PRV.004.068

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TMSIS Dataguide

Medicaid.gov

Version 3.27.0

LICENSE-ISSUING-ENTITY-ID

Data Element

DE Number

PRV068

System DE Number

PRV.004.068

File Name

File Segment Number

File Segment Name

PROV-LICENSING-INFO

Last updated

No Updates

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	A free text field to capture the identity of the entity issuing the license or accreditation. Enter the applicable state code, county code, municipality name, "DEA", professional society's name, or the CLIA accreditation body's name. -If associated License Type is equal to 1 and issuing authority is a State, then value must be ANSI State abbreviation code. - If associated License Type is equal to 1 and issuing authority is a county, then value must be a 5-digit, concatenated code consisting of the ANSI state code plus the ANSI county code.A list of codes can be found here: https://www.nrcs.usda.gov/wps/portal/nrcs/detail/national/home/?cid=nrcs143_013697 - If associated License Type is equal to 1 and issuing authority is a municipality, then enter a text string with the name of the municipality. -If associated License Type is equal to 3, then enter the text string identifying the professional society issuing the accreditation. -If associated License Type is equal to 4, then value must be the text string identifying the CLIA accreditation body's name.
Size	X(60)
FLF Start Position	74
FLF Stop Position	133
Segment Key Field Identifier	5
Coding Requirements	1. Value must not contain a pipe or asterisk symbol 2. Value must be 60 characters or less 3. (required) if associated License or Accreditation Number (PRV.004.069) value is populated, then value is mandatory and must be provided 4. Mandatory 5. Value must equal 'DEA' when associated License Type equals '2'

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

RULE ID	RULE Definition
RULE-2885	If the license issuing entiry id is populated on the provider licensing information file, then the license issuing entiry id reported must not contain any pipe or asterisk characters.
RULE-2886	If the provider licensing information segment has a value populated for license or accreditation number, then the segment must have a value populated for license issuing entity ID.
RULE-2887	If the provider licensing information segment has a license type equal to '2', then the license issuing entity ID must equal 'DEA'.
RULE-6757	If a segment is a provider licensing information segment from a PRV file, then the license issuing entity identification value reported must be compatible with the specified T-MSIS picture format: X(60).

Measure ID	Measure Name
MIS-11-024-24	% distinct SUBMITTING-STATE-PROV-IDs with only missing values in any active segment: LICENSE-ISSUING-ENTITY-ID (PRV00004)

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name

Published Date	Data Guide Version	Data Element	Action	Field	Before	After