(Medicare Claims Processing Manual)

Addendum A - Provider Specific File  (Rev. 12234, Issued: 08-31-23, Effective: 10-01-2023, Implementation: 10-02-2023)   Data Element  File Position  Format  Title  Description  1 1-10 X(10)  National Provider Identifier (NPI)  Alpha -numeric 10 character  NPI number.  Data Element  File Position  Format  Title  Description   11-16 X(6)  Provider CMS Certification Number (CCN)  Alpha -numeric 6 character provider number.  Cross check to provider type.  Positions 3 and 4 of: Provider #  Provider Type  00-08 Blanks, 00, 07 -11, 13-17, 21-22; NOTE: 14 and 15 no longer valid, effective 10/1/12  12 18 13 23,37  20-22 02 30 04 33 05 40-44 03 50-64 32-34, 38  15-17 35 70-84, 90 -99 36 Codes for special units are in the third position of the provider CMS Certification Number (CCN) and should correspond to the appropriate provider type, as shown below ( NOTE:  SB = swing bed): Special Unit  Prov. Type  M - Psych unit in CAH  49 R  - Rehab unit in CAH  50 S - Psych Unit  49 T - Rehab Unit  50 U - SB for short -term hosp.  51 W - SB for LTCH  52 Y - SB for Rehab  53 Z - SB for CAHs  54  3 17-24 9(8) Effective Date  Must be numeric, CCYYMMDD.  This is the effective date of the provider's first PPS period, or for subsequent PPS periods, the effective date of a change to the PROV file.  If a termination date is present for this record, the effective date must be equal to or less than the termination date. Year: Greater than 82, but not greater than current year.  Month: 01-12 Day: 01 -31 Data Element  File Position  Format  Title  Description  4 25-32 9(8) Fiscal Year Beginning Date Must be numeric, CCYYMMDD.  Year: Greater than 81, but not greater than current year.  Month: 01-12 Day: 01-31 Must be updated annually to show the current year for providers receiving a blended payment based on their FY begin date.  Must be equal to or less than the effective date.  5 33-40 9(8) Report Date  Must be numeric, CCYYMMDD.  Date file created/run date of the PROV report for submittal to CMS CO.  6  41-48 9(8) Termination Date  Must be numeric, CCYYMMDD.  Termination Date in this context is the date on which the reporting MAC ceased servicing the provider. Must be zeros or contain a termination date.  Must be equal to or greater than the effective date.  If the provider is terminated or transferred to another MAC, a termination date is placed in the file to reflect the last date the provider was serviced by the outgoing MAC.  Likewise, if the provider identification number changes, the MAC must place a ter mination date in the PROV file transmitted to CO for the old provider identification number. 7 49 X(1)  Waiver Indicator  Enter a Y or N.  Y = waived (Provider is not under PPS). N = not waived (Provider is under PPS).  8 50-54 9(5) Intermediary Number  Assigned intermediary number.  9 55-56 X(2)  Provider Type  This identifies providers that require special handling.  Enter one of the following codes as appropriate. 00 or blanks = Short Term Facility 02 Long Term 03 Psychiatric 04 Rehabilitation Facility  05 Pediatric 06 Hospital Distinct Parts  Data Element  File Position  Format  Title  Description  (Provider type 06 is effective until July 1, 2006.  At that point, provider type 06 will no longer be used.  Instead, MACs will assign a hospital distinct part as one of the following provider types: 49, 50, 51, 52, 53, or 54) 07 Rural Referral Center  08 Indian Health Service 13 Cancer Facility  14 Medicare Dependent Hospital  (during cost reporting periods that began on or after April 1, 1990).  15 Medicare Dependent Hospital/Referral Center  (during cost reporting periods that began on or after April 1, 1990.  Invalid October 1, 1994 through September 30, 1997).   16 Re-based Sole Community Hospital 17 Re-based Sole Community Hospital/ Referral Center  18 Medical Assistance Facility  21 Essential Access Community Hospital 22 Essential Access Community Hospital/Referral Center  23 Rural Primary Care Hospital 32 Nursing Home Case Mix Quality Demo Project  Phase II  33 Nursing Home Case Mix Quality Demo Project  Phase III  Step 1  34 Reserved  35 Hospice 36 Home Health Agency  37 Critical Access Hospital  38 Skilled Nursing Facility (SNF)  For non-demo PPS SNFs  effective for cost reporting periods beginning on or after July 1, 1998 40 Hospital Based ESRD Facility  41 Independent ESRD Facility 42 Federally Qualified Health Centers  43 Religious Non- Medical Health Care Institutions  44 Rural Health Clinics -Free Standing  Data Element  File Position  Format  Title  Description  45 Rural Health Clinics -Provider Based  46 Comprehensive Outpatient Rehab Facilities  47 Community Mental Health Centers 48 Outpatient Physical Therapy Services  49 Psychiatric Distinct Part 50 Rehabilitation Distinct Part 51 Short- Term Hospital  Swing Bed 52 Long- Term Care Hospital  Swing Bed 53 Rehabilitation Facility  Swing Bed 54 Critical Access Hospital  Swing Bed NOTE:  Provider Type values 49- 54 refer to special unit designations that are assigned to the third position of the provider CMS Certification Number (CCN) (See field #2 for a special unit- to-provider type cross -walk).  10 57 9(1) Current Census Division  Must be numeric (1 -9).  Enter the Census division to which the facility belongs for payment purposes.  When a facility is reclassified for the standardized amount, MACs must change the census division to reflect the new standardized amount location.  Valid codes a re: 1 New England 2 Middle Atlantic  3 South Atlantic  4 East North Central  5 East South Central 6 West North Central  7 West South Central  8 Mountain 9 Pacific  NOTE:  When a facility is reclassified for purposes of the standard amount, the MAC changes the census division to reflect the new standardized amount location.  11 58 X(1)  Change Code Wage Index Reclassification  Enter "Y" if hospital's wage index location has been reclassified for the year. Enter "N" if it has not been reclassified for the year.  Adjust annually.  12 59-62 X(4)  Actual Geographic Location - MSA  Enter the appropriate code for the MSA 0040-9965, or the rural area, (blank) (blank) 2 digit numeric State code such as Data Element  File Position  Format  Title  Description  _ _36 for Ohio, where the facility is physically located.  13 63-66 X(4)  Wage Index Location - MSA  Enter the appropriate code for the MSA, 0040-9965, or the rural area, (blank) (blank) (2 digit numeric State code) such as _ _ 3 6 for Ohio, to which a hospital has been reclassified due to its prevailing wage rates.  Leave blank or enter the actual location MSA (field 13), if not reclassified.  Pricer will automatically default to the actual location MSA if this field is left blank.  14 67-70 X(4)  Standardized Amount MSA Location  Enter the appropriate code for the MSA, 0040-9965, or the rural area, (blank) (blank) (2 digit numeric State code) such as _ _ 3 6 for Ohio, to which a hospital has been reclassified for standardized amount.  Leave blank or enter the actual location MSA (field 13) if not reclassified.  Pricer will automatically default to the actual location MSA if this field is left blank.  15 71-72 X(2)  Sole Community or Medicare Dependent Hospital  Base Year  Leave blank if not a sole community hospital (SCH) or a Medicare dependent hospital (MDH) effective with cost reporting periods that begin on or after April 1, 1990.  If an SCH or an MDH, show the base year for the operating hospital specific rate, the higher of either 82 or 87.  See 20.6 .  Must be completed for any SCH or MDH that operated in 82 or 87, even if the hospital will be paid at the Federal rate.   16  73 X(1)  Change Code for Lugar reclassification  Enter an "L" if the MSA has been reclassified for wage index purposes under 1886(d)(8)(B) of the Act.  These are also known as Lugar reclassifications, and apply to ASC-approved services provided on an outpatient basis when a hospital qualifies for payment under an alternate wage index MSA. Leave blank for hospitals if there has not been a Lugar reclassification.  Data Element  File Position  Format  Title  Description  17 74 X(1)  Temporary Relief Indicator  Enter a Y if this provider qualifies for a payment update under the temporary relief provision, otherwise leave blank. IPPS : Effective October 1, 2004, code a Y if the provider is considered low volume. IPF PPS : Effective January 1, 2005, code a Y if the acute facility where the unit is located has an Emergency Department or if the freestanding psych facility has an Emergency Department.  IRF PPS:  Effective October 1, 2005, code a Y for IRFs located in the state and county in Table 2 of the Addendum of the August 15, 2005 Federal Register (70 FR 47880).  The table can also be found at the following website:  www.cms.hhs.gov/InpatientRehabFacPPS/07DataFiles.asp#topOfPage LTCH PPS: Effective 04/21/16 through 12/31/16, code a Y for an LTCH that is a grandfathered HwH (hospitals that are described in  412.23(e)(2)(i) that currently meets the criteria of  412.22(f)); and is located in a rural area or is reclassified rural by meeting the provisions outlined in 412.103, as set forth in the regulations at 412.522(b)(4).  18 75 X(1)  Federal PPS Blend Indicator HH PPS:  For From dates before 1/1/2021:  Enter the value to indicate if normal percentage payments should be made on RAP and/or whether payment should be reduced under the Quality Reporting Program.  Valid values: 0 = Make normal percentage payment  1 = Pay 0% 2 = Make final payment reduced by 2% 3 = Make final payment reduced by 2%, pay RAPs at 0% NOTE: All new HHAs enrolled after January 1, 2019 must have this value set to 1 or 3 (no RAP payments).  For From dates on or after 1/1/2021: Enter the value to indicate whether Data Element  File Position  Format  Title  Description  payment should be reduced under the Quality Reporting Program.  Valid values: 0 = Make normal percentage payment  2 = Make final payment reduced by 2%  IRF PPS:  All IRFs are 100% Federal for cost reporting periods beginning on or after 10/01/2002. LTCH PPS:   For cost reporting periods beginning on or after 10/01/2002, enter the appropriate code for the blend ratio between federal and facility rates for the LTCH provider:    Federal %  Facility%  1 20 80 2 40 60 3 60 40 4 80 20 5 100 00  For LTCH cost reporting periods beginning on or after 10/01/2015 enter the appropriate code for the blend year representing 50% site neutral payment and 50 % standard payment.