Provider Data Requirements

Transcription

1 Provider Data Requirements The following list indicates the data that is required in order for HP to add, update or inactivate a provider on the provider database. Action (Add/Update/Inactivate) Indicator This field indicates whether the network provider is to be added to or inactivated from the MCOs network, or if there is an update to the provider on file. The valid values for this field are A = Add, U = Update, I = Inactivate. Medicaid ID of MCO Network Provider NPI Atypical Provider Indicator There should only be 1 add record per provider id and type and specialty. Subsequent changes should be sent as an update transaction. This field indicates the 9 digit Medicaid ID of the MCO. CHN Aetna Americhoice The field contains the National Provider Identifier (NPI) of the network This may be spaces only when the provider is atypical and the Atypical Provider Indicator is Y. This field indicates if the provider is an atypical provider (i.e. they do not have an NPI). The valid values for this field are Y = provider is atypical, or N = provider is NOT atypical (provider has an NPI) Character 9 R Character 15 S Revised 04/01/2010 1

2 Billing/Rendering Provider Indicator Participating/Nonparticipating Provider Indicator Primary Taxonomy Additional Taxonomy 1 This field indicates if the network provider is a billing (group) provider, rendering provider (member of a group) or an individual The valid values for this field are B = Billing, R = Rendering Provider, or Blank = Individual This field indicates if the network provider is a participating or a non- participating The valid values are P = Participating or N = Non-participating. This field indicates the primary taxonomy for the type and specialty of the network A provider can only have 1 primary taxonomy per type and specialty. This may be spaces only when an atypical provider (atypical provider indicator must by Y). the type and specialty of the network Character 10 S Additional Taxonomy 2 the type and specialty of the network Revised 04/01/2010 2

3 Additional Taxonomy 3 the type and specialty of the network Additional Taxonomy 4 Provider Effective Date Provider End Date Provider Name the type and specialty of the network This field indicates the network provider contract effective date with the MCO. Format CCYYMMDD. When adding initially, send only one transaction with the effective date. Any changes after the initial add should be sent as an update transaction. This field indicates the network provider contract end date with the MCO. Format CCYYMMDD. The default end date is When adding initially, send only one transaction with the end date. Any changes after the initial add should be sent as an update transaction. This field indicates the network provider s name. Include spacing between first, last etc. If the network provider is an individual entity, the name should be submitted in the Last Name, Number 8 R Number 8 R Character 50 R Revised 04/01/2010 3

4 First Name format. Provider Address Line 1 Provider Address Line 2, if applicable City State Zip Code Zip + 4 Phone Number Phone Number Extension Federal Tax ID Type Federal Tax ID License Number This field indicates the first address line for the network This field indicates the second address line for the network This field indicates the city of the network This field indicates the state of the network This field indicates the zip code of the network This field indicates the zip code extension of the network If unknown, enter zeros. This field indicates the telephone number of the network Blank if unknown or not applicable. This field indicates the telephone number extension of the network Blank if unknown or not applicable. This field indicates the federal tax ID type of the network The valid values are F = FEIN or S = SSN. This field indicates the federal tax ID or SSN of the network This field indicates the license number of the network Blank if unknown. Character 30 R Character 30 R Character 15 R Character 2 R Character 5 R Character 4 R Character 4 O Character 9 R Revised 04/01/2010 4

5 Organization Code State Tax ID Provider Type Provider Specialty FFS Medicaid ID This field indicates the organization code for the network The valid values for this field are: 1 = Corporation, 2 = Public Service Corp, 3 = Partnership, 4 = Sole Proprietor, 5 = Government Owned, 6 = Not-for-profit 7 = Estate/Trust, 8 = Limited Liability Corporation. If this value is unknown for a network provider, the value may be defaulted to any of the above. This field indicates the network provider s state tax ID number, if applicable, otherwise leave blank. This field indicates the type of the network provider based on the provider s primary taxonomy. Must be numeric. This field indicates the specialty of the network provider based on the provider s primary taxonomy. Must be numeric. This field contains the internal FFS Medicaid ID. The MCO is required to send this field for any provider that does not have an NPI. The Atypical indicator must by Y. Character 2 R Character 3 R Character 9 S Update Status HP will return the FFS Medicaid ID in the response file for non-atypical providers. This field indicates the status of the electronic transaction processed by interchange. The MCO does not need to send this field. The Character 2 R Revised 04/01/2010 5

6 Update Error Internal Provider ID File Tracking Number Update Status will be sent back to the MCO in the response file. Valid values are: A1 new provider added to interchange, A2 new contract added for existing provider, A3 Update existing contract during add action, A4 Duplicate add action no change, U1 networkonly provider updated in interchange, U2 contract data updated for network provider, D1- network provider inactive in interchange, E1 electronic update failed. This code indicates the error encountered while attempting to update the interchange system. The code is sent in the response file to the MCO. This field may be used by the MCOs to store their internal network provider IDs. This field may be used by the MCOs to store their internal file tracking number. Character 2 S Character 15 O Character 15 O Revised 04/01/2010 6