Provider Demographic Data File Specification

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 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, F = female, O = other, U = unknown
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. * See Provider Category and Facility Type for allowed values and additional information.
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. Valid codes are defined at https://www.nucc.org/index.php/code-sets-mainmenu-41/provider-taxonomy-mainmenu-40/csv-mainmenu-57
24	Primary_Taxonomy	varchar	1	Yes	Optional	Yes	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. * See Provider Category and Facility Type for allowed values and additional information.
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	Yes	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	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	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

Facility_Type Common Allowed Values

Value	Display Name
HOSP	Hospital
SNF	Skilled Nursing Facility
CHR	Chronic Care Facility
PSYCHF	Psychatric Care Facility
ER	Emergency Room
PHARM	Pharmacy

For a complete list of allowed values see: https://terminology.hl7.org/2.0.0/ValueSet-v3-ServiceDeliveryLocationRoleType.html

Articles in this section

Introduction

File Format and Naming

File Delivery

Data Schema

Duplicate Data Handling

Provider Category and Facility Type

Comments

Articles in this section

Introduction

File Format and Naming

File Delivery

Data Schema

Duplicate Data Handling

Provider Category and Facility Type

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