COT.002.112

BILLING-PROV-NUM

Data Element

DE Number

COT112

System DE Number

COT.002.112

File Name

COT - CLAIM OTHER

File Segment Number

COT00002

File Segment Name

CLAIM-HEADER-RECORD-OT

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	A unique identification number assigned by the state to a provider or capitation plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan. For sub-capitation payments, report the state-assigned provider identifier for the sub-capitated entity, when available or required.
Size	X(30)
FLF Start Position	697
FLF Stop Position	726
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be 30 characters or less 2. Conditional 3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or 4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.081) equal to '1' 5. When Type of Claim is in ['1','3','A','C'], then value must be populated 6. When Type of Claim in ('1','3','A','C’) then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active) 7. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or 8. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) 9. When Type of Service (COT.003.186) is not in ['119', ‘120’, ‘122’], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1'

Valid Value Code Set	Valid Value Code	Valid Value Name	Valid Value Description	Effective Start Date	Effective End Date

RULE ID	RULE Definition
RULE-1540	If the billing provider number is populated on a non-denied, non-capitated claim from the OT file, then either the billing provider number value reported must be equal to a provider identifier value reported with a provider identifier type value for state-assigned Medicaid provider identifiers on a provider identifiers segment from a PRV file where the effective and end dates of the provider identifiers segment overlap with the beginning date of service and (if populated) ending date of service on the claim OR the billing provider number value reported must be equal to a submitting state provider ID on a provider main attributes segment from a PRV file where the effective and end dates of the provider main attributes segment overlap with the beginning date of service and (if populated) ending date of service on the claim.
RULE-6272	If a claim is a non-denied claim from an OT file, then the billing provider number value reported must be compatible with specified T-MSIS picture format: X(30).
RULE-7303	If a claim is a non-denied claim from an OT file, and is a Medicaid or Medicaid-expansion FFS, Medicaid or Medicaid-expansion CHIP Encounter, Separate CHIP FFS or Separate CHIP Encounter claim and is an original claim or a replacement/resubmission claim payment then either the billing provider NPI number or billing provider number must be populated.
RULE-7307	If a claim is a non-denied claim from an OT file, and is a Medicaid or Medicaid-expansion FFS, Medicaid or Medicaid-expansion CHIP Encounter, Separate CHIP FFS or Separate CHIP Encounter claim and is an original claim or a replacement/resubmission claim payment then the billing provider number must be populated.
RULE-7441	If the billing provider number is populated on a non-denied claim from an OT file and the claim is a Medicaid and S-CHIP FFS and encounter original or adjustment paid claim, the billing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the beginning date of service.
RULE-7758	If a claim is a non-denied claim from an OT file, and is a Medicaid or Medicaid-expansion CHIP Encounter or Separate CHIP Encounter claim and is an original claim or a replacement/resubmission claim payment then the billing provider number must be populated.
RULE-7766	If a claim is a non-denied claim from an OT file, and is a Medicaid or Medicaid-expansion CHIP Encounter or Separate CHIP Encounter claim and is an original claim or a replacement/resubmission claim payment then either the billing provider NPI number or billing provider number must be populated.
RULE-7823	If a claim is a non-denied claim from an OT file, and is a Medicaid or Medicaid-expansion CHIP Fee-for-service or Separate CHIP Fee-for-service claim and is an original claim or a replacement/resubmission claim payment then the billing provider number must be populated.
RULE-7826	If a claim is a non-denied claim from an OT file, and is a Medicaid or Medicaid-expansion CHIP Fee-for-service or Separate CHIP Fee-for-service claim and is an original claim or a replacement/resubmission claim payment then either the billing provider NPI number or billing provider number must be populated.
RULE-7923	If the billing provider number is populated on a non-denied claim from an OT file and the claim is a Medicaid or M-CHIP Encounter or Separate CHIP Encounter original or adjustment paid claim, the billing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the beginning date of service.
RULE-7931	If the billing provider number is populated on a non-denied claim from an OT file and the claim is a Medicaid or M-CHIP FFS or Separate CHIP FFS original or adjustment paid claim, the billing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the beginning date of service.

Measure ID	Measure Name
MCR-25-002-1	% of claim lines with TYPE-OF-SERVICE = 12, 29, 15, 2, 61, 28, 41 where Servicing Provider Number = Billing Provider Number
RULE-7823	% missing: BILLING-PROV-NUM (COT00002)
RULE-7758	% missing: BILLING-PROV-NUM (COT00002)
PRV-1-015-3	OT - % of unique combinations of billing providers and PROV-LOCATION-IDs that are found in the provider record's practice and service locations
PRV-1-011-7	OT - % of billing providers with all PROV-LOCATION-IDs represented in the practice and service locations in the Provider file
RULE-7441	% of claim headers with a BILLING-PROV-NUM that does not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Beginning Date of Service
MIS-83-007-7	% missing: BILLING-PROV-NUM (COT00002)
MIS-25-007-7	% missing: BILLING-PROV-NUM (COT00002)
RULE-1540	% of claim headers with a Billing Provider Number that is not found on the provider file during the dates of service
MIS-6-008-8	% missing: BILLING-PROV-NUM (COT00002)
MCR-9-006_2-19	% of PCCM capitated payments with a non-missing plan ID where plan ID number equals the Billing Provider Number or Billing Provider NPI Number
ALL-21-003-3	% of BILLING-PROV-NUM on claim headers that do not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Beginning Date of Service
MCR-24-003-2	% of claim lines with TYPE-OF-SERVICE = 12, 29, 15, 2, 61, 28, 41 where Servicing Provider Number = Billing Provider Number
MCR-24-001-3	% of claim lines with Billing Provider ID
MCR-22-002-1	% of claim lines with TYPE-OF-SERVICE = 12, 29, 15, 2, 61, 28, 41 where Servicing Provider Number = Billing Provider Number
MCR-21-003-2	% of claim lines with TYPE-OF-SERVICE = 12, 29, 15, 2, 61, 28, 41 where Servicing Provider Number = Billing Provider Number
MCR-21-001-3	% of claim lines with Billing Provider ID
MCR-13-006_2-19	% of PCCM capitated payments with a non-missing plan ID where plan ID number equals the Billing Provider Number or Billing Provider NPI Number
FFS-23-002-1	% of claim lines with TYPE-OF-SERVICE = 12, 29, 15, 2, 61, 28, 41 where Servicing Provider Number = Billing Provider Number
FFS-22-002-2	% of claim lines with TYPE-OF-SERVICE = 12, 29, 15, 2, 61, 28, 41 where Servicing Provider Number = Billing Provider Number
FFS-18-002-2	% of claim lines with TYPE-OF-SERVICE = 12, 29, 15, 2, 61, 28, 41 where Servicing Provider Number = Billing Provider Number
ALL-4-003-3	% of billing and servicing provider numbers on claims that are not found in the provider file

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP179	CIP.002.179	BILLING-PROV-NUM	CIP00002	CLAIM-HEADER-RECORD-IP
CLT130	CLT.002.130	BILLING-PROV-NUM	CLT00002	CLAIM-HEADER-RECORD-LT
CRX070	CRX.002.070	BILLING-PROV-NUM	CRX00002	CLAIM-HEADER-RECORD-RX

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
08/16/2023	3.12.0	COT.002.112	UPDATE	Coding requirement	1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.081) equal to '1' 5. When Type of Claim is in ['1','3','A','C'], then value must be populated 6. When Type of Claim in ('1','3','A','C’) then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active)7. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) 9. When Type of Service (COT.003.186) is not in ['119', ‘120’, ‘122’], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1'	1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.081) equal to '1' 5. When Type of Claim is in ['1','3','A','C'], then value must be populated6. When Type of Claim in ('1','3','A','C’) then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active)7. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)9. When Type of Service (COT.003.186) is not in ['119', ‘120’, ‘122’], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1'
08/16/2023	3.12.0	COT.002.112	UPDATE	Coding requirement	1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier5. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)7. When Type of Service (COT.003.186) is not in ['119', '120', '122'], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1'	1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.081) equal to '1' 5. When Type of Claim is in ['1','3','A','C'], then value must be populated 6. When Type of Claim in ('1','3','A','C’) then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active)7. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) 9. When Type of Service (COT.003.186) is not in ['119', ‘120’, ‘122’], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1'
08/09/2023	3.11.0	COT.002.112	UPDATE	Definition	A unique identification number assigned by the state to a provider or capitation plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan.	A unique identification number assigned by the state to a provider or capitation plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan.For sub-capitation payments, report the state-assigned provider identifier for the sub-capitated entity, when available or required.
08/09/2023	3.11.0	COT.002.112	UPDATE	Last update date	12/08/2022	8/9/2023
05/21/2021	3.0.0	BILLING-PROV-NUM (COT.002.112)	UPDATE	Data Dictionary	When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type = '1'	N/A
12/17/2021	3.0.0	BILLING-PROV-NUM (COT112)	UPDATE	Data Dictionary	\|DE NO\| DATA ELEMENT NAME\| DEFINITION\| NECESSITY \|CODING REQUIREMENT\| \|COT112\|BILLING-PROV-NUM\| Not Applicable \|Not Applicable \|Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1'\|	\|DE NO\| DATA ELEMENT NAME\| DEFINITION\| NECESSITY \|CODING REQUIREMENT\| \|COT112\|BILLING-PROV-NUM\| Not Applicable \|Not Applicable \|When Type of Service (COT.003.186) not in ('119', ‘120’, ‘122’), then value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1'\|
12/17/2021	3.0.0	BILLING-PROV-NUM (COT112)	UPDATE	Data Dictionary	\|DE NO\| DATA ELEMENT NAME\| DEFINITION\| NECESSITY \|CODING REQUIREMENT\| \|COT112\|BILLING-PROV-NUM\| Not Applicable \|Not Applicable \|Not Applicable\|	\|DE NO\| DATA ELEMENT NAME\| DEFINITION\| NECESSITY \|CODING REQUIREMENT\| \|COT112\|BILLING-PROV-NUM\| Not Applicable \|Not Applicable \|When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider IDorWhen Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type = '1'\|
12/17/2021	3.0.0	BILLING-PROV-NUM (COT112)	UPDATE	Data Dictionary	\|DE NO\| DATA ELEMENT NAME\| DEFINITION\| NECESSITY \|CODING REQUIREMENT\| \|COT112\|BILLING-PROV-NUM\| Not Applicable \|Not Applicable \|When Type of Service (COT..003.186) is in ['119', ‘120', '122'] value must match Plan ID Number (COT.002.066)\|	\|DE NO\| DATA ELEMENT NAME\| DEFINITION\| NECESSITY \|CODING REQUIREMENT\| \|COT112\|BILLING-PROV-NUM\| Not Applicable \|Not Applicable \|Not Applicable\|
07/15/2022	3.0.1	COT112	UPDATE	Data Dictionary	DE NO\| DATA ELEMENT NAME COMPUTING\|DEFINITION COT112\|BILLING-PROV-NUM\|A unique identification number assigned by the state to a provider or capitation plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan.	DE NO\| DATA ELEMENT NAME COMPUTING\|DEFINITION COT112\|BILLING-PROV-NUM\|A unique identification number assigned by the state to a provider or capitation plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan. For sub-capitation payments, report the state-assigned provider identifier for the sub-capitated entity, when available or required.