Report the value that defines the Service Service Provider entity type. Only Provider Lookup Service Provider individuals should be identified with a MC 28 Entity 11/8/12 - int[1] Entity Identifier All 98% A0 1. Facilities, professional groups and Type integer Code clinic sites should all be identified Qualifier with a 2. EXAMPLE: 1 = Person Value Description 1 Person 2 Non-person entity Service Report the individual's first name Provider Name First name of here. If provider is a facility or MC 29 11/8/12 Text All 92% C First Provider Service Provider organization , do not report any value Name here Service Report the individual's middle initial Provider Name Middle Middle initial of here. If provider is a facility or MC 30 11/8/12 Text All 2% C Middle Provider Service Provider organization , do not report any value Initial here Servicing Report the name of the organization Provider Last name or or last name of the individual Last Name Last / Organization MC 31 6/24/10 Text provider. determines if this is an All 94% A2 Name or Org Provider Name of Service Organization or Individual Name Provider reported here. Name Report the individuals name-suffix when applicable here. Used to Service Lookup capture the generation of the Provider Name MC 32 Provider 10/15/10 Table - int[1] individual clinician (e.g., Jr. Sr., III). All 2% Z Suffix Suffix Integer Do not report degree acronyms here. EXAMPLE: 0 = Unknown / Not Applicable Description 1 I. 2 II. 3 III. 4 Jr.
MC 28 Service Provider Entity Type Qualifier 11/8/12 Lookup - integer int[1] Service Provider Entity Identifier Code Report the value that defines the Service Provider entity type. Only individuals should be identified with a 1. Facilities, professional groups and clinic sites should all be identified with a 2. EXAMPLE: 1 = Person All 98% A0 Value Description 1 Person 2 Non-person entity MC 29 Service Provider First Name 11/8/12 Text Name Provider First name of Service Provider Report the individual's first name here. If provider is a facility or organization , do not report any value here All 92% C MC 30 Service Provider Middle Initial 11/8/12 Text Name Middle Provider Middle initial of Service Provider Report the individual's middle initial here. If provider is a facility or organization , do not report any value here All 2% C MC 31 Servicing Provider Last Name or Name 6/24/10 Text Name Last / Org Provider Last name or Organization Name of Service Provider Report the name of the organization or last name of the individual provider. determines if this is an Organization or Individual Name reported here. All 94% A2 MC 32 Service Provider Suffix 10/15/10 Lookup Table - Integer int[1] Provider Name Suffix Report the individuals name-suffix when applicable here. Used to capture the generation of the individual clinician (e.g., Jr. Sr., III). Do not report degree acronyms here. EXAMPLE: 0 = Unknown / Not Applicable All 2% Z Description 1 I. 2 II. 3 III. 4 Jr.
v3-1-apcd-medical-claim-file-submission-guide-2013-06.docx