How the Center A provider is an entity CHIA analyzes information on defines a provider associated with either: providers, clinicians, hospitals, providing services to physician groups and integrated patients delivery systems. submitting claims for services on behalf of a servicing provider providing business services or contracting arrangements for a servicing provider How a unique Conceptually, a unique CHIA realizes that submitters provider is to be provider is an instance of a store their provider data in a defined provider (Who), with a variety of formats and data particular affiliation structures. It has been (Relationship), at a particular determined that this method location (where), during a provides the greatest flexibility timeframe (when). The in analyzing the various ways Center will utilize multiple data submitters maintain provider elements to create a unique relationships. provider record within each carrier/submitter file. Types of providers All Massachusetts contracted CHIA is required to create to be included in providers, regardless of cross-submitter provider files for the file whether they are on the claims analysis and therefore requires file for the time period. data on all providers in a Additionally, provider carrier’s or submitter’s network. information for out of state Additionally, all claims may be providers, who are on the analyzed by provider dimensions claims file for the time period that require provider information of the corresponding claims for corresponding out of state submission If available. TPAs claims. – (including PBMs, DBAs, CSOs, etc.) who may not contract directly with providers, are expected to include providers who are on the claims file for the time period of the corresponding claims submission. Otherwise use default values as provided in the document: File “Provider Examples.xls”. ( Available at: )
How the Center defines a provider A provider is an entity associated with either: providing services to patients submitting claims for services on behalf of a servicing provider providing business services or contracting arrangements for a servicing provider CHIA analyzes information on providers, clinicians, hospitals, physician groups and integrated delivery systems. How a unique provider is to be defined Conceptually, a unique provider is an instance of a provider (Who), with a particular affiliation (Relationship), at a particular location (where), during a timeframe (when). The Center will utilize multiple data elements to create a unique provider record within each carrier/submitter file. CHIA realizes that submitters store their provider data in a variety of formats and data structures. It has been determined that this method provides the greatest flexibility in analyzing the various ways submitters maintain provider relationships. Types of providers to be included in the file All Massachusetts contracted providers, regardless of whether they are on the claims file for the time period. Additionally, provider information for out of state providers, who are on the claims file for the time period of the corresponding claims submission – If available. TPAs (including PBMs, DBAs, CSOs, etc.) who may not contract directly with providers, are expected to include providers who are on the claims file for the time period of the corresponding claims submission. Otherwise use default values as provided in the document: “Provider File Examples.xls”. ( Available at: ) CHIA is required to create cross-submitter provider files for analysis and therefore requires data on all providers in a carrier’s or submitter’s network. Additionally, all claims may be analyzed by provider dimensions that require provider information for corresponding out of state claims.
v3-1-apcd-provider-file-submission-guide-2013-06.docx