Provider Demographic Data File Specification

Version: 1.8
Date: January 7, 2021

Introduction

This document defines the file format for the electronic transfer of provider demographic data between a specific PLAN (or their designee) and Performance Health Technology (PH TECH) required to configure PH TECH’s claims administration platform or other data services.

File Format and Naming

Files should be delivered in one of the following formats

Pipe delimited text file with headers
Text Qualified CSV - with headers

File naming convention should be the following depending on file format above:

Clientnm_providerdemographics_yyyymmdd.txt
Clientnm_providerdemographics_yyyymmdd.csv

File Delivery

File drop locations if using PH TECH SFTP server:

Test Files : /home/entities/other/client name/to phtech/providerdata/testing
Production Files : /home/entities/other/client name/to phtech/providerdata/

For more information regarding using PH TECH SFTP please see: SFTP Data Transfer

Data Schema

Column	Field Name	Field Type	Field Length	Claims Administration Required	Provider Directory Required	CMS Interop Required	Description
1	Provider_Last_Name	varchar	50	Yes	Yes	Yes	Provider's last name
2	Provider_First_Name	varchar	35	Yes	Yes	Yes	Provider's first name
3	Provider_Middle_Name	varchar	1	No	Optional	Optional	The first initial of the provider's middle name
4	Provider_Suffix	varchar	15	No	No	Optional	The suffix that would indicate providers MD, DO
5	Provider_Gender	varchar	1	Optional	Yes	Yes	Gender of the provider, M = male or F = female
6	Provider_DOB	date	8	No	No	Optional	Provider's date of birth. MMDDYYYY
7	Provider_Category	varchar	50	No	No	Optional	Type of provider Plan may use to categorize groups of provider types * See Appendix for available values below . This will post a warning in the post load report file if not supplied.
8	Address_Designation	varchar	10	Yes	Yes	Yes	Indicates if the office listed is the primary working office of the provider. A provider can only have one primary office.
9	Effective_Date_of_Office_Designation	date	8	No	No	No	Date the provider began work at the practice office MMDDYYYY
10	Termination_Date_of_Office_Designation	date	8	No	No	No	Date the provider left the practice office MMDDYYYY or blank if still active
11	Practice_Name	varchar	100	Yes	Yes	Yes	Name of the practice office
12	Practice_Address_1	varchar	55	Optional	Yes	Yes	First Address line for the practice
13	Practice_Address_2	varchar	55	No	No	Optional	Second Address line for the practice
14	Practice_City	varchar	35	Optional	Yes	Yes	City of the practice office
15	Practice_State	varchar	2	Optional	Yes	Yes	State abbreviation of the practice office
16	Practice_Zip	varchar	10	Optional	Yes	Yes	Zip code for the practice office; #####- ####
17	Practice_Phone	varchar	13	Optional	Yes	Yes	Phone number for the practice office ###-###-####. This will post a warning in the post load report file if not supplied.
18	Practice_Fax	varchar	13	No	No	Optional	Fax number for the practice office; ###-###-####. This will post a warning in the post load report file if not supplied.
19	Provider_Tax_ID_SSN	varchar	9	No	No	No	SSN or TAX ID for the provider. If PH TECH is completing provider enrollments this is required.
20	Provider_IS_PCP	varchar	1	Yes	Yes	Optional	Indicates if the provider is a PCP. Yes = Y No = N or blank. Utilized for member assignments and claims adjudication.
21	Provider_License_Number	varchar	35	No	No	Optional	State license number for the provider. If PH TECH is completing provider enrollments this is required.
22	Provider_NPI_Number	varchar	10	Yes	Yes	Yes	Provider's registered National Provider ID
23	Provider_Taxonomy_Code	varchar	35	Yes	Yes	Yes	Provider's taxonomy code. Note - The Taxonomy code is required for claims submittal to OHA. If this value is unknown to the PLAN there are two options: 1) Obtain the value from OHA if the provider is already enrolled 2) Utilize NPPES if they are not enrolled with OHA.
24	Primary_Taxonomy	varchar	1	Yes	Yes	Yes	Indicates the taxonomy code provided is the primary taxonomy for the provider
25	Provider_Network	varchar	50	No	No	No	Name of the network that a provider can provide services in
26	Network_Effective_Date	date	8	No	No	No	Date the provider became effective on the network. MMDDYYYY
27	Network_Termination_Date	date	8	No	No	No	Date the provider became terminated from the network. MMDDYYYY or blank if still active.
28	Billing_Provider_Name	varchar	100	Yes	Yes	No	Name of the billing provider (provider group/network) for the provider
29	Billing_Provider_Doing_Business_As_Name	varchar	100	No	No	No	If the billing provider has a different name printed on a check than what is actually printed on the bill
30	Facility	varchar	1	No	No	No	Used in authorization management to specify a facility where work should be completed. If the billing provider location should be considered as a facility that patients are referred to then this value should be Y. The default value is N.
31	Billing_Provider_NPI_Number	varchar	10	Yes	Yes	No	The National Provider ID for the billing provider
32	Billing_Provider_Taxonomy	varchar	35	No	No	No	The primary taxonomy for the billing provider
33	Billing_Provider_Tax_ID	varchar	9	Yes	Yes	No	The Tax ID for the billing provider
34	Billing_Provider_Phone	varchar	13	Yes	Yes	No	The primary phone number for the billing provider; ###-###-####
35	Billing_Provider_Fax	varchar	13	No	No	No	The primary fax number for the billing provider; ###-###-####
36	Billing_Provider_Physical_Street_Address_1	varchar	55	Yes	Yes	No	The first line physical address location of the billing provider. This has to be a physical address, PO Boxes are not allowed.
37	Billing_Provider_Physical_Street_Address_2	varchar	55	No	No	No	The second line physical address location of the billing provider
38	Billing_Provider_Physical_City	varchar	35	Yes	Yes	No	The physical city of the billing provider
39	Billing_Provider_Physical_State	varchar	2	Yes	Yes	No	The physical state of the billing provider
40	Billing_Provider_Physical_Zip	varchar	15	Yes	Yes	No	The physical zip code of the billing provider; #####-####
41	Pay_To_Street_Address_1	varchar	55	No	No	No	The first line mailing address for the billing provider
42	Pay_To_Street_Address_2	varchar	55	No	No	No	The second line mailing address for the billing provider
43	Pay_To_City	varchar	35	No	No	No	The mailing city for the billing provider
44	Pay_To_State	varchar	2	No	No	No	The mailing state for the billing provider
45	Pay_To_Zip	varchar	15	No	No	No	The mailing zip code for the billing provider; #####-####
46	Panel_Open	varchar	1	Optional	Yes	Yes	For Provider Directory use and is ONLY applicable for PCP. “Y” indicates that the provider is accepting new patients. “N” indicates that the provider is NOT accepting new patients. Default = “Y”. For compliance, it is very important that this data be as accurate as possible.
47	Include_in_Directory	varchar	1	Optional	Yes	No	For Provider Directory use. “Y” indicates that the provider is to be included in the directory. “N” indicates that the provider is NOT to be included in the directory. Default = “Y”.
48	Directory_Specialty	varchar	100	Optional	Yes	No	For Provider Directory use. This is a friendly description that would be understood by a typical member. This is not intended to be populated with a taxonomy code description captured previously.
49	Language_1	varchar	100	Optional	Yes	Optional	For Provider Directory use. This is the primary language of the provider as it will appear in the Provider Directory.
50	Language_2	varchar	100	No	No	Optional	For Provider Directory use. This is the secondary language of the provider as it will appear in the Provider Directory.
51	Internal_Provider_ID	varchar	50	No	No	Optional	Optional identifier that is unique to the provider from the originating system that can be used for tracking and identification of that provider for downstream processes.
52	Facility_Type	varchar	100	No	No	Optional	For Provider Directory use. This is for identifying the specific type of facility that a practice office is e.g. Hospital.
53	Non_Par_OnCall_Start	date	8	Optional	No	No	Indicates the start date that a provider is valid but non participating in the plan. Usually this is while contracting is pending.
54	Non_Par_OnCall_End	date	8	Optional	No	No	Indicates the end date that a provider is valid but non participating in the plan. Usually this is while contracting is pending.
55	Practice_Office_URL	varchar	255	No	No	Optional	For Provider Directory use. Practice office website url if applicable
56	Practice_Office_Accessibility	varchar	1	Optional	Yes	Yes	For Provider Directory use. Whether the provider's office/facility has accommodations for people with physical disabilities, including offices, exam room(s) and equipment. (Y=Yes, N=No)
57	Age_Restriction	varchar	20	Optional	Yes	Yes	For Provider Directory use. Are there any age restrictions for this provider at this location (Adults Only, Pediatrics Only etc)
58	Cultural_Competency_Certification	varchar	1	Optional	Yes	Yes	For Provider Directory use. Has the provider completed the Cultural Competency Certification course. (Y=Yes, N=No)

Note: Fields marked Optional will be loaded if they are received on a record but not required.

Articles in this section

Introduction

File Format and Naming

File Delivery

Data Schema

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Articles in this section

Introduction

File Format and Naming

File Delivery

Data Schema

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