 2 |
| 196 |
| $7 |
| Secondary Procedure 3 |
| 203 |
| $7 |
| Secondary Procedure 4 |
| 210 |
| $7 |
| Secondary Procedure 5 |
| 217 |
| $7 |
| Secondary Procedure 6 |
| 224 |
| $7 |
| Secondary Procedure 7 |
| 231 |
| $7 |
| Secondary Procedure 8 |
| 238 |
| $7 |
| Secondary Procedure 9 |
| 245 |
| $7 |
| Secondary Procedure 10 |
| 252 |
| $7 |
| Secondary Procedure 11 |
| 259 |
| $7 |
| Type of Admission |
| 266 |
| $1 |
| Code indicating the type of admission. |
| 1 = Emergency |
2 = Urgent 3 = Elective 4 = Newborn 5 = Trauma Center 9 = Unknown blank = Missing
| Source of Admission |
| 267 |
| $1 |
| Code indicating how the patient came to the institution. This field is commonly used to identify transfers, admissions from the ER, and births. Note that records are often coded with "information not available" however. The value of "admitted from the ER" is not generally correct. |
| 1 = Physician referral |
2 = Clinic referral 3 = HMO referral 4 = Transfer from a hospital 5 = Transfer from a skilled nursing facility 6 = Transfer from another health care facility 7 = Emergency Room 8 = Court/Law Enforcement 9 = Information Not Available A = Transfer from a Critical Access Hospital B = Transfer from Another HHA C = Readmission to the Same Home Health Agency D = Transfer from Hospital in same facility resulting in separate claim E = Unknown F = Unknown For Newborn:
1 = Normal Delivery 2 = Premature Delivery 3 = Sick Baby 4 = Extramural baby 5 = Born Inside This Hospital 6 = Born Outside This Hospital
| Disposition Status |
| 268 |
| $2 |
| Code indicating how the patient left the institution. This field is often used to identify transfers, deaths, and routine discharges. Can also be used to identify which patients are still in the hospital. |
| See Reference Table: Disposition Status |
| Authorized Days |
| 270 |
| N3.0 |
| Days authorized for payment. |
| Number of days that TRICARE authorized for the stay. The patient may stay more or less than what is authorized. |
| Administrative Claim Count Code 1 |
| 273 |
| N1.0 |
| Code indicating whether this claim counts for administrative purposes. |
| 1 = Positive administrative payment |
0 = No administrative payment
| Beneficiary Category |
| 274 |
| $1 |
| Code identifying category of beneficiary. |
| 1 = Dependents of Active Duty or Guard/Reserve on Active Duty |
2 = Retired 3 = All Others 4 = Active Duty and Guard/Reserve on Active Duty
5 = Medicare Eligible Retiree Health Care Fund (MERFC) eligible beneficiaries
| Benefit Claim Count Code |
| 275 |
| N1.0 |
| Code indicating whether or not this record represents the primary bill for a service. Supplemental bills, adjustments and cancellations are not primary bills. |
| 1 = Primary Benefit |
0 = No Benefit
| Contractor Number |
| 276 |
| $2 |
| Code identifying the contractor who processed the claim. |
| 10 = TOP, TRICARE Overseas Program (Start Date: 201609) |
15 = TOP, TRICARE Overseas Program (Start Date: 201009 End Date: 201609)
| ICD Version |
| 278 |
| $1 |
| Edition number of ICD clinical code data (diagnosis and procedure). |
9 = ICD-9
0 = ICD-10
| Diagnosis Related Group |
| 279 |
| $2 |
| Same as derived DRG, except that DRG is set to 000 if the facility is not an acute care facility. |
See Reference Table: DRG Codes.
| Raw DRG |
| 281 |
| $3 |
| DRG assigned during claims adjudication. This field is not populated unless the DRG is the basis of payment. |
See Reference Table: DRG Codes.
| Derived DRG |
| 284 |
| $3 |
| DRG assigned using the TRICARE DRG Grouper. This field is always populated, regardless of institution type. |
Populated FY12 and back.
Users should be using MSDRG.
| MS DRG (All Care) |
| 287 |
| $3 |
| Same as MSDRG but filled for all records, regardless of institution type. |
| Populated FY07+. |
FY07 and FY08 are grouped using the FY09 grouping software with diagnosis and procedure codes mapped for proper grouping.
See Reference Table: Medicare Severity DRG (MS-DRG).
| DEERS Alternate Care Value (ACV) |
| 290 |
| $1 |
| Alternate care value derived from MDR DEERS Longitudinal File. This field is updated when the MDR receives updated information about a patient's demographics. This means that using this field, your data will represent the most accurate enrollment status of the beneficiary on the date of admission. Especially valuable to identify newborn records for enrolled patients. |
| A=Active Duty Prime |
B=TRICARE Global Remote Overseas Prime Active Duty D=TRICARE Senior Prime E=Non-Active Duty Prime F=TRICARE Global Remote Overseas Prime Active Duty Family Member G=TRICARE Plus, (Includes Private Sector Coverage, TFL) H=TRICARE Overseas Prime Active Duty J=TRICARE Overseas Prime Active Duty Family Member L=TRICARE Plus, DC Entitlement Only (No Private Sector Coverage, No TFL) M=AD not reported enrolled (added FY05) Q=AD enrolled to Op Forces R=TRICARE Reserve Select
U=USTF/USFHP
V=TRICARE Retired Reserve null / blank = Not Enrolled
| Bed Days |
| 291 |
| N3.0 |
| Bed Days for this claim. |
| Admission Count |
| 294 |
| N1.0 |
| Number of admissions credited for this claim. |
| This is usually one, however, for continuation claims, an admission count is not credited, generally. There are some known exceptions however. |
| Number of Births |
| 295 |
| N2.0 |
| Number of births for this record, includes stillbirths, only populated on mother's records. |
| Billing Frequency Code |
| 297 |
| $1 |
| Code indicating whether the claim is an interim bill. |
| 0 = Non-payment/zero claim |
1 = Admit Through Discharge 2 = Interim Initial 3 = Interim 4 = Interim Final 7 = replacement 8 = Void/Cancellation 9 = Final Claim for Home Health PPS Episode
| Total Amount Billed |
| 298 |
| N12.2 |
| Amount billed by facility. |
| Total Amount Allowed |
| 310 |
| N12.2 |
| Amount allowed by TRICARE; unless the claim is for a Medicare eligible (Non-AD). In this case, this field is not reliable. |
| Total OHI Paid |
| 322 |
| N12.2 |
| Amount paid by other health insurance. |
| Total Patient Cost Share |
| 334 |
| N12.2 |
| Amount patient paid out of pocket. |
| Total Amount Paid |
| 346 |
| N12.2 |
| Amount paid by TRICARE. |
| Only includes payments made by TRICARE. Other payers, including the patient, may exist. |
| Patient Pay |
| 358 |
| N12.2 |
| Amount of payment not made by TRICARE. This is the difference between the amount allowed and the amount paid. |
| Take caution as this contains other health insurance! |
| Provider State/Country Code |
| 370 |
| $3 |
| State or country code where the provider rendered care. |
| See Reference Table: state/country codes. |
| Provider Tax ID (Scrambled) |
| 373 |
| $9 |
| Internal Revenue Service Tax Identification number of the provider. |
| Note: The Provider Tax ID is scrambled for all records using a consistent algorithm across all data provided with this extraction. |
| Multiple Provider Suffix |
| 382 |
| $4 |
| Code used to identify individual entities reporting under a provider Tax ID. |
| Provider Zip Code |
| 386 |
| $5 |
| Zip or country code of the location of care. This field will contain a country code when care is provided outside of the U.S. |
| See Reference Table: State/Country Codes for values if not populated with a zip code. |
| Type of Institution |
| 391 |
| $2 |
| Code indicating the type of institution where care was delivered. |
| See Reference Table: Institution Types. |
| Provider Participation Indicator |
| 393 |
| $1 |
| Code indicating whether or not the provider accepted assignment of benefits. |
| Y = Yes |
N = No
| Provider Network Status Indicator |
| 394 |
| $1 |
| Code indicating whether or not the provider is affiliated with the TRICARE Network. |
| 1 = Network Provider |
2 = Non-Network Provider
| Service Branch |
| 395 |
| $1 |
| Code indicating branch of service of sponsor. |
| A = Army |
C = Coast Guard D = Office of the Secretary of Defense F = Air Force H = Public Health Service M = Marine Corps N = Navy O = National Oceanic and Atmospheric Administration X = Not Applicable Z = Unknown 1 = Foreign Army 2 = Foreign Navy 3 = Foreign Marine Corp 4 = Foreign Air Force
| Sponsor Status |
| 396 |
| $1 |
| Code indicating status of sponsor. |
| A = Active duty member |
B = Presidential Appointee C = DoD civil service employee, except Presidential Appointee D = Disabled American veteran E = DoD contract employee F = Former member (Reserve service, discharged from the Ready Reserve or Standby Reserve following notification of retirement eligibility) G = National Guard Member (mobilized or on active duty for 31 days or more) H = Medal of Honor recipient I = Non-DoD civil service employee, except Presidential Appointee J = Academy student K = Non-Appropriated Fund DoD employees L = Lighthouse service M = Non-government agency personnel N = National Guard member O = Non-DoD contract employee P = Transitional Assistance Management Program (TAMP) Q = Reserve retiree not yet eligible for retired pay (gray area retiree) R = Retired military member eligible for retired pay S = Reserve Member (mobilized or on active duty for 31 days or more) T = Foreign military member U = Authorized foreign national civilian V = Reserve member W = DoD Beneficiary, a person who receives benefits from the DoD based on prior association, condition or authorization, an example is a former spouse Y = Service Affiliates (including ROTC and Merchant Marines)
1 = Transitional Compensation Beneficiaries
| Member Relationship Code |
| 397 |
| $1 |
| Code indicating relationship of member to sponsor. |
| A = Self (i.e., the person and the other person are the same person) |
B = Spouse C = Child or stepchild D = Pre-adoptive child E = Ward (court ordered) F = Dependent parent, dependent stepparent, dependent parent- in-law, or dependent stepparent-in-law G = Surviving spouse H = Former spouse (20/20/20) (not assignable after RAPIDS 6.3) I = Former spouse (20/20/15) (not assignable after RAPIDS 6.3) J = Former spouse (10/20/10) (not assignable after RAPIDS 6.3) K = Former spouse (transitional assistance (composite)) (not assignable after RAPIDS 6.3) Z = Unknown
| Enrollment Status |
| 398 |
| $2 |
| Code indicating enrollment or other program under which claim was processed. |
| AD enrollees are not identifiable if enrolled to a CONUS (non-TPR) DMISID. Must be used in conjunction with enrollment site if you want to limit your report to Prime enrollees. See Reference Table: Enrollment Status codes. |
| Special Processing Code 1 |
| 400 |
| $2 |
| Code indicating whether special rules were required for processing the claim. This field is very valuable for isolating TRICARE Program data. Search all occurrences of special processing code when looking for a particular program. The value "W" is not always properly coded. |
| See Reference Table: Special Processing Codes. |
| Special Processing Code 2 |
| 402 |
| $2 |
| Special Processing Code 3 |
| 404 |
| $2 |
| Special Processing Code 4 |
| 406 |
| $2 |
| Override Code 1 |
| 408 |
| $2 |
| The first of three codes that indicate that certain questionable data has been identified and approved by the contractor and that normal editing and processing rules should be bypassed for this record. |
| See Reference Table: override codes. |
| Override Code 2 |
| 410 |
| $2 |
| The second of three codes that indicate that certain questionable data has been identified and approved by the contractor and that normal editing and processing rules should be bypassed for this record. |
| See Reference Table: override codes. |
| Override Code 3 |
| 412 |
| $2 |
| The third of three codes that indicate that certain questionable data has been identified and approved by the contractor and that normal editing and processing rules should be bypassed for this record. |
| See Reference Table: override codes. |
| HCDP |
| 414 |
| $3 |
| Code indicating enrollment or other program under which claim was processed. |
| See Reference Table: HCDP Codes. |
| Health Care Delivery Program Special Entitlement Code |
| 417 |
| $2 |
| Code to identify a co-payment or deductible exception. Not always properly coded for OCO. Recommend using Reservist Status Code in lieu of this field. |
| 00 = Not Applicable |
01 = Bosnia 02 = Noble Eagle (Sponsors only) 03 = Enduring Freedom 04 = Routine TAMP 05 = Extra TAMP 06 = Kosovo 07 = Iraqi Freedom (Sponsor only) 30 = TRICARE Senior Rx grandfathered population 31 = TRICARE Senior Rx-Direct care 65+ with Medicare A and B and no TFL
| Pricing Rate Code |
| 419 |
| $2 |
| Code used to indicate the contractor's pricing methodology. |
| CA = Critical Access Hospital Reimbursement |
D = Discount Agreement H = DRG Reimbursement, Short Stay Outlier I = DRG Reimbursement, with cost outlier J = DRG Reimbursement with no outlier K = Hospital specific psych per diem L = Region specific psych per diem P = Per diem rate U = Supp. Care V = Medicare Reimbursement Rate blank = Missing
| Reserve Status |
| 421 |
| $1 |
| Code indicating the status of the sponsor while called up for OCO (only applies to guard/reserve and their family members). |
| A = Early Alert for Guard/Reserve |
E = TAMP extended for Guard/Reserve O = TAMP original for Guard/Reserve M = Mobilization for Guard/Reserve T = TAMP for Guard/Reserve I = TAMP for involuntary separation from Active Duty L = TAMP for stop/loss from Active Duty
| Residence Catchment Area Service Branch |
| 422 |
| $1 |
| Code indicating service branch of residence catchment area. |
A = Army DHP B = Army Civilian Resource Sharing C = Coast Guard D = Army Line Unit F = Air Force DHP G = AF Civilian Resource Sharing I = Inactive J = US Defense Attache Office (USDAO) L = AF Line Unit M = Managed Care Support Contractor N = Navy DHP O = Other Q = Navy Line Unit R = Navy Civilian Resource Sharing S = Non-catchment T = US Family Health Plan (USFHP) V = Veterans Admin X = AdministrativeBlank = Unknown
| Residence Catchment Area |
| 423 |
| $4 |
| Code indicating which, if any, inpatient MTF's 40 mile catchment area the beneficiary resides in. Filled with DMISID Values. If the beneficiary does not live near an inpatient MTF, this code is populated with values representing state or country level non catchment areas. |
See Reference Table: DMIS ID Information.
| Residence PRISM Area |
| 427 |
| $4 |
| Code indicating which, if any, MTF's 20 mile PRISM area the beneficiary resides in. Filled with DMISID Values. If the beneficiary does not live near an MTF, this code is populated with values representing state or country level non PRISM areas. |
See Reference Table: DMIS ID Information.
| Residence TNEX Region |
| 431 |
| $1 |
| Code indicating TNEX region of residence, derived from zip code and MDR Omni Catchment Area Directory. |
| N = North |
W = West S = South
A = AK
O = OCONUS
blank = unknown
| Enrollment HSSC Region |
| 432 |
| $1 |
| Code indicating TNEX region of enrollment. |
| N = North |
W = West S = South
A = AK
| Enrollment Site Service Branch |
| 433 |
| $1 |
| Code indicating branch of service of enrollment site. |
| A = Army DHP |
B = Army Civilian Resource Sharing C = Coast Guard D = Army Line Unit F = Air Force DHP G = AF Civilian Resource Sharing I = Inactive J = US Defense Attaché Office (USDAO) L = AF Line Unit M = Managed Care Support Contractor N = Navy DHP O = Other Q = Navy Line Unit R = Navy Civilian Resource Sharing S = Non-catchment T = US Family Health Plan (USFHP), FY 1998-2001, 2007-2009 U = US Family Health Plan (USFHP), FY 2002-2006 V = Veterans Admin X = Administrative blank = Unknown
| Relative Weighted Product |
| 434 |
| N8.4 |
| A measure of workload credit derived from the DRG, length of stay and transfer status. Only populated when the care is delivered in an acute care facility. |
| The higher the RWP, the more complex the case! |
Populated FY12 and back.
Users should be using the MSDRG and associated RWP fields.
| Acceptance Date |
| 442 |
| $8 |
| Date claim was accepted for payment by the TRICARE claims system (PEPR). This date does not change when a claim is adjusted. |
YYYYMMDD
| Process to Completion Date |
| 450 |
| $8 |
| Date the fiscal intermediary finished processing the claim. |
YYYYMMDD
| Cycle Number |
| 458 |
| $8 |
| Date that the claim was processed into the TED system. |
| YYYYMMCC where CC is the sequential cycle number. This field is often useful for isolating reporting peculiarities. |
| Fiscal Year |
| 466 |
| $4 |
| Fiscal year of end date of care. |
| Fiscal Month |
| 470 |
| $2 |
| Fiscal month of end date of care. |
| Fiscal Year of Acceptance Date |
| 472 |
| $4 |
| See acceptance date. |
| Fiscal Month of Acceptance Date |
| 476 |
| $2 |
| See acceptance date. |
| TED Indicator |
| 478 |
| $1 |
| Code indicating whether the claim is a TED or a HCSR. |
| T = TED |
A = TED Adjustment to a HCSR
H = HCSR
| Principal Diagnosis Present on Admission |
| 479 |
| $1 |
| Principal Diagnosis Present on Admission |
| Y = diagnosis was present at time of admission |
N = diagnosis was not present at time of admission
U = insufficient documentation to determine if POA
W = provider unable to clinically determine if POA
1 / blank = exempt from POA reporting
| Secondary Diagnosis 1 Present on Admission |
| 480 |
| $1 |
| Secondary Diagnosis Present on Admission |
| Y = diagnosis was present at time of admission |
N = diagnosis was not present at time of admission
U = insufficient documentation to determine if POA
| Secondary Diagnosis 2 Present on Admission |
| 481 |
| $1 |
| Secondary Diagnosis 3 Present on Admission |
| 482 |
| $1 |
| Secondary Diagnosis 4 Present on Admission |
| 483 |
| $1 |
| Secondary Diagnosis 5 Present on Admission |
| 484 |
| $1 |
| Secondary Diagnosis 6 Present on Admission |
| 485 |
| $1 |
| Secondary Diagnosis 7 Present on Admission |
| 486 |
| $1 |
| Secondary Diagnosis 8 Present on Admission |
| 487 |
| $1 |
| Secondary Diagnosis 9 Present on Admission |
| 488 |
| $1 |
| Secondary Diagnosis 10 Present on Admission |
| 489 |
| $1 |
| Secondary Diagnosis 11 Present on Admission |
| 490 |
| $1 |
| Beneficiary T3 Region |
| 491 |
| $2 |
| Code that identities the T3 Region of beneficiary residence (or duty for active duty or guard/reserve). |
| A = Alaska |
N = North
S = South
W = West
OE = Overseas Europe
OL = Overseas Latin America
OP = Overseas Pacific blank = all other or not defined (or not enrolled)
| Enrollment Site T3 Region |
| 493 |
| $2 |
| Code that identifies the T3 Region associated with the enrollment site. |
| A = Alaska |
N = North
S = South
W = West
OE = Overseas Europe
OL = Overseas Latin America
OP = Overseas Pacific blank = all other or not defined (or not enrolled)
| MERHCF Flag |
| 495 |
| $1 |
| Code indicating the beneficiary's status with respect to the Medicare Eligible Retiree Health Care Fund (MERHCF). Only records with the values of T or U quality for the MERHCF. |
| T = TFL |
U = Under 65 Medicare Eligible
A = AD/ADFM
N = all others
| Residence TPR Flag |
| 496 |
| $1 |
| Indicates whether the Beneficiary Zip Code is in a TRICARE Prime Remote area. |
| Y = Yes |
N = No
| TRICARE Young Adult Flag |
| 497 |
| $1 |
| TRICARE Young Adult Flag |
| 0 = No |
1 = Yes
| Eligibility Group |
| 498 |
| $1 |
| Specifies a beneficiary's basic relationship with the MHS. |
| C = Continued Health Care Benefit Program (CHCBP) |
D = Direct Care Only
E = TRICARE Eligible
L = TRICARE for Life (TFL)
R = TRICARE Retired Reserve (TRR)
S = TRICARE Reserve Select (TRS)
Y = TRICARE Young Adult (TYA)
Z = None
Note: This field is only populated for January 2018 forward
| Enrollment Group |
| 499 |
| $1 |
| Reports the enrolled relationship that the beneficiary has with the MHS. |
| P = TRICARE Prime |
D = Direct Care Only
L = TRICARE Plus
S = TRICARE Select
U = Designated Provider (USFHP)
Z = Not Enrolled
Blank = pre-2018
See ACV Group for FY18 and back.
| PCM Type Code |
| 500 |
| $1 |
| For enrollees (Enrollment Group = P, U, L), this field groups beneficiaries according to characteristics of their enrollment PCM. |
| C = Network PCM |
M = MTF PCM
N = No PCM
O = Ops Forces
R = TRICARE Prime Remote (TPR)
U = Designated Provider (USFHP)
Z = Not Enrolled
Note: This field is only populated for January 2018 forward
| DEERS Alternate Care Value (ACV) Group |
| 501 |
| $15 |
| Grouping of ACVs intro TRICARE Programs. |
| DP = Designated Provider (USFHP) |
OP = TRICARE Global Remote Overseas Prime
PL = TRICARE Plus
PR = TRICARE Prime
R = MHS-Reliant
O = Other
Populated through FY18.
See Enrollment Group for FY18 and forward.
| Beneficiary Res T2017 Region |
| 516 |
| $2 |
| Code that identities the T17 Region of beneficiary residence (or duty for active duty or guard/reserve). |
| A = Alaska |
E = East
W = West
OE = Overseas Europe
OL = Overseas Latin America
OP = Overseas Pacific
O = OCONUS
blank = all other or not defined (or not enrolled)
| Enrollment Site T2017 Region |
| 518 |
| $2 |
| Code that identifies the T17 Region associated with the enrollment site. |
| A = Alaska |
E = East
W = West
OE = Overseas Europe
OL = Overseas Latin America
OP = Overseas Pacific blank = all other or not defined (or not enrolled)
Non-Institutional Data File
TRICARE detail TED non-institutional data, for claims with acceptance date between September 1, 2015 and August 31, 2018.
· This feed includes TED records with Fiscal year of end date of care (FY) from 2012 through 2018. Data were extracted on December 16, 2018.
· Each record represents a non-denied line item claim for services (other than hospital or institutional care for inpatients) provided in the private sector.
The record layout for the TRICARE non-institutional detail data are provided below. The records are fixed width. A “$” indicates a character variable, and the number indicates the length of the field.
| Field Name |
| Position |
| Length |
| Comments |
| Valid Values |
| TED Number |
| 1 |
| $24 |
| Unique key identifying the claim. Concatenation of the filing date, filing state/country code, sequence number, time stamp and adjustment key. This field, along with the line item number, is a unique identifier for the claim. |
| Note: The TED number is scrambled for all records using a consistent algorithm across all data provided with this extraction. |
| Line Item Number |
| 25 |
| N3.0 |
| Identifies the line item being billed. This field, together with the TED number, is a unique identifier for the claim. |
| Begin Date of Care |
| 28 |
| $8 |
| Begin date of billing period. |
| YYYYMMDD |
| End Date of Care |
| 36 |
| $8 |
| End date of billing period. |
| YYYYMMDD |
| Sponsor SSN (Scrambled) |
| 44 |
| $9 |
| Sponsor Social Security Number is scrambled for all records using a consistent algorithm across all data provided with this extraction. |
| Date of Birth |
| 53 |
| $8 |
| Birth date of patient. |
| YYYYMMDD |
| EDI_PN (Scrambled) |
| 61 |
| $10 |
| DEERS Person ID is scrambled for all records using a consistent algorithm across all data provided with this extraction. |
| Gender |
| 71 |
| $1 |
| Gender of patient/beneficiary. |
| F = Female |
M = Male Z = Unknown
| Patient Age |
| 72 |
| N3.0 |
| Age of patient. |
| Patient Zip Code |
| 75 |
| $5 |
| Patient's zip code if there is one; otherwise contains code indicating the country of residence for the patient. |
| If the value in this field is not numeric, refer to "State/country codes". |
| Submission Code |
| 80 |
| $1 |
| Derived code indicating the type of submission. |
| Submission type of last transaction |
A = Adjustment to TED record
I = Initial TED record submission
O = Zero payment TED record due to 100% OHI
R = Resubmission of an initial TED that was rejected due to errors
| Claim Form Type |
| 81 |
| $1 |
| Code indicating whether the claim was electronic or paper. |
| B = DD Form 2642 |
C = HCFA 1500
F = UB92
G = Electronic Inst H = Electronic NI I = Electronic Drug Claim J = Other
| Enrollment DMISID |
| 82 |
| $4 |
| Code indicating enrollment site of beneficiary at the time of service. This field will be populated whether the beneficiary is enrolled in TRICARE Prime, or TRICARE Plus. Use enrollment status to determine which program the beneficiary is enrolled to. |
| See Reference Table: DMIS ID Information. For HCSRs, this field will not generally represent the enrollment DMISID on active duty or OCONUS records. It is recommended that you use the DEERS enrollment site if you need this kind of information. For TEDs, all claims will use this field to represent the enrollment site except OCONUS, where again, DEERS enrollment site is a better choice. |
| Principle Diagnosis |
| 86 |
| $7 |
| After study, the diagnosis code which represents the diagnosis which led to the admission. |
| FY15 and back: ICD-9-CM |
FY16 and forward: ICD-10-CM
| Secondary Diagnosis 1 |
| 93 |
| $7 |
| Secondary diagnosis code. If available may be coded up to 7 occurrences. |
| FY15 and back: ICD-9-CM, left aligned, no decimals (assumed after third position). |
FY16 and forward: ICD-10-CM, left aligned, no decimals (assumed after 3 third position).
| Secondary Diagnosis 2 |
| 100 |
| $7 |
| Secondary Diagnosis 3 |
| 107 |
| $7 |
| Secondary Diagnosis 4 |
| 114 |
| $7 |
| Secondary Diagnosis 5 |
| 121 |
| $7 |
| Secondary Diagnosis 6 |
| 128 |
| $7 |
| Secondary Diagnosis 7 |
| 135 |
| $7 |
| Administrative Claim Count Code 1 |
| 142 |
| N1.0 |
| Code indicating whether this claim counts for administrative purposes. |
| 1 = Positive administrative payment |
0 = No administrative payment
| Beneficiary Category |
| 143 |
| $1 |
| Code identifying category of beneficiary. This data element is based on information submitted on the claim. |
| 1 = Dependents of Active Duty or Guard/Reserve on Active Duty |
2 = Retired 3 = All Others 4 = Active Duty and Guard/Reserve on Active Duty
5 = Medicare Eligible Retiree Health Care Fund (MERFC) eligible beneficiaries
| Benefit Claim Count Code |
| 144 |
| N1.0 |
| Code indicating whether or not this record represents the primary bill for a service. Supplemental bills, adjustments and cancellations are not primary bills. |
| 1 = Primary Benefit |
0 = No Benefit
| Contractor Number |
| 145 |
| $2 |
| Code identifying the contractor who processed the claim. |
| 10 = TOP, TRICARE Overseas Program (Start Date: 201609) |
15 = TOP, TRICARE Overseas Program (Start Date: 201009 End Date: 201609)
| ICD Version |
| 147 |
| $1 |
| Edition number of ICD clinical code data (diagnosis and procedure). |
| 9 = ICD-9 |
0 = ICD-10
| Derived MDC |
| 148 |
| $2 |
| Major Diagnostic Category |
| See Reference Table: MDC Codes. |
| Procedure Code |
| 150 |
| $5 |
| HCPCS Code for this claim. |
| Includes some TMA-Specific codes. |
| Procedure Code Modifier 1 |
| 155 |
| $2 |
| Code indicating modification to the reported procedure code. If available may report 0 – 4 codes. |
| See Reference Table: CPT Modifiers. |
| Procedure Code Modifier 2 |
| 157 |
| $2 |
| Procedure Code Modifier 3 |
| 159 |
| $2 |
| Procedure Code Modifier 4 |
| 161 |
| $2 |
| Primary Procedure Flag |
| 163 |
| $1 |
| Indicates whether this line item is the primary procedure on the claim. |
| 0 = Not primary procedure |
1 = Primary procedure
| National Drug Code |
| 164 |
| $11 |
| The National Drug Code that denotes a particular product as to labeler, product (drug), and package size. |
| 5 digit labeler + 4 digit product + 2 character package = 11 |
characters. No dashes between labeler, product and package.
| Medicare Pharmacy Indicator |
| 175 |
| $1 |
| Code indicating whether or not the patient has Medicare Pharmacy coverage. Only populated on pharmacy claims. |
| Y = Yes N = No |
| Number of Services |
| 176 |
| N5.0 |
| Number of units of service associated with procedure code and modifiers. |
| Number of Visits |
| 181 |
| N3.0 |
| This field was intended to measure the number of visits but does not work well for that purpose. The contractor is not required to report a visit count and visits are not generally derivable from information on the claim. This field may be used as a general measure of workload, but should not be represented as the number of face to face encounters between a patient and a provider. |
| Take extreme caution with this field. It can be extremely misleading when mistaken for "face to face encounters". |
| Amount BILLED |
| 184 |
| N12.2 |
| Amount billed for this line item. |
| Amount ALLOWED |
| 196 |
| N12.2 |
| Amount allowed by TRICARE; unless the claim is for a Medicare eligible (Non-AD). In this case, this field is not reliable. |
| OHI Paid |
| 208 |
| N12.2 |
| Amount paid by other health insurance. |
| Note that for HCSR records, only line item 1 for a given claim will report OHI. That OHI is for the entire claim, not just for that line item. |
| Amount Patient Cost SHARE |
| 220 |
| N12.2 |
| Amount patient paid out of pocket. |
| Amount Paid |
| 232 |
| N12.2 |
| Amount paid by TRICARE for this line item. |
| Estimated for HCSRs, actual for TEDs. |
Under TPharm contract (contractor 70), mail order only (Type of Service 2 = M), amount paid does not include dispensing fee
| Amount Patient Pay |
| 244 |
| N12.2 |
| Amount of payment not made by TRICARE. This is the difference between the amount allowed and the amount paid. |
| Take caution as this contains other health insurance! |
| Amount Applied to Deductible |
| 256 |
| N8.2 |
| Amount applied to the patient's annual deductible for this claim. |
| Provider State/Country Code |
| 264 |
| $3 |
| State or country code where the provider rendered care. |
| See Reference Table: State/Country Codes. |
| Provider Tax ID (Scrambled) |
| 267 |
| $9 |
| Internal Revenue Service Tax Identification number of the provider. |
| Note: The Provider Tax ID is scrambled for all records using a consistent algorithm across all data provided with this extraction. |
| Multiple Provider Suffix |
| 276 |
| $4 |
| Code used to identify individual entities reporting under a provider Tax ID. |
| Provider Zip |
| 280 |
| $5 |
| Zip or country code of the location of care. This field will contain a country code when care is provided outside of the US. |
| See Reference Table: State/Country Codes for values if not populated with a zip code. |
| Provider Specialty Code |
| 285 |
| $10 |
| Code describing major specialty of provider of care. Uses HIPAA standards. |
| Not populated for HCSRs. |
| Provider Specialty Code - Derived |
| 295 |
| $2 |
| Code indicating specialty of the provider. |
| Note that this field is not consistent with the direct care coding scheme. Take caution when comparing direct and purchased care. Also note that one provider may have more than one specialty. This code is derived from the specialty that the provider submitted on the claim. |
| Provider Participation Indicator |
| 297 |
| $1 |
| Code indicating whether or not the provider accepted assignment of benefits. |
| Y = Yes |
| Provider Network Status Indicator |
| 298 |
| $1 |
| Code indicating whether or not the provider is affiliated with the TRICARE Network. |
| 1 = Network Provider |
2 = Non-Network Provider
| Place of Service |
| 299 |
| $2 |
| Code indicating the place that the service was provided. Note that "place of service=26" represents care provided within an MTF. These codes are particularly useful for filtering. |
| See Reference Table: Place of Service Codes. |
| Type of Service 1 |
| 301 |
| $1 |
| Code representing the setting of the service. |
| A = Ambulatory surgery cost-share as inpatient (Active Duty Only) |
I = Inpatient K = Emergency Room Admission cost shared as inpatient M = Outpatient maternity cost-share as inpatient N = Outpatient cost-shared as inpatient O = Outpatient-excluding M, P, or N P = Outpatient partial psychiatric hospitalization
| Type of Service 2 |
| 302 |
| $1 |
| Code representing type of service. |
| 1 = Medical Care |
2 = Surgery 3 = Consultation 4 = Diagnostic/Therapeutic X-Ray 5 = Diagnostic Laboratory 6 = Radiation Therapy 7 = Anesthesia 8 = Assistance at Surgery 9 = Other Medical Service A = DME Rental/Purchase B = Retail Rx C = Ambulatory Surgery D = Hospice E = Second Opinion on Elective Surgery F = Maternity G = Dental H = Mental Health Care I = Ambulance J = Program for Persons with Disabilities K = Physical/occupational therapy L = Speech Therapy M = Mail Order Rx
| Service Branch |
| 303 |
| $1 |
| Code indicating branch of service of sponsor. |
| A = Army |
C = Coast Guard D = Office of the Secretary of Defense F = Air Force H = Public Health Service M = Marine Corps N = Navy O = National Oceanic and Atmospheric Administration X = Not Applicable Z = Unknown 1 = Foreign Army 2 = Foreign Navy 3 = Foreign Marine Corp 4 = Foreign Air Force
| Sponsor Status |
| 304 |
| $1 |
| Code indicating status of sponsor. |
| A = Active duty member |
B = Presidential Appointee C = DoD civil service employee, except Presidential appointee D = Disabled American veteran E = DoD contract employee F = Former member (Reserve service, discharged from the Ready Reserve or Standby Reserve following notification of retirement eligibility) G = National Guard Member H = Medal of Honor recipient I = Non-DoD civil service employee, except Presidential appointee J = Academy student K = Non-Appropriated Fund DoD employees L = Lighthouse service M = Non-government agency personnel N = National Guard member O = Non-DoD contract employee P = Transitional Assistance Management Program Q = Reserve retiree not yet eligible for retired pay (gray area retiree) R = Retired military member eligible for retired pay S = Reserve member (mobilized or on active duty for 31 days or more) Early ID Status T = Foreign military U = Authorized foreign national civilian V = Reserve member W = DoD Beneficiary, a person who receives benefits from the DoD based on prior association, condition or authorization, an example is a former spouse Y = Service Affiliates
1 = Transitional Compensation Beneficiaries
| Member Relationship Code |
| 305 |
| $1 |
| Code indicating relationship of member to sponsor. |
| A = Self |
B = Spouse C = Child or stepchild D = Pre-adoptive child E = Ward F = Dependent parent, dependent stepparent, dependent parent-in-law, or dependent stepparent-in-law G = Surviving spouse H = Former spouse (20/20/20) I = Former spouse (20/20/15) J = Former spouse (10/20/10) K = Former spouse (transitional assistance (composite))
| Enrollment Status |
| 306 |
| $2 |
| Code indicating enrollment or other program under which claim was processed. |
| AD enrollees are not identifiable if enrolled to a CONUS (non-TPR) DMISID. Must be used in conjunction with enrollment site if you want to limit your report to Prime enrollees. See Reference Table: Enrollment Status codes. |
| Special Processing Code 1 |
| 308 |
| $2 |
| Code indicating whether special rules were required for processing the claim. This field is very valuable for isolating TRICARE Program data. Search all occurrences of special processing code when looking for a particular program. The value "W" is not always properly coded. |
| See Reference Table: Special Processing Codes. |
| Special Processing Code 2 |
| 310 |
| $2 |
| Special Processing Code 3 |
| 312 |
| $2 |
| Special Processing Code 4 |
| 314 |
| $2 |
| Override Code 1 |
| 316 |
| $2 |
| The first of three codes that indicate that certain questionable data has been identified and approved by the contractor and that normal editing and processing rules should be bypassed for this record. |
See Reference Table: override codes.
| Override Code 2 |
| 318 |
| $2 |
| The second of three codes that indicate that certain questionable data has been identified and approved by the contractor and that normal editing and processing rules should be bypassed for this record. |
See Reference Table: override codes.
| Override Code 3 |
| 320 |
| $2 |
| The third of three codes that indicate that certain questionable data has been identified and approved by the contractor and that normal editing and processing rules should be bypassed for this record. |
| See Reference Table: override codes. |
| HCDP |
| 322 |
| $3 |
| Code identifying the TRICARE Plan of the beneficiary on the date of admission. Derived from MDR DEERS Longitudinal File. This field is updated when the MDR receives updated information about a patient's demographics. This means that using this field, your data will represent the most accurate enrollment status of the beneficiary on the begin date of care. Especially valuable to identify newborn records for enrolled patients. |
| See Reference Table: Health Care Delivery Program Codes. |
| Health Care Delivery Program Special Entitlement Code |
| 325 |
| $2 |
| Code to identify a co-payment or deductible exception. Not always properly coded for OCO. Recommend using Reservist Status Code in lieu of this field. |
| 00 = Not Applicable |
01 = Bosnia 02 = Noble Eagle (Sponsors only) 03 = Enduring Freedom 04 = Routine TAMP 05 = Extra TAMP 06 = Kosovo 07 = Iraqi Freedom (Sponsor only) 30 = TRICARE Senior Rx grandfathered population 31 = TRICARE Senior Rx-Direct care 65+ with Medicare A and B and no TFL
| Pricing Rate Code |
| 327 |
| $2 |
| Code used to indicate the contractor's pricing methodology. |
| 0 = Pricing not applicable |
1 = Priced manually 2 = Prevailing charge (state) 3 = Conversion amount (state) 4 = Paid as billed 5 = Paid on negotiated rate A = National prevailing charge B = National conversion factor C = Ambulatory surgery facility D = Discounted ambulatory surgery facility payment rate E = Ambulatory surgery paid as billed F = Claim auditing software-added proc, priced manually G = Claim auditing software-added proc, prevailing charge (state) H = Claim auditing software-added proc, conversion factor (contractor) I = Claim auditing software-added proc, paid as billed J = Claim auditing software-added proc, paid on negotiated rate N = Claim auditing software-added proc, national prevailing charge O = Claim auditing software-added proc, national conversion factor P = Claim auditing software-added proc, amb surgery facility pmt rate Q = Claim auditing software-added proc, discounted amb surg fac pmt rate R = Claim auditing software-added proc, ambulatory surgery paid as billed T = Claim auditing software-added proc, allowed as billed, paid < billed U = SHCP or Active Duty Member TPR claim paid outside normal limits V = Medicare reimbursement rate W = Priced over CMAC CA = Critical Access Hospital (CAH) Reimbursement GG = Global Rate Agreement (used with corporate service providers only) GP = Per Diem Rate Agreement (used with corporate service providers only) LC = TRICARE Claim-added procedure, CMAC priced laboratory code P1 = Outpatient Prospective Payment System (OPPS) P2 = OPPS with Cost Outlier P3 = OPPS with Discount P5 = Hospital Based Partial Hospitalization-paid as OPPS
| Reservist Status |
| 329 |
| $1 |
| Code indicating the status of the sponsor while called up for OCO (only applies to guard/reserve and their family members.) |
| A = Early Alert for Guard/Reserve |
E = TAMP extended for Guard/Reserve O = TAMP original for Guard/Reserve M = Mobilization for Guard/Reserve T = TAMP for Guard/Reserve I = TAMP for involuntary separation from Active Duty L = TAMP for stop/loss from Active Duty
| DEERS Alternate Care Value (ACV) |
| 330 |
| $1 |
| Alternate care value derived from MDR DEERS Longitudinal File. This field is updated when the MDR receives updated information about a patient's demographics. This means that using this field, your data will represent the most accurate enrollment status of the beneficiary on the begin date of care. Especially valuable to identify newborn records for enrolled patients. |
| A = Active Duty Prime |
B = TRICARE Global Remote Overseas Prime Active Duty D = TRICARE Senior Prime E = Non-Active Duty Prime F = TRICARE Global Remote Overseas Prime Active Duty Family Member G = TRICARE Plus, (Includes Private Sector Coverage, TFL) H = TRICARE Overseas Prime Active Duty J = TRICARE Overseas Prime Active Duty Family Member L = TRICARE Plus, DC Entitlement Only (No Private Sector Coverage, No TFL) M = AD not reported enrolled (added FY05) Q = AD enrolled to Op Forces R=TRICARE Reserve Select S = Continued Healthcare Benefit Program (CHCBP)
U = USTF/USFHP
V = TRICARE Retired Reserve null / blank = Not Enrolled
| Residence Catchment Area Service Branch |
| 331 |
| $1 |
| Code indicating service branch of residence catchment area. |
| A = Army DHP |
B = Army Civilian Resource Sharing C = Coast Guard D = Army Line Unit F = Air Force DHP G = AF Civilian Resource Sharing I = Inactive J = US Defense Attache Office (USDAO) L = AF Line Unit M = Managed Care Support Contractor N = Navy DHP O = Other Q = Navy Line Unit R = Navy Civilian Resource Sharing S = Non-catchment T = US Family Health Plan (USFHP) V = Veterans Admin X = Administrative Blank = Unknown
| Residence Catchment Area |
| 332 |
| $4 |
| Code indicating which, if any, inpatient MTF's 40 mile catchment area the beneficiary resides in. Filled with DMISID Values. If the beneficiary does not live near an inpatient MTF, this code is populated with values representing state or country level non catchment areas |
See Reference Table: DMIS ID Information.
| Residence PRISM Area |
| 336 |
| $4 |
| Code indicating which, if any, MTF's 20 mile PRISM area the beneficiary resides in. Filled with DMISID Values. If the beneficiary does not live near an MTF, this code is populated with values representing state or country level non PRISM areas. |
See Reference Table: DMIS ID Information.
| Residence TNEX Region |
| 340 |
| $1 |
| Code indicating TNEX region of residence, derived from zip code and MDR Omni Catchment Area Directory. |
| N = North |
W = West S = South
A = AK
| Enrollment HSSC Region |
| 341 |
| $1 |
| Code indicating TNEX region of enrollment. |
| N = North |
W = West S = South
A = AK
| Enrollment Site Service Branch |
| 342 |
| $1 |
| Code indicating branch of service of enrollment site. |
| A = Army DHP |
B = Army Civilian Resource Sharing C = Coast Guard D = Army Line Unit F = Air Force DHP G = AF Civilian Resource Sharing I = Inactive J = US Defense Attaché Office (USDAO) L = AF Line Unit M = Managed Care Support Contractor N = Navy DHP O = Other Q = Navy Line Unit R = Navy Civilian Resource Sharing S = Non-catchment T = US Family Health Plan (USFHP), FY 1998-2001, 2007-2009 U = US Family Health Plan (USFHP), FY 2002-2006 V = Veterans Admin X = Administrative blank = Unknown
| RVU Simple |
| 343 |
| N8.2 |
| Work RVU. Does not incorporate modifiers. |
| Relative Value Unit - Work |
| 351 |
| N8.2 |
| Work Relative Value Unit assigned based on a list of Provider Specialty Codes designated as providers that should receive RVU credit for work provided. RVU assignment incorporates modifiers and numbers of services. |
| Note that RVUs are calculated for both ambulatory and inpatient services. Take caution when comparing with direct care, where RVUs are captured for ambulatory care, but not for all types of inpatient care. Recommend limiting records to only ambulatory when comparing with the direct care side, in general. |
| Relative Value Unit - Practice Expense |
| 359 |
| N8.2 |
| Relative Value Unit for practice expense, assigned based on a list of Provider Specialty Codes designated as providers that should receive RVU credit for work provided and the location where the care was received (Home/Office or Other). |
| Provisional Acceptance Indicator |
| 367 |
| $1 |
| Code indicating whether or not this claim is in a provisional acceptance status. |
| 0 = Not a provisionally accepted claim |
1 = Provisionally accepted claim
| Acceptance Date |
| 368 |
| $8 |
| Date claim was accepted for payment by the TRICARE claims system. This date does not change when a claim is adjusted. |
| YYYYMMDD |
| Process to Completion Date |
| 376 |
| $8 |
| Date the fiscal intermediary finished processing the claim. |
| YYYYMMDD |
| Cycle Number |
| 384 |
| $8 |
| Date that the claim was processed into the TED system. |
| YYYYMMCC where CC is the sequential cycle number. This field is often useful for isolating reporting peculiarities. |
| Fiscal Year |
| 392 |
| $4 |
| Fiscal year of end date of care. |
| Fiscal Month |
| 396 |
| $2 |
| Fiscal month of end date of care. |
| Fiscal Year of Acceptance Date |
| 398 |
| $4 |
| See acceptance date. |
| Fiscal Month of Acceptance Date |
| 402 |
| $2 |
| See acceptance date. |
| TED Indicator |
| 404 |
| $1 |
| Code indicating whether the claim is a TED or a HCSR. |
| T = TED |
A = TED Adjustment to a HCSR
H = HCSR
| Principal Diagnosis Present on Admission |
| 405 |
| $1 |
| Principal Diagnosis Present on Admission |
| Y = diagnosis was present at time of admission |
N = diagnosis was not present at time of admission
U = insufficient documentation to determine if POA
| Secondary Diagnosis 1 Present on Admission |
| 406 |
| $1 |
| Secondary Diagnosis Present on Admission |
| Y = diagnosis was present at time of admission |
N = diagnosis was not present at time of admission
U = insufficient documentation to determine if POA
| Secondary Diagnosis 2 Present on Admission |
| 407 |
| $1 |
| Secondary Diagnosis 3 Present on Admission |
| 408 |
| $1 |
| Secondary Diagnosis 4 Present on Admission |
| 409 |
| $1 |
| Secondary Diagnosis 5 Present on Admission |
| 410 |
| $1 |
| Secondary Diagnosis 6 Present on Admission |
| 411 |
| $1 |
| Secondary Diagnosis 7 Present on Admission |
| 412 |
| $1 |
| Secondary Diagnosis 8 Present on Admission |
| 413 |
| $1 |
| Secondary Diagnosis 9 Present on Admission |
| 414 |
| $1 |
| Secondary Diagnosis 10 Present on Admission |
| 415 |
| $1 |
| Secondary Diagnosis 11 Present on Admission |
| 416 |
| $1 |
| Beneficiary T3 Region |
| 417 |
| $2 |
| Code that identities the T3 Region of beneficiary residence (or duty for active duty or guard/reserve). |
| A = Alaska |
N = North
S = South
W = West
OE = Overseas Europe
OL = Overseas Latin America
OP = Overseas Pacific blank = all other or not defined (or not enrolled)
| Enrollment Site T3 Region |
| 419 |
| $2 |
| Code that identifies the T3 Region associated with the enrollment site. |
| A = Alaska |
N = North
S = South
W = West
OE = Overseas Europe
OL = Overseas Latin America
OP = Overseas Pacific blank = all other or not defined (or not enrolled)
| MERHCF Flag |
| 421 |
| $1 |
| Code indicating the beneficiary's status with respect to the Medicare Eligible Retiree Health Care Fund (MERHCF). Only records with the values of T or U quality for the MERHCF. |
| T = TFL |
U = Under 65 Medicare Eligible
A = AD/ADFM
N = all others
| Residence TPR Flag |
| 422 |
| $1 |
| Indicates whether the Beneficiary Zip Code is in a TRICARE Prime Remote area. |
| Y = Yes |
| TRICARE Young Adult Flag |
| 423 |
| $1 |
| TRICARE Young Adult Flag |
| 0 = No |
1 = Yes
| Eligibility Group |
| 424 |
| $1 |
| Specifies a beneficiary's basic relationship with the MHS. |
| C = Continued Health Care Benefit Program (CHCBP) |
D = Direct Care Only
E = TRICARE Eligible
L = TRICARE for Life (TFL)
R = TRICARE Retired Reserve (TRR)
S = TRICARE Reserve Select (TRS)
Y = TRICARE Young Adult (TYA)
Z = None
Note: This field is only populated for January 2018 forward
| Enrollment Group |
| 425 |
| $1 |
| Reports the enrolled relationship that the beneficiary has with the MHS. |
| P = TRICARE Prime |
D = Direct Care Only
L = TRICARE Plus
S = TRICARE Select
U = Designated…
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