Health care data and information submitted by Health Care Payers to CHIA is not a public record. No public disclosure of any health plan information or data shall be made unless specifically authorized under 114.5 CMR 21.00 or 114.5 CMR 22.00. Acronyms Frequently Used APCD – All-Payer Claims Database CHIA – Center for Health Information and Analysis CSO – Computer Services Organization DBA – Delegated Benefit Administrator DBM – Dental Benefit Manager DOI – Division of Insurance GIC – Group Insurance Commission ID – Identification; Identifier MA APCD – Massachusetts’ Claims Database PBM – Pharmacy Benefit Manager QA – Quality Assurance RA – Risk Adjustment; Risk Adjuster TME / RP – Total Medical Expense / Relative Pricing TPA – Third Party Administrator The File Types: DC – Dental Claims MC – Medical Claims ME – Member Eligibility PC – Pharmacy Claims PR – Product File PV – Provider File BP – Benefit Plan Control Total File
How the Center defines 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 a unique provider is 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). The Center 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. Types of providers to be included in the file All Massachusetts contracted providers, regardless of whether they are on the claims file for the time period. Additionally, provider information for out of state providers, who are on the claims file for the time period of the corresponding claims submission – If available. TPAs (including PBMs, DBAs, CSOs, etc.) who may not contract directly with providers, are expected to include providers who are on the claims file for the time period of the corresponding claims submission. Otherwise use default values as provided in the document: “Provider File Examples.xls”. ( Available at: ) CHIA is required to create cross-submitter provider files for analysis and therefore requires data on all providers in a carrier’s or submitter’s network. Additionally, all claims may be analyzed by provider dimensions that require provider information for corresponding out of state claims.
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 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 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 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 11/8/12 Decimal - Numeric ID Version char[3] Submission Guide Version Report the version number as presented on the APCD Provider File Submission Guide in 0.0 Format. Sets the intake control for editing elements. Version must be accurate else file will drop. EXAMPLE: 3.0 = Newest Version Mandatory 100% HM Code Description 2.1 Version; valid only for reporting periods prior to October 2013 3.0 Current Version; required for reporting periods as of October 2013
PV 19 State Code 11/8/12 External Code Source 2 - Text Address 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 three-character 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 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 37 Date 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Provider Start Date Report the date the provider or facility becomes eligible / contracted to perform services for plan members in CCYYMMDD Format. Do not report any value here for providers that do not render services. All 98% A2 PV 38 End Date 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Provider End Date Report the Date the provider or facility is no longer eligible to perform services for plan members / insureds in CCYYMMDD Format. Do not report any value here for providers that are still actively eligible to provide services, or Providers who do not render services (i.e., Parent Organizations). Required when PV034 = 0, 1, 2, 3, 4, or 5 98% B PV 39 National Provider ID 11/8/12 External Code Source 3 - Integer External Code Source 3 - National Provider ID int[10] National Provider Identification (NPI) of the Provider Report the NPI of the Provider / Clinician / Facility / Organization defined in this record. Required when PV034 = 0, 1, 2, 3, 4, or 5 98% B PV 40 National Provider ID 2 11/8/12 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 Other NPI of the Provider / Clinician / Facility / Organization defined in this record. Required when = 0, 1, 2, 3, 4, or 5 1% C 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 11/8/12 Carrier Defined Table - Text Carrier Defined Table - Specialty Specialty Code Report the submitter's proprietary specialty code for the provider here. Known 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 1% B
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 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 = 0, 1, 2, 3, 4, or 5 0% B PV 44 Other Specialty Code 3 11/8/12 Carrier Defined Table - OR - External Code Source 4 - Integer External Code Source 4 - Specialties - OR – Carrier Defined 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 = 0, 1, 2, 3, 4, or 5 0% B PV 45 Pay for Flag 11/8/12 Lookup Table - Integer int[1] Indicator - Provider Contract Payment Report the value that defines the element. Pay-for-performance bonuses or year-end withhold returns based on performance for at least one service performed by this provider within the month. EXAMPLE: 1 = Yes, provider has a contract incentive. Required when PV034 = 1, 2, or 3 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable PV 46 NonClaims Flag 11/8/12 Lookup Table - Integer int[1] Indicator - Provider Contract Payment Report the value that defines the element. NonClaims payments that occur at least once within the month must be reported. EXAMPLE: 1 = Yes, provider may be eligible to receive other payments not flowing through the claims system. All 100% A2
Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable PV 47 Uses Electronic Health Records 11/8/12 Lookup Table - Integer int[1] Indicator - EHR Utilization Report the value that defines the element. EXAMPLE: 1 = Yes, provider uses Electronic Health Records All 100% A2 Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable PV 48 EHR Vendor 11/8/12 Text Name Vendor Electronic Health Record Vendor Name Report the name of the vendor the provider uses for EHR processing. Required when PV047 = 1 98% B PV 49 Accepting New Patients 11/8/12 Lookup Table - Integer int[1] Indicator - New Patients Accepted Report the value that defines the element. EXAMPLE: 1 = Yes, provider or provider group is accepting new patients as of the day the file was created for this submission. Required when PV034 = 1, 2, or 3 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 Other
5 Not Applicable PV 50 Offers 11/8/12 Lookup Table - Integer int[1] Indicator - eVisit Option Report the value that defines the element. EXAMPLE: 1 = Yes, provider has capacity to perform eVisits. Required when PV034 = 1, 2, 3, or 4 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable PV 51 Filler 11/8/12 Filler Filler char[0] Filler The APCD reserves this element for future use. Do not populate with any data. All 0% Z PV 52 Has multiple offices 11/8/12 Lookup Table - Integer int[1] Indicator - Multiple Office Provider Report the value that defines the element. EXAMPLE: 1 = Yes, provider has multiple offices. Required when PV034 = 1, 2, or 3 100% A0 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable PV 53 Filler 11/8/12 Text Filler char[0] Filler The APCD reserves this element for future use. Do not populate with any data. All 0% Z 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 = 1, 2, or 3 0% B
PV 60 Office Type 11/8/12 Lookup Table - Integer tlkpOfficeType int[1] Office Type Code Report the value that defines the provider's service setting. EXAMPLE: 1 = Facility Required when PV034 = 0, 1, 2, 3, 4, or 5 98% A0 Code Description 1 Facility 2 Doctors office 3 Clinic 4 Walk in Clinic 5 Laboratory 0 PV 61 Prescribing Provider 11/8/12 Lookup Table - Integer int[1] Indicator - Prescribing Authority Report the value that defines the element. EXAMPLE: 1 = Yes, provider has prescribing privileges for pharmaceuticals or DME. All 100% A2 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable PV 62 Provider Affiliation Start Date 11/8/12 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Provider Start Date Report the 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 value 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 Filler 4/5/13 Filler Filler char[0] Filler The APCD reserves this field for future use. Do not populate with any data. All 0% Z PV 66 Filler 4/5/13 Filler Filler char[0] Filler The APCD reserves this for future use. Do not populate with any data. All 0% Z PV 67 Filler 4/5/13 Filler Filler char[0] Filler The APCD reserves this field for future use. Do not populate with any data. All 0% Z PV 68 Filler 4/5/13 Filler Filler char[0] Filler The APCD reserves this field for future use. Do not populate with any data. All 0% Z PV 69 Filler 4/5/13 Filler Filler char[0] Filler The APCD reserves this for future use. Do not populate with any data. All 0% Z