| Name: | Provider File Submission |
|---|---|
| State: | Virginia |
| Definition: | Not Provided |
| Version | August 2013 - v1.2 |
| Data Element ID | Data Element | Description | Type | Format | Length |
|---|---|---|---|---|---|
| HD001 | Record Type | Not Provided | char | 2 | |
| HD002 | Payer Code | NAIC code (example: 12345); leave blank if not applicable | varchar | 8 | |
| HD003 | Payer Name | Not Provided | varchar | 75 | |
| HD004 | Beginning Month | Example: 200801 | Date | CCYYMM | 6 |
| HD005 | Ending Month | Example: 200812 | Date | CCYYMM | 6 |
| HD006 | Record count | Total number of records submitted in the medical eligibility file, excluding header and trailer records | int | 10 | |
| MP001 | Provider ID | Unique identified for the provider as assigned by the reporting entity | varchar | 30 | |
| MP002 | Provider Tax ID | Tax ID of the provider. Do not code punctuation. | varchar | 10 | |
| MP003 | Provider Entity | Not Provided | char | 1 | |
| MP004 | Provider First Name | Individual first name. Set to null if provider is a facility or organization. | varchar | 25 | |
| MP005 | Provider Middle Name or Initial | Not Provided | varchar | 25 | |
| MP006 | Provider Last Name or Organization Name | Full name of provider organization or last name of individual provider | varchar | 60 | |
| MP007 | Provider Suffix | Example: Jr;null if provider is an organization. Do not use credentials such as MD or PhD | varchar | 10 | |
| MP008 | Provider Specialty | Report the HIPAA-compliant health care provider taxonomy code. Code set is freely available at the National Uniform Claims Committee's web site http://www.nucc.org/ | varchar | 50 | |
| MP009 | Provider Office Street Address | Physical address - address where provider delivers health care services | varchar | 50 | |
| MP010 | Provider Office City | Physical address - address where provider delivers health care services | varchar | 30 | |
| MP011 | Provider Office State | Physical address - address where provider delivers health care services. Use postal service standard 2 letter abbreviations. | char | 2 | |
| MP012 | Provider Office Zip | Physical address - address where provider delivers health care services. Minimum 5 digit code. | varchar | 11 | |
| MP013 | Provider DEA Number | Not Provided | varchar | 12 | |
| MP014 | Provider NPI | Not Provided | varchar | 20 | |
| MP015 | Provider State License Number | Prefix with two-character state of licensure with no punctuation. Example COLL12345 | varchar | 15 | |
| MP899 | Record Type | Not Provided | char | 2 | |
| TR001 | Record Type | Not Provided | char | 2 | |
| TR002 | Payer Code | NAIC code (example: 12345); leave blank if not applicable | varchar | 8 | |
| TR003 | Payer Name | Not Provided | varchar | 75 | |
| TR004 | Beginning Month | Example: 200801 | Date | CCYYMM | 6 |
| TR005 | Ending Month | Example: 200812 | Date | CCYYMM | 6 |
| TR006 | Extraction Date | Not Provided | Date | CCYYMMDD | 8 |
| Data Element ID | Data Element | Code | Value |
|---|---|---|---|
| HD001 | Record Type | MP | |
| MP003 | Provider Entity | F | Facility |
| G | Group Practice | ||
| I | IPA | ||
| P | Practitioner | ||
| MP899 | Record Type | MP | |
| TR001 | Record Type | MP |
Agency for Healthcare Research and Quality • 5600 Fishers Lane, Rockville, MD 20857 • Telephone: (301) 427-1364
