Brief Issue Description
This guidance document outlines the challenges states have faced with provider location ID (PROV‐LOCATION‐ ID), which occurs both in each T‐MSIS Claim file at the claim header level and in multiple record segments in the Provider file, and recommends best practices for states’ reporting. CMS expects states to report information about the location in which beneficiaries used and providers rendered services in T‐MSIS claims and provider files. To accomplish this, states must understand and comply with CMS’s expectations for states regarding populating the T‐MSIS data elements necessary to maintain data integrity and perform this type of geo‐spatial analysis. T‐MSIS claims data contain very little geographic information; therefore, CMS needs a way to link T‐ MSIS claims data to servicing location information in the T‐MSIS provider file.
In the T‐MSIS Provider file, a unique provider (i.e., SUBMITTING‐STATE‐PROV‐ID) can be associated with one or more servicing locations. Each servicing location can be reported with:
- A PROV‐LOCATION‐ID
- Up to four types of addresses (ADDR‐TYPE — billing, mailing, practicing, and servicing location address)
- One or more auxiliary provider IDs (PROV‐IDENTIFIER‐TYPE – state‐specific Medicaid provider ID, NPI, Medicare ID, NCPDP ID, federal tax ID, state tax ID, SSN, or some other type of ID)
- When applicable, up to four facility bed types (BED‐TYPE‐CODE – intermediate care facility for individuals with intellectual disabilities, inpatient, nursing facility, Title 18 skilled nursing facility [T18 SNF])
- When applicable, facility bed counts (BED‐COUNT).
A common location ID (that is, PROV‐LOCATION‐ID) across the claims and provider files is necessary to link services rendered/utilized from the claim with the servicing location address of the provider from the provider file. PROV‐LOCATION‐ID values can be alphanumeric, alpha‐only, or numeric‐only and can be up to five positions long. Special characters other than pipes (|) and asterisks (*) may be part of the provider location ID. These tier 1 validation rules are applied to the IP, LT, OT, and RX files.
States face a challenge in populating PROV‐LOCATION‐ID in a manner that complies with T‐MSIS validation rules. In each of the T‐MSIS claims files, PROV‐LOCATION‐ID is captured at the claim header level, so only one PROV‐ LOCATION‐ID value is reported per claim (including all of the associated claim lines). According to validation rules, the provider location ID reported on each claim should correspond with the servicing provider number at the claim line/detail level of a claim (IP, LT, and OT claims) or the dispensing provider number at the claim header (RX claims). Multiple claim lines can be reported on a claim, and it is possible that services reported on those lines were performed at different locations. Under current reporting, only one location could be associated with a provider on the claim. In addition, multiple providers can provide services on the same claim, but only one of those providers can be used for identifying the location ID on the claim.
The provider file must contain a record for each location address (PROV‐ADDR‐TYPE = 4 on the PROV‐LOCATION‐ AND‐CONTACT‐INFO‐PRV00003 segment) at which a provider performs a service. Each location will require all associated provider identifiers to be reported on the provider identifiers record segment (PROV‐IDENTIFIERS‐ PRV00005). In addition, records capturing the providers licensing information for each location should be reported in the provider licensing information segment (PROV‐LICENSING‐INFO‐PRV00004). Finally, any information regarding inpatient beds should be reported on the bed type information segment, if applicable (PROV‐BED‐TYPE‐INFO‐PRV00010).
CMS is currently researching options to capture all possible servicing locations that can be reported on the claim. It is important that all provider addresses be reported to ensure that the locations reported on the claim are consistent with expected provider locations on the provider field.