Brief Issue Description
There is a lack of uniformity with respect to how states identify and define facilities, groups, and individuals. The goal of this guidance is to enhance cross-state consistency by clearly defining each Facility-Group-Individual (FGI) code value and by providing a list of characteristics to which each FGI code value will be expected to conform. In doing so, the guidance will allow states to validate FGI codes and related data elements, and it will help researchers to interpret the FGI code in their work.
Background
In the Transformed Medicaid Statistical Information System (T-MSIS), the FGI Code identifies whether the SUBMITTING-STATE-PROV-ID is assigned to an individual, a group of providers, or a facility. The Facility-Group-Individual-Code (PRV026) in the PROV-ATTRIBUTES-MAIN (PRV00002) segment is a “cornerstone” variable for the entire set of provider segments. A provider’s classification as a facility, group, or individual will influence how multiple variables across several provider segments should be interpreted. Given the special significance of the FGI value, it is very important that states populate this information accurately.
Table 1. Definitions of Facility-Group-Individual-Code from the T-MSIS Data Dictionary V2.1
| Valid Values | Description |
|---|---|
| 01 | Facility - The entity identified by the associated SUBMITTING-STATE-PROV-ID is a facility. |
| 02 | Group - The entity identified by the associated SUBMITTING-STATE-PROV-ID is a group of individual practitioners. |
| 03 | Individual - The entity identified by the associated SUBMITTING-STATE-PROV-ID is an individual practitioner. |
Challenges
How states determine the characteristics that define facilities, groups, or individuals varies from one state to another. For example, some states use a physical location as the defining characteristic of a facility and therefore assign each address a location-specific SUBMITTING-STATE-PROV-ID. Other states use federal tax identifiers as the defining characteristic of a facility and allow a single SUBMITTING-STATE-PROV-ID to have multiple addresses. This guidance seeks to improve consistency in these areas.
In an ideal world, all states would follow the same standards for facility, group, or individual codes. However, each state sets up its own Medicaid Management Information System (MMIS) to fit its specific needs, making a “one size fits all” approach to assigning FGI codes difficult if not impossible. This guidance provides a number of options to which most states should be able to conform given their current system. If the need arises, CMS will address cases in which states simply cannot comply with the guidance.
Previously Issued Related Guidance
CMS has released the following guidance documents that address some of the T-MSIS data elements discussed in this document.
CMS Guidance
The following section defines the characteristics of each kind of provider, provides a set of tables that highlight specific data elements in the T-MSIS provider file segments, and explains how CMS will interpret and test these data.
Definitions
Providers that deliver or facilitate health-related treatments and health care services, or that support activities of daily living fall into three categories:
- An organization, institution, place, building, or agency that furnishes, conducts, and operates health care services for the prevention, diagnosis, or treatment of human disease, pain, or injury. Examples include hospitals, nursing facilities, home health agencies, schools, or transportation organizations.
- A group of two or more physicians, advanced practice nurses, and/or physician’s assistants who work together and share facilities. The physicians may have different specialties.
- An individual who provides medical or non-medical services
Individual providers that operate as sole practitioners can be further subdivided into 2 categories:
- Incorporated sole practitioners are sole practitioners with legal separation between themselves and their practice. Incorporated sole practitioners will have two national provider ids: one for themselves as individuals and one for their practice.
- Non-incorporated sole practitioners (i.e., sole proprietors) are sole practitioners who operate with no legal distinction between themselves and their practice. Non-incorporated sole practitioners will only have one SUBMITTING-STATE-PROV-ID and will have characteristics associated with both individuals and organizations.
Defining attributes of FACILITY-GROUP-INDIVIDUAL-CODE categories
SUBMITTING-STATE-PROV-ID reported with FGI Code 01 (Facilities) and FGI Code 02 (Groups)
- How to uniquely identify providers categorized as facilities or groups
- National Provider Identifier (NPI): When allowed by their MMIS configuration, states should uniquely identify providers categorized as facilities or groups at the NPI level (found in segment PRV00005). If a state chooses this option, it should apply the option to all facilities and groups reported in its T-MSIS data when possible.
- Within a state, a single individual SUBMITTING-STATE-PROV-ID should have only one NPI, and each NPI should be linked to only one SUBMITTING-STATE-PROV-ID. CMS will address rare cases in which an NPI is simultaneously active for two Submitting-State-Provider-IDs on a case-by-case basis.
- Federal Tax Identification Number (FTIN): If a state is not able to uniquely identify facilities and groups at the NPI level, facilities and groups should be uniquely identified at the FTIN level (found in segment PRV00005). FTINs are more properly referred to as Federal Employee Identification Numbers (EINs), but for the sake of consistency, this guidance refers to them as FTINs.
- Within a state, a single SUBMITTING-STATE-PROV-ID should have only one active FTIN at a time, and each FTIN should be linked only to one SUBMITTING-STATE-PROV-ID.
- Facilities and groups can capture multiple organizational NPIs, but a single organizational NPI should only be associated with one facility or group.
- Because we are asking facilities and groups to be identified at the NPI or FTIN level, a single SUBMITTING-STATE-PROV-ID can encompass multiple locations and/or atypical Medicaid provider identifiers. This also means that multiple SUBMITTING-STATE-PROV-IDs can operate out of the same address.
- We understand that not all states will be able to completely conform to this guidance due to their MMIS configuration. The options described above represent an ideal state, and we are asking that states conform as closely to this guidance as possible. For states that are unable to uniquely identify providers at the NPI or the FTIN level, CMS will help them to find a solution that fits their data needs while keeping the data suitable for research purposes. All states that are not able to conform to this guidance must supply a detailed description of the methodology they used to determine how they assign SUBMITTING-STATE-PROV-IDs in their data so that appropriate data quality tests can be designed for them.
- National Provider Identifier (NPI): When allowed by their MMIS configuration, states should uniquely identify providers categorized as facilities or groups at the NPI level (found in segment PRV00005). If a state chooses this option, it should apply the option to all facilities and groups reported in its T-MSIS data when possible.
- If a provider is enrolled by a state with an NPI, the state must report that NPI in T-MSIS. A given state is responsible only for its enrolled providers and their NPIs.
- Any NPI values reported in PRV00005 for facilities or groups must be classified as a Type 2 (organizational) NPI by the National Plan and Provider Enumeration System (NPPES). NPIs and the associated NPI types can be downloaded from NPPES .
- Although states are being asked to use NPIs and FTINs to determine how SUBMITTING-STATE-PROV-IDs are assigned, states can enumerate SUBMITTING-STATE-PROV-IDs in whatever manner they see fit. However, states should consider using a SUBMITTING-STATE-PROV-ID that is different from the NPI/FTIN to make it easier to track changes over time.
- A SUBMITTING-STATE-PROV-ID reported in PRV00002 with FGI ‘01’ or ‘02’ should not have characteristics associated with individuals, such as social security numbers (SSNs) or dates of birth.
- States should report relationships between facilities, groups, and individuals in segment PRV00008 (PROV-AFFILIATED-GROUPS).
- Tables 2 through 4 provide a more comprehensive list of the characteristics of facilities and groups.
SUBMITTING-STATE-PROV-ID reported with FGI Code 03 (Individuals)
- How to uniquely identify individuals
- Individuals that have been assigned an NPI
- When the NPI is available, it should uniquely identify the individual.
- Within a state, a single individual SUBMITTING-STATE-PROV-ID should have only one NPI, and each NPI should be linked only to one SUBMITTING-STATE-PROV-ID. In very rare instances, a single individual may have more than one active NPI. CMS will evaluate this and make exceptions on a case-by-case basis.
- Individuals who have not been assigned an NPI
- Individuals who do not have an NPI, such as some home-based care providers, can be validated at the SSN or the FTIN level.
- A single individual SUBMITTING-STATE-PROV-ID should have only one SSN/FTIN, and each SSN/FTIN should be linked only to one SUBMITTING-STATE-PROV-ID.
- As with the guidance regarding facilities and groups, we understand that not all states will be able to completely conform to this guidance due to their MMIS configuration. The options described above represent an ideal state, and we ask that states conform as closely to this guidance as possible. For states that are unable to uniquely identify individual providers at the NPI or the FTIN level, CMS will help them to find a solution that fits their data needs and while keeping their data suitable for research purposes. All states that are not able to conform to this guidance must supply a detailed description of the methodology they used to determine how they assigned SUBMITTING-STATE-PROV-IDs in their data so that CMS can design appropriate data quality tests for them.
- Individuals that have been assigned an NPI
- If an individual practitioner with an NPI is enrolled in a state, the state must report the NPI in T-MSIS.
- For non-U.S. residents and resident aliens who have an Individual Tax Identification Number (ITIN) but do not have an SSN/FTIN, the state should report the ITIN as an FTIN until an actual SSN/FTIN becomes available.
- Any NPI values reported in PRV00005 for individuals must be classified as a Type 1 (individual) NPI by NPPES. NPIs and the associated NPI types can be downloaded from NPPES .
- Although states are being asked to use NPIs and FTINs to determine how SUBMITTING-STATE-PROV-IDs are assigned, states can choose to enumerate SUBMITTING-STATE-PROV-IDs in whatever manner they see fit. However, states should consider using a SUBMITTING-STATE-PROV-ID that is different from the NPI/FTIN to make it easier to track changes over time.
- Individuals should be reported with the characteristics that are associated with people, not with characteristics associated with facilities or groups. For example, an individual should have a first and last name but not a bed count.
- Sole proprietors that have an individual-level NPI and an organizational-level NPI will have more than one SUBMITTING-STATE-PROV-ID: one linked to the individual-level NPI with an FGI equal to 3 (individual) and one linked to the organizational-level NPI with an FGI code equal to 1 (facility) or 2 (group).
- Non-incorporated sole practitioners represent a special case in the provider tables. Though these providers operate both as a business entity and an individual provider, they will only have an individual level NPI and will therefore only have a single submitting state provider ID. They will retain the properties of an individual (e.g., will have a first and last name as well as a social security number), but will also have properties not normally associated with individuals (e.g., may have an OWNERSHIP-CODE). Additionally, these individuals may be assigned an EIN that is not the same as their SSN. Whether or not a sole practitioners EIN is the same as their SSN, they are expected to have a value populated in the FTIN field.
- States should report relationships between facilities, groups, and individuals in segment PRV00008 (PROV-AFFILIATED-GROUPS).
- Tables 2 through 4 at the end of this guidance provide a more comprehensive list of characteristics belonging to individuals.
Data elements influenced by this guidance
This guidance may influence other data elements and table segments, such as the PROV-LOCATION-ID and the PROV-AFFILIATED-GROUPS table segment. To help states navigate these relationships, CMS will issue future guidance for these tables and data elements.
A Statement about Data Inclusivity
T-MSIS is only as valuable as the data it contains, and it is important that these data are as complete as possible. States should not artificially limit the data that they report in order to force compliance with this guidance. Exceptions exist for every rule, and there will likely be cases in which real-world circumstances conflict with the guidance. The data will be richer if these cases are preserved. CMS will evaluate potential outliers on an individual basis and make exceptions when necessary.
Relationship between FACILITY-GROUP-INDIVIDUAL-CODE codes across provider segments
Table 2 – FGI Code Relationships in PRV00002 (PROV-ATTRIBUTES-MAIN)
| Field |
FGI 01 (Facility) |
FGI 02 (Group) |
FGI 03 (individual) |
|---|---|---|---|
| PRV023: PROV-LEGAL-NAME | The legal name on a state’s provider agreement | The legal name on a state’s provider agreement | The legal name on a state’s provider agreement |
| PRV024: PROV-ORGANIZATION-NAME | The organization’s name | The organization’s name | Should use PROV-LAST-NAME |
| PRV025: PROV-TAX-NAME | Use the exact name that is on IRS filings | Use the exact name that is on IRS filings | Use the exact name that is on IRS filings |
| PRV028: PROV-FIRST-NAME | Blank | Blank | The practitioner’s first name |
| PRV029: PROV-MIDDLE-INITIAL | Blank | Blank | The practitioner’s middle initial (if available) |
| PRV030: PROV-LAST-NAME | Blank | Blank | The practitioner’s last name |
| PRV031: SEX | Blank | Blank | Must be populated with valid values (i.e., F-Female, M-Male, U-Unknown) |
| PRV032: OWNERSHIP-CODE (when available) | Populate with valid codes denoting ownership interest | Populate with valid codes denoting ownership interest | Populate with valid codes denoting ownership interest for non-incorporated sole practitioners. For all other individual providers this should always be either “88” or blank |
| PRV033: PROV-PROFIT-STATUS (when available) | Populate with a valid value but NOT with a code “88” | Populate with a valid value but NOT with a code “88” | Populate with a valid value for non-incorporated sole practitioners. For all other individual providers this should always be either “88” or blank |
| PRV034: DATE-OF-BIRTH (when available) | Blank | Blank | Populate for individuals only |
| PRV035: DATE-OF-DEATH (when available) | Blank | Blank | Populate for individuals only |
Note: This table includes a subset of the data elements in segment PRV00002. This does not mean that unlisted data elements are optional or that they will not be used to differentiate between facilities, groups, and individuals in the future. Please continue to provide data that are as complete as possible, and follow the data dictionary instructions when populating all data elements.
Table 3 – FGI Codes and PRV077: Prov-Identifier-Type in PRV00005 (PROV-IDENTIFIERS)
| PROV-IDENTIFIER-TYPE |
FGI 01 (Facility) |
FGI 02 (Group) |
FGI 03 (individual) |
|---|---|---|---|
| 2: NPI | NPIs for facilities should be Type 2 in the NPPES data. Ideally, an NPI should not be active for more than one SUBMITTING-STATE-PROV-ID at the same time. | NPIs for facilities should be Type 2 in the NPPES data. Ideally, an NPI should not be active for more than one SUBMITTING-STATE-PROV-ID at the same time. | Every individual should have only one active NPI at a time, and few individuals should ever have more than one NPI in their history. When an individual has been assigned an NPI by NPPES, it must be listed here. All NPIs must be Type 1 in the NPPES data. Ideally, an NPI should not be active for more than one SUBMITTING-STATE-PROV-ID at the same time. |
| 4: National Council for Prescription Drug Programs (NCPDP) ID (when available) | Each subpart or unit should have a unique NCPDP ID. | Each subpart or unit should have a unique NCPDP ID. | Populate with a valid value for non-incorporated sole practitioners that have an NCPDP ID. This field is not applicable for all other individual practitioners. |
| 5: FTIN | Each facility SUBMITTING-STATE-PROV-ID must have one FTIN, and that FTIN should only be the EIN. | Each group SUBMITTING-STATE-PROV-ID must have one FTIN, and that FTIN should only be the EIN. | For non-U.S. residents and resident aliens who have an ITIN but do not have an SSN/FTIN, treat the ITIN as an FTIN until an SSN/FTIN becomes available. Non-incorporated sole practitioners may have an FTIN that is different from their SSN. All other individual providers should not have an FTIN. |
| 7: SSN | Blank | Blank | (If available) A SUBMITTING-STATE-PROV-ID should have only one SSN in its history. |
Note: This table includes a subset of the PROV-IDENTIFIER-TYPE categories. This does not mean that unlisted PROV-IDENTIFIER-TYPE categories are optional or that they will not be used to differentiate between facilities, groups, and individuals in the future. Please continue to provide data that are as complete as possible, and follow the data dictionary instructions when populating all categories.
Table 4 – FGI Code Relationships to PRV088: Provider Classification Types in PRV00006 (PROV-TAXONOMY-CLASSIFICATION)
Refer to the T-MSIS Data Dictionary Appendix A for PROV-CLASSIFICATION-TYPE and PROV-CLASSIFICATION-CODE values
|
PRV088: |
FGI 01 (Facility) | FGI 02 (Group) | FGI 03 (individual) |
|---|---|---|---|
| 1: Taxonomies | Must be classified as a Non-Individual Taxonomy Code according to wpc-edi.com (see Appendix L in the T-MSIS Data Dictionary Appendices V2.1) | Must be classified as an Individual or Groups (of Individuals) Taxonomy Code according to wpc-edi.com (see Appendix L in the T-MSIS Data Dictionary Appendices V2.1) | Must be classified as an Individual or Groups (of Individuals) Taxonomy Code according to wpc-edi.com (see Appendix L in the T-MSIS Data Dictionary Appendices V2.1) |
Note: This table contains a subset of the PROV-CLASSIFICATION-TYPE categories. This does not mean that unlisted PROV-CLASSIFICATION-TYPE categories are optional or that they will not be used to differentiate between facilities, groups, and individuals in the future. Please continue to provide data that are as complete as possible, and follow the data dictionary instructions when populating all categories.