CMS Technical Instructions: Provider Classification Requirements in T-MSIS

The ability to identify provider specialization in T-MSIS is vital for investigating a number of different research questions. States have historically reported a lack of clarity with respect to which provider specialization identifiers should be used and how those identifiers should be reported. This lack of clarity has resulted in the inconsistent reporting of provider specialization data in T-MSIS across states. T-MSIS data on provider specialization reported inconsistently across states. This technical instruction document seeks to provide clarification in this area.

All providers in the PROV-ATTRIBUTES-MAIN (PRV00002) file segment are expected to have at least one code in the PROV-TAXONOMY-CLASSIFICATION (PRV00006) file segment.^[1]

The PROV-TAXONOMY-CLASSIFICATION (PRV00006) file segment captures information specific to provider specialization and authorization. In that file segment, the value in the PROV-CLASSIFICATION-TYPE (PRV088) data element indicates which of four classification types the value in the PROV-CLASSIFICATION-CODE (PRV089) data element represents. The four PROV-CLASSIFICATION-TYPE code values and corresponding PROV-CLASSIFICATION-CODE code sets are presented in Table 1.

Table 1: PROV-CLASSIFICATION-TYPE and PROV-CLASSIFICATION-CODE codes and descriptions

States have struggled to provide all four provider classification types for every provider. To help states with this challenge, CMS will only require taxonomy codes (PROV-CLASSIFICATION-TYPE=1) for providers that have a National Provider Identifiers (NPIs) and Authorized Category of Service (PROV-CLASSIFICATION-TYPE=4) for providers that do not have NPIs. Further challenges regarding limitations in ability to report taxonomy and instructions to address are covered below. If states have other specialization information for each provider time, reporting of that information is encouraged.

The reporting of provider specialization data in the PROV-TAXONOMY-CLASSIFICATION (PRV00006) file segments should align with provider taxonomy, provider specialty, and provider type values in claims file data elements. , There has also been a need to clarify the alignment between values provided in the PROV-TAXONOMY-CLASSIFICATION (PRV00006) file segment and values provided in the claims data. This technical instruction document will provide mappings between PROV-TAXONOMY-CLASSIFICATION (PRV00006) file segment and data elements in the claims file segments.

Notably, states may use state-specific code sets for reporting provider specialization. While states may continue to do this internally, CMS maintains that the codes reported in T-MSIS must correspond to values provided by the National Uniform Claim Commission (NUCC) (the Provider Taxonomy Code List) or the T-MSIS valid values for PROV-CLASSIFICATION-CODE code sets found in the T-MSIS Data Guide. Consistency across states in this area is vital for any type of analysis using provider specialization.

Finally, some states have voiced concern with their ability to identify provider specialization information from claims resources. Specifically, states have requested CMS assistance with identifying where to find specialization and identification information for providers performing various roles associated with claims/encounters in the X-12 claim transaction sets. This technical instruction provides a crosswalk for extracting provider information for T-MSIS from the X-12 sets.

PROV-TAXONOMY-CLASSIFICATION (PRV00006) Segment

CMS has identified provider taxonomy (PROV-CLASSIFICATION-TYPE=1) as the preferred method of reporting provider specialization in T-MSIS. Again, within the context of T-MSIS, the term provider taxonomy refers to the Health Care Provider Taxonomy Code Set maintained by the NUCC. Using provider taxonomy to identify provider specialization has several advantages over the other provider classification codes sets:

• The Health Care Provider Taxonomy Code Set is nationally standardized and actively maintained by the NUCC. This means that the available provider taxonomy codes and their definitions should be consistent across states, and new taxonomy codes will be added as new provider specializations are introduced.
• The NUCC provider taxonomy codes can be very detailed and will provide enough granularity for most research purposes.
• Providers must supply a valid NUCC taxonomy code when they apply for a National Provider Identifier (NPI). As such, all providers with NPIs will have self-identified with at least one provider taxonomy code.^[2]

Although all states are encouraged to adopt the NUCC provider taxonomy as a method to identify provider specialization, states that are not able to do so will not be penalized. The following scenarios present challenges to using the NUCC provider taxonomy and alternative approaches to reporting provider specialization in T-MSIS.

• State does not use NUCC in credentialing process: Not all states use the NUCC provider taxonomy in their provider credentialing process, so the relationship between a provider and their taxonomy(s) will not always be available in some state Medicaid Management Information Systems. States that provide documentation indicating their provider credentialing system does not use taxonomy codes will be permitted to use provider specialty (PROV-CLASSIFICATION-TYPE = 2) and provider type (PROV-CLASSIFICATION-TYPE = 3) codes instead of provider taxonomy. If a state cannot provide a taxonomy code for a provider that has an NPI, and the provider specialty and provider type code lists do not contain a valid value for the provider (as is the case for dentists), states should use the authorized category of service code for the provider (PROV-CLASSIFICATION-TYPE = 4). Provider is Atypical: Atypical providers that do not have NPIs, such as those that provide transportation or some home health services, may not have specializations that easily map to the taxonomy, specialty or provider type codes (PROV-CLASSIFICATION-TYPE = 1, 2, or 3). For these providers, states should provide authorized category of service codes (PROV-CLASSIFICATION-TYPE = 4).

Please note that though only one PROV-CLASSIFICATION-CODE (PRV089) is required for each provider, states are encouraged to provide all available data. Providers that have more than one value for a given classification type (e.g., more than one taxonomy) and/or more than one classification type (e.g., a taxonomy and a specialty), will have multiple simultaneously active PROV‐TAXONOMY‐CLASSIFICATION‐PRV00006 record segments. If a given provider’s specialization changes over time, retired entries should be end dated and new entries should be given appropriate start dates so that dates in the PROV-TAXONOMY-CLASSIFICATION file segment align with dates found in the claims data.

Claims File Segment and PRV00006 Reporting

The codes provided in the claims data elements must have corresponding values in the PROV-TAXONOMY-CLASSIFICATION (PRV00006) file segment. Since there is no column to report authorized category of service code in any of the claims file segments, claims submitted by atypical providers are not expected to have taxonomy, specialty, or provider type values (though they can be reported if they are available). Again, however, these claims may be submitted with an authorized category of service codes (PROV-CLASSIFICATION-TYPE = 4).

The values provided in the claim file segments should come directly from the claims when they are submitted, values provided by managed care organizations, or values derived from NUCC taxonomy codes that came in on the claims. States should not populate missing data elements on the claims file segments by mapping values from the PROV-TAXONOMY-CLASSIFICATION (PRV00006) file segment to the claims file segments. This is to avoid complications that may arise in situations when a provider has more than one value for a given PROV-CLASSIFICATION-TYPE code in the PROV-TAXONOMY-CLASSIFICATION (PRV00006) file segment. For example, if a paid claim was missing the taxonomy for the rendering provider and the rendering provider has more than one taxonomy in PROV-TAXONOMY-CLASSIFICATION (PRV00006) (e.g., a hand surgeon that sub-classifies under plastic surgery), it is not immediately obvious which taxonomy code should be populated on the claim.

The relationship between the codes provided in the PROV-TAXONOMY-CLASSIFICATION file segment and the claims file segments are outlined in Table 2.

Table 2: Relationships between Claims data elements and PROV-CLASSIFICATION-TYPE code

PRV0006 and X-12 Claim Transaction Sets

Some states have requested assistance with identifying where to find NPIs and taxonomy codes for providers who performed various roles associated with the claim/encounter in the X-12 claim transaction sets.

Provider role information needed for the T-MSIS claim files can be extracted from the standard X-12 transactions. Tables 3-7 below represent the T-MSIS to X-12 crosswalks for each provider role.

In each table, the first column identifies the provider role. The second and third columns identify the specific T-MSIS record segments and data elements used to capture the NPI and taxonomy of the provider performing the specified role. The fourth, fifth, sixth, and seventh columns in tables “A” through “E” provide the X-12 transaction name, data element identifier, data element description and loop id that map to the T-MSIS data element. The fourth, fifth, sixth, and seventh columns in table “F” provide the segment name, field identifier, field name and definition of the applicable NCPDP D.0 data set fields.

Use tables “A” through “F” to map the provider roles that are contained in the T-MSIS claim record layouts to their corresponding X-12 standard transaction data elements.

If the T-MSIS data element does not exist in the X-12 transaction set (shown as “N/A” in the tables below), 8-fill, leave blank or space-fill the T-MSIS data element when building T-MSIS claim files.

As noted previously, non-missing values reported in the claims file segments must have corresponding entries in the PROV-TAXONOMY-CLASSIFICATION file segment. Instances in which values do not match between file segments are an indication of incomplete or incorrect data. Future data quality evaluations may include checks that will flag such data inconsistencies.

Table A: Provider roles on T-MSIS CLAIMIP files and their corresponding locations on the X-12 transactions

Table B: Provider roles on T-MSIS CLAIMLT files and their corresponding locations on the X-12 transactions

Table C: Provider roles on T-MSIS CLAIMOT (facility claims) files and their corresponding locations on the X-12 transactions

Table D: Provider roles on T-MSIS CLAIMOT (professional claims) files and their corresponding locations on the X-12 transactions

Table E: Provider roles on T-MSIS CLAIMOT (dental claims) files and their corresponding locations on the X-12 transactions

Table F: Provider roles on T-MSIS CLAIMRX files and their corresponding locations on the X-12 transactions