Reporting SUBMITTING-STATE-PROVIDER-ID in the T-MSIS Provider File (Provider)

Brief Issue Description

This document outlines the challenges states have faced when reporting the state-assigned provider ID reported in the data element SUBMITTING-STATE-PROV-ID on the T-MSIS Provider file and recommends best practices for state reporting. Per the data dictionary, all individuals, practice groups, facilities, and other entities that provide Medicaid/CHIP goods or services to the state's Medicaid and CHIP enrollees should be reflected in the T-MSIS provider file. 

Background Discussion

Context

The SUBMITTING-STATE-PROV-ID¹ is a state-assigned, unique identifier that states should report with all individual providers, practice groups, facilities, and other entities reported on the Provider file. The state-assigned provider ID is first established on the PROV-ATTRIBUTES-MAIN-PRV00002 segment for each set of unique provider IDs. States should use this record segment to report high-level information regarding the provider's business, such as the provider's "doing business as name" information; whether the provider record is for a facility, group practice, or individual provider; and other types of information. Changes to the any of these main attributes (that is, any data elements in the PROV-ATTRIBUTES-MAIN-PRV00002 record segment) will require reporting a new record on the main provider attributes segment with the same SUBMITTING-STATE-PROV-ID. This identifier is one of the key data elements used to link all of the record segments in the provider file.  Additionally, the SUBMITTING-STATE-PROV-ID links the provider information in the provider file with the provider information reported on the claims files, identified in Table 2 at the end of this document. 

Challenge

A state-assigned provider ID, SUBMITTING-STATE-PROV-ID, should be assigned to each provider reported in the provider file; however, states face multiple challenges when reporting this ID:

1. The SUBMITTING-STATE-PROV-ID is not reported on all provider record segments for that provider, which prevents the ability to link all of the provider information in the Provider file.
2. A new record under the same state-assigned provider ID is not created when the provider's attributes change, which prevents linking historical characteristics about a provider to current provider characteristics (e.g., a former "doing-business-as" name to a provider's current "doing-business-as" name). 
3. The provider ID reported on the claims file does not match the SUBMITTING-STATE-PROV-ID, which prevents linking the provider information in the provider file with the provider information reported on the claims files.

Regarding the first challenge, it is expected that a provider's information will be reported on most segments of the provider file. However, if the SUBMITTING-STATE-PROV-ID is reported on the main attributes segment but not some of the provider file child segments, it will appear the documentation is incomplete. If a state-assigned provider ID is reported on the provider file child record segment but not on the main attributes segment, this will generate an edit.

Regarding the second challenge, consider the following example:  A provider is currently being reported on the provider file with a SUBMITTING-STATE-PROV-ID of "123A482" and PROV-DOING-BUSINESS-AS-NAME data element reported with "Evergreen Physicians Group". The provider changes its "doing business as"² name to "Northwest Physicians Group". Instead of creating a new record under the same state-assigned provider ID to capture the new "doing business as" name, the PROV-DOING-BUSINESS-AS-NAME is incorrectly changed on the original record to capture the new information. 

Regarding the third challenge, most claims are expected to be reported with a provider that is also reported on the provider file. Only a small percentage of claims are expected to be reported for providers not on the provider file, primarily out-of-state providers or non-network providers. 

CMS Guidance

The SUBMITTING-STATE-PROV-ID data element is the primary data element used to link the provider's main attributes information with the additional provider information reported on the provider file record segments. States may determine the format they use to assign this ID, as long as it meets the following requirements: (1) the ID is alphanumeric, (2) the ID is no more than 30 characters, and (3) the ID is unique; the ID is only assigned to one provider on the PROV-ATTRIBUTES-MAIN-PRV00002 record segment, and a given provider has only one SUBMITTING-STATE-PROV-ID. Any records reported on provider file record segments PROV00003 through PRV00010 must be reported with a SUBMITTING-STATE-PROV-ID that matches a SUBMITTING-STATE-PROV-ID reported on the main attributes segment. 

A SUBMITTING-STATE-PROV-ID is assigned to the set of information related to a unique provider reported in the provider main attributes record segment. Any changes to the information on that record will require that a new record be created on PROV-ATTRIBUTES-MAIN-PRV00002 record segment under the same provider ID number. 

For example, if an individual provider's "doing business as" name changes, then a new record will be added to the PROV-ATTRIBUTES-MAIN-PRV00002 record segment with the new "doing business as name" with  the same provider ID assigned with an effective date starting on the date the new "doing business as" name takes effect. The original record will change the end date to reflect the last day the original "doing business as" name was used. All other data elements on the two records will be identical. In this case, the two records reported on the PROV-ATTRIBUTES-MAIN-PRV00002 record segment will be identical except for the following changes:

• PROV-ATTRIBUTES-END-DATE will be updated on the original record to reflect the last day on which the old "doing business as" name is used. The PROV-ATTRIBUTES-END-DATE on the new record should be reported as open-ended, with a value of 99991231.
• PROV-ATTRIBUTES-EFF-DATE on the new record will reflect the first day on which the new "doing business as" name is used. 
• PROV-DOING-BUSINESS-AS-NAME reported on the new record will capture the new "doing business as" name.

An additional record on the PROV-ATTRIBUTES-MAIN-PRV00002 record segment is only required when a provider changes information on that record. If a change is required because a data element is populated with incorrect information, then a new record is not required. Instead, the data element on the record with the incorrect information should be updated with the correct information.

Additionally, there are certain data elements on the PROV-ATTRIBUTES-MAIN-PRV00002 record segment that cannot be updated. These data elements remain fixed in relation to that specific provider, and should only change if the original value reported was incorrect. These data elements are listed below:

• PRV026 : FACILITY-GROUP-INDIVIDUAL-CODE
• PRV032 : OWNERSHIP-CODE
• PRV033 : PROV-PROFIT-STATUS
• PRV034 : DATE-OF-BIRTH
• PRV035 : DATE-OF-DEATH

States should pay particular attention when filling out the FACILITY-GROUP-INDIVIDUAL-CODE value for the provider.  Unique provider information will need to be reported for providers even if they provide services at a facility. Additionally, individual provider information for providers who are members of a provider group will need to be recorded in the provider file, if available. For example, Dr. Emily Young practices at Northwest Orthopedics physician group and performs surgery and Evergreen Hospital. Three distinct records would need to be created: one for Dr. Emily Young as an individual practitioner, one for Northwest Orthopedics as a group practice, and one for Evergreen Hospital as a facility. 

In addition to linking the provider file segments, the SUBMITTING-STATE-PROV-ID is also the primary data element to link provider information reported in the T-MSIS claims file with the more detailed provider information reported in the T-MSIS provider file.  In the T-MSIS claims files, the state-assigned unique provider ID should be reported in the X-PROV-NUM (where the "X" represents the provider's role on the claim, such as the billing provider, the rendering provider, and the like. See Table 2 for the data element name and data element number). 

States should populate the BILLING-PROV-NUM field on every claim header record.  The X-PROV-NUM data elements for providers performing other roles in the encounter should be reported if the information is available, where "X" represents the provider role other than billing provider.  For the fields listed in table 2, if the provider's NPI number is reported on the claim record, then the state assigned provider number should be populated as well. Even if an NPI number is not reported, an X-PROV-NUM should be reported as another method to identify the provider.

1 The data element name SUBMITTING-STATE-PROV-ID is reported on segments PRV00002 through PROV00010 on the provider file, under the data element numbers PRV019, PRV042, PRV063, PRV075, PRV087, PRV097, PRV109, PRV118, and PRV128.

2 The PROV-DOING-BUSINESS-AS-NAME is the name the public commonly uses for the provider when the "doing business as" name differs from the legal name. DBA is an abbreviation for "doing business as." Businesses operating under a name that differs from the company's legal name must register a DBA (Source: T‐MSIS V2_0 Data Dictionary Appendices, November 2015).