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TRICARE Systems Manual 7950.4-M, April 2021
TRICARE Encounter Data (TED)
Chapter 2
Section 1.2
Data Reporting- Provider File Record Submission
Revision:
1.0General
1.1ContractorSubmission of TRICARE Encounter Provider Records (TEPRVs) Requirements
Record Content. Required informationfor each Health Care Provider:
•A Unique Provider ID Number(PROVIDER TAXPAYER NUMBER).
•Name.
•Address.
•Medical Specialty.
•Authorization Period.
•Denied services and TRICAREEncounter Data (TED) record cancellations will be excluded fromthe TEPRV check.
•The TEPRV must be present onthe Provider File at the Defense Health Agency (DHA) prior to reporting associatedTED records.
•The data will be used by DHAto track services rendered by each provider.
1.2Accountability For TEPRVs
The contractor having contractualauthority for provider certification in a given region has accountabilityfor the TEPRVs for providers in that region and is responsible forensuring these TEPRVs pass the DHA edits and for performing allmaintenance transactions. This responsibility extends to those TEPRVssubmitted in support of claims processing by another contractorwith the exception of pharmacy TEPRVs which can be submitted byany contractor.
1.3DataSubmission
The contractormust provide a separate record for each provider who renders careto a TRICARE beneficiary.
1.3.1TheInitial Load Of The Provider Information
1.3.1.1The initial load of the Providerinformation must be submitted following the rules listed below.Every effort must be made to ensure that duplicate Provider recordsare not submitted and that only active Provider records are submitted.
1.3.1.2For non-institutional providers,multiple records will be required when more than one provider is billingunder the same PROVIDER TAXPAYER NUMBER (e.g., clinics). In thiscase, the PROVIDER ZIP CODE and PROVIDER SUB-IDENTIFIER must beused to identify unique providers. Refer to these elements for further instructions.
1.3.2Transition Of Future ProviderInformation Between Contractors
The transition of future providerinformation between contractors must retain the provider recordkey information. For institutional providers the record key is:PROVIDER TAXPAYER NUMBER, PROVIDER ZIP CODE, and PROVIDER MAJORSPECIALTY/TYPE OF INSTITUTION. For non-institutional providers therecord key is: PROVIDER TAXPAYER NUMBER, PROVIDER ZIP CODE, andPROVIDER SUB-IDENTIFIER.
1.3.3InactiveProviders
When thecontractor removes a provider from their active provider files (e.g.,due to long periods of inactivity), a TEPRV must be submitted toTRICARE as a modify Transaction Code with a Provider TerminationDate reflecting when the provider was removed from the contractor’sfiles.
1.4InstitutionalProviders that are Part of a Multi-Hospital Chain
1.4.1Providersmust be identified within the PROVIDER TAXPAYER NUMBER by the ZIPcode.
1.4.2In addition, multiple recordswill be required for institutional providers with both DRG-exemptand DRG-non-exempt units under the same PROVIDER TAXPAYER NUMBER.
1.4.3These are to be identifiedby the PROVIDER SPECIALTY/TYPE OF INSTITUTION. Only one DRG-non-exemptTYPE OF INSTITUTION will be allowed per PROVIDER TAXPAYER NUMBERand ZIP code, while multiple DRG-exempt types of facility will beallowed.
1.4.4No duplicates within the PROVIDERTAXPAYER NUMBER, PROVIDER ZIP CODE, and PROVIDER MAJOR SPECIALTY/TYPEOF INSTITUTION will be allowed.
1.5InstitutionProvides Outpatient Care
1.5.1AdditionalTEPRVs must be reported to DHA. For outpatient services (e.g., ambulatorysurgery in hospital, emergency room, hospital services), submita TEPRV with PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION = FACILITYCHARGES (refer to edit 3-160-05R) and INSTITUTIONAL/NON-INSTITUTIONALINDICATOR = N.
1.5.2If theinstitution has a clinic associated with it, additional TEPRVs mustbe reported to DHA using the PROVIDER SUB-IDENTIFIER in the samemanner as a stand alone clinic.
2.0Provider File Record Maintenance
The Provider File is a dynamicfile where records can be added, modified, or inactivated when achange is required.
2.1FileSubmission
2.1.1The contractor must submitTEPRVs indicating the type of change and updated information.
2.1.2 TEPRVs will be submitted onan as needed basis.
2.1.3Each groupof TEPRVs must be preceded by a batch header record that identifiesthe subsequent records as provider transaction records.
2.2Add Transactions
2.2.1The TRANSACTION CODE must be A.
2.2.2 All required data elementsmust be included.
2.2.3An ADDcannot be made for institutional providers if the PROVIDER TAXPAYERNUMBER, PROVIDER SUB-IDENTIFIER, PROVIDER ZIP CODE, and PROVIDERMAJOR SPECIALTY/TYPE OF INSTITUTION are already on file.
2.2.4An ADD for non-institutionalproviders cannot be made if the PROVIDER TAXPAYER NUMBER, PROVIDER ZIPCODE and PROVIDER SUB-IDENTIFIER are already on file.
2.3Modify Transactions
2.3.1The TRANSACTION CODE must be M.
2.3.2All required data elementsmust be included.
2.3.3The MODIFYis used to make changes to an existing provider record, such asa termination of authorization or reauthorization.
2.3.4A MODIFY will replace the previousrecord with a new record. Records being replaced will be held in history.Multiple periods of authorization will be stored on the DHA masterprovider file.
2.3.5For institutionalproviders, a MODIFY will not be accepted if the PROVIDER TAXPAYERNUMBER, PROVIDER SUB-IDENTIFIER, PROVIDER ZIP CODE, and PROVIDERMAJOR SPECIALTY/TYPE OF INSTITUTION are not already on the file.
2.3.6For non-institutional providers,a MODIFY will not be accepted if the PROVIDER TAXPAYER NUMBER, PROVIDERZIP CODE and PROVIDER SUB-IDENTIFIER are not already on the file.
2.4Inactivate Transactions
The TRANSACTION CODE must be I.
2.4.1Institutional Providers
The INACTIVATE process is tobe used when there is an error on the PROVIDER TAXPAYER NUMBER,PROVIDER SUB-IDENTIFIER, PROVIDER ZIP CODE, or PROVIDER MAJOR SPECIALTY/TYPEOF INSTITUTION data elements.
2.4.2Non-InstitutionalProviders
2.4.2.1The INACTIVATE process is usedwhen there is an error on either the PROVIDER TAXPAYER NUMBER, PROVIDERZIP CODE, or the PROVIDER SUB-IDENTIFIER data elements.
2.4.2.2To correct an error on thesedata elements, the incorrect record must be inactivated and thecorrect record added using two separate transactions.
2.4.2.3When correcting an error onthese data elements for a clinic, all provider records associatedwith the clinic must also be inactivated. This process also applieswhen replacing a record containing a contractor Assigned ProviderNumber (APN) with a record containing the actual PROVIDER TAXPAYERNUMBER.
3.0Resubmission of Provider Batchesand Provider Records
3.1Batches that fail anyedits at the header record level will be rejected and returnedto the contractor for correction. Header level rejections requirethe resubmission of the entire batch with the appropriate data corrections.The RESUBMISSION NUMBER must not be incremented from what was reportedon the prior submission.
3.2TEPRVs thatfail any edits will be rejected and returned to the contractor forcorrection and resubmission in a new batch.
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