N.H. Code Admin. R. Ins 4010.05
(a) Provider File Header Record Layout
Table 4010.05 (a) Provider File Header Record Layout
Data Element #
Element
Type
Length (decimal places)
Description/Codes/Sources
HD001
Record Type
Text
2
HD
HD002
Payer
Text
8
Payer submitting payments. NHID Submitter Code
HD003
National Plan ID
Text
30
CMS National Plan ID
HD004
Type of File
Text
2
MP Provider File
HD005
Period Beginning Date
Date
8
Beginning of span of coverage period
HD006
Period Ending Date
date
8
End of span of coverage period
HD008
Comments
Text
80
Submitter may use to document this submission by assigning a filename, system source, etc.
(b) Provider File Trailer Record Layout
Table 4010.05 (b) Provider File Trailer Record Layout
Data Element #
Element
Type
Length (decimal places)
Description/Codes/Sources
TR001
Record Type
Text
2
TR
TR002
Payer
Text
8
Payer submitting payments. NHID Submitter Code
TR003
National Plan ID
Text
30
CMS National Plan ID
TR004
Type of File
Text
2
MP Provider File
TR005
Period Beginning Date
Date
8
Beginning of span of coverage period
TR006
Period Ending Date
Date
8
End of span of coverage period
TR007
Extraction Date
Date
8
Date file was created
TR008
Record Count
Number
10 (0)
Total number of records submitted in this file
(c) Provider File Detailed Specifications
Table 4010.05 (c) Provider File Detailed Specifications
Data Element #
Element
Type
Length (decimal places)
Description/Codes/Sources
MP001
Payer
Text
8
Payer submitting payments. NHID Submitter Code
MP002
Plan ID
Text
30
CMS National Plan ID or NAIC code.
MP003
Provider ID
Text
30
Unique identified for the provider as assigned by the reporting entity
MP004
Provider Tax ID
Text
10
Federal taxpayer's identification number –if the tax id is a provider’s social security number use ‘SSN’ and ‘NA’ if unavailable. Do not code punctuation.
MP005
Provider Entity
Text
1
Specify the value that defines the type of entity
1 Person; physician, clinician, orthodontist, and any individual that is licensed/certified to perform health care services.
2 Facility; hospital, health center, long term care, rehabilitation and any building that is licensed to transact health care services.
3 Professional Group; collection of licensed/certified health care professionals that are practicing health care services under the same entity name and Federal Tax Identification Number.
4 Retail Site; brick-and-mortar licensed/certified place of transaction that is not solely a health care entity, i.e., pharmacies, independent laboratories, vision services.
5 E-Site; internet-based order/logistic system of health care services, typically in the form of durable medical equipment, pharmacy or vision services. Address assigned should be the address of the company delivering services or order fulfillment.
6 Financial Parent; financial governing body that does not perform health care services itself but directs and finances health care service entities, usually through a Board of Directors.
7 Transportation; any form of transport that conveys a patient to/from a healthcare provider.
8 Other; any type of entity not otherwise defined that performs health care services.
MP006
Provider First Name
Text
35
Individual first name. Leave blank if provider is a facility or organization
MP007
Provider Middle Name or Initial
Text
25
MP008
Provider Last Name or Organization Name
Text
60
Full name of provider organization or last name of individual provider
MP009
Provider Suffix
Text
10
Example: Jr; Set as leave blank if provider is an organization. Do not use credentials such as MD or PhD
MP010
Provider Specialty
Text
10
Report the HIPAA-compliant health care provider taxonomy code. Code set is available at the National Uniform Claims Committee’s web site at http://www.nucc.org/
MP011
Provider Office Street Address
Text
50
Physical address – address where provider delivers health care services
MP012
Provider Office City
Text
30
Physical address – address where provider delivers health care services
MP013
Provider Office State
Text
2
Physical address – address where provider delivers health care services. Use postal service standard 2 letter abbreviations
MP014
Provider Office Zip
Text
9
Physical address – address where provider delivers health care services. Minimum 5 digit code. Do not include dashes
MP015
Provider DEA Number
Text
12
MP016
Provider NPI
Text
20
MP017
Provider State License Number
Text
30
MP018
Entity Code
Text
2
Enter the value that defines the entity provider type. Required when MP005 does not = 1
1 Academic Institution
2 Adult Foster Care
3 Ambulance Services
4 Hospital Based Clinic
5 Stand-Alone, Walk-In/Urgent Care Clinic
6 Other Clinic
7 Community Health Center - General
8 Community Health Center - Urgent Care
9 Government Agency
10 Health Care Corporation
11 Home Health Agency
12 Acute Hospital
13 Chronic Hospital
14 Rehabilitation Hospital
15 Psychiatric Hospital
16 DPH Hospital
17 State Hospital
21 Licensed Hospital Satellite Emergency Facility
22 Hospital Emergency Center
23 Nursing Home
24 Pharmacy
MP899
Record Type
Text
2
MP
Source. #10877, eff 7-10-15; ss by #13136, eff 11-24-20