Version: 2.0
Date: April 13, 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 |
Provider Directory Required |
CMS Interop Required |
Description |
1 |
Provider_Last_Name |
varchar |
100 |
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, F = female, O = other, U = unknown/unspecified |
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. For all records either Provider_Category or Facility_Type must be specified but NOT both. |
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 |
Optional |
Optional |
Indicates the taxonomy code provided is the primary taxonomy for the provider |
25 |
Provider_Network |
varchar |
50 |
No |
No |
Yes |
Name of the network that a provider can provide services in |
26 |
Network_Effective_Date |
date |
8 |
No |
No |
Optional |
Date the provider became effective on the network. MMDDYYYY |
27 |
Network_Termination_Date |
date |
8 |
No |
No |
Optional |
Date the provider became terminated from the network. MMDDYYYY or blank if still active. |
28 |
Billing_Provider_Name |
varchar |
100 |
Yes |
No |
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 |
No |
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 |
No |
No |
The Tax ID for the billing provider |
34 |
Billing_Provider_Phone |
varchar |
13 |
Yes |
No |
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 |
No |
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 |
No |
No |
The physical city of the billing provider |
39 |
Billing_Provider_Physical_State |
varchar |
2 |
Yes |
No |
No |
The physical state of the billing provider |
40 |
Billing_Provider_Physical_Zip |
varchar |
15 |
Yes |
No |
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 |
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 |
“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 |
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 |
This is the primary language of the provider as it will appear in the Provider Directory. |
50 |
Language_2 |
varchar |
100 |
No |
No |
Optional |
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 |
This is for identifying the specific type of facility. For all records either Provider_Category or Facility_Type must be specified but NOT both. |
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 |
Practice office website url if applicable |
56 |
Practice_Office_Accessibility |
varchar |
1 |
Optional |
Yes |
Optional |
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 |
Optional |
Are there any age restrictions for this provider at this location (Adults Only, Pediatrics Only etc) |
58 |
Cultural_Competency_Certification |
varchar |
1 |
Optional |
Yes |
Optional |
Has the provider completed the Cultural Competency Certification course. (Y=Yes, N=No) |
59 |
Provider_IS_Dental |
varchar |
1 |
Yes |
Yes |
No |
Indicates if the provider is a dental provider. Yes = Y No = N or blank. Utilized for member assignments and claims adjudication. |
60 |
Provider_IS_Mental_Health |
varchar |
1 |
Yes |
Yes |
No |
Indicates if the provider is a mental health provider. Yes = Y No = N or blank. Utilized for member assignments and claims adjudication. |
Note: Fields marked Optional will be loaded if they are received on a record but not required.
Duplicate Data Handling
Please note that in the event that a Provider Record has multiple practice offices and/or specialities PH TECH would prefer that a unique record be sent for each situation. For example, if a Provider Record has three practice offices then three records would be delivered in the data file and one of these records needs to be marked as the primary practice office. Similarly, if a Provider Record has two specialties then two records would be delivered in the data file and one of these records needs to be marked as the primary specialty.
Sample Data for Multiple Practice Offices and Specialties
Transmit one provider row for each address and/or specialty (all of the other provider data would be the exact same except for the practicing address as follows). Note that the sample below is condensed for simplicity and formatting purposes.
Provider_Last_Name |
Provider_First_Name |
Address_Designation |
Provider_NPI_Number |
Practice_Address_1 |
Provider_Taxonomy_Code |
Primary_Taxonomy |
Smith |
John |
Primary |
123456789 |
123 Main Street NW |
207RR0500X |
N |
Smith |
John |
Second |
123456789 |
595 West Morrison Street SE |
207RR0500X |
N |
Smith |
John |
Primary |
123456789 |
123 Main Street NW |
207Q00000X |
Y |
Smith |
John |
Second |
123456789 |
595 West Morrison Street SE |
207Q00000X |
Y |
Provider Category and Facility Type
Provider_Category is used to identify individuals providing medical services such as doctors/nurses/pharmacists.
Facility_Type is used to identify the type of location where medical services are provided.
Every record must contain either a Provider_Category or a Facility_Type but NOT both. If both values are specified the record will be rejected during import.
Provider_Category Allowed Values
Code | Display | Definition |
ap | Admitting Privileges | Practitioner has admitting privileges at hospital (organization) |
apn | Advanced Practice Nursing Providers | Advanced Practice Nursing Providers |
at | Athletic Trainer | Athletic Trainer |
au | Audiologist | Audiologist |
bh | Behavioral Health & Social Service Providers | Behavioral Health & Social Service Providers |
ba | Board Certified Behavior Analyst | Board Certified Behavior Analyst |
bt | Member Of | Has a relationship of participation with. This does NOT represent a member of an insurance plan, but other types of membership such as membership of physician in the AMA |
cnw | Certified Nurse Midwife | Certified Nurse Midwife |
crnp | Certified Registered Nurse Practitioner | Certified Registered Nurse Practitioner |
ch | Chiropractor | Chiropractor |
cs | Christian Science Practitioner | Christian Science Practitioner |
co | Counselor | Counselor |
dp | Dental Provider | Dental Provider |
de | Dentist | Dentist |
drr | Developmental, Rehabilitative and Restorative Service Providers | Developmental, Rehabilitative and Restorative Service Providers |
dn | Dietary and Nutritional Service Provider | Dietary and Nutritional Service Provider |
om | Doctor of Oriental Medicine | Doctor of Oriental Medicine |
em | Emergency Medical Service Provider | Emergency Medical Service Provider |
ho | Homeopath | Homeopath |
lpn | Licensed Practical Nurse | Licensed Practical Nurse |
mt | Marriage/Family Therapist | Marriage/Family Therapist |
ma | Massage Therapist | Massage Therapist |
nh | Naprapath | Naprapath |
na | Naturopath | Naturopath |
nu | Nursing Service Related Providers | Nursing Service Related Providers |
ot | Occupational Therapist | Occupational Therapist |
op | Optician | Optician |
oo | Optometrist | Optometrist |
os | Other Service Provider | Other Service Provider |
rx | Pharmacy Service Providers | Pharmacy Service Providers |
pt | Physical Therapist | Physical Therapist |
ph | Physician | Physician |
pa | Physician Assistant | Physician Assistant |
po | Podiatrist | Podiatrist |
py | Psychologist | Psychologist |
rn | Registered Nurse | Registered Nurse |
rt | Respiratory Therapist | Respiratory Therapist |
sw | Social Worker | Social Worker |
sp | Speech Language Pathologist | Speech Language Pathologist |
sh | Speech, Language and Hearing Service Providers | Speech, Language and Hearing Service Providers |
te | Technologists, Technicians and Other Technical Service Providers | Technologists, Technicians and Other Technical Service Providers |
http://hl7.org/fhir/us/davinci-pdex-plan-net/STU1/ValueSet-PractitionerRoleVS.html
Facility_Type Allowed Values
Value |
Display Name |
ACC | Accident Site |
RHAT | Addiction Treatment Center |
ALL | Allergy Clinic |
AMB | Ambulance |
CARD | Ambulatory Health Care Facilities; Clinic/Center; Rehabilitation: Cardiac Facilities |
AMPUT | Amputee Clinic |
BMTC | Bone Marrow Transplant Clinic |
BMTU | Bone Marrow Transplant Unit |
BREAST | Breast Clinic |
CATH | Cardiac Catheterization Lab |
CVDX | Cardiovascular Diagnostics Or Therapeutics Unit |
CHEST | Chest Unit |
CANC | Child And Adolescent Neurology Clinic |
CAPC | Child And Adolescent Psychiatry Clinic |
CHR | Chronic Care Facility |
COAG | Coagulation Clinic |
CRS | Colon And Rectal Surgery Clinic |
COMM | Community Location |
CSC | Community Service Center |
CCU | Coronary Care Unit |
DADDR | Delivery Address |
DERM | Dermatology Clinic |
DX | Diagnostics Or Therapeutics Unit |
ECHO | Echocardiography Lab |
ER | Emergency Room |
ETU | Emergency Trauma Unit |
ENDO | Endocrinology Clinic |
ENDOS | Endoscopy Lab |
EPIL | Epilepsy Unit |
FMC | Family Medicine Clinic |
GI | Gastroenterology Clinic |
GIDX | Gastroenterology Diagnostics Or Therapeutics Lab |
GIM | General Internal Medicine Clinic |
GYN | Gynecology Clinic |
HAND | Hand Clinic |
HEM | Hematology Clinic |
HD | Hemodialysis Unit |
HOSP | Hospital |
HLAB | Hospital Laboratory |
HU | Hospital Unit |
GACH | Hospitals; General Acute Care Hospital |
HTN | Hypertension Clinic |
IEC | Impairment Evaluation Center |
INFD | Infectious Disease Clinic |
INV | Infertility Clinic |
INLAB | Inpatient Laboratory |
INPHARM | Inpatient Pharmacy |
RHII | Intellectual Impairment Center |
ICU | Intensive Care Unit |
LYMPH | Lymphedema Clinic |
MGEN | Medical Genetics Clinic |
MBL | Medical Laboratory |
ONCL | Medical Oncology Clinic |
MHSP | Military Hospital |
MOBL | Mobile Unit |
NEPH | Nephrology Clinic |
NEUR | Neurology Clinic |
NCCS | Neurology Critical Care And Stroke Unit |
RNEU | Neuroradiology Unit |
NS | Neurosurgery Unit |
NCCF | Nursing Or Custodial Care Facility |
OB | Obstetrics Clinic |
OPH | Ophthalmology Clinic |
OPTC | Optometry Clinic |
OMS | Oral And Maxillofacial Surgery Clinic |
ORTHO | Orthopedics Clinic |
ENT | Otorhinolaryngology Clinic |
OF | Outpatient Facility |
OUTLAB | Outpatient Laboratory |
OUTPHARM | Outpatient Pharmacy |
PAINCL | Pain Clinic |
PRC | Pain Rehabilitation Center |
RHMAD | Parents With Adjustment Difficulties Center |
PTRES | Patient's Residence |
PEDCARD | Pediatric Cardiology Clinic |
PEDE | Pediatric Endocrinology Clinic |
PEDGI | Pediatric Gastroenterology Clinic |
PEDHEM | Pediatric Hematology Clinic |
PEDID | Pediatric Infectious Disease Clinic |
PEDICU | Pediatric Intensive Care Unit |
PEDNICU | Pediatric Neonatal Intensive Care Unit |
PEDNEPH | Pediatric Nephrology Clinic |
PEDHO | Pediatric Oncology Clinic |
PEDRHEUM | Pediatric Rheumatology Clinic |
PEDU | Pediatric Unit |
PEDC | Pediatrics Clinic |
PHARM | Pharmacy |
RHPIH | Physical Impairment - Hearing Center |
RHPIMS | Physical Impairment - Motor Skills Center |
RHPIVS | Physical Impairment - Visual Skills Center |
RHPI | Physical Impairment Center |
PLS | Plastic Surgery Clinic |
POD | Podiatry Clinic |
PREV | Preventive Medicine Clinic |
PC | Primary Care Clinic |
PROCTO | Proctology Clinic |
PROS | Prosthodontics Clinic |
PROFF | Provider's Office |
PSYCHF | Psychiatric Care Facility |
PHU | Psychiatric Hospital Unit |
PSY | Psychiatry Clinic |
PSI | Psychology Clinic |
RADO | Radiation Oncology Unit |
RADDX | Radiology Diagnostics Or Therapeutics Unit |
HRAD | Radiology Unit |
RH | Rehabilitation Hospital |
RHU | Rehabilitation Hospital Unit |
RTF | Residential Treatment Facility |
RHEUM | Rheumatology Clinic |
SCHOOL | School |
SNF | Skilled Nursing Facility |
SLEEP | Sleep Disorders Unit |
HUSCS | Specimen Collection Site |
SPMED | Sports Medicine Clinic |
SURF | Substance Use Rehabilitation Facility |
SU | Surgery Clinic |
TR | Transplant Clinic |
TRAVEL | Travel And Geographic Medicine Clinic |
UPC | Underage Protection Center |
URO | Urology Clinic |
WORK | Work Site |
WND | Wound Clinic |
RHYAD | Youths With Adjustment Difficulties Center |
https://terminology.hl7.org/2.0.0/ValueSet-v3-ServiceDeliveryLocationRoleType.html