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TMSIS Dataguide Medicaid.gov
Version 3.29.0

PROV-LICENSING-INFO

File Segment

File Segment Number

PRV00004

File Name

PRV - PROVIDER

Last updated

No Updates

Data Elements Reference
DE Number System DE Number Data Element Definition Valid Values
PRV060 PRV.004.060 RECORD-ID The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). PRV060 Values
PRV061 PRV.004.061 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. PRV061 Values
PRV062 PRV.004.062 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A
PRV063 PRV.004.063 SUBMITTING-STATE-PROV-ID The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. N/A
PRV064 PRV.004.064 PROV-LOCATION-ID A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier value on a Provider Location and Contact Info (PRV.003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. N/A
PRV065 PRV.004.065 PROV-LICENSE-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A
PRV066 PRV.004.066 PROV-LICENSE-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A
PRV067 PRV.004.067 LICENSE-TYPE A code to identify the kind of license or accreditation number that is captured in the License or Accreditation Number data element. PRV067 Values
PRV068 PRV.004.068 LICENSE-ISSUING-ENTITY-ID 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. N/A
PRV069 PRV.004.069 LICENSE-OR-ACCREDITATION-NUMBER A data element to capture the license or accreditation number issued to the provider by the licensing entity or accreditation body identified in the License Issuing Entity ID data element. N/A
PRV070 PRV.004.070 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A
Definition
A record to capture licensing and accreditation information relevant to the provider.

File Segment Length
1100