The Department of Health and Hospitals (LDH) will provide maintenance of all documentation changes to this Guide using the Change Control Table as shown below. Change Control Table Author of Change Sections Changed Description Reason Date Andrea Hollins/ Kerri Capello Version 1.0 10/11/15 Kerri Capello Appendix G Updated Provider Types & Provider Specialties LDH Provider Types & Provider Specialties missing from grid 10/13/15 Kerri Capello Appendix J Removed paragraph under LTC CSoC File layout Isn’t applicable to file 10/13/15 Kerri Capello Appendix E Removed the word Interim. Reporting denied claims in encounter is not included in CSoC contract. Denied claims will be reported in the monthly claims report for this contract. 10/14/15 Jacques Kado Appendix J Updated the LTC LBHP/CSoC PIHP Segment Layout Provided additional clarification 10/21/15 Andrea Hollins Appendix L Added the Lookup Taxonomy Table Magellan requested the table be added 10/29/15 Andrea Hollins Section 7 Removed Codes – H0018, T2048, S5145, and H2013 Codes are not covered services 10/29/15 Andrea Hollins/ Tamara Manuel Version 2 NOTE: Appendices have been updated with new letters starting with Appendix C. Will be noted in the below entries. 11/18/15 Andrea Hollins Section 2 Reporting Interest Payment Explanation of how interest is to be reported 11/2/15 Tamara Manuel Appendix C Blank – Not Utilized in Version 1 11/18/15 Tamara Manuel Appendix D System Generated Reports Changed Appendix letter to “C”. 11/18/15
Tamara Manuel Appendix E PIHP Generated Reports Changed Appendix letter to “D” 11/18/15 Tamara Manuel Appendix F Encounter Edit Codes Changed Appendix letter to “E” 11/18/15 Tamara Manuel Appendix G Provider Directory/Network Provider and Sub Registry Changed Appendix letter to “F” 11/18/15 Tamara Manuel Appendix H Test Plan Changed Appendix letter to “G” 11/18/15 Tamara Manuel Appendix I Websites Changed Appendix letter to “H” 11/18/15 Tamara Manuel Appendix J LTC CSoC PIHP Segment Layout Changed Appendix letter to “I” 11/18/15 Tamara Manuel Appendix K Prior Authorization File Changed Appendix letter to “J” 11/18/15 Tamara Manuel Appendix L Provider Type – Provider Specialty – Taxonomy Crosswalk Changed Appendix letter to “K” 11/18/15 Andrea Hollins Tamara Manuel Appendix M Supplemental Claims History File Layout Highlighted fields are the items used to identify BH services. TM – Changed Appendix letter to “L” 11/2/15 TM – 11/18/15 Tamara Manuel Appendix N Provider Supplemental Record Layout Added the Provider Supplemental Record Layout Changed Appendix letter to “M” 11/4/15 TM – 11/18/15 Tamara Manuel Appendix N CSoC Chisholm Electronic File Layout Added CSoC Chisholm Electronic File Layout 11/18/15 Andrea Hollins/ Tamara Manuel Appendix O Master File Exchange Schedule Added Inbound/Outbound File Schedule Changed Appendix letter from N to “O”. Updated schedules with new Inbound/Outbound files with naming conventions noted in yellow highlight. 11/2/15 TM - 11/18/15 Tamara Manuel December 2015 - Version 2.1 See Updates Below starting with date 11/23/2015 11/23/15 Tamara Manuel Section 3 Encounter Edit Codes Deleted Edit Codes that were designated to be turned off or educational. Off – 001,004,012, 013,018, 019, 031, 065, 088, 11/23/15 and 12/06/15
Tamara Manuel Appendix O Master File Exchange Schedule Added the FILE and supporting information to the Outbound File Exchange. 01/07/16 Tamara Manuel Appendix I LTC CSoC PIHP SEGMENT LAYOUT Update Plan File submission criteria for File number 8 to include the following: When edit 139 is used the end date must be ONE day prior to the begin date. 01/08/16 Tamara Manuel Appendix O Master File Exchange Schedule Added the CSoC Monthly 820 file information in the Outbound File Schedule. Name of file: 01/14/16 Tamara Manuel Appendix Q ELIG RECON FILE LAYOUT Added the file layout for the information. 01/27/16 Tamara Manuel Appendix O Master File Exchange Schedule Added the following file to the Inbound File Exchange listing: 01/27/16 Tamara Manuel Appendix O Master File Exchange Schedule Added the following return files to the Outbound File Exchange listing: 01/28/16 Tamara Manuel Table of Contents Footer Updated Footer Information (Version 2.3 January 2016) 01/28/16 Tamara Manuel Table of Contents Appendix Q Added Appendix Q & Naming Convention of Layout: Elig Recon File Layout with Page Number 01/28/16 Tamara Manuel Appendix M UPDATED Provider Supplemental Record Layout Revised verbiage under the Notes Section to Columns 9-19 and and then changed Column from O = Optional to R = Required. 02/10/16 26 16
Tamara Manuel Section 3 Encounter Edit Code(s): Deny (Repairable or Repairable Under Limited Circumstances): Deleted the following codes that have been turned Off: 914, 930, 931, 933, 946, 949 and 980. 02/15/16 Tamara Manuel Appendix E Encounter Edit Codes Deleted the following “Informational” codes that have been turned Off: 651, 701, 711, 730, 790, 792, 795, 918, 921, 947, 961, 962, 969, 977 and 981. 02/15/16 Tamara Manuel Appendix E Encounter Edit Codes Deleted the following “Non Repairable Denials” Table that have been turned Off: 642, 673, 758, 791, 813, 942, 948, 951, 952, 954, and 972. 02/15/16 Tamara Manuel Appendix E Encounter Edit Codes Added the following codes to the “Informational” Table: 791 and 813. 02/15/16 Tamara Manuel Appendix E Encounter Edit Codes Added the following codes to the “Non-Repairable Denials” Table: 807, 851, 852, and 860. 02/15/16 Tamara Manuel Table of Contents through Appendix Q Reformatted/Page Numbering Reformatted entire document for automatic processing of all type of headings and page numbering. 02/16/16 Tamara Manuel Appendix E Encounter Edit Codes Deleted the following “Informational” code 556. 02/23/16 Tamara Manuel Appendix E Encounter Edit Codes Added the following code to the “Non-Repairable Denials” Table: 556. 02/23/16 Tamara Manuel Change Control Table Column Dates Corrected dates for the above entries for Encounter Edit Codes starting after 02/10/2016. Changed all 12/15/16 dates to 02/15/16. 02/23/16 Tamara Manuel Table of Contents Footer Footer Information (Updated Draft to February 2016) 02/23/16 Tamara Manuel Appendix M UPDATED PROVIDER SUPPLEMENTAL RECORD LAYOUT Changed the “License End Date 2 through 5” from R = Required to O = Optional. 02/29/16 Tamara Manuel Appendix M UPDATED PROVIDER SUPPLEMENTAL RECORD LAYOUT Added verbiage for Part 1 Plan File Submission 03/15/16
Tamara Manuel Table of Contents Footer Corrected Month of the Footer Information to MARCH 2016 Version 2.5. 03/15/16 Tamara Manuel Appendix O Master File Exchange Schedule Added the following file to the Inbound File Exchange listing: 03/21/16 Tamara Manuel Appendix O Master File Exchange Schedule Added the following file to the Outbound File Exchange listing: and the 03/21/16 Tamara Manuel Table of Contents Footer Corrected Month of the Footer Information to APRIL 2016 Version 2.5. 04/04/16 Tamara Manuel Appendix E Encounter Edit Codes Deleted the following Denial” code 556. 04/04/16 Tamara Manuel Appendix E Encounter Edit Codes Added the following code to the “Educational” Table: 556. 04/04/16 Tamara Manuel Section 2 Batch Submissions Updated/Clarified verbiage to paragraphs. 04/12/16 Tamara Manuel Section 12 Magellan CSoC Quarterly Retro Process for PMPM Adjustments Added the business processes for the Magellan CSoC Qtrly. Retro Process for PMPM Adjustments 04/21/16 Tamara Manuel Appendix C SYSTEM GENERATED REPORTS - Subsection: 820 File (FI to PIHP) Added the REF=Reference Information (1st occurrence) and the REF=Reference Information (2nd occurrence – used only for duplicate recipient recoveries) 04/26/16 Tamara Manuel Section 13 PMPM Payment Recovery for Duplicate Recipient Medicaid IDs (Magellan) Added criteria/business process for PMPM Payment Recoveries for Duplicate Recipient Medicaid IDs. 04/27/16 Tamara Manuel Appendix R FILE LAYOUT Added the FILE LAYOUT 04/27/16 Tamara Manuel Appendix O Master File Exchange Schedule Added the following file and file information to the Outbound File Exchange listing: Recipient Voided IDs.txt file. 04/27/16 Repairable
Tamara Manuel Appendix P PIHP CSoC Batch Electronic File Layout for TPL Information Added the TPL File Layout to Magellan with the the following: 05 PIC x(02). 07/22/16 Tamara Manuel Table of Contents Title Page & Footer of Document Corrected Month of the Footer Information to August 2016 Version 6. 08/02/16 Tamara Manuel Appendix I LTC CSoC PIHP SEGMENT LAYOUT Updated PART 2: SUBMISSION EDIT PROCESS to include the new Error Code 060 ME CSOC Overlap and description. 08/03/16 Tamara Manuel Appendix E Encounter Edit Codes Added the following code to the “Non-Repairable Denials” Table: 349 – Recipient not covered for this service. 08/11/16 Tamara Manuel Appendix O Inbound Files to Molina Removed the Monthly.txt” file information. 09/19/16 Tamara Manuel Table of Contents Title Page & Footer of Document Corrected Month of the Footer Information to November 2016 Version 7 11/02/16 Tamara Manuel Table of Contents Title Page & Footer of Document Corrected Month of the Footer Information to February 2017 Version 8 02/16/17 Tamara Manuel Appendix S Third Party Liability (TPL) Batch Full Reconciliation File Layout Added the TPL Batch Full Reconciliation File Layout 02/16/17 Tamara Manuel Table of Contents Reformatted Document Reformatted entire document for automatic processing several headings and page numbering. 02/20/17 Tamara Manuel Appendix P PIHP CSoC Batch Electronic File Layout for TPL Information Removed the TPL File Layout to Magellan with the following: 05 PIC x(02), etc. 11/07/17 Tamara Manuel Appendix T Third Party Liability (TPL) File Layout to Magellan Added the MBI Field to the TPL File Layout – Incremental & Reconciliation 11/07/17 Tamara Manuel Appendix T Third Party Liability (TPL) File Layout to Magellan Added the Tables for the 2 character predetermined (assigned) field that denotes the initiator of the private insurance segments to Appendix T. 11/08/17 CODE CODE
1000B N103 ID Code Qualifier “FI” - Federal Taxpayer ID number 1000B N104 Identification Code Premium Payer ID 2000B INDIVIDUAL REMITTANCE ENT=Individual Remittance Sample: ENT*1*2J*34*123456789~ 2000B Assigned Number Sequential Number assigned for differentiation within a transaction set 2000B Entity Identifier Code “2J” - Individual 2000B Identification Code Qualifier “34” - Social Security Number 2000B Identification Code Individual Identifier - SSN 2100B INDIVIDUAL NAME NM1=Policyholder Name Sample: NM1*QE*1*DOE*JOHN*Q***N*1234567890123~ 2100B Entity Identifier Code “QE” - Policyholder (Recipient Name) 2100B Policyholder “1” - Person 2100B Name Last Individual Last Name 2100B Name First Individual First Name 2100B Name Middle Individual Middle Initial 2100B NOT USED NOT USED 2100B NOT USED NOT USED
2100B Identification Code Qualifier “N” – Insurer’s Unique ID number 2100B Identification Code Recipient ID 2300B INDIVIDUAL PREMIUM REMITTANCE DETAIL RMR=Organization Summary Remittance Detail Sample: RMR*AZ*1234567890123**400.00~ 2300B Reference Identification Qualifier “11” - Account Number 2300B Reference Identification Claim ICN 2300B Monetary Amount Detail Premium Payment Amount REF=Reference Information (1st occurrence) Sample: REF*ZZ*001~ 2300B Reference Identification Qualifier “ZZ” - Mutually Identified S 2300B Reference Identification Capitation Code D 2300B Not Used 2300B Not Used 9
DTM=Individual Coverage Period Sample: DTM*582****RD8*20120101-20120131~ 2300B Date/Time Qualifier “582” - Report Period 2300B NOT USED NOT USED 2300B NOT USED NOT USED 2300B NOT USED NOT USED 2300B Date Time Period Format Qualifier “RD8” – Range of Dates 2300B Date Time Period Coverage Period, expressed as Transaction Set Trailer Sample: SE*39*0001~ SE SE01 Transaction Segment Count SE02 Transaction Set Control Number Remark: The transaction set control numbers in ST02 and SE02 must be identical. This number must be unique within a specific group and interchange, but the number can repeat in other groups and interchanges. 4
530 RECIPIENT WAS REIMBURSED FOR THIS SERVICE 631 EPSDT AGE OVER 21 644 VISIT CODE ALREADY PAID FOR THIS DATE OF SERVICE 689 MHR SERVICES ALREADY PAID FOR THIS DATE OF SERVICE 695 ONE HOSPITAL DISCHARGE SERVICE PAID PER ADMISSION 704 ER VISIT ON DATE OF INP HOS SERVICES 712 ONE INITIAL HOSPITAL INPATIENT SERVICE PAID PER ADMISS 716 PROCEDURE INCLUDED IN THE PHYSICIAN OFFICE VISIT 735 PREVIOUSLY PAID ANES.OR SUPERVISING ANES SAME RECI/DOS 746 SAME ATTENDING PROV PAID INPT CONSULTATION SAME STAY 794 INPT HOSP SERV PAID FOR SAME DOS TO SAME ATTENDING PROV 797 DUPLICATE ADJUSTMENT RECORDS ENTERED 798 HISTORY RECORD ALREADY ADJUSTED 800 DUPLICATE OF PREVIOUSLY PAID CLAIM 801 EXACT DUPLICATE ERROR: IDENTICAL HOSPITAL CLAIMS 802 EXACT DUPLICATE ERROR: HOSPITAL AND 805 EXACT DUPLICATE ERROR: IDENTICAL OUTPATIENT CLAIMS 806 EXACT DUPLICATE ERROR: OUTPATIENT AND REHAB SERVICES 807 EXACT DUPLICATE ERROR: OUTPATIENT AND HOME HEALTH 814 EXACT DUPLICATE ERROR: PHYSICIAN AND TITLE18 849 ALREADY PAID SAME ATTENDING DIFFERENT BILLING PROVIDER 851 SUSPCT DUPLICATE ERROR: IDENTICAL HOSPITAL CLAIMS 852 SUSPCT DUPLICATE ERROR: HOSPITAL AND TITLE 18 860 INVALID COB-1 ID COB-1 PAYER ID MUST BE PLAN ID 898 EXACT DUPE SAME ICN - DROPPED 926 EXACT DUPLICATE OF ANOTHER ADJUSTMENT.
the end of the item so that it fits in the positions. 75 Delimiter 1 Character, use the ^ character value 76-105 Provider Business Mailing Address (First line address) 30 Character R 106 Delimiter 1 Character, use the ^ character value 107-136 Provider Business Mailing Address (Second line address) 30 Character O 137 Delimiter 1 Character, use the ^ character value 138-167 Provider Business Mailing Address (City,) 30 Character R 168 Delimiter 1 Character, use the ^ character value 169-170 Provider Business Mailing Address (State) USPS state code abbreviation 2 Character R 171 Delimiter 1 Character, use the ^ character value 172-181 Provider Business Mailing Address (9-Digit Postal Code) 10 Character, right-fill with spaces if necessary R 182 Delimiter 1 Character, use the ^ character value justify,
183-192 Provider Business Mailing Address (Country Code if outside U.S.) Leave blank if business mailing address is not outside the U.S. 10 Character, right-fill with spaces if necessary O 193 Delimiter 1 Character, use the ^ character value 194-203 Provider Business Mailing Address (Telephone Number) Do not enter dashes or parentheses. 10 Numeric R 204 Delimiter 1 Character, use the ^ character value 205-214 Provider Business Mailing Address (Fax Number) Do not enter dashes or parentheses. 10 Numeric O 215 Delimiter 1 Character, use the ^ character value 216-245 Provider Business Location Address (First line address) No P.O. Box here, please use a physical address. 30 Character R 246 Delimiter 1 Character, use the ^ character value 247-276 Provider Business Location Address (Second line address) 30 Character O 277 Delimiter 1 Character, use the ^ character value 278-307 Provider Business Location Address (City,) 30 Character R
308 Delimiter 1 Character, use the ^ character value 309-310 Provider Business Location Address (State) 2 USPS state code abbreviation R 311 Delimiter 1 Character, use the ^ character value 312-321 Provider Business Location Address (Postal Code) 10 Character, right-fill with spaces if necessary R 322 Delimiter 1 Character, use the ^ character value 323-332 Provider Business Location Address (Country Code if outside U.S) Leave blank if business mailing address is not outside the U.S. 10 Character, right-fill with spaces if necessary O 333 Delimiter 1 Character, use the ^ character value 334-343 Provider Business Location Address (Telephone Number) Do not enter dashes or parentheses. 10 Numeric R 344 Delimiter 1 Character, use the ^ character value 345-354 Provider Business Location Address (Fax Number) Do not enter dashes or parentheses. 10 Numeric O 355 Delimiter 1 Character, use the ^ character value 356-365 Healthcare Provider 10 Character R
396 Delimiter 1 Character, use the ^ character value 397-400 Other Provider Identifier Type Code Provider Type and Provider Specialty 1st 2 characters are provider type; last 2 characters (3-4) are provider specialty. See PIHP Companion Guide for list of applicable provider types and specialties. R 401 Delimiter 1 Character, use the ^ character value 402-409 Provider Enumeration Date NPPES enumeration date. 8 Numeric, format YYYYMMDD R 410 Delimiter 1 Character, use the ^ character value 411-418 Last Update Date NPPES last update date; leave all zeros if not available. 8 Numeric, format YYYYMMDD O 419 Delimiter 1 Character, use the ^ character value 420-439 NPI Deactivation Reason Code NPPES deactivation reason; leave blank if appropriate. 20 Left with spaces. O 440 Delimiter 1 Character, use the ^ character value 441-448 NPI Deactivation Date NPPES deactivation date; leave all zeros if not appropriate. 8 Numeric, format YYYYMMDD O
(Title or Position) 566 Delimiter 1 Character, use the ^ character value 567-576 Authorized Official Contact Information (Telephone Number) Do not enter dashes or parentheses. 10 Numeric R 577 Delimiter 1 Character, use the ^ character value 578 Panel Open Indicator Y=Yes, panel is open. N=No, panel is not open. 1 Character R for PCPs; otherwise optional. 579 Delimiter 1 Character, use the ^ character value 580 Language Indicator 1 (this is the primary language indicator) patients only 2=Accepts patients 3=Accepts patients 4=Accepts patients 5=Accepts patients 1 Character R for PCPs, specialists and other professionals; otherwise optional. 581 Delimiter 1 Character, use the ^ character value 582 Language Indicator 2 (this is a secondary 0=no other language supported 1 Character O
5=Accepts patients 589 Delimiter 1 Character, use the ^ character value 590 Age Restriction Indicator 0=no age restrictions 1=adult only 2=pediatric only 1 Character R for PCPs, specialists and other professionals; otherwise optional. 591 Delimiter 1 Character, use the ^ character value 592-596 PCP Linkage Maximum Numeric 5 Numeric, left fill with zeroes. This number represents the maximum number of patients that can be linked to the PCP. It should be left all zeroes if the provider is not a PCP/specialist. R for PCPs; otherwise optional. 597 Delimiter 1 Character, use the ^ character value 598-602 PCP Linkages with PIHP Numeric 5 Numeric, left fill with zeroes. This number represents the maximum number of PIHP enrollees that can be linked to the PCP. It should be left all zeroes if the provider is not a PCP/specialist. R for PCPs; otherwise optional.
603 Delimiter 1 Character, use the ^ character value 604-608 PCP Linkages with Others Numeric 5 Numeric, left fill with zeroes. This number represents the maximum number of enrollees in other plans (not PIHP ) that can be linked to the PCP. It should be left all zeroes if the provider is not a PCP/specialist. R for PCPs; otherwise optional. 609 Delimiter 1 Character, use the ^ character value 610 PIHP Enrollment Indicator N=New enrollment C=Change to existing enrollment D=Disenrollment 1 Use this field to identify new providers, changes to existing providers, and disenrolled providers R 611 Delimiter 1 Character, use the ^ character value 612-619 PIHP Enrollment Indicator Effective Date Effective date of Enrollment Indicator above. 8 Numeric, format YYYYMMDD R 620 Delimiter 1 Character, use the ^ character value 621 Family Only Indicator 0=no restrictions 1=family members only 1 R for PCPs; otherwise optional. 622 Delimiter 1 Character, use the ^ character value
PIHP and the provider started 671 Delimiter 1 Character, use the ^ character value 672-679 PIHP Contract Term Date Date that the contract between the PIHP and the provider was terminated. 8 Numeric date value in the form YYYYMMDD O 680 Delimiter 1 Character, use the ^ character value 681-682 Provider Parish served – 1st or primary Parish code value that represents the primary parish that the provider serves 2 2-digit parish code value. See the PIHP Companion Guide. R 683 Delimiter 1 Character, use the ^ character value 684-685 Provider Parish served – 2nd Parish code value that represents a secondary or other parish that the provider serves. Use only if necessary; otherwise enter 00. 2 2-digit parish code value. See the PIHP Companion Guide. O 686 Delimiter 1 Character, use the ^ character value 687-688 Provider Parish served – 3rd Parish code value that represents a secondary or other parish that the provider serves. Use only if necessary; 2 2-digit parish code value. See the PIHP Companion Guide. O
otherwise enter 00. 689 Delimiter 1 Character, use the ^ character value 690-691 Provider Parish served – 4th Parish code value that represents a secondary or other parish that the provider serves. Use only if necessary; otherwise enter 00. 2 2-digit parish code value. See the PIHP Companion Guide. O 692 Delimiter 1 Character, use the ^ character value 693-694 Provider Parish served – 5th Parish code value that represents a secondary or other parish that the provider serves. Use only if necessary; otherwise enter 00. 2 2-digit parish code value. See the PIHP Companion Guide. O 695 Delimiter 1 Character, use the ^ character value 696-697 Provider Parish served – 6th Parish code value that represents a secondary or other parish that the provider serves. Use only if necessary; otherwise enter 00. 2 2-digit parish code value. See the PIHP Companion Guide. O 698 Delimiter 1 Character, use the ^ character value
699-700 Provider Parish served – 7th Parish code value that represents a secondary or other parish that the provider serves. Use only if necessary; otherwise enter 00. 2 2-digit parish code value. See the PIHP Companion Guide. O 701 Delimiter 1 Character, use the ^ character value 702-703 Provider Parish served – 8th Parish code value that represents a secondary or other parish that the provider serves. Use only if necessary; otherwise enter 00. 2 2-digit parish code value. See the PIHP Companion Guide. O 704 Delimiter 1 Character, use the ^ character value 705-706 Provider Parish served – 9th Parish code value that represents a secondary or other parish that the provider serves. Use only if necessary; otherwise enter 00. 2 2-digit parish code value. See the PIHP Companion Guide. O 707 Delimiter 1 Character, use the ^ character value 708-709 Provider Parish served – 10th Parish code value that represents a secondary or other parish that 2 2-digit parish code value. See the PIHP Companion Guide. O
the provider serves. Use only if necessary; otherwise enter 00. 710 Delimiter 1 Character, use the ^ character value 711-712 Provider Parish served – 11th Parish code value that represents a secondary or other parish that the provider serves. Use only if necessary; otherwise enter 00. 2 2-digit parish code value. See the PIHP Companion Guide. O 713 Delimiter 1 Character, use the ^ character value 714-715 Provider Parish served – 12th Parish code value that represents a secondary or other parish that the provider serves. Use only if necessary; otherwise enter 00. 2 2-digit parish code value. See the PIHP Companion Guide. O 716 Delimiter 1 Character, use the ^ character value 717-718 Provider Parish served – 13th Parish code value that represents a secondary or other parish that the provider serves. Use only if necessary; 2 2-digit parish code value. See the PIHP Companion Guide. O
otherwise enter 00. 719 Delimiter 1 Character, use the ^ character value 720-721 Provider Parish served – 14th Parish code value that represents a secondary or other parish that the provider serves. Use only if necessary; otherwise enter 00. 2 2-digit parish code value. See the PIHP Companion Guide. O 722 Delimiter 1 Character, use the ^ character value 723-724 Provider Parish served – 15th Parish code value that represents a secondary or other parish that the provider serves. Use only if necessary; otherwise enter 00. 2 2-digit parish code value. See the PIHP Companion Guide. O 725 Delimiter 1 Character, use the ^ character value 726 Prescriber Indicator Used for prescriber types: medical psychologists, physicians, psychiatrists, etc. Valid values are: blank=not applicable or no prescriptive authority. 1 Character R for prescriber types; otherwise leave blank.
01 General Practice 1 19,20 02 General Surgery 1 19, 20, 93 03 Allergy 1 19,20 04 Otology, Laryngology, Rhinology 1 19,20 05 Anesthesiology 1 19, 20, 91 06 Cardiovascular Disease 1 19,20 07 Dermatology 1 19,20 08 Family Practice 1 19, 20, 78 09 Gynecology (DO only) 1 19 10 Gastroenterology 1 19,20 11 Not in Use n/a n/a 12 Manipulative Therapy (DO only) 1 19 13 Neurology 1 19,20 14 Neurological Surgery 1 19,20 15 Obstetrics (DO only) 1 19 16 OB/GYN 1 19, 20, 78, 90 17 Ophthalmology, Otology, Laryngology, Rhinology (DO only) 1 19 18 Ophthalmology 1 20 19 Orthodontist 1 19,20 20 Orthopedic Surgery 1 19,20 21 Pathologic Anatomy; Clinical Pathology (DO only) 1 19 22 Pathology 1 20 23 Peripheral Vascular Disease or Surgery (DO only) 1 19 24 Plastic Surgery 1 19,20 25 Physical Medicine Rehabilitation 1 19,20 26 Psychiatry 1 19, 20, 93 27 Psychiatry; Neurology (DO only) 1 19 28 Proctology 1 19,20 29 Pulmonary Diseases 1 19,20 30 Radiology 1 19,20 31 Roentgenology, Radiology (DO only) 1 19 32 Radiation Therapy (DO only) 1 19 33 Thoracic Surgery 1 19,20 Specialty Code Description Type: 1=Specialty, 2=Subspecialty Related Specialty (if Subspecialty) Related Provider Types 34 Urology 1 19,20 35 Chiropractor 1 30,35 36 Pre-Vocational Habilitation 1 13 37 Pediatrics 1 19, 20, 78 38 Geriatrics 1 19,20 39 Nephrology 1 19,20 40 Hand Surgery 1 19,20 41 Internal Medicine 1 19,20 42 Federally Qualified Health Centers 1 72 43 Not in Use n/a n/a 44 Public Health 1 66,70
4S Ochsner Med School 2 19,20 4U OPH Registered Dietitian 1 AU 4W Waiver Services 1 42 4X Waiver-Only Transportation 1 42 4Y EHR Managed Care (Medical) 2 IP 5A PCS-LTC 1 24 5B PCS-EPSDT 1 24 5C PAS 1 24 5D PCS-LTC, PCS-EPSDT 1 24 5E PCS-LTC, PAS 1 24 5F PCS-EPSDT, PAS 1 24 5G PCS-LTC, PCS-EPSDT, PAS 1 24 5H Community Mental Health Center 18 5I Statewide Management Organization (SMO) 1 AB 5J Youth Support 1 AC 5K Family Support 1 AC 5L Both Youth and Family Support 1 AC 5M Multi-Systemic Therapy 12 5N Substance Abuse and Alcohol Abuse Center 1 68 5P PACE 1 50 5Q CCN-P (Coordinated Care Network, Pre-paid) 1 05 5R CCN-S (Coordinated Care Network, Shared Savings) 1 52 5S Tulane Med School 2 19,20 5T Community Choices Waiver (CCW) 1 5U Individual 1 AD 5V Agency/Business 1 AD 5W Community Choices Waiver - Personal Assistance Service 2 87 44 5X Therapeutic Group Homes 1 AT 5Y PRCS Addiction Disorder 1 5Z Therapeutic Group Home Disorder 1 6A Psychologist -Clinical 1 31 6B Psychologist-Counseling 1 31 6C Psychologist - School 1 31 6D Psychologist - Developmental 1 31 6E Psychologist - Non-Declared 1 31 6F Psychologist - All Other 1 31 6G Medical Psychologist 1 31 6H LaPOP 1 01 6N Endodontist 1 27 6P Periodontist 1 27 6S E Jefferson Fam Practice Ctr - Residency Program 2 19,20 6T Community Choices Waiver - Physical Therapy 2 65, 87, 75 35, 44, 65 6U Applied Behavioral Analyst 1 AX 6W Licensed Mid-Wife 1 MW Specialty Code Description Type: 1=Specialty, 2=Subspecialty Related Specialty (if Subspecialty) Related Provider Types
Diagnosis Type DIAG_TYPE Indicates ICD9 or 10 INT 2 545-546 Level of Care Full text of Final Outcome 50 547-596 Place of Service PLS_OF_SVC Full text of Place of Service 50 597-646 Problem Type PROB_TYPE Full text of Problem Type 50 647-696 Admission Date ADMIT_DT Initial Admission Date 8 697-704 Admission Type ADMIT_TYPE 1 705-705 Authorization Start Date START_DT Initial Start Date Start date of the not this particular CR 8 706-713 Authorization End Date END_DT End Date Final End date of the not this particular CR 8 714-721 Closing Resolution Full text of Closing Resolution Closed cases only on CRs 50 722-771 Denial Reason Full text of Denial Reason Denials only on CRs 50 772-821 Field Common Name Field File Name Field Description Notes Type Data Length Columns Denial Reason Full text of Denial Reason Denials only on CRs 50 772-821
Authorization Status Denials only on CRs 1 822-822 Units Requested UNIT_REQ Units Requested in this CR INT 3 823-825 Units Approved UNIT_APPR Units Approved in this CR INT 3 826-828 CPT 1 Code CPT1_CODE First CPT Code of CR 5 829-833 CPT 1 Units CPT1_UNITS Units for this CPT code in this CR INT 3 834-836 CPT 1 Modifier 1 CPT1_MOD1 2 837-838 CPT 1 Modifier 2 CPT1_MOD2 2 839-840 CPT 2 Code CPT2_CODE Second CPT Code of CR 5 841-845 CPT 2 Units CPT2_UNITS Units for this CPT code in this CR INT 3 846-848 CPT 2 Modifier 1 CPT2_MOD1 2 849-850 CPT 2 Modifier 2 CPT2_MOD2 2 851-852 CPT 3 Code CPT3_CODE Third CPT Code of CR 5 853-857 CPT 3 Units CPT3_UNITS Units for this CPT code in this CR INT 3 858-860 CPT 3 Modifier 1 CPT3_MOD1 2 861-862 CPT 3 Modifier 2 CPT3_MOD2 2 863-864 CPT 4 Code CPT4_CODE Fourth CPT Code of CR 5 865-869 CPT 4 Units CPT4_UNITS Units for this CPT code in this CR INT 3 870-872 CPT 4 Modifier 1 CPT4_MOD1 2 873-874 CPT 4 Modifier 2 CPT4_MOD2 2 875-876 US
Appendix K Provider Type – Provider Specialty – Taxonomy Crosswalk LTX_Prov_ Specialty_ Desc LTX_Taxonomy_Desc 1 FISCAL AGENT (WVR) 4A Disabled (DD) 253Z00000X Agencies In Home Supportive Care 1 FISCAL AGENT (WVR) 6H LaPOP 253Z00000X Agencies In Home Supportive Care 2 SUPPORT (WVR) 4A Disabled (DD) 225C00000X Respiratory, Developmental, Rehabilitative and Restorative Service Providers Rehabilitation Counselor 3 CHILDRENS CHOICE (WVR)(IN-ST) 9E Children's Choice Waiver 101Y00000X Behavioral Health & Social Service Providers Counselor 4 PEDI DAY HLTH CARE (IN-ST) 1Z Pediatric Day Health Care 261QM3000X Ambulatory Health Care Facilities Clinic/Center Medically Fragile Infants and Children Day Care 5 MANAGED CARE ORG - PREPAID 5Q CCN-P Care Network, Pre-paid) 302R00000X Managed Care Organizations Health Maintenance Organization 6 NOW SERVICES 4B NOW RN 163W00000X Nursing Service Providers Registered Nurse 6 NOW SERVICES 4C NOW LPN 363L00000X Physician Assistants & Advanced Practice Nursing Providers/Nurse Practitioner 6 NOW SERVICES 4D NOW Psychologist 103T00000X Behavioral Health & Social Service Providers/Psychologist 6 NOW SERVICES 4E NOW Social Worker 104100000X Behavioral Health & Social Service Providers Social Worker TRANSITION PROFESSION AL
7 CASE & TODD (IN-ST) 81 Case 171M00000X Other Service Providers Case Manager/Care Coordinator LTX_Prov_ Specialty_ Desc LTX_Taxonomy_Desc 8 OAAS CASE MGMT 81 Case 171M00000X Other Service Providers Case Manager/Care Coordinator 9 HOSPICE SERVICES (IN-ST) 93 Hospice Service for Dual Elig. 315D00000X Nursing & Custodial Care Facilities Hospice, Inpatient 10 COMM SUPPORT SRV 70 Clinic or Other Group Practice 253Z00000X Agencies In Home Supportive Care 11 SHARED LIVING (WVR) 4A Disabled (DD) 372600000X Nursing Service Related Providers Adult Companion 12 THER (IN-ST) 5M Therapy 261QP2000X Ambulatory Health Care Facilities Clinic/Center Physical Therapy 13 PREVOC REHAB (WVR) 36 Habilitation 251C00000X Agencies Day Training, Developmentally Disabled Services 14 DAY HABILITAT (WVR) 50 Day Habilitation 261QA0600X Ambulatory Health Care Facilities Clinic/Center Adult Day Care 15 ENVIR ACC ADAP (WVR) (IN-ST) 80 Adaptations 171W00000X Other Service Providers Contractor 16 PERS EMERG RESP SYS (WVR) 90 Personal Emergency Response Sys (Waiver) 333300000X Suppliers Emergency Response System Companies 17 ASSISTIVE DEVICES (WVR) 91 Assistive Devices 225CA2400X Respiratory, Developmental, Rehabilitative and Restorative Service Providers Rehabilitation Counselor Assistive Technology Practitioner 18 COMM MENTAL HLTH CTR/PART HOSP 5H Community Mental Health Center 261QM0801X Ambulatory Health Care Facilities/Clinic/Center, Mental Health
19 DR OF OSTEOPATH MED (IND & GP) 1 General Practice 208D00000X Allopathic & Osteopathic Physicians/General Practice 19 DR OF OSTEOPATH MED (IND & GP) 2 General Surgery 208600000X Allopathic & Osteopathic Physicians/Surgery 19 DR OF OSTEOPATH MED (IND & GP) 3 Allergy 207K00000X Allopathic & Osteopathic Physicians/Allergy and Immunology 19 DR OF OSTEOPATH MED (IND & GP) 4 Otology, Rhinology 207YX0901X Allopathic & Osteopathic & Neurotology LTX_Prov_ Specialty_ Desc LTX_Taxonomy_Desc 19 DR OF OSTEOPATH MED (IND & GP) 5 207L00000X Allopathic & Osteopathic Physicians/Anesthesiology 19 DR OF OSTEOPATH MED (IND & GP) 6 Disease 207RC0000X Allopathic & Osteopathic Physicians/Internal Medicine, Cardiovascular Disease 19 DR OF OSTEOPATH MED (IND & GP) 7 207N00000X Allopathic & Osteopathic Physicians/Dermatology 19 DR OF OSTEOPATH MED (IND & GP) 8 Family Practice 207Q00000X Allopathic & Osteopathic Physicians/Family Medicine 19 DR OF OSTEOPATH MED (IND & GP) 9 Gynecology (DO only) 207V00000X Allopathic & Osteopathic Physicians/Obstetrics & Gynecology 19 DR OF OSTEOPATH MED (IND & GP) 10 207RG0100X Allopathic & Osteopathic Physicians/Internal Medicine, Gastroenterology 19 DR OF OSTEOPATH MED (IND & GP) 12 Therapy (DO only) 207R00000X Allopathic & Osteopathic Physicians/Internal Medicine 19 DR OF OSTEOPATH MED (IND & GP) 12 Therapy (DO only) 207R00000X Allopathic & Osteopathic Physicians/Internal Medicine
20 PHYSICIAN (IND & GP) 39 Nephrology 207RN0300X Allopathic & Osteopathic Physicians/Internal Medicine, Nephrology LTX_Prov_ Specialty_ Desc LTX_Taxonomy_Desc 20 PHYSICIAN (IND & GP) 40 Hand Surgery 207XS0106X Allopathic & Osteopathic Physicians/Orthopaedic Surgery/Hand Surgery 20 PHYSICIAN (IND & GP) 41 Internal Medicine 207R00000X Allopathic & Osteopathic Physicians/Internal Medicine 20 PHYSICIAN (IND & GP) 48 Podiatry - Surgical Chiropody 213E00000X Podiatric Medicine and Surgery Providers - Podiatrists 20 PHYSICIAN (IND & GP) 49 (Admin. Medicine) 207R00000X Allopathic & Osteopathic Physicians/Internal Medicine 20 PHYSICIAN (IND & GP) 70 Clinic or Other Group Practice 193200000X Multi-Specialty Group 21 THIRD PARTY BILL 9U Medicare Advantage Plans NA NULL 21 THIRD PARTY BILL 9V OCDD - Point of Entry NA NULL 21 THIRD PARTY BILL 9W OAAS - Point of Entry NA NULL 21 THIRD PARTY BILL 9X OAD - Point of Entry NA NULL 21 THIRD PARTY BILL 9Y Juvenile Court/Drug Treatment Center NA NULL 21 THIRD PARTY BILL 9Z Other Contract with a State Agency NA NULL 22 PERSONAL CARE ATTENDANT (WVR) 82 Personal Care Attendant 3747P1801X Nursing Service Related Providers Technician Personal Care Attendant 23 LAB 69 Independent Laboratory (Billing 291U00000X Laboratories/Clinical Medical Laboratory
23 LAB 72 Diagnostic Laboratory 291U00000X Laboratories/Clinical Medical Laboratory 24 PERSONAL CARE SERVICES (IN-ST) 5A PCS-LTC 3747P1801X Nursing Service Related Providers Technician Personal Care Attendant LTX_Prov_ Specialty_ Desc LTX_Taxonomy_Desc 24 PERSONAL CARE SERVICES (IN-ST) 5B 3747P1801X Nursing Service Related Providers Technician Personal Care Attendant 24 PERSONAL CARE SERVICES (IN-ST) 5C Personal Assistant Service (PAS) 3747P1801X Nursing Service Related Providers Technician Personal Care Attendant 24 PERSONAL CARE SERVICES (IN-ST) 5D PCS-LTC, 3747P1801X Nursing Service Related Providers Technician Personal Care Attendant 24 PERSONAL CARE SERVICES (IN-ST) 5E Personal Assistant Service (PAS) 3747P1801X Nursing Service Related Providers Technician Personal Care Attendant 24 PERSONAL CARE SERVICES (IN-ST) 5F PAS 3747P1801X Nursing Service Related Providers Technician Personal Care Attendant 24 PERSONAL CARE SERVICES (IN-ST) 5G PCS-LTC, PAS 3747P1801X Nursing Service Related Providers Technician Personal Care Attendant 25 MOBILE THRPY CT 63 Portable Supplier (Billing 261QR0208X Ambulatory Health Care Facilities/Clinic-Center, Radiology, Mammography 26 PHARMACY 87 All Other 333600000X Suppliers/Pharmacy 27 DENTIST (IND & GP) 66 General Dentistry (DDS/DMS) 122300000X Dental Providers Dentist 27 DENTIST (IND & GP) 67 Oral and Surgery 1223S0112X Dental Providers - Dentists - Oral and Maxillofacial Surgery 27 DENTIST (IND & GP) 68 Pediatric Dentistry 1223P0221X Dental Providers - Dentists - Pediatric Dentistry 27 DENTIST (IND & GP) 6N Endodontist 1223E0200X Dental Providers - Dentists - Endodontics
27 DENTIST (IND & GP) 6P Periodontist 1223P0300X Dental Providers - Dentists – Periodontics 28 (IND & GP) 88 Optician / Optometrist 152W00000X Eye and Vision Service Providers/Optometrist 29 EARLYSTEPS (IND & GP) (IN-ST) 62 Psychologist Crossovers only 103T00000X Behavioral Health & Social Service Providers/Psychologist 29 EARLYSTEPS (IND & GP) (IN-ST) 64 Audiologist (Billing 231H00000X Speech, Language and Hearing Service Providers/Audiologist 29 EARLYSTEPS (IND & GP) (IN-ST) 65 Indiv Physical Therapist 225100000X Respiratory, Developmental, Rehabilitative & Restorative Service Providers/Physical Therapist LTX_Prov_ Specialty_ Desc LTX_Taxonomy_Desc 29 EARLYSTEPS (IND & GP) (IN-ST) 71 Speech Therapy 235500000X Speech, Language and Hearing Service Providers Specialist/Technologist 29 EARLYSTEPS (IND & GP) (IN-ST) 74 Therapy 225X00000X Respiratory, Developmental, Rehabilitative & Restorative Service Providers/Occupational Therapist 30 (IND & GP) 35 Chiropractor 111N00000X Chiropractic Providers/Chiropractor 31 (LIC/MED) (IN-ST) 62 Psychologist Crossovers only 103T00000X Behavioral Health & Social Service Providers/Psychologist 31 (LIC/MED) (IN-ST) 6A Psychologist -Clinical 103T00000X Behavioral Health & Social Service Providers/Psychologist 31 (LIC/MED) (IN-ST) 6B 103T00000X Behavioral Health & Social Service Providers/Psychologist 31 (LIC/MED) (IN-ST) 6C Psychologist - School 103T00000X Behavioral Health & Social Service Providers/Psychologist 31 (LIC/MED) (IN-ST) 6D Psychologist - 103T00000X Behavioral Health & Social Service Providers/Psychologist 31 (LIC/MED) (IN-ST) 6E Psychologist - 103T00000X Behavioral Health & Social Service Providers/Psychologist 31 (LIC/MED) (IN-ST) 6F Psychologist - All Other 103T00000X Behavioral Health & Social Service Providers/Psychologist Independent
31 (LIC/MED) (IN-ST) 95 Psychologist (PBS Program Only) 103T00000X Behavioral Health & Social Service Providers/Psychologist 31 (LIC/MED) (IN-ST) 96 Psychologist (PBS Program and X-Overs) 103T00000X Behavioral Health & Social Service Providers/Psychologist 32 PODIATRIST (IND & GP) 48 Podiatry - Surgical Chiropody 213E00000X Podiatric Medicine & Surgery Service Providers/Podiatrist 33 ONLY PROVIDER 92 ONLY PROVIDER NA NULL 34 (IN-ST) 64 Audiologist (Billing 231H00000X Speech, Language and Hearing Service Providers/Audiologist LTX_Prov_ Specialty_ Desc LTX_Taxonomy_Desc 35 PHYSICAL THERAPIST (IN-ST) 35 Chiropractor 111N00000X Chiropractic Providers/Chiropractor 35 PHYSICAL THERAPIST (IN-ST) 65 Indiv Physical Therapist 225100000X Respiratory, Developmental, Rehabilitative & Restorative Service Providers/Physical Therapist 36 NOT ASSIGNED NULL NA NULL 37 THERAPIST (IN-ST) 74 Therapy 225X00000X Respiratory, Developmental, Rehabilitative & Restorative Service Providers/Occupational Therapist 38 SCHOOL BSED HEALTH CTR (IN-ST) 7A SBHC - NP - Part Time - less than 20 hrs week 261Q00000X Ambulatory Health Care Facilities Clinic/Center 38 SCHOOL BSED HEALTH CTR (IN-ST) 7B SBHC - NP - Full Time - 20 or more hrs week 261Q00000X Ambulatory Health Care Facilities Clinic/Center 38 SCHOOL BSED HEALTH CTR (IN-ST) 7C SBHC - MD - Part Time - less than 20 hrs week 261Q00000X Ambulatory Health Care Facilities Clinic/Center 38 SCHOOL BSED HEALTH CTR (IN-ST) 7D SBHC - MD - Full Time - 20 or more hrs week 261Q00000X Ambulatory Health Care Facilities Clinic/Center
38 SCHOOL BSED HEALTH CTR (IN-ST) 7E SBHC - NP + MD - Part Time - total = less than 20 hrs week 261Q00000X Ambulatory Health Care Facilities Clinic/Center 38 SCHOOL BSED HEALTH CTR (IN-ST) 7F SBHC - NP + MD - Full Time - total = 20 or more hrs week 261Q00000X Ambulatory Health Care Facilities Clinic/Center 39 THERAP 4W Waiver Services 235500000X Speech, Language and Hearing Service Providers Specialist/Technologist 39 THERAP 71 Speech Therapy 235500000X Speech, Language and Hearing Service Providers Specialist/Technologist 40 DME 2Y OPH Genetic Disease Program 332B00000X Suppliers/Durable Medical Equipment & Medical Supplies LTX_Prov_ Specialty_ Desc LTX_Taxonomy_Desc 40 DME 51 Med Supply / Certified Orthotist 332B00000X Suppliers/Durable Medical Equipment & Medical Supplies 40 DME 52 Med Supply / Certified Prosthetist 332B00000X Suppliers/Durable Medical Equipment & Medical Supplies 40 DME 53 Direct Care Worker 332B00000X Suppliers/Durable Medical Equipment & Medical Supplies 40 DME 54 Med Supply / Not Included in 51, 52, 53 332B00000X Suppliers/Durable Medical Equipment & Medical Supplies 40 DME 55 Indiv Certified Orthotist 332B00000X Suppliers/Durable Medical Equipment & Medical Supplies 40 DME 56 Indiv Certified Prosthetist 332B00000X Suppliers/Durable Medical Equipment & Medical Supplies 40 DME 57 Indiv Certified Prosthetist - Orthotist 332B00000X Suppliers/Durable Medical Equipment & Medical Supplies 40 DME 58 Indiv Not Included in 55, 56, 57 332B00000X Suppliers/Durable Medical Equipment & Medical Supplies
40 DME 87 All Other 332B00000X Suppliers/Durable Medical Equipment & Medical Supplies 41 REGISTERED DIETICIAN (IN-ST) 4R Registered Dietician 133V00000X Dietary & Nutritional Service Providers/Dietician, Registered 42 NON-EMER MED TRANSPORT (IN-ST) 45 NEMT - Non-profit 343900000X Transportation Services Medical Transport (VAN) 42 NON-EMER MED TRANSPORT (IN-ST) 46 NEMT - Profit 343900000X Transportation Services Medical Transport (VAN) 42 NON-EMER MED TRANSPORT (IN-ST) 47 NEMT - F+F 343900000X Transportation Services Medical Transport (VAN) 42 NON-EMER MED TRANSPORT (IN-ST) 4W Waiver Services 343900000X Transportation Services Medical Transport (VAN) 42 NON-EMER MED TRANSPORT (IN-ST) 4X 343900000X Transportation Services Medical Transport (VAN) LTX_Prov_ Specialty_ Desc LTX_Taxonomy_Desc 43 CASE MGT - NHV/FTM (IN-ST) 81 Case 163WC0400X Nursing Service Providers Registered Nurse Case Management 44 HOME HEALTH AGENCY 87 All Other 251E00000X Agencies/Home Health 45 CASE MGMT - (IN-ST) 81 Case 171M00000X Other Service Providers Case Manager/Care Coordinator 46 CASE MGMT - HIV 81 Case 171M00000X Other Service Providers Case Manager/Care Coordinator 47 CASE MGMT - CMI 81 Case 171M00000X Other Service Providers Case Manager/Care Coordinator 48 CASE MGMT - PREGNANT WOMEN 81 Case 171M00000X Other Service Providers Case Manager/Care Coordinator 49 CASE MGMT - DEVELOP DISABLED 81 Case 171M00000X Other Service Providers Case Manager/Care Coordinator
50 PACE CARE-ELD) 5P PACE 251T00000X Agencies PACE Provider Organization 51 AMBULANCE 59 Ambulance Service Supplier, Private 341600000X Transportation Services/Ambulance 52 CO-ORDIN CARE 5R CCN-S Care Network, Shared Savings) 302R00000X Managed Care Organizations Health Maintenance Organization 53 SELF SUPPORT NULL 172V00000X Other Service Providers Community Health Worker 54 SURGI CTR (IN-ST) 70 Clinic or Other Group Practice 261QA1903X Ambulatory Health Care Facilities/Clinic-Center, Ambulatory Surgical 55 EMERG ACCESS HOSPITAL (IN-ST) 86 Hospitals and Nursing Homes 261QC0050X Ambulatory Health Care Facilities Clinic/Center Critical Access Hospital 56 PRESCRIBER ONLY FOR MCO NULL NA NULL 57 OPH REGISTERED NURSE 60 Public Health or Welfare Agencies & Clinics 163W00000X Nursing Service Providers Registered Nurse 58 NOT ASSIGNED NULL NA NULL LTX_Prov_ Specialty_ Desc LTX_Taxonomy_Desc 59 NEURO REHAB HOSPITAL (IN-ST) 86 Hospitals and Nursing Homes 273Y00000X Hospital Units/Rehabilitation Unit 60 HOSPITAL 85 Extended Care Hospital 282N00000X Hospitals/General Acute Care Hospital 60 HOSPITAL 86 Hospitals and Nursing Homes 282N00000X Hospitals/General Acute Care Hospital 60 HOSPITAL 87 All Other 282N00000X Hospitals/General Acute Care Hospital
71 FMLY PLANNING CLINIC 97 Family Planning Clinic 261QF0050X Ambulatory Health Care Facilities Clinic/Center Family Planning, Non-Surgical 72 FED QUALIFIED HLTH CTR (IN-ST) 42 Federally Qualified Health Centers 261QF0400X Ambulatory Health Care Facilities/Federally Qualified Health Center (FQHC) 72 FED QUALIFIED HLTH CTR (IN-ST) 9L RHC/FQHC OPH Certified SBHC 261QF0400X Ambulatory Health Care Facilities/Federally Qualified Health Center (FQHC) 73 LIC CL SOCIAL WORKER 73 Social Worker Enrollment 104100000X Behavioral Health & Social Service Providers Social Worker 74 MENTAL HEALTH CLINIC 70 Clinic or Other Group Practice 261QM0801X Ambulatory Health Care Facilities/Clinic/Center, Mental Health 75 OPTICAL SUPPLIER 88 Optician / Optometrist 332H00000X Suppliers Eyewear Supplier (Equipment, not the service) 76 CENTER (IN-ST) 70 Clinic or Other Group Practice 261QE0700X Ambulatory Health Care Facilities/End-Stage Renal Disease (ESRD) Treatment 77 MENTAL REHAB AGENCY 78 Mental Health Rehab 103TR0400X Behavioral Health & Social Service Providers/Psychologist, Rehabilitation 78 NURSE (IND & GP) 8 Family Practice 363LF0000X Physician Assistants and Advanced Practice Nursing Providers - Nurse Practitioner - Family 78 NURSE (IND & GP) 16 OB/GYN 363LX0001X Physician Assistants and Advanced Practice Nursing Providers - Nurse Practitioner - Obstetrics & Gynecology 78 NURSE (IND & GP) 26 Psychiatry 364SP0808X Physician Assistants & Advanced Practice Nursing Providers/Clinical Nurse Specialist, Psychiatric/Mental Health 78 NURSE (IND & GP) 37 Pediatrics 363LP0200X Physician Assistants and Advanced Practice Nursing Providers - Nurse Practitioner - Pediatrics 78 NURSE (IND & GP) 79 Nurse Practitioner 363L00000X Physician Assistants & Advanced Practice Nursing Providers/Nurse Practitioner 79 RURAL HLTH 94 Rural Health Clinic 261QR1300X Ambulatory Health Care Facilities/Clinic/Center, Rural Health
LTX_Prov_ Specialty_ Desc LTX_Taxonomy_Desc 80 NURSING FACILITY (IN-ST) 86 Hospitals and Nursing Homes 314000000X Nursing and Custodial Care Facilities/Skilled Nursing Facility 81 CASE MGMT - VENT ASSTD CARE 81 Case 171M00000X Other Service Providers Case Manager/Care Coordinator 82 PERS CARE ATTEND (WVR) 82 Personal Care Attendant 3747P1801X Nursing Service Related Providers Technician Personal Care Attendant 82 PERS CARE ATTEND (WVR) 8D Community Choices Waiver - Caregiver Temporary Support 3747P1801X Nursing Service Related Providers Technician Personal Care Attendant 83 CTR BASED RESPITE CARE (IN-ST) 83 Respite Care 385H00000X Respite Care Facility Respite Care 85 ADLT DAY HLTH CA (WVR) 76 Adult Day Care 261QA0600X Ambulatory Health Care Facilities Clinic/Center Adult Day Care 85 ADLT DAY HLTH CA (WVR) 77 Habilitation 261QA0600X Ambulatory Health Care Facilities Clinic/Center Adult Day Care 86 ICF/DD NULL 261QR0400X Ambulatory Health Care Facilities/Clinic/Center, Rehabilitation 87 RURAL HLTH 94 Rural Health Clinic 261QR1300X Ambulatory Health Care Facilities/Clinic/Center, Rural Health 88 ICF/DD - GROUP HOME 86 Hospitals and Nursing Homes 261QD1600X Ambulatory Health Care Facilities Clinic/Center Developmental Disabilities 89 SPRVISE INDEP LIV (WVR)(IN-ST) 89 Supervised Living 372600000X Nursing Service Related Providers Adult Companion 90 CERTIFIED NURSE MIDWIFE 16 OB/GYN 367A00000X Physician Assistants & Advanced Practice Nursing Providers/Midwife, Certified Nurse 91 CERT REG NURS ANEST (IND & GP) 5 163W00000X Nursing Service Providers Registered Nurse
91 CERT REG NURS ANEST (IND & GP) 70 Clinic or Other Group Practice 163W00000X Nursing Service Providers Registered Nurse 92 PRIVATE DUTY NURSE NULL NA NULL 93 CLINICAL NURSE SPECIALIST 2 General Surgery 364S00000X Physician Assistants & Advanced Practice Nursing Providers/Clinical Nurse Specialist LTX_Prov_ Specialty_ Desc LTX_Taxonomy_Desc 94 PHYSICIAN ASSISTANT 26 Psychiatry 364SP0808X Physician Assistants & Advanced Practice Nursing Providers/Clinical Nurse Specialist, Psychiatric/Mental Health 94 PHYSICIAN ASSISTANT 2R Physician Assistant 363A00000X Physician Assistants & Advanced Practice Nursing Providers/Physician Assistant 95 AMERICAN INDIAN/638 FACILITY 2T American Indian / Native Alaskan 332800000X Suppliers Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy 96 PSYCH RESID TREAT FACILITY 8L PRTF 323P00000X Residential Treatment Facilities Psychiatric Residential Treatment Facility 96 PSYCH RESID TREAT FACILITY 8P IP - Physician - MD 323P00000X Residential Treatment Facilities Psychiatric Residential Treatment Facility 96 PSYCH RESID TREAT FACILITY 9B Psychiatric Residential Treatment Facility 323P00000X Residential Treatment Facilities Psychiatric Residential Treatment Facility 97 ADULT CARE FAC 9D Residential Care 3747P1801X Nursing Service Related Providers Technician Personal Care Attendant 98 SUPPORTED EMPLYMENT (IN-ST) 98 Supported 251C00000X Agencies Day Training, Developmentally Disabled Services 99 GREAT NO COMM HLTH CONN(IN-ST) 9P GNOCHC - Greater New Orleans Community Health Connection 251K00000X Agencies/Public Health or Welfare AA ASSERTIVE COMM TREAT TEAM NULL 261QC1500X Ambulatory Health Care Facilities Clinic/Center Community Health AB PREPAID INPATIENT HLTH PLAN 5I Statewide 305R00000X Managed Care Organizations Preferred Provider Organization
(SMO) AC FAMILY SUPPORT 5J Youth Support 364SF0001X Physician Assistants & Advanced Practice Nursing Providers/Clinical Nurse Specialist, Family Health AC FAMILY SUPPORT 5K Family Support 364SF0001X Physician Assistants & Advanced Practice Nursing Providers/Clinical Nurse Specialist, Family Health AC FAMILY SUPPORT 5L Both Youth and Family Support 364SF0001X Physician Assistants & Advanced Practice Nursing Providers/Clinical Nurse Specialist, Family Health AD 5U Individual 251C00000X Agencies Day Training, Developmentally Disabled Services LTX_Prov_ Specialty_ Desc LTX_Taxonomy_Desc AD TRANSITION 5V Agency / Business 251C00000X Agencies Day Training, Developmentally Disabled Services AE RESPITE CARE SERVICE AGENCY 83 Respite Care 385H00000X Respite Care Facility Respite Care AF CRISIS RECEIVING CENTER 8E CSoC/ Behavioral Health 261Q00000X Ambulatory Health Care Facilities Clinic/Center AG HLTH REHAB AGENCY 8E CSoC/ Behavioral Health 251S00000X Agencies Community/Behavioral Health AH LIC MARRIAGE & FAMILY THERAPY 8E CSoC/ Behavioral Health 106H00000X Behavioral Health & Social Service Providers Marriage & Family Therapist AH LIC MARRIAGE & FAMILY THERAPY 8E CSoC/ Behavioral Health 106H00000X Behavioral Health & Social Service Providers Marriage & Family Therapist AJ LICENSED ADDICTION COUNSELOR 8E CSoC/ Behavioral Health 101YA0400X Behavioral Health & Social Service Providers Counselor Addiction (Substance Use Disorder) AK LICENSED COUNSELOR 8E CSoC/ Behavioral Health 101YP2500X Behavioral Health & Social Service Providers Counselor Professional COMMUNITY CHOICE 8K ADHC HCBS 251K00000X Agencies/Public Health or Welfare
owners 17 Voluntary /Proprietary 18 Proprietary/Government 19 Voluntary/Government 88 N/A – The individual only practices as part of a group, e.g., as an employee 59-59 Delimiter Use the ^ character value 1 Character R 60-61 The FIPS State code is a 2-digit code developed by the Census Bureau for state designation. To obtain the correct state designation, please click the name of the field. 2 Numeric O 62-62 Delimiter Use the ^ character value 1 Character R 63-65 The FIPS County code is a code developed by the US Census Bureau for county designation within a state. To obtain the correct county designation, please click the name of the field. 3 Numeric O 66-66 Delimiter Use the ^ character value 1 Character R 67-126 Provider Business Mailing Email Address The email address associated with the provider's billing address. Blank (Space filled) if no email address exists. 60 Character O 127-127 Delimiter Use the ^ character value 1 Character R 128-187 Provider Business Location Email Address The email address associated with the provider's physical address. Blank (Space filled) if no email address exists. 60 Character O 188-188 Delimiter Use the ^ character value 1 Character R 189-189 License Type 1 1 State, county, or municipality professional or business license 2 DEA license 3 Professional society accreditation 4 CLIA accreditation 5 Other 1 Numeric R 190-190 Delimiter Use the ^ character value 1 Character R 191-210 License Or 1 A data element to capture the license or accreditation number issued to the provider by the licensing entity or accreditation body. 20 Character R
578-578 Delimiter Use the ^ character value 1 Character R 579-586 License effective date 4 The beginning effective date of the license 8 Date O 587-587 Delimiter Use the ^ character value 1 Character R 588-595 License End date 4 The last date the license was active. (20991231 for open and unknown) 8 Date O 596-596 Delimiter Use the ^ character value 1 Character R 597-597 License Type 5 1 State, county, or municipality professional or business license 2 DEA license 3 Professional society accreditation 4 CLIA accreditation 5 Other Blank (Space filled) if no additional license or accreditation 1 Numeric O 598-598 Delimiter Use the ^ character value 1 Character R 599-618 License Or 5 A data element to capture the license or accreditation number issued to the provider by the licensing entity or accreditation body. 20 Character O 619-619 Delimiter Use the ^ character value 1 Character R 620-679 License issuing ID 5 A free text field to capture the identity of the entity issuing the license or accreditation. 60 Character O 680-680 Delimiter Use the ^ character value 1 Character R 681-688 License effective date 5 The beginning effective date of the license 8 Date O 689-689 Delimiter Use the ^ character value 1 Character R 690-697 License End date 5 The last date the license was active. (20991231 for open and unknown) 8 Date O 698-698 Delimiter Use the ^ character value 1 Character R 699-706 MCO Enrollment Begin Date 1 Effective beginning date of services which can be paid by MCO 8 Date R 707-707 Delimiter Use the ^ character value 1 Character R 708-715 MCO Enrollment End Date 1 Effective ending date of services of which can be paid by MCO 20991231 if no ending date is available. 8 Date R 716-716 Delimiter Use the ^ character value 1 Character R
717-718 MCO Enrollment Termination Code 1 60 Term - Abuse of billing privileges 61 Term - Action Taken by Medicaid/CHIP 62 Term - Action Taken by Medicare 63 Term - Change of Ownership 64 Term - Failure to report a change of address/ownership 65 Term - False or misleading information 66 Term - Federal exclusion/ debarment, etc. 67 Term - Felony conviction 68 Term - Involuntary Termination 69 Term - License Expired 70 Term - License Revoked 71 Term - Loss of license or other State action 72 Term - Medicare/Medicaid Exclusion 73 Term - Medicaid Authority 74 Term - Medicare Termination 75 Term - Misuse of billing number 76 Term - No Claims Activity 77 Term - Non-Compliance 78 Term - Onsite review/ Provider is no longer operational 79 Term - Other 80 Term - Provider Deceased 81 Term - State exclusion/ debarment, etc. 82 Term - Unknown 83 Term - Voluntary Termination Blank if contract is still enforce 2 Numeric R 719-719 Delimiter Use the ^ character value 1 Character R 720-727 MCO Enrollment Begin Date 2 Effective beginning date of services which can be paid by MCO 8 Date O 728-728 Delimiter Use the ^ character value 1 Character R 729-736 MCO Enrollment End Date 2 Effective ending date of services of which can be paid by MCO 20991231 if no ending date is available. 8 Date O 737-737 Delimiter Use the ^ character value 1 Character R
evening and Friday after Weekly Processing CSOC-RETURN-YYYYMMDD.txt CSOC Return File Daily Every Work Day MOLINA Extract of retroactive recipient eligibility changes that may impact the coverage period in Magellan 1.0 or CSOC contract. Weekly Every Saturday, but occasionally on early Sunday MOLINA Weekly PA Extract for MCO Weekly Each Tuesday by COB MOLINA MCO List of Medicaid providers enrolled since 2011 Weekly Each Tuesday by COB MOLINA MCO Twice Weekly Supplemental Edit Response File Twice Weekly Every Wednesday and Friday night unless it is a holiday and then you may submit the file on the previous applicable work day MOLINA MCO MCNA MW-W-50-xxxxxxx-ccyymmdd.PDF Twice Weekly Supplemental Edit Response File Report Every Wednesday and Friday night unless it is a holiday and then you may submit the file on the previous applicable work day Molina MCO MCNA ( MCO NAME) Weekly Denied Encounter Error Analysis and Encounter EOB Analysis Reports Weekly Every Thursday Night MOLINA MCO
CLAIMS_WEEKLY_{DAILY8}.ZIP FFS Weekly claims extracts Exclude Age 22 and older with DOS 12/01/2015 Weekly Every Weekend MOLINA Encounter Weekly claims extracts Exclude Age 22 and older with DOS 12/01/2015 Weekly Every Weekend MOLINA Pharmacy Weekly FFS/ENC claims extracts Exclude Age 22 and older with DOS 12/01/2015 Weekly Every Weekend MOLINA PROVIDER REGISTRY Weekly Provider Registry edit reports Weekly Every Friday Night MOLINA MCO MCNA Weekly full Provider extracts Weekly Every Weekend MOLINA Weekly full Recipient extracts Exclude periods of eligibility the month after a recipient turns 22 years of age. Weekly Every Weekend MOLINA Weekly summarization of the errors incurred for encounters processing Weekly Each Tuesday by COB MOLINA Weekly summarization of the edit codes for encounters processing Weekly Each Tuesday by COB MOLINA MCNA Weekly list of all encounters and their error codes, including denied error codes, for encounter processing Weekly Each Tuesday by COB MOLINA MCNA Weekly edit report of TPL records submitted by MCOs Weekly Every Thursday Night MOLINA MCNA ZIP
Weekly 837 files (Inpatient, Outpatient, Professional) Crossover 837 encounters files Weekly Weekly on Thursday by 12:00 noon CT MOLINA Supplement to Fee Schedule Weekly File is available to the MCO on Fridays, is sent to the MCO's sFTP verified site address MOLINA MCO MCNA Response file Weekly Every Tuesday MOLINA MM-O-310 report Weekly Every Tuesday COB MOLINA Unformatted (tab delimited) version of report Weekly Every Tuesday COB MOLINA CAP-2177141-20160111-CSOC.txt Monthly PMPM payments 820 files for CSoC Monthly On payment schedule MOLINA CCN_Carrier_File_CCYYMMDD.txt List of LMMIS TPL carrier code assignments Monthly COB on first work day of each month MOLINA MCO MCNA CCN_CLIA_CCYYMMDD.zip List of all CLIA (clinical laboratory improvements amendment) registrations associated with laboratory providers enrolled with the Louisiana Medicaid MMIS. Monthly COB on first work day of each month MOLINA MCO, List of all diagnosis codes applicable to the Inpatient Certification (Pre-cert) operation with Louisiana Medicaid MMIS Monthly COB on first work day of each month MOLINA MCO,
CCYYMMDD_PLANID_PR.txt Weekly provider registry records submitted by the MCOs for processing Weekly Every Friday COB First working day of following week COB MCO Weekly provider registry records submitted by the MCOs for processing Weekly Every Friday COB First working day of following week COB Weekly provider registry records submitted by the MCOs for processing Weekly Every Friday COB First working day of following week COB MCNA Weekly site provider registry records submitted by the MCOs for processing Weekly Every Friday COB First working day of following week COB MCO Twice-Weekly provider supplemental records submitted by MCOs for TMSIS Twice Weekly Every Wednesday and Friday by 5:00 pm unless it is a holiday and then you may submit the file on the previous appli-cable work day A PDF error report and an error text file will be generated and sent back via the sFTP. MCO MCNA Weekly list of Prior Authorizations submitted by MCOs Weekly Every Friday COB First working day of following week COB PREPAID PLAN Weekly list of Prior Authorizations submitted by MCOs Weekly Every Friday COB First working day of following week COB TPL records submitted by MCOs for processing Weekly Every Thursday COB First working day of following week COB MCO, MCNA Monthly list of historical Prior Authorizations submitted by MCOs Weekly Every Friday COB until 2 years of history are submitted First working day of following week COB MCO
Monthly list of historical Prior Authorizations submitted by MCOs Weekly Every Friday COB until 2 years of history are submitted First working day of following week COB Plan PCP Linkage file Weekly Last working day of Week by COB First working day of following week COB MCO Encounter files 837 and NCPDP encounter submission files Weekly By Thursday 12:00 noon CT. Note that NCPDP encounters may not be submitted on Thursday On Check Write Schedule MCO SPECLNK_{DAILY8}.CSV Specially requested and LDH-approved Bayou Health linkage update (initial enrollment and disenrollment) transactions received from Maximus, to be applied to the LMMIS system. When Specially Requested by LDH MGLN-PA-YYYYYMMDD.txt PA file Layout 9/30/15, 10/25/15, 11/13/15 then daily from Specific days then daily from LTC CSoC Segment File Layout * Every Workday then daily beginning 12/1/15 *Every Work Weeknight until 12/1/15 then nightly (Monday thru Friday) NOTE: Subject to change by LDH
Field Nbr Field O=Optional Notes 6 35-35 delimiter char(1) R Constant value of tab 7 36-43 Recipient Birth Date num(8) R Recipient Birth Date 8 44-44 delimiter char(1) R Constant value of tab 9 45-52 Eligibility Begin Date num(8) R Begin date of the eligibility segment to be matched. 10 53-53 delimiter char(1) R Constant value of tab 11 54-61 Eligibility End Date num(8) R End date of the eligibility segment to be matched. 12 62-62 delimiter char(1) R Constant value of tab 13 63-111 Message char(49) R Text field containing any messages created. 14 112-112 delimiter char(1) R Constant value of tab END OF RECORD LAYOUT
Appendix T THIRD PARTY LIABILITY (TPL) FILE LAYOUT to MAGELLAN (Incremental and full reconciliation files) DataBase Name: EB-RECIPIENT-HEADER Location: File Extract Column Name or Field name Columns Length Data Type Accepted Values Description RECIP-ID-CURRENT 1-13 13 Numeric 13-digit Medicaid Recipient ID number The recipient’s current Medicaid ID number RECIP-ID-ORIGINAL 14-26 13 Numeric 13-digit Medicaid Recipient ID number The recipient’s original Medicaid ID number RECIP-HIC 27-38 12 CHAR SSOC CLAIM BENEFITS(HIC) NUMBER RECIP-SSN 39-47 9 Numeric RECIP-LAST-NAME 48-59 12 CHAR RECIP-FIRST-NAME 60-71 12 CHAR RECIP-MID-INITIAL 72-72 1 CHAR RECIP-RECIP-TITLE 73-75 3 CHAR RECIP-RECIP-SUFFIX 76-78 3 CHAR 79-90 12 CHAR 91-102 12 CHAR 103-103 1 CHAR RECIP-ADDR-LN1 104-128 25 CHAR Street Address RECIP-ADDR-LN2 129-153 25 CHAR Street Address, additional if necessary RECIP-CITY 154-171 18 CHAR RECIP-STATE 172-173 2 CHAR Uses USPS Standard State Abbreviation RECIP-ZIP-CODE 174-182 9 Numeric 9-digit USPS code RECIP-BIRTH-DATE 183-190 8 Numeric Format YYYYMMDD The recipient’s DOB RECIP-SEX 191-191 1 CHAR 1=Male, 2=Female, 9=Unknown.
347-347 1 CHAR Middle initial of Head of Household or SDX payee May or may not be available. 348-356 9 Numeric Social security number of Head of Household or SDX payee May be zeroes if not available. 357-358 2 CHAR See ' tab RECIP-EXP-ADDR-LN1 359-393 35 CHAR Expanded Address field – line1 RECIP-EXP-ADDR-LN2 394-428 35 CHAR Expanded Address field – line2 RECIP-EXP-ADDR-LN3 429-463 35 CHAR Expanded Address field – line3 RECIP-EXP-CITY 464-483 20 CHAR RECIP-EXP-STATE 484-485 2 CHAR RECIP-EXP-ZIP-CODE 486-494 9 Numeric RECIP-EXP-LAST-NAME 495-519 25 CHAR 520-539 20 CHAR 540-540 1 CHAR 541-543 3 CHAR 544-546 3 CHAR RECIP-EXTRA-PHONE1 547-556 10 Numeric RECIP-EXTRA-PHONE2 557-566 10 Numeric RECIP-PHY-ADDRESS-1 567-601 35 CHAR Recipient's Physical address 1 RECIP-PHY-ADDRESS-2 602-636 35 CHAR Recipient's Physical Address 2 RECIP-PHY-ADDRESS-3 637-671 35 CHAR Recipient's Physical Address 3 RECIP-PHY-CITY-REC2 672-691 20 CHAR Recipient's Physical City of Residence 692-693 2 CHAR Recipient's Physical State of Residence RECIP-PHY-ZIP-REC2 694-702 9 CHAR Recipient's Physical Zip Code 703-752 50 CHAR Email of the recipient as provided. RECIP-CURR-PARISH 753-754 2 CHAR Current Parish of the recipient RECIP-RENEWAL-DATE 755-762 8 CHAR Format YYYYMMDD Recipient's Renewal Date Column Name or Field Name Columns Length Data Type Accepted Values Description