CAQH ProView Roster Data Exchange Guidelines v2.1, Study notes of Communication

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CAQH ProView

Roster Data Exchange

Guidelines

for

Participating Organizations

CONTENTS

• 1 INTRODUCTION
  • 1.1 OVERVIEW
  • 1.2 PURPOSE
  • 1.3 TARGET AUDIENCE
  • 1.4 DOCUMENT OWNER
• 2 ROSTER SUBMISSION
  • 2.1 DATA TRANSFER
  • 2.2 FILE SCHEDULES AND NAMING CONVENTIONS
  • 2.3 ROSTER DATA FILE LAYOUT
• 3 RETURN ROSTER
  • 3.1 PARTICIPATING ORGANIZATION RETURN ROSTER
  • 3.1.1 DATA TRANSFER
  • 3.1.2 FILE SCHEDULES AND NAMING CONVENTIONS
  • 3.1.3 RETURN ROSTER DATA FILE LAYOUT
• 4 ROSTER EXCEPTION
  • 4.1 DATA TRANSFER
  • 4.2 FILE SCHEDULES AND NAMING CONVENTIONS
  • 4.3 ROSTER EXCEPTION DATA FILE LAYOUT
• APPENDIX
  • 4.4 ROSTER EXCEPTION TYPES
  • 4.5 PROVIDER TYPES
  • 4.6 INSTRUCTIONS TO CONVERT A TAB-DELIMITED TEXT FILE TO A PIPE-DELIMITED TEXT FILE
  • 4.7 CAQH PROVIEW SUPPORT CENTER – CONTACT INFORMATION
  • 4 .8 REVISION LOG

1.4 Document Owner

CAQH ProView’s product management team within CAQH owns the maintenance of this data transfer

guideline document. Updates to these guidelines will be made available to Participating Organization’s via

the portal in CAQH ProView, and email notifications will be sent when they are made to highlight the

changes.

2 Roster Submission

In order to participate in CAQH ProView, an organization must submit a roster to the CAQH ProView

system. Participating Organizations can include providers whom they are currently affiliated with or in the

process of contracting, or other providers such as non-par or non-licensed providers, on their rosters. If a

Participating Organization includes a provider in their roster submission who is not currently in CAQH

ProView, CAQH will initiate an outreach to invite them to join.

The format, structure and submission process of these files are detailed below.

2.1 Data Transfer

Participating Organizations can submit their rosters to an “Incoming” folder in the CAQH ProView secure

FTP server. CAQH ProView will pull the files from the FTP server and process the roster files.

Alternately, Participating Organization users can also upload a roster through the ‘Upload Roster’ page on

the ProView portal under ‘Files and Reports’ menu. The user will need special privileges given by the

Participating Organization’s administrator in order to accomplish this.

2.2 File Schedules and Naming Conventions

The roster files must be submitted with a file name following the same naming convention as listed in the

table below. An Organization ID (POID) is an identifier assigned by CAQH ProView for all its Participating

Organizations at the contract stage. For help with your Organization ID, please contact the CAQH

ProView Support Center – 888 - 600 - 9802.

A Participating Organization can submit multiple rosters, however the rosters will be processed in the

order in which they are received. If the same provider record is in multiple roster files, the data in the

subsequent rosters will be rejected if the action flag is ‘Add’, or overwritten by the information in

subsequent roster files if the action flag is ‘Update’.

File Name Description Frequency Delimiter _ProviderRoster_YYYY_MM_DD_HH_M M.txt The is the identifier supplied by CAQH to each Participating Organization Ad hoc Pipe delimited

2.3 Roster Data File Layout

Participating Organizations are required to submit their roster data in a pipe ‘ | ‘ delimited ASCII text file

format. The first record in the roster file should correspond to the field names as specified in the table

below, i.e. a header record must be included in the roster file.

Every roster file must include all columns even when no data is present for every field. The absence of

data must be represented as a blank in the text file. The maximum width for each field is also listed in the

table below. Values in each field must not be padded with spaces if the width is less than the maximum

allowed.

The records within a roster should correspond to all of the unique providers. The submitted roster

file may contain new records (Action flag = ‘A’), changed records (Action flag = ‘U’) or deleted

records (Action flag=’D’). CAQH ProView will process each record detecting any changes based

on the ‘Action Flag’.

General Guidelines:

• In order to achieve a higher rate of success during the matching process with CAQH ProView

providers, Participating Organizations are encouraged to submit as much information as possible for

records with an action flag of ‘A’. They are also encouraged to do the same for an initial roster file.

• All required fields (noted with an ‘R’ (required) in the table below) must be populated. The required

fields vary for each action flag. Action Flag is mandatory for every record in the roster file.

• For non-required fields, if data is not available, the field must be left empty.
• CAQH Provider ID and Organization ID are required for ALL updates and deletes. (Action flag ‘U’ and

‘D’)

• CAQH Provider ID and Organization ID are required for a “Quick Add” action. “Quick Add” operation

allows an organization to add a provider (who is already in CAQH ProView) to their roster by simply

providing their CAQH Provider ID, in addition to the Organization ID.

• The address should reflect the location at which the provider can be reached when CAQH ProView

initiates outreach to them. In most cases, this address might be the same as provider’s primary

practice location address. If an incorrect address is provided, outreach to the provider will not be

successful and the provider will be placed in “Return Mail” status. No further follow-up will be initiated

by CAQH for providers in “Return Mail” status unless an updated address or email is provided.

• Participating organizations are strongly encouraged to submit an email address for each provider.

This email address is used for provider outreach and is also CAQH ProView’s preferred method of

communication with the provider.

• For “Initial Adds”, at least one of the data elements in the following list must be populated (highlighted

with a ‘*’ in the layout table below) in order to match providers in CAQH ProView.

o NPI

o DEA Number

o UPIN Number

Ø File does not contain all required columns.

Ø File contains an invalid delimiter.

# Field Name Format (^) SizeMax Field Definition Required-R / Optional – O / Conditional - C Initial Add Quick Add with CAQH ID Update Delete 1 Action_Flag Char 1 A flag that denotes if the record is an “Add”, “Update”, “Delete”. Valid values are ‘A’,’U’,’D’

R R R R

2 Provider_First_Name varchar 150 A text field that contains the First Name of the Provider.

R R R R

3 Provider_Middle_Name varchar 150 A text field that contains the Middle Name or Initial of the Provider.

O O

4 Provider_Last_Name varchar 150 A text field that contains the Last Name of the Provider.

R R R R

5 Provider_Name_Suffix varchar 10 A text field that contains the suffix associated with a Provider’s Name. Note: The value must be from the list of standard suffix values.

O O

6 Provider_Gender Char 1 A code that denotes the gender of the Provider. Valid values are ‘M’ – Male, ‘F’- Female

O O

# Field Name Format (^) SizeMax Field Definition Required-R / Optional – O / Conditional - C Initial Add Quick Add with CAQH ID Update Delete 11 Provider_Address_Zip Integer 5 A numeric field that denotes a provider’s outreach/correspondence address zipcode.

R O

12 Provider_Address_Zip_E xtn Integer 4 An integer field that denotes a provider’s outreach/correspondence address zip extension.

O O

13 Provider_Phone Integer 10 A field that denotes a provider’s primary phone number.

O O

14 Provider_Fax Integer 10 A field that denotes a provider’s fax number for correspondence.

O O

15 Provider_Email varchar 150 The primary email address used for correspondence with the provider and for provider outreach.

O O

16 Provider_Practice_State Char 2 The two-character ANSI state code that corresponds to the provider’s primary practice state. Note: This helps CAQH ProView identify state mandated requirements (if any) for the provider.

R O

17 Provider_Birthdate Date 8 This field denotes the provider’s date of birth. (Format: YYYYMMDD)

R O

18 Provider_SSN Integer 9 This field denotes the provider’s Social Security Number. O ***** O

# Field Name Format (^) SizeMax Field Definition Required-R / Optional – O / Conditional - C Initial Add Quick Add with CAQH ID Update Delete 19 Short_SSN Integer 2 This field denotes last two characters of the provider’s SSN. This is required for Illinois providers if the following is true: Primary Practice State = ‘IL’ and Provider_SSN is null and Application_Type =’ 2 ’ for re-credentialing.

C O

20 Provider_DEA Char 9 This field denotes the provider’s Drug Enforcement Administration (DEA) Number. (Format is ‘AA9999999’) O ***** O 21 Provider_UPIN Char 6 This field denotes the provider’s Unique Physician Identification Number (UPIN). (Format is ‘A99999’) O ***** O 22 Provider_Type varchar 4 This field denotes the provider type code based on a list of Standard or Allied provider type codes from CAQH ProView. Note: The value must be taken from the list of standard CAQH ProView Provider Type codes (see Appendix A – Section 4.5).

R O

# Field Name Format (^) SizeMax Field Definition Required-R / Optional – O / Conditional - C Initial Add Quick Add with CAQH ID Update Delete 27 CAQH_Provider_ID Integer 10 The field denotes the CAQH assigned provider Identifier. CAQH assigns a provider ID for all providers in CAQH ProView. If a provider is not found in the CAQH ProView (after a rigorous match process), a new ID is assigned after roster processing. Not Applic able

R R R

28 PO_Provider_ID varchar 50 This field denotes the Participating Organization’s internal identifier for the provider.

O O O

29 Last_Recredential_Date Date 8 This field denotes the date the provider was last recredentialed by the Participating Organization. (Format: YYYYMMDD)

O O O

30 Next_Recredential_Date Date 8 This field denotes the date the provider will be recredentialed again by the Participating Organization. (Format: YYYYMMDD)

O O O

# Field Name Format (^) SizeMax Field Definition Required-R / Optional – O / Conditional - C Initial Add Quick Add with CAQH ID Update Delete 31 Delegation_Flag Char 1 A flag that identifies if a provider is delegated or not for credentialing purposes. Delegated Providers are providers who furnish health care services through partnerships, associations or other legal entities including but not limited to individual practice associations (IPAs) and physician hospital organizations (PHOs). Valid values are ‘Y’ – Delegated or ‘N’ – Not Delegated Note: If a provider is marked as “Y” for delegated, the provider’s full data set and supporting documentation will not be available in the data extract.

O O

32 Application_Type Integer 1 Identifies if a provider requires an initial application or a recred application (applicable only for Illinois providers) Valid values are 1 or 2: 1 = “Initial Credentialing”, 2 = “Re-credentialing” Required if Primary Practice State = ‘IL’

C O

# Field Name Format (^) SizeMax Field Definition Required-R / Optional – O / Conditional - C Initial Add Quick Add with CAQH ID Update Delete 35 Region_ID Integer 5 This field denotes a Participating organization’s region identifier. Region ID is an identifier assigned by CAQH ProView to assist large organizations in decentralizing CAQH ProView usage based on regional demographics. Note: If you don’t know your Region ID, please contact the CAQH ProView Support Center.

O O O

3 Return Roster

A return roster file is a list of providers associated with a Participating Organization at any given time. The

list includes both active and inactive providers associated with an organization. This file is mostly used by

Participating Organizations to keep their internal systems in sync with CAQH ProView data.

A Participating Organization’s user can select the return roster frequency through the CAQH ProView

portal. The option is available in the ‘Schedule and Download Files’ drop down under ‘Files and Reports’

menu.

3.1 Participating Organization Return Roster

3.1.1 Data Transfer

The return roster for each Participating Organization is available from the “Outgoing” directory in their

respective accounts in CAQH ProView’s secure FTP server. In addition, the return rosters will also be

available to download from the ‘Schedule and Download Files’ drop down under ‘Files and Reports’

menu.

3.1.2 File Schedules and Naming Conventions

The return roster file is an ASCII pipe-delimited file. The return rosters are generated based on the

Participating Organization’s requested frequency.

File Name Description Frequency Delimiter _ReturnRoster_YYYY_MM_DD.zip The zip file will contain: _ReturnRoster_YYYY_MM_DD.txt The is the identifier supplied by CAQH ProView to each Participating Organization Daily or Weekly as scheduled by the user on the ProView portal Pipe delimited

3.1.3 Return Roster Data File Layout

The data in the return roster data will be presented to the Participating Organization as follows.

# Field Name Format Max Size Field Definition 1 Organization_ID Integer 5 Participating Organization’s Identifier 2 Authorization_Flag Character 1 A flag that denotes if the provider has authorized the health plan to view data. Valid values are ‘Y’ and ‘N’ 3 Provider_Status Character 30 The status of the provider in CAQH ProView.

# Field Name Format Max Size Field Definition 19 Provider_UPIN Character 6 Provider UPIN (Format is ‘A99999’) 20 Provider_DEA Character 9 Provider DEA Number (Format is ‘AA9999999’) 21 Provider_NPI Integer 10 Provider Type 1 (Individual) NPI number Format: 9 numeric digits followed by one numeric check digit 22 Roster_Status Character 10 Status of the provider on the Plan’s current roster. Valid Values: ‘ACTIVE’, ‘INACTIVE’ 23 Non_Responder_Flag Character 1 Indicates whether the provider has not responded to follow-up messages 24 Delegation_Flag Character 1 Indicates whether the provider is delegated or not for credentialing purposes. Valid values are ‘Y’ – Delegated or ‘N’ – Not Delegated Note: If a provider is marked as “Y” for delegated, the provider’s full data set, replica, or supporting documentation will not be available in the data extract.

# Field Name Format Max Size Field Definition 25 Affiliation_Flag Character 2 The field denotes if the provider has entered into an agreement with the Participating Organization or currently in their network. Valid values are ‘A’ – Affiliated or ‘NA’ – Non-Affiliated Note: “NA” can be used to indicate non-participating providers. If a provider is marked as “NA” for non- affiliated, the provider’s full data set, replica, or supporting documentation will not be available in the data extract. 26 Provider_Practice_State Character 2 This is the primary practice state of the provider. 27 Anniversary_Date Date 8 Provider anniversary date for the Participating Organization’s billing activity (Format: YYYYMMDD)