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Provider File Submission

Utah



Name:Provider File Submission
State:Utah
Definition:Not Provided
VersionDecember 5, 2013 - v2.0

File Specification for Provider File Submission

Data Element ID Data Element Description Type Format Length
MP001 Provider ID Unique identified for the provider as assigned by the reporting entity Must match MC024. 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 Provider Middle Name or Initial varchar 25
PM006 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 at 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 Provider DEA Number varchar 12
MP014 Provider NPI Provider NPI varchar 20
MP015 Provider State License Number Prefix with two-character state of licensure with no punctuation. Example UTLL12345 varchar 20
MP899 Record Type Not Provided char 2

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Data Element ID Data Element Code Value
MP003 Provider Entity F Facility
G Provider
I IPA
P Practitioner
MP899 Record Type MP
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