CRX.002.070

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TMSIS Dataguide

Medicaid.gov

Version 3.27.0

BILLING-PROV-NUM

Data Element

DE Number

CRX070

System DE Number

CRX.002.070

File Name

CRX - CLAIM PHARMACY

File Segment Number

File Segment Name

CLAIM-HEADER-RECORD-RX

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.
Size	X(30)
FLF Start Position	477
FLF Stop Position	506
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. Prescription Fill Date (CRX.002.085) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or 8. Prescription Fill Date (CRX.002.085) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)

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

RULE ID	RULE Definition
RULE-1845	If the billing provider number is populated on a non-denied claim from the RX 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 prescription fill date 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 prescription fill date on the claim.
RULE-6176	If a claim is a non-denied claim from an RX file, then the billing provider number value reported must be compatible with specified T-MSIS picture format: X(30).
RULE-7308	If a claim is a non-denied claim from an RX 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-7442	If the billing provider number is populated on a non-denied claim from an RX 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 prescription fill date.
RULE-7759	If a claim is a non-denied claim from an RX 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-7824	If a claim is a non-denied claim from an RX 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-7924	If the billing provider number is populated on a non-denied claim from an RX 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 prescription fill date.
RULE-7932	If the billing provider number is populated on a non-denied claim from an RX 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 prescription fill date.

Measure ID	Measure Name
ALL-21-004-4	% 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 Prescription Fill Date
ALL-4-004-4	% of billing and dispensing provider numbers on claims that are not found in the provider file
MIS-8-007-7	% missing: BILLING-PROV-NUM (CRX00002)
RULE-1845	% of claim headers with a Billing Provider Number that is not found on the provider file on the Prescription Fill Date
MIS-27-005-5	% missing: BILLING-PROV-NUM (CRX00002)
MIS-85-005-5	% missing: BILLING-PROV-NUM (CRX00002)
RULE-7442	% 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 Prescription Fill Date
PRV-1-012-10	RX - % of billing providers with all PROV-LOCATION-IDs represented in the practice and service locations in the Provider file
PRV-1-016-6	RX - % of unique combinations of billing providers and PROV-LOCATION-IDs that are found in the provider record's practice and service locations
RULE-7759	% missing: BILLING-PROV-NUM (CRX00002)
RULE-7824	% missing: BILLING-PROV-NUM (CRX00002)

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
COT112	COT.002.112	BILLING-PROV-NUM	COT00002	CLAIM-HEADER-RECORD-OT

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
08/16/2023	3.12.0	CRX.002.070	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. Prescription Fill Date (CRX.002.085) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Prescription Fill Date (CRX.002.085) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)	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. Prescription Fill Date (CRX.002.085) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or 8. Prescription Fill Date (CRX.002.085) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)
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