VALIDITYEDITS
2-285-01V
MUST BE A VALID HCC MEMBERCATEGORY CODE (REFER TO Section 2.5)
RelationalEdits
2-285-01R
IF HCC MEMBER RELATIONSHIPCODE =
A
SELF
THEN HCC MEMBERCATEGORY MUST ≠
A
ACTIVE DUTY OR
G
NATIONAL GUARD MEMBER (MOBILIZEDOR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
J
ACADEMY STUDENT OR
N
NATIONAL GUARD (NOT ON ACTIVEDUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS) OR
S
RESERVE MEMBER (MOBILIZED ORON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
T
FOREIGN MILITARY MEMBER OR
V
RESERVE MEMBER (NOT ON ACTIVEDUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS)
UNLESS ENROLLMENT/HEALTHPLAN CODE =
W
TPR SERVICE MEMBER - USA OR
X
FOREIGN SERVICE MEMBER OR
Y
CHCBP - NON-NETWORK OR
AA
CHCBP - NETWORK OR
SN
SHCP - NON-MTF/eMSM-REFERREDCARE OR
SO
SHCP - NON-TRICARE ELIGIBLE OR
SR
SHCP - MTF/eMSM REFERRED CARE OR
ST
SHCP - TRICARE ELIGIBLE OR
SU
SHCP - REFERRAL DESIGNATIONUNKNOWN OR
WA
TPR FOREIGN SERVICE MEMBER
OR ANY OCCURRENCEOF SPECIAL PROCESSING CODE =
SC
SHCP - NON-TRICARE ELIGIBLE OR
SE
SHCP - TRICARE ELIGIBLE OR
SM
SHCP - EMERGENCY
OR HCDP PLAN COVERAGECODE =
306
TRICARE SELECT - RESERVE SELECTSPONSORS AND FAMILY MEMBERS OR
307
TRICARE SELECT - RETIRED RESERVESPONSORS AND FAMILY MEMBERS OR
401
TRS TIER 1 MEMBER-ONLY COVERAGE(CONTINGENCY OPERATIONS) OR
402
TRS TIER 1 MEMBER AND FAMILYCOVERAGE (CONTINGENCY OPERATIONS) OR
405
TRS TIER 2 MEMBER-ONLY COVERAGE(CERTIFIED QUALIFICATIONS) OR
406
TRS TIER 2 MEMBER AND FAMILYCOVERAGE (CERTIFIED QUALIFICATIONS) OR
407
TRS TIER 3 MEMBER-ONLY COVERAGE(SERVICE AGREEMENT) OR
408
TRS TIER 3 MEMBER AND FAMILYCOVERAGE (SERVICE AGREEMENT) OR
409
TRS SURVIVOR CONTINUING WITHINDIVIDUAL COVERAGE OR
410
TRS SURVIVOR CONTINUING WITHFAMILY COVERAGE OR
411
TRS SURVIVOR NEW INDIVIDUALCOVERAGE OR
412
TRS SURVIVOR NEW FAMILY COVERAGE OR
413
TRS MEMBER-ONLY COVERAGE OR
414
TRS MEMBER AND FAMILY COVERAGE OR
418
TRICARE RETIRED RESERVE (TRR)MEMBER-ONLY COVERAGE OR
419
TRR MEMBER AND FAMILY COVERAGE OR
420
TRR SURVIVOR INDIVIDUAL COVERAGE OR
421
TRR SURVIVOR FAMILY COVERAGE
2-285-02R
IF ANY OCCURRENCE OF SPECIAL PROCESSINGCODE =
PF
ECHO
THEN HHC MEMBERCATEGORY CODE MUST =
A
ACTIVE DUTY OR
G
NATIONAL GUARD MEMBER (MOBILIZEDOR ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
J
ACADEMY STUDENT OR
P
TAMP MEMBER OR
S
RESERVE MEMBER (MOBILIZED ORON ACTIVE DUTY FOR 31 DAYS OR MORE)
2-285-03R
IF TYPE OF SERVICE (FIRST POSITION)=
A
AMBULATORY SURGERY COST-SHAREDAS INPATIENT
THEN HCC MEMBERCATEGORY CODE MUST =
A
ACTIVE DUTY OR
G
NATIONAL GUARD MEMBER (MOBILIZEDOR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
J
ACADEMY STUDENT OR
N
NATIONAL GUARD MEMBER (NOTON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS) OR
P
TAMP MEMBER OR
S
RESERVE MEMBER (MOBILIZED ORON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
T
FOREIGN MILITARY MEMBER OR
V
RESERVE MEMBER (NOT ON ACTIVEDUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS) OR
Z
UNKNOWN
UNLESS AMOUNTALLOWED BY PROCEDURE CODE = 0
2-285-04R
IF HCDP PLAN COVERAGE CODE=
004
DIRECT CARE FOR SURVIVORS OFACTIVE DUTY DECEASED SPONSORS OR
005
TRICARE STANDARD FOR SURVIVORSOF ACTIVE DUTY DECEASED SPONSORS OR
016
DIRECT CARE FOR SURVIVORS OFGUARD/RESERVE DECEASED SPONSORS OR
017
TRICARE STANDARD FOR SURVIVORSOF GUARD/RESERVE DECEASED SPONSORS OR
021
TFL FOR SURVIVORS OF ACTIVEDUTY DECEASED SPONSORS OR
023
TFL FOR SURVIVORS OF GUARD/RESERVEDECEASED SPONSORS OR
110
TRICARE PRIME FOR INDIVIDUALCOVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
111
TRICARE PRIME FAMILY COVERAGEFOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
114
TRICARE USFHP DIRECT CARE INDIVIDUALCOVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
115
TRICARE USFHP DIRECT CARE FAMILYCOVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
136
TRICARE PRIME INDIVIDUAL COVERAGEFOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
137
TRICARE PRIME FAMILY COVERAGEFOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
138
TRICARE USFHP DIRECT CARE INDIVIDUALCOVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
139
TRICARE USFHP DIRECT CARE FAMILYCOVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
143
TRICARE PLUS COVERAGE FOR SURVIVORSOF ACTIVE DUTY DECEASED SPONSORS OR
144
TRICARE PLUS WITH CHC COVERAGEFOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
148
TRICARE PLUS COVERAGE FOR SURVIVORSOF GUARD/RESERVE DECEASED SPONSORS OR
149
TRICARE PLUS COVERAGE WITHCHC FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
205
TDP INDIVIDUAL COVERAGE FORSURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
206
TDP FAMILY COVERAGE FOR SURVIVORSOF ACTIVE DUTY DECEASED SPNSORS OR
212
TDP INDIVIDUAL COVERAGE FORSURVIVORS OF SELECTED RESERVE (SelRes) DECEASED SPONSORS OR
213
TDP FAMILY COVERAGE FOR SURVIVORSOF SELECTED RESERVE (SelRes) DECEASED SPONSORS OR
306
TRICARE SELECT - RESERVE SELECTSPONSORS AND FAMILY MEMBERS OR
345
TRICARE PLUS - DIRECT CAREONLY (PRESENTATION LAYER) OR
346
TRICARE PLUS OR
409
RESERVE SELECT SURVIVOR CONTINUINGWITH INDIVIDUAL COVERAGE OR
410
RESERVE SELECT SURVIVOR CONTINUINGWITH FAMILY COVERAGE OR
411
RESERVE SELECT SURVIVOR NEWINDIVIDUAL COVERAGE OR
412
RESERVE SELECT SURVIVOR NEWFAMILY COVERAGE
OR ENROLLMENT/HEALTHPLAN CODE =
AS
TRICARE SELECT - ACTIVE DUTYSURVIVORS OR
GS
TRICARE SELECT - GUARD/RESERVESURVIVORS
OR AMOUNT ALLOWEDBY PROCEDURE CODE = 0
THEN BYPASS THISEDIT
ELSE IF TYPE OFSERVICE (SECOND POSITION) =
C
AMBULATORY SURGERY
THEN HCC MEMBERCATEGORY CODE MUST =
D
DISABLED AMERICAN VETERAN OR
F
FORMER MEMBER OR
H
MOH RECIPIENT OR
R
RETIRED OR
W
FORMER SPOUSE OR
Z
UNKNOWN
2-285-05R
IF HCC MEMBER CATEGORY CODE=
T
FOREIGN MILITARY MEMBER
THEN ONE OCCURRENCEOF OVERRIDE CODE =
M
NATO
