Brief Issue Description
States have faced challenges in reporting valid values in the PROV-IDENTIFIER (PRV081) data element in the PROV-IDENTIFIERS (PRV00005) record segment. Valid and accurate provider identifiers are important for linking provider data to other T-MSIS files, for linking to other databases, and for analyzing Medicaid and CHIP data. It is also important for provider identifier values to be consistent with the identification attributes found in other source data. The guidance in this brief defines each type of provider identifier captured in T-MSIS and provides a high-level description of how states’ source systems can validate provider identifier values for reporting in T-MSIS.
The PROV-IDENTIFIER data element captures the different ways in which states distinguish providers from one another on claims and other transactions. It is also a critical data element for linking to other data sources. Additionally, the PROV-IDENTIFIER links the provider information in the provider file with the provider information reported in the claims files. The PROV-IDENTIFIER-TYPE (PRV077) data element is used to identify the specific type of identifier represented by PROV-IDENTIFIER. If a provider has a state-specific Medicaid Provider ID, a National Provider Identifier (NPI), a Medicare ID, a National Council for Prescription Drug Programs (NCPDP) ID, a Federal Tax ID, a State Tax ID, or a Social Security number (SSN), then the state should provide the appropriate PROV-IDENTIFIER-TYPE code and supply the associated ID in the PROV-IDENTIFIER data element.
Key Record Segments
As shown in Figure 1, the PROV-IDENTIFIERS segment is a child to the PROV-LOCATION-AND-CONTACT-INFO (PRV00003) segment and links to that segment by the required data elements SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, and PROV-LOCATION-ID. PROV-LOCATION-AND-CONTACT-INFO, in turn, links to the PROV-ATTRIBUTES-MAIN (PRV00002) record segment by the SUBMITTING-STATE and SUBMITTING-STATE-PROV-ID fields. Each record in the PROV-IDENTIFIERS segment must have corresponding records in the PROV-LOCATION-AND-CONTACT-INFO and in the PROV-ATTRIBUTES-MAIN segments that contain effective and end-date ranges that span the effective and end-date range reported in the PROV-IDENTIFIERS segment.
Figure 1. Table Relationships for PROV-IDENTIFIERS
PROV-IDENTIFIERS (PRV00005) Segment Fields
Critical fields that can be used to assess the validity of the PROV-IDENTIFIERS segment information include PROV-IDENTIFIER-EFF-DATE (PRV079), PROV-IDENTIFIER-END-DATE (PRV080), PROV-IDENTIFIER-TYPE (PRV077), PROV-IDENTIFIER-ISSUING-ENTITY-ID (PRV078), and PROV-IDENTIFIER (PRV081). This section reviews these fields.
PROV-IDENTIFIER-EFF-DATE and PROV-IDENTIFIER-END-DATE
PROV-IDENTIFIER-EFF-DATE is a required field and represents the first day of the time span during which the values in all data elements in the PROV-IDENTIFIERS segment are in effect. PROV-IDENTIFIER-EFF-DATE must be a valid date and populated in CCYYMMDD format.
PROV-IDENTIFIER-END-DATE represents the last day of the time span during which the values of the data elements in the PROV-IDENTIFIERS segment are in effect. If the time span of the segment is open ended (that is, there is no end date), then states should populate PROV-IDENTIFIER-END-DATE with "99991231." If PROV-IDENTIFIER-END-DATE is blank, or space filled, it will be treated as if it were populated with "99991231." In all other cases, PROV-IDENTIFIER-END-DATE must be a valid date and populated in CCYYMMDD format. When provided, PROV-IDENTIFIER-END-DATE must occur on or after PROV-IDENTIFIER-EFF-DATE, and the time span must be within the time span defined by PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE and by PROV-LOCATION-AND-CONTACT-INFO-END-DATE with the same SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, and PROV-LOCATION-ID. Overlapping time span segments are not allowed for records with the same SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-LOCATION-ID, PROVIDER-IDENTIFIER-TYPE, PROV-IDENTIFIER-ISSUING-ENTITY-ID, and PROVIDER-IDENTIFIER.
PROV-IDENTIFIER-TYPE is a code that identifies the kind of identifier captured in the PROV-IDENTIFIER data element. The valid values and associated descriptions are:
|1||State-specific Medicaid Provider ID|
|5||Federal Tax ID|
|6||State Tax ID|
For every unique combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, and PROV-LOCATION-ID, states should provide to T-MSIS the identifiers associated with the provider for PROVIDER-IDENTIFIER-TYPE of 1 through 7 whenever it is applicable to the provider. A description of each PROV-IDENTIFIER-TYPE valid value follows.
- State-specific Medicaid Provider ID
The state-specific Medicaid Provider ID is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state’s Medicaid Management Information System (MMIS).
States should report NPIs for all providers enrolled in their MMIS when those providers have been assigned an NPI by the National Plan and Provider Enumeration System (NPPES). The NPI is a unique, 10-digit identification number for covered health care providers. There are two types of NPIs: Type 1 NPIs are for individuals, and Type 2 NPIs are for organizations. All NPIs assigned to SUBMITTING-STATE-PROV-IDs identified as individuals by FACILITY-GROUP-INDIVIDUAL (PRV026) in the PRV00002 segment should be Type 1 NPIs, and all NPIs assigned to SUBMITTING-STATE-PROV-IDs identified as facilities or groups by FACILITY-GROUP-INDIVIDUAL should be Type 2 NPIs. Access the NPI registry; Download a file containing NPIs. This file can be used for validation purposes. NPPES also supports an application programming interface (API) to programmatically query the registry. View information concerning the API. Values reported for NPI should be valid NPPES-issued NPIs. An NPI will only be considered valid if it is included in the NPPES NPI registry. States should not report invalid NPIs in T-MSIS.
- Medicare ID
For Medicare Part A providers, the Medicare Identification Number (MIN) is the CMS Certification Number (CCN). For Medicare Part B suppliers other than suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), the MIN is the Provider Identification Number (PIN). For DMEPOS suppliers, the MIN is the number that the NSC issues to the supplier. Note that for Part B and DMEPOS suppliers, the MIN may sometimes be referred to as the Provider Transaction Access Number (PTAN).
- NCPDP ID
States should provide to T-MSIS an NCPDP ID for every enrolled pharmacy. The NCPDP assigns a seven-digit identifier to every licensed pharmacy and to qualified non-pharmacy dispensing sites (NPDS) in the United States. NCPDP IDs can be validated through the use of data extracts and real-time query facilities.
- Federal Tax ID
States should submit to T-MSIS provider Federal Tax Identification Numbers (FTINs) issued by the Internal Revenue Service. These include Employer Identification Numbers (EINs) issued to employers and Individual Tax Identification Numbers (ITINs) issued to individuals who are not eligible for SSNs. State agencies responsible for business registration (for example, divisions of revenue or state corporate commissions) should be able to validate FTINs.
- State Tax ID
States should provide a State Tax ID Number (state TIN) to T-MSIS for every enrolled provider that uses a state TIN as its identifier with the state tax authority. The state agencies responsible for business registration (for example, divisions of revenue or state corporate commissions) should be able to validate state TINs.
States should provide a SSN to T-MSIS for every individual provider. A provider should have only one SSN.
If the state or its fiscal agent uses a provider identifier to administer its program that is other than one of the seven identifiers listed above, then the state or the agent should provide this identifier to T-MSIS.
The value stored in PROV-IDENTIFIER-TYPE will determine the appropriate value of PROV-IDENTIFIER-ISSUING-ENTITY-ID. Table 1 shows the relationship between PROV-IDENTIFIER-TYPE and PROV-IDENTIFIER-ISSUING-ENTITY-ID.
Table 1. Mapping PROV-IDENTIFIER-TYPE Values to PROV-IDENTIFIER-ISSUING-ENTITY-ID
|If the value of PROV-IDENTIFIER-TYPE is:||Then the value of PROV-IDENTIFIER-ISSUING-ENTITY-ID must be:|
|1) State-specific Medicaid Provider ID||The state numeric code|
|3) Medicare ID||"CMS"|
|4) NCPDP ID||"NCPDP"|
|5) Federal Tax ID||"IRS"|
|6) State Tax ID||The name of the state’s taxation division|
|8) Other||The name of the issuing entity|
PROV-IDENTIFIER should be populated with the identifier that corresponds to the segment’s PROV-IDENTIFIER-TYPE and PROV-IDENTIFIER-ISSUING-ENTITY-ID.
States are facing some challenges in accurately populating the PROV-IDENTIFIERS segment. Some common anomalies are described below.
- Required data elements on the PROV-IDENTIFIERS segment—including PROV-IDENTIFIER, PROV-IDENTIFIER-TYPE, PROV-IDENTIFIER-ISSUING-ENTITY-ID, PROV-IDENTIFIER-EFF-DATE, and PROV-IDENTIFIER-END-DATE—are not always populated. These data elements are necessary for the PROV-IDENTIFIERS segment to be meaningful and useful.
- Values submitted in the PROV-IDENTIFIER-TYPE field are inconsistent with other provider fields such as the FACILITY-GROUP-INDIVIDUAL-CODE data element on the PROV-ATTRIBUTES-MAIN segment. For example, CMS does not expect to receive SSNs for providers coded as facilities or groups. Similarly, CMS would not expect to see individual providers with an NCPDP ID, as these identifiers are assigned to pharmacies. Logical inconsistencies of this nature are data quality issues that call into question the accuracy of the T-MSIS submission.
- NPIs are not populated for all health care providers. All providers covered by the Health Insurance Portability and Accountability Act (HIPAA) are required to have NPIs. The only legitimate exclusions are atypical providers that do not provide health care as defined under HIPAA but are reimbursed under Medicaid (for example, taxi services, home and vehicle modifications, and respite services).
- Provider identifiers are improperly formatted. Many identifiers (for example, NPI, CCN, SSN, and EIN) have well-defined lengths and formats. For example, NPIs are 10-digit numeric identifiers that contain a check digit, whereas CCNs are six characters, the first two being numeric state identifiers. States that submit identifiers to T-MSIS should meet to the respective data standards.
- Some individual providers have multiple NPIs. Every individual provider should have only one active NPI at a time, and few individuals should ever have more than one NPI in their history. When NPPES has assigned an NPI to an enrolled individual, the NPI must be both listed and a Type 1 individual NPI in the NPPES registry.
States should work with their MMIS vendors to ensure that:
- They implement the following best practices when assigning identifiers to providers at enrollment.
- The PROV-IDENTIFIERS data segment is being populated correctly.
- Using the external resources that are available, the state MMIS should validate provider identifiers during the enrollment process. Table 2 shows available data sources by PROV-IDENTIFIER-TYPE. When preparing T-MSIS files, states should determine whether the IDs comply with the stated validation criteria. In the event that they do not, states should coordinate with the MMIS vendor to ensure that the data are being properly captured in the source systems.
Table 2. Validating Provider Identifiers
PROV-IDENTIFIER-TYPE Validation procedures to confirm with MMIS 1) State-specific Medicaid Provider ID State MMIS 2) NPI NPIs should be available from feeds and APIs. The NPI should be 10-digit numeric and should have a valid check digit. 3) Medicare ID Medicare IDs should be properly formatted. 4) NCPDP ID NCPDP IDs can be validated through the use of data extracts and real-time query facilities. 5) Federal Tax ID State agencies responsible for business registration (for example, divisions of revenue or state corporate commissions) should be able to validate federal TINs. 6) State Tax ID State agencies responsible for business registration (for example, divisions of revenue or state corporate commissions) should be able to validate state TINs. 7) SSN SSNs should be 9-digit numeric values.
- States should adhere to the provider identifier coding requirements as stated in the T-MSIS data dictionary and in supplemental guidance. In particular:
- For every PROV-IDENTIFIERS record segment, there must be an active corresponding PROV-ATTRIBUTES-MAIN (PRV00002) record segment and an active corresponding PROV-LOCATION-AND-CONTACT-INFO (PRV00003) record segment.
- Both PROV-IDENTIFIER-EFF-DATE and PROV-IDENTIFIER-END-DATE must be valid dates and fall within a corresponding time span for the same SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, and PROV-LOCATION-ID combination in the PROV-LOCATION-AND-CONTACT-INFO-PRV00003 segment.
- PROV-IDENTIFIER-TYPE must have a valid value and map to PROV-IDENTIFIER-ISSUING-ENTITY-ID.
- The state should provide the identifiers for PROV-IDENTIFIER-TYPE 1 through 7 whenever they are applicable for a given provider. The state should also supply its specific Medicaid Provider ID for every provider. If a provider has an NPI, CCN, NCPDP ID, FTIN, state TIN, or SSN, the state should report these values to T-MSIS.
- States should provide an FTIN to T-MSIS for every provider. If the provider is either a facility or a group, then the FTIN should be the EIN with a PROV-IDENTIFIER-TYPE = 5. Individuals without SSNs should have an ITIN provider identifier with a PROV-IDENTIFIER-TYPE = 5. For providers with SSNs, the states should report their SSNs with a PROV-IDENTIFIER-TYPE = 7.
 CMS. Medicare Program Integrity Manual. Chapter 15 – Medicare Enrollment, p. 14. Available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c15.pdf. Accessed on January 8, 2019.
 See https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/Downloads/NPIcheckdigit.pdf for NPI coding requirements and how to validate the check digit.