CMS Technical Instructions: Reporting Provider Location ID in the Provider File

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. The Provider Location Identifier values reported on IP, LT OT and RX claim header segments must correspond to an active Provider Location Identifier value on a Provider Location and Contact Info (PRV.003) segment.

Prior to V4.0.0, states faced 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 provider location could be reported per claim (including all of the associated claim lines).

Though PROV-LOCATION-ID has been retained in T-MSIS Data Dictionary V4.0.0, several new data elements were added on the IP, OT, and LT claims files to allow states to report multiple provider location IDs for when there are services performed at different locations on the same claim. The full list of new data elements is provided below.

In the IP, LT, and OT files, the following new data elements for Billing Provider Location were added at the header level.

• BILLING-PROV-ADDR-LN-1 (CIP298, CLT244, COT236)
• BILLING-PROV-ADDR-LN-2 (CIP299, CLT245, COT237)
• BILLING-PROV-CITY (CIP300, CLT246, COT238)
• BILLING-PROV-STATE (CIP301, CLT247, COT239)
• BILLING-PROV-ZIP-CODE (CIP302, CLT248, COT240)

In the IP, LT, and OT files, the following new data elements for Service Facility Location were added at the header level. Note that the Service Facility Location data elements can only be reported for a facility, not an individual provider. Service Facility Location data elements were also added at the line level in the OT file.

• SERVICE-FACILITY-LOCATION-ORG-NPI (CIP303, CLT249, COT241, COT258)
• SERVICE-FACILITY-LOCATION-ADDR-LN-1 (CIP304, CLT250, COT242, COT259)
• SERVICE-FACILITY-LOCATION-ADDR-LN-2 (CIP305, CL251, COT243, COT260)
• SERVICE-FACILITY-LOCATION-CITY (CIP306, CLT252, COT244, COT261)
• SERVICE-FACILITY-LOCATION-STATE (CIP307, CLT253, COT245, COT262)
• SERVICE-FACILITY-LOCATION-ZIP-CODE (CIP308, CLT254, COT246, COT263)

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). Any information regarding inpatient beds should be reported on the bed type information segment, if applicable (PROV‐BED‐TYPE‐INFO‐PRV00010).