Revision History Date Version Description Author 12/1/2012 3.0 Administrative Bulletin 12-01; issued 11/8/2012 M. Prettenhofer 4/5/2013 3.1 Changed to Registered Provider Organization ID (placeholder). Changed – PV070 to Filler (reserved for future use). H. Hines 5/31/2013 3.1 Updated ‘Non-Massachusetts Resident’ section Updated Provider File Submitters narrative (pg 9) H. Hines 10//2014 4.0 Administrative Bulletin 14-08 K. Hines Table of Contents
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 957 CMR 5.00 –Health Care Claims. Case Mix and Charge Data Release Procedures. 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’ All-Payer Claims Database NPI – National Provider Identifier PBM – Pharmacy Benefit Manager QA – Quality Assurance RA – Risk Adjustment; Risk Adjuster TME / RP – Medical Expense / Relative Pricing TPA – 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
identify a provider and that provider’s affiliation, when applicable as well as the provider's practice location within this provider file. The following are the elements that are required to link to PV002: Provider File Link: – Provider Affiliation; Member Eligibility Links: ME036 – Health Care Home ID; ME046 – Member PCP ID; Medical Claim Links: MC024 – Service Provider Number; MC076 – Billing Provider Number; MC112 – Referring Provider ID; MC125 – Attending Provider; MC134 – Plan Rendering Provider Identifier; MC135 – Provider Location; Pharmacy Claim Links: PC043 – Prescribing Provider ID; PC059 – Recipient PCP ID; Dental Claim Link: DC018 – Service Provider Number Loading a record where PV002 = PV056 establishes a base record for a provider. All other instances of that PV002 value represent affiliations or additional locations for a provider. See the “Provider File Examples.xls” document for sample data. (Available at: ) New Data Elements Administrative Simplification, CHIA has worked with Division of Insurance, The Connector, Group Insurance Commission and our own internal departments to identify new elements to be added to the MA APCD Dataset to satisfy that goal. Below is a list of those elements, the submitter type expected to report them, the reason and the data expected within the element. PV065 – Disbursement Code; MassHealth only; to aid in payment methodology analysis
PV 12 Entity Name 11/8/12 Text Name Provider Entity / Facility name Report the Provider Entity Name when Provider ID does not 1 (person). . This should only be populated for facilities or groups. Limited punctuation may be included. Required when PV034 = 2, 3, 4, 5, 6, 7, or 0 98% A1 PV 13 Entity Code 11/8/12 Lookup Table - Text tlkpEntityCode char[2] Provider entity code Report the value that defines the entity provider type. EXAMPLE: 12 = Acute Hospital Required when does not = 1 98% A0 Value Description 01 Academic Institution 02 Foster Care 03 Ambulance Services 04 Hospital Based Clinic 05 Stand-Alone, Walk-In/Urgent Care Clinic 06 Other Clinic 07 Community Health Center - General 08 Community Health Center - Urgent Care 09 Government Agency 10 Health Care Corporation 11 Home Health Agency 12 Acute Hospital 13 Chronic Hospital 14 Rehabilitation Hospital 15 Psychiatric Hospital 16 DPH Hospital 17 State Hospital 18 Veterans Hospital
PV 18 City Name 6/24/10 Text Address City Provider City of the Provider Report the city name where provider sees plan members. If only mailing address is available, please send the mailing address in this element in addition to putting it in the mailing address element. If the provider sees members at two locations the provider should have a unique record for each to capture each site where the provider practices. All 98% A1 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 31 Provider ID 11/8/12 Integer ID OrgID varchar[6] CHIA defined and maintained Org ID for Providers Report the Practice Group OrgID number as assigned / maintained by CHIA for Total Medical Expense (TME) reporting Data must be reported in aggregate for all practices in which the Local Practice Group’s member months are below 36,000 and the practice has no parent Physicians’ Group. This group is to be identified as “Groups below minimum threshold” with an ORGID of 999996. For Local Practice Groups below the 36,000 member month threshold that are part of a larger Physicians’ Group, payers will report the ORGID of the Parent Physician Group. Required when submitter is identified as a TME/RP Submitter 100% A2 PV 32 Registered Provider ID (RPO) 4/5/13 Text Health Policy Commission OrgID Placeholder Char[30] Registered Provider Organization ID Report the Health Policy Commission-assigned unique identifier for every service provider (persons, facilities or other entities involved in claims transactions) that it has in its system(s). This information is required for TME/RP reporting and analysis. Assigned submitters only 0% Z PV 33 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 34 Provider ID Code 11/8/12 Lookup - Integer int[1] Provider Identification Code Report the value that defines type of entity associated with PV002. The value reported here drives intake edits for quality purposes. EXAMPLE: 1 = Person; Physician, Clinician, Orthodontist, etc. All 100% A0
0 Other; any type of entity not otherwise defined that performs health care services. PV 35 SSN Id 11/8/12 Numeric ID Tax char[9] Provider's Social Security Number Report the SSN of the individual provider in PV002. Do not zero-fill. Do not report any value here if not available or not applicable. Required when PV034 = 1 98% A1 PV 36 Medicare ID 6/24/10 Text ID Medicare Provider's Medicare Number, other than UPIN Report the Medicare ID (OSCAR, Certification, Other, Unspecified, NSC or PIN) of the provider or entity in PV002. Do not report UPIN here, see PV004. Required when PV034 = 0, 1, 2, 3, 4, or 5 90% B PV 37 Begin 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 Full Date - Integer Century Year 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). All 98% B PV 39 National Provider ID 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 = 0, 1, 2, 3, 4, or 5 98% A PV 40 National Provider ID 2 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 PV034 = 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 Table - 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 = 0, 1, 2, 3, 4, or 5 and PV030 is blank 90% A 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 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 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 PV034 = 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 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 Value Description 1 Yes 2 No 3 Unknown 4 Other 5 Not Applicable PV 47 Filler filler Filler Char[1] Filler the MA APCD reserves this field. Do not populate with any data. All 0% Z PV 48 Filler Filler Filler Char[40] Filler The MA APCD reserves the field. Do not populate with any data. All 0% Z PV 49 Accepting New Patients 11/8/12 Lookup - 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 56 Provider Affiliation 6/24/10 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 99% B PV 57 Provider Telephone 6/24/10 Numeric Telephone Telephone number associated with the provider identified in 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 4 5 Not Applicable PV 59 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 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 Other PV 61 Prescribing Provider 11/8/12 Lookup Table - Integer int[1] Indicator - Prescribing Authority Report the 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 Day - CCYYMMDD int[8] Provider 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 = 0, 1, 2, 3, 4, or 5 100% A0
PV 71 Record Type 6/24/10 Text ID File char[2] File Type Identifier Report PV here. This validates the type of file and the data contained within the file. This must match HD004. All 100% A0 1 Record Type 6/24/10 Text ID Record char[2] Trailer Record Identifier Report TR here. Indicates the end of the data file. Mandatory 100% TM 2 Submitter 11/8/12 Integer ID Submitter varchar[6] Trailer Submitter / Carrier ID defined by CHIA Report the Unique Submitter ID as defined by CHIA here. This must the Submitter ID reported in HD002. Mandatory 100% TM 3 National Plan ID 11/8/12 Integer ID Nat'l PlanID int[10] CMS National Plan Identification Number (PlanID) Do not report any value here until National PlanID is fully implemented. This is a unique identifier as outlined by Centers for Medicare and Medicaid Services (CMS) for Plans or Sub plans. Situational 0% TS 4 Type of File 6/24/10 Text ID File char[2] Validates the file type defined in HD004. Report PV here. This must match the File Type reported in HD004. Mandatory 100% TM 5 Period Beginning Date 6/24/10 Date Period - Integer Century Year - CCYYMM int[6] Trailer Period Start Date Report the Year and of the reported submission period in CCYYMM format. This date period must match the date period reported in HD005 and HD006. Mandatory 100% TM 6 Period Ending Date 6/24/10 Date Period - Integer Century Year Month - CCYYMM int[6] Trailer 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 TR005 and HD005 and HD006. Mandatory 100% TM 7 Date Processed 6/24/10 Full Date - Integer Century Year Month Day - CCYYMMDD int[8] Trailer Processed Date Report the full date that the submission was compiled by the submitter in CCYYMMDD Format. Mandatory 100% TM Appendix – External Code Sources