What is the frequency of submission? The Provider file is submitted monthly. CHIA requires monthly submission of this file to insure matching algorithms and reporting requirements of TME / RP. What is the format of the file? Each submission must be a variable field length asterisk delimited file. An asterisk cannot be used within an element in lieu of another character. Example: if the file includes in the Last Name, the system will read an incorrect number of elements and drop the file. What does each row in a file represent? A row represents a unique instance of a provider entity, and that provider’s affiliation to another entity, or a provider’s affiliation to a specific location. CHIA is required to analyze information on providers, clinicians, hospitals, physician groups and integrated delivery systems for the purposes of standardization and reporting. How does CHIA define a provider? A provider is an entity associated with either: providing services to patients submitting claims for services on behalf of a servicing provider providing business services or contracting arrangements for a servicing provider. CHIA analyzes information on providers, clinicians, hospitals, physician groups and integrated delivery systems. How is a unique provider to be defined? Conceptually, a unique provider is an instance of a provider (who), with a particular affiliation (relationship), at a particular location (where), during a timeframe (when). CHIA will utilize multiple data elements to create a unique provider record within each carrier/submitter file. CHIA realizes that submitters store their provider data in a variety of formats and data structures. It has been determined that this method provides the greatest flexibility in analyzing the various ways submitters maintain provider relationships.
4 Type of File 11/8/12 Text ID File char[2] Defines the file type and data expected. Report PV here. Indicates that the data within this file is expected to be PROVIDER-based. This must match the File Type reported in TR004. Mandatory 100% HM 5 Period Beginning Date 11/8/12 Date Period - Integer Century Year Month - CCYYMM int[6] Header Period Start Date Report the Year and Month of the reported submission period in CCYYMM format. This date period must be repeated in HD006, TR005 and TR006. This same date must be selected in the upload application for successful transfer. Mandatory 100% HM 6 Period Ending Date 11/8/12 Date Period - Integer Century Year Month - CCYYMM int[6] Header Period Ending Date Report the Year and Month of the reporting submission period in CCYYMM format. This date period must match the date period reported in HD005 and be repeated in TR005 and TR006. Mandatory 100% HM 7 Record Count 11/8/12 Integer Counter Header Record Count Report the total number of records submitted within this file. Do not report leading zeros, space fill, decimals, or any special characters. Mandatory 100% HM 8 Comments 11/8/12 Text Free Text Field Header Carrier Comments May be used to document the submission by assigning a filename, system source, compile identifier, etc. Optional 0% HO 9 APCD Version Number 2/2016 Decimal - Numeric ID Version char[3] Submission Guide Version Report the version number as presented on the APCD Provider File Submission in 0.0 Format. Sets the intake control for editing elements. Version must be accurate else file will drop. EXAMPLE: 3.0 = Version 3.0 Mandatory 100% HM Code Description 2.1 Prior Version; valid only for reporting periods prior to October 2013 3.0 Version 3.0; required for reporting periods as of October 2013; No longer VALID as of May 2015
PV 19 State Code 11/8/12 External Code Source 2 - Text Address State External Code Source 2 - States char[2] State of the Provider Report the of the site in which the provider sees plan members. When only a mailing address is available, populate with mailing state here as well as PV026. When a provider sees patients at two or more locations, the provider should have a unique record for each location to capture all possible practice sites. All 98% A0 PV 20 Country Code 12/1/10 External Code Source 1 - Text Address Country External Code Source 1 - Countries char[3] Country Code of the Provider Report the country code as defined by ISO 3166-1, Alpha 3. All 98% C PV 21 Zip Code 11/8/12 External Code Source 2 - Text Address Zip External Code Source 2 - Zip Codes varchar[9] Zip code of the Provider Report the 5 or 9 digit Zip Code as defined by the United States Postal Service. When submitting the 9-digit Zip Code do not include hyphen. All 98% A0 PV 22 Taxonomy 11/8/12 External Code Source 5 - Text External Code Source 5 - Taxonomy char[10] Taxonomy Code Report the standard code that defines this provider for this line of service. Taxonomy values allow for the reporting of many types of clinicians, assistants and technicians, where applicable, as well as Physicians, Nurses, Groups, Facilities, etc. Required when PV034 = 0, 1, 2, 3, 4, or 5 75% C PV 23 Mailing Street Address1 Name 6/24/10 Text Address 1 Provider Street address of the Provider / Entity Report the mailing address of the Provider / Entity in PV002. All 98% A0 PV 24 Mailing Street Address2 Name 6/24/10 Text Address 2 Provider Secondary Street address of the Provider / Entity Report the mailing address of the Provider / Entity in PV002. All 2% B PV 25 Mailing City Name 6/24/10 Text Address City Provider City name of the Provider / Entity Report the mailing city address of the Provider / Entity in PV002. All 98% A0
PV 26 Mailing State Code 11/8/12 External Code Source 2 - Text Address External Code Source 2 - States char[2] name of the Provider / Entity Report the mailing state address of the Provider / Entity in PV002. All 98% A0 PV 27 Mailing Country Code 12/1/10 External Code Source 1 - Text Address Country External Code Source 1 - Countries char[3] Country name of the Provider / Entity Report the three-character country code as defined by ISO 3166-1, Alpha 3. All 98% C PV 28 Mailing Zip Code 11/8/12 External Code Source 2 - Text Address Zip External Code Source 2 - Zip varchar[9] Zip code of the Provider Report the 5 or 9 digit Zip Code as defined by the United States Postal Service. When submitting the 9-digit Zip Code do not include hyphen. All 98% A0 PV 29 Provider Type Code 6/24/10 Carrier Defined Table - Text Carrier Defined - Provider Type Code Provider Type Code Report the Provider Type code associated with the individual provider or facility. The carrier/submitter must provide the MA APCD with Reference tables. This element distinguishes clinicians, facilities, and other. Clinicians are physicians and other practitioners who can perform an E&M service (thereby start an episode of care). Facilities can sometimes start episodes (i.e. patient goes to ER at onset of symptoms). Providers classified as 'other' never start episodes. The MA APCD may use this element to perform further clinical and analytic grouping. Entities not seeing patients should have a classification of 'Other'. All 98% A1 PV 30 Primary Specialty Code 11/8/12 External Code Source 4 - Integer External Code Source 4 - Specialties varchar [3] Specialty Code Report the standard Primary Specialty code of the Provider here. Required when PV034 = 0, 1, 2, 3, 4, or 5 98% A2
PV 40 National Provider ID 2 2/2016 External Code Source 3 - Integer External Code Source 3 - National Provider ID int[10] National Provider Identification (NPI) of the Provider Report the Secondary or NPI of the Provider / Clinician / Facility / Organization defined in this record. NPPES entity type code of the NPI must agree with the type of provider coded in PV034. (i.e. If PV034 = 1 then the NPPES entity code for the NPI in PV040 must be 1.) Required when = 0, 1, 2, 3, 4, or 5 1% B PV 41 GIC Provider Link ID 11/8/12 Text ID GIC GIC Provider Link ID for GIC Carriers only Report the GIC Assigned Provider Link ID. If not applicable, do not report any value here. Required when Submitter is identified as a GIC Submitter 0% B PV 42 Proprietary Specialty Code Carrier Defined Table - Text Carrier Defined - Specialty Specialty Code Report the submitter's proprietary specialty code for the provider here. additional specialty code for a provider should be populated in elements PV043 and PV044. Value comes from a Carrier Defined Table only. Required when PV034 = 0, 1, 2, 3, 4, or 5 and PV030 is blank 90% A0 PV 43 Other Specialty Code 2 11/8/12 Carrier Defined Table - OR - External Code Source 4 - Integer External Code Source 4 – Specialties - OR – Carrier Defined Table Specialty Code See mapping for primary specialty code in PV030. Known additional specialty code for a provider should be populated in this element. Value can come from either a Carrier Defined Table or the External Code Source. Required when PV034 = 0, 1, 2, 3, 4, or 5 0% B PV 44 Other Specialty Code 3 11/8/12 Carrier Defined - OR - External Code Source 4 - Integer External Code Source 4 - Specialties - OR – Carrier Defined Table Specialty Code See mapping notes for primary specialty code in PV030. Known additional specialty code for a provider should be populated in this element. Value can come from either a Carrier Defined Table or the External Code Source. Required when PV034 = 0, 1, 2, 3, 4, or 5 0% B
PV 54 Medical / Healthcare Home ID 6/24/10 Text ID Link to PV002 Medical Home Identification Number Report the identifier of the medical home the provider is linked-to here. The value in this element must have a corresponding Provider ID (PV002) in this or a previously submitted provider file. Require when PV034 = 1, 2, or 3 0% B PV 55 PCP Flag 11/8/12 Lookup Table - Integer int[1] Indicator - Provider is a PCP Report the that defines the element. EXAMPLE: 1 = Yes, provider is a PCP. Required when PV034 = 1 100% A0 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable PV 56 Provider Affiliation 2/2016 Text ID Link to PV002 Provider Affiliation Code Report the Provider ID for any affiliation the provider has with another entity or parent company. If the provider is associated only with self, record the same value here as PV002. All 90% A2 PV 57 Provider Telephone 6/24/10 Numeric Telephone Telephone number associated with the provider identified in PV002 Report the telephone number of the provider associated with the identification in PV002. Do not separate components with hyphens, spaces or other special characters. All 10% C PV 58 Delegated Provider Record Flag 11/8/12 Lookup Table - Integer int[1] Indicator - Delegated Record Report the value that defines the element. EXAMPLE: 1 = Yes, provider record was sourced from the delegated provider’s system. All 100% A2 Value Description 1 Yes 2 No 3 Unknown
PV 62 Provider Affiliation Start Date 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Provider Start Date Report the start date of provider's relationship with parent entity / group in PV056 (Provider Affiliation) in CCYYMMDD Format. Providers that are self-affiliated (or no affiliation) should have the same value reported here as in PV037. All 98% A0 PV 63 Provider Affiliation End Date 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Provider End Date Report the end date of provider's relationship with parent entity / group in PV056 (Provider Affiliation) in CCYYMMDD Format. Do not report any value here if the affiliation is still active, or if there is no known affiliation in PV056. Self-affiliations should report the same value here as in PV038. All 98% B PV 64 PPO Indicator 11/8/12 Lookup Table - Integer int[1] Indicator - Provider PPO Contract Report the that defines the element. EXAMPLE: 1 = Yes, provider is a contracted network provider. Required when PV034 = 0, 1, 2, 3, 4, or 5 100% A0 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable PV 65 Code Lookup Table – Integer int[1] MassHealth Disbursement Method Code Report the that defines the element. Required when submitter is 100% A2 Value Description 0 Pay 1 State Agency 2 Muni-Med