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Provider Fixed Format File Submission

Maryland

Versions: Provider Fixed Format File Submission• Provider Fixed Format File Submission• Provider Fixed Format File SubmissionCompare Versions


Name:Provider Fixed Format File Submission
State:Maryland
Definition:Not provided
VersionJanuary 9, 2014

File Specification for Provider Fixed Format File Submission

Data Element ID Data Element Description Type Format Length
Multiple versions1 Record Identifier The value is 3 numeric 1
Multiple versions2 Practitioner/Supplier ID Payor-specific identifier for a practitioner, practice, or office facility rendering health care service(s). alphanumeric 11
Multiple versions3 Practitioner/Supplier Federal Tax ID Employer Tax ID # of the practitioner, practice or office facility receiving payment for services. alphanumeric 9
Multiple versions4 Practitioner/Supplier Last Name or Multi-practitioner Health Care Organization Last name of practitioner or complete name of multi- practitioner health care organization. alphanumeric 31
Multiple versions5 Practitioner/Supplier First Name Practitioner's first name. alphanumeric 19
Multiple versions6 Practitioner Middle Initial Not Provided alphanumeric 1
Multiple versions7 Practitioner Name Suffix Not Provided alphanumeric 4
Multiple versions8 Practitioner Credential Not Provided alphanumeric 5
Multiple versions9 Practitioner/Supplier Specialty - 1 The health care field in which a practitioner is licensed, certified, or otherwise authorized under Health Occupations Article, Annotated Code of Maryland, to provide health care services in the ordinary course of business or practice of a profession or in an approved education or training program. Up to 3 codes may be listed. alphanumeric 10
Multiple versions10 Practitioner/Supplier Specialty - 2 The health care field in which a practitioner is licensed, certified, or otherwise authorized under Health Occupations Article, Annotated Code of Maryland, to provide health care services in the ordinary course of business or practice of a profession or in an approved education or training program. Up to 3 codes may be listed. alphanumeric 10
Multiple versions11 Practitioner/Supplier Specialty - 3 The health care field in which a practitioner is licensed, certified, or otherwise authorized under Health Occupations Article, Annotated Code of Maryland, to provide health care services in the ordinary course of business or practice of a profession or in an approved education or training program. Up to 3 codes may be listed. alphanumeric 10
Multiple versions12 Practitioner DEA # Drug Enforcement Agency number assigned to an individual registered under the Controlled Substance Act. alphanumeric 11
Multiple versions13 Indicator for Multi-Practitioner Health Care Organization Not Provided alphanumeric 1
Multiple versions14 Practitioner Individual National Provider Identifier (NPI) number Federal identifier assigned by the federal government for use in all HIPAA transactions to an individual practitioner. alphanumeric 10
Multiple versions15 Practitioner Organizational National Provider Identifier (NPI) number Federal identifier assigned by the federal government for use in all HIPAA transactions to an organization for billing purposes. alphanumeric 10
Multiple versions16 Payor ID Number Payor assigned submission identification number. alphanumeric 4
Multiple versions17 Source System Identify the source system (platforms or business units) from which the data was obtained by using an alphabet letter (A, B, C, D, etc...) (Note: In your documentation on page 15, please be sure to list the source system that corresponds with the letter assigned.) For payors with all data coming from one system only, leave the field blank. alphanumeric 1
18 Reporting Quarter Indicate the quarter number for which the data is being submitted. numeric 1

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Data Element ID Data Element Code Value
1 Record Identifier 3 Provider Services
13 Indicator for Multi-Practitioner Health Care Organization 0 Solo Practitioner
1 Multiple Practitioners
18 Reporting Quarter 1 First Quarter = January 1 thru March 31
2 Second Quarter = April 1 thru June 30
3 Third Quarter = July 1 thru September 30
4 Fourth Quarter = October 1 thru December 31
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