PRV.002.019

SUBMITTING-STATE-PROV-ID

Data Element

DE Number

PRV019

System DE Number

PRV.002.019

File Name

PRV - PROVIDER

File Segment Number

PRV00002

File Segment Name

PROV-ATTRIBUTES-MAIN

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	The State-specific Medicaid Provider Identifier 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.
Size	X(30)
FLF Start Position	22
FLF Stop Position	51
Segment Key Field Identifier	2
Coding Requirements	1. Value must be 30 characters or less 2. Mandatory

Valid Value Code Set	Valid Value Code	Valid Value Name	Valid Value Description	Effective Start Date	Effective End Date

RULE ID	RULE Definition
RULE-6156	If a segment is a provider attributes main segment from a PRV file, the submitting state provider ID value reported must be compatible with the specified T-MSIS picture format: X(30).
RULE-7587	If submitting state provider ID is populated on a provider attributes main segment from an PRV file, and facility group individual code is equal to '01' (facility) or '02' (group), and the provider identifier type = '2' and the submitting state provider ID is a valid NPI in the NPPES file, then the entity type code is equal to '2' (organization) in the NPPES NPI data file.
RULE-7589	If submitting state provider ID is populated on a provider attributes main segment from an PRV file, and facility group individual code is equal to '03' (individual), and the provider identifier type = '2' and the submitting state provider ID is a valid NPI in the NPPES file, then the entity type code is equal to '1' (individual) in the NPPES NPI data file.

Measure ID	Measure Name
RULE-8723	% of records with a PAYEE ID that is not found on the provider file during the performance period start date (FTX00006) (PAYEE-ID-TYPE = '04', '05')
RULE-7923	% of claim headers with a Billing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Beginning Date of Service
RULE-7924	% of claim headers with a Billing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Prescription Fill Date
RULE-7929	% of claim headers with a Billing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Admission Date
RULE-7930	% of claim headers with a Billing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Beginning Date of Service
RULE-7931	% of claim headers with a Billing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Beginning Date of Service
RULE-7932	% of claim headers with a Billing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Prescription Fill Date
RULE-8719	% of records with a PAYEE ID that is not found on the provider file during the capitation period start date (FTX00002) (PAYEE-ID-TYPE = '04', '05')
RULE-8720	% of records with a PAYEE ID that is not found on the provider file during the premium period start date (FTX00003) (PAYEE-ID-TYPE = '04', '05')
RULE-8721	% of records with a PAYEE ID that is not found on the provider file during the premium period start date (FTX00004) (PAYEE-ID-TYPE = '04', '05')
RULE-8722	% of records with a PAYEE ID that is not found on the provider file during the coverage period start date (FTX00005) (PAYEE-ID-TYPE = '04', '05')
RULE-7922	% of claim headers with a Billing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Beginning Date of Service
RULE-8724	% of records with a PAYEE ID that is not found on the provider file during the payment period start date (FTX00007) (PAYEE-ID-TYPE = '04', '05')
RULE-8725	% of records with a PAYEE ID that is not found on the provider file during the cost settlement period start date (FTX00008) (PAYEE-ID-TYPE = '04', '05')
RULE-8726	% of records with a PAYEE ID that is not found on the provider file during the wrap period start date (FTX00009) (PAYEE-ID-TYPE = '04', '05')
RULE-8727	% of records with a PAYEE ID that is not found on the provider file during the payment period start date (FTX00095) (PAYEE-ID-TYPE = '04', '05')
RULE-8737	% of records with a PAYEE ID that is not found on the provider file during the capitation period start date (FTX00002) (PAYEE-ID-TYPE = '04')
RULE-8741	% of records with a PAYEE ID that is not found on the provider file during the performance period start date (FTX00006) (PAYEE-ID-TYPE = '04')
RULE-8742	% of records with a PAYEE ID that is not found on the provider file during the payment period start date (FTX00007) (PAYEE-ID-TYPE = '04')
RULE-8743	% of records with a PAYEE ID that is not found on the provider file during the cost settlement period start date (FTX00008) (PAYEE-ID-TYPE = '04')
RULE-8744	% of records with a PAYEE ID that is not found on the provider file during the wrap period start date (FTX00009) (PAYEE-ID-TYPE = '04')
RULE-8745	% of records with a PAYEE ID that is not found on the provider file during the payment period start date (FTX00095) (PAYEE-ID-TYPE = '04')
RULE-689	% of claim headers with a Billing Provider Number that is not found on the provider file during the dates of service
ALL-4-002-2	% of billing and servicing provider numbers on claims that are not found in the provider file
ALL-4-003-3	% of billing and servicing provider numbers on claims that are not found in the provider file
ALL-4-004-4	% of billing and dispensing provider numbers on claims that are not found in the provider file
PRV-2-010-10	% of Submitting State Provider IDs (FACILITY-GROUP-INDIVIDUAL-CODE = 03) with more than one NPI (PROV-IDENTIFIER-TYPE = 2) (across all time)
RULE-1126	% of claim headers with a Billing Provider Number that is not found on the provider file during the dates of service
RULE-1246	% of claim headers with a Servicing Provider Number that is not found on the provider file during the dates of service
RULE-1540	% of claim headers with a Billing Provider Number that is not found on the provider file during the dates of service
RULE-1663	% of claim headers with a Servicing Provider Number that is not found on the provider file during the dates of service
RULE-1845	% of claim headers with a Billing Provider Number that is not found on the provider file on the Prescription Fill Date
RULE-1964	% of claim headers with a Dispensing Provider Number that is not found on the provider file on the Prescription Fill Date
ALL-4-001-1	% of billing and servicing provider numbers on claims that are not found in the provider file
RULE-810	% of claim headers with a Servicing Provider Number that is not found on the provider file during the dates of service
PRV-6-001-1	% of Submitting State Provider IDs with FACILITY-GROUP-INDIVIDUAL-CODE = 01, 02 (facility or group) that do not have a Provider Classification Code that indicates a facility or group
PRV-6-002-2	% of Submitting State Provider IDs with FACILITY-GROUP-INDIVIDUAL-CODE = 03 (individual) that do not have a Provider Classification Code that indicates an individual
PRV-6-003-3	% of Submitting State Provider IDs with FACILITY-GROUP-INDIVIDUAL-CODE = 01, 02 (facility or group) that are missing Provider Classification Code
PRV-6-004-4	% of Submitting State Provider IDs with FACILITY-GROUP-INDIVIDUAL-CODE = 03 (individual) that are missing Provider Classification Code
RULE-7569	% of Provider Attributes Main segments for individual providers (FACILITY-GROUP-INDIVIDUAL-CODE = 03) with more than one NPI (PROV-IDENTIFIER-TYPE = 2) (across all time)
RULE-7728	% of individual providers where Provider Last Name is missing
RULE-7735	% of providers without a corresponding Provider Location and Contact Information segment
RULE-7921	% of claim headers with a Billing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Admission Date

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
PRV042	PRV.003.042	SUBMITTING-STATE-PROV-ID	PRV00003	PROV-LOCATION-AND-CONTACT-INFO
PRV063	PRV.004.063	SUBMITTING-STATE-PROV-ID	PRV00004	PROV-LICENSING-INFO
PRV075	PRV.005.075	SUBMITTING-STATE-PROV-ID	PRV00005	PROV-IDENTIFIERS
PRV087	PRV.006.087	SUBMITTING-STATE-PROV-ID	PRV00006	PROV-TAXONOMY-CLASSIFICATION
PRV097	PRV.007.097	SUBMITTING-STATE-PROV-ID	PRV00007	PROV-MEDICAID-ENROLLMENT
PRV109	PRV.008.109	SUBMITTING-STATE-PROV-ID	PRV00008	PROV-AFFILIATED-GROUPS
PRV118	PRV.009.118	SUBMITTING-STATE-PROV-ID	PRV00009	PROV-AFFILIATED-PROGRAMS
PRV128	PRV.010.128	SUBMITTING-STATE-PROV-ID	PRV00010	PROV-BED-TYPE-INFO

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
09/16/2024	4.0.0	PRV.002.019	UPDATE	File segment	None	88
09/16/2024	4.0.0	PRV.002.019	ADD	N/A		Created