Collection of Dental Provider Information

Insure Kids Now

Attachment B

Insure Kids Now

Provider Data Submission Technical Information

October 1, 2009

Centers for Medicare & Medicaid Services (CMS)

Health Resources Services Administration (HRSA)

Table of Contents

Section Page

Provider Data Submission Technical Information 1

What is eRoom? 1

Option 1: Submission of Oral Health Provider Data Files Produced from a State’s Automatic Data Processing Systems 2

Option 2: Direct Entry on Oral Health Provider Data using eRoom Database 4

Option 4: Link to State Providers Website 6

APPENDIX A: Add Files Procedure 1

APPENDIX B: Entry of Federally Qualified Health Centers Provider Data 1

APPENDIX C: Format for Text Data File Submission 1

Provider Data Submission Technical Information

The Insure Kids Now (IKN) website project entails collecting data about qualified Oral Health Providers¹ within each State or Territory and development of a locator application to make this data available to the public over the web. Centers for Medicare & Medicaid Services (CMS) and Health Resources and Services Administration (HRSA) will be using the eRoom collaborative environment to collect and disseminate information about the IKN website project and to coordinate with our State² partners in this effort.

The data are collected and reported as a “provider” who sees patients that are clients of a particular “coverage plan” at a specific “location”. For the purposes of this document, the following definitions apply:

A “provider” is an individual, group practice, or health center (or other facility). Where individual provider names are supplied they will appear on the website along with the group practice and / or facility name (if supplied). Each record must have at least one of these three items included; it is preferred that individual providers be listed wherever possible.

A “coverage plan” is the combination of State Program (e.g. Medicaid or SCHIP) and any subsidiary plan or option associated with it (as for example managed care options or different plans that cover children of differing ages)

A “location” is a specific physical address top which patients could be directed to receive care.

What is eRoom?

The eRoom is a secure portal for sharing electronic project data and information including: documents, databases, files, schedules, calendars. Each State will be part of the IKN community and have access to the common data and restricted access to their own State information and data. Only personnel from your State (and the system administrators) will be able to access your State’s IKN eRoom. Each State is to inform the IKN eRoom Site Administrator of the personnel who will be granted access to the IKN community and the State specific eRoom. The administrator will provide the users the log in instructions, identification, and passwords so that they can gain access to the IKN eRoom. The eRoom will have documents and information on the fields we are collecting, how the data will be used, the Access Data Collection Tool, additional instructions for the various types of ways to provide the data, and an eRoom database for collecting this data.

Because the States manage their provider data in a variety of ways, CMS and HRSA have identified two options for creating and submitting the required data (in effect large and small scale data options). The first is creation of the data files from a State’s automatic data processing (ADP) system, and the second is entry of data in an uncomplicated web data table. The States will need to inform CMS and HRSA which option the State will employ. Each of the options is described below.

Option 1: Submission of Oral Health Provider Data Files Produced from a State’s Automatic Data Processing Systems

CMS and HRSA are asking States to provide Oral Health Provider Data in two text files. The first is the control file which provides identifying information for the data. This control file needs to be called IKN_CONTROL_PP_XX.txt (where PP denotes the program name or type – Medicaid or CHIP —and XX is the State abbreviation) and must contain the name of preparer, the contact name, contact phone number, contact e-mail (if available), the number of records, indicator of what program (Medicaid or CHIP) the data correspond to, and the data as-of date.

The second file, called IKN_PP_XX.txt (again where PP denotes the program name or type – Medicaid or CHIP —and XX is the State abbreviation), is a text file that contains the data. Each data value should be vertical pipe ( | ) delimited. (The pipe symbol separates the fields.) This file (or files) contains the data elements in the required order as described in Appendix C, Format for Data File Submission. It is acceptable to submit more than one file—for example one for Medicaid and one for CHIP, or one for each health plan your States offers—but please be sure they are clearly identified.

The first line of each data file should include the pipe-delimited list of field names (see Figure 1 below and Appendix C) as this will be used in validation of the submission. If you are submitting a file where one or more of the optional field is not included, please either omit that field from the file header or use the instructions in the following paragraph regarding how to “skip” a value. In either case, it is essential that the field layout in your file’s header exactly match the layout in the data records.

In the data records themselves, for values you are leaving blank, two pipes will be together with nothing in between. Here is an example record showing the first few data fields of the first two lines in a data file.

Note that John Smith has no middle name, but the position is maintained by the two pipes with nothing in between. There are some data elements which are optional; if a State does not have these data elements at this time, a blank entry is acceptable. For fields that allow for multiple entries within them (i.e. Language), please use a comma (,) to separate the multiple entries (example: |Spanish, Chinese|.

Distinct providers need to be identified. The National Provider Identification number is the preferred identifier, but some other identifier is acceptable provided that it is “persistent” (i.e. does not change over time) and unique to a provider. In cases where only a group practice or facility (such as a health center) is represented, the identifier for the practice or facility should be used rather than an identifier for a particular individual.

Each distinct physical location at which a provider practices needs a record. As guidance, some provider and location scenarios and the expected pipe-delimited data records are described below:

• One Provider in One Plan at One Location: If a provider has one location and sees patients only from one coverage plan, then the IKN_PP_XX.txt file would have a single complete record for that provider.

• One Provider in One Plan, with Multiple Locations: If a provider sees patients from a single coverage plan but has three locations then the IKN_PP_XX.txt file would have three complete records for that provider.

• One Provider in Multiple Plans at One Location: if a provider sees patients from more than one plan, but does so at a single location, the data would include one complete record for each plan in which the provider participates.

• One Provider, Multiple Plans, Multiple Locations: if a provider participates in more than one plan, and sees patients in those plans at more than one location the data should contain one complete record for each combination of provider, plan, and location. NOTE that the total number of records may not equal the product of plans times locations, as not all providers see patients from each plan in which they participate at every location where the provider sees patients.

• Practice with More than One Provider and One Location: If a practice has two providers at a single location then the IKN_PP_XX.txt file would have two complete records (one for each provider), so long as the providers are willing to be listed. Otherwise, there would be a single record for the group practice as an entity but no details as to the individual providers in the practice.

• Practice with More than One Provider and Multiple Locations: If a practice has two providers and three locations then the IKN_PP_XX.txt file would have complete records for each provider associated with each location at which that provider practices.

Please refer to Appendix B, Entry of Federally Qualified Health Centers and Group Practice Provider Data for special instructions for handing of the Federally Qualified Health Center (FQHC) data.

The data submission files IKN_CONTROL_PP_XX.txt (control) and IKN_PP_XX.txt (pipe-delimited provider data) will be uploaded by the State into their IKN eRoom by the required date as noted in the cover letter. Please refer to Appendix A, Add Files Procedure for assistance with the file upload process. Remember a state’s submission is not complete unless both the control and provider data files have been uploaded in the State’s eRoom.

Option 2: Direct Entry on Oral Health Provider Data using eRoom Database

With Option 2, uploading of data files is not required. Each State may have its own eRoom CHIP Oral Health Care Providers Database. This database will allow the State to key in their provider data from scratch or start with the import of a CSV file and edit it in the eRoom. The State will complete their data entry by the required date and HRSA/CMS will directly retrieve the data from each State’s eRoom database. There are some data elements which are optional. If a State does not have these data elements at this time, a blank entry is acceptable; please refer to Appendix C for the required and optional data elements. This may be the best option for States where there are a limited number of providers (under 50) or provider lists where there is little change from quarter to quarter, since data can be updated over the web. HRSA/CMS will be responsible for storing and backing up the data. If a State needs to use their data for other purposes once they have been entered, the eRoom database can be exported using a button on the database page (see Figure 2 below).

When States are entering data in an eRoom database, keep in mind that each distinct physical location at which an oral health provider (as defined by their National Provider Identifier or State Medicaid Number) works needs a record. The same guidance applies as is described in Option 1 as regards the number of records that should be entered based on the number of plans in which the provider participates and locations at which the provider practices.

Please refer to Appendix B, Entry of Federally Qualified Health Centers and Group Practice Provider Data for special instructions for handing of the Federally Qualified Health Center (FQHC) data.

Figure 1. eRoom Database Page.

Option 3: Link to State Providers Website

If your state has an existing website that allows beneficiaries to find CHIP / Medicaid oral health providers, we may be able to satisfy the statutory requirements by posting a link to it from the Insure Kids Now website. The website must at a minimum provide the provider name, address, phone number, and whether or not he/she accepts new patients. If this is the option you would like to take, contingent on CMS approval, please send the website URL to James Resnick ([email protected]) by Friday, July 10, 2009. You will still be required to submit description of dental benefits in MS Word format, as specified in Attachment A.

NOTE: if your State submitted a link during the original submission cycle, and if that link has not changed, you do not need to re-submit it.

NOTE: Unless you submit actual provider data via eRoom, beneficiaries from your state will not be able to find oral health providers using the national providers website.

APPENDIX A: Add Files Procedure

The procedure to add files is described here. The description is uses the specific instances of adding the IKN_CONTROL_PP_XX.txt control file and the IKN_PP_XX.txt pipe-delimited provider data file). Remember a submission is not complete until both files have been uploaded in the state’s eRoom.

The process for doing this is to first log into your state IKN eRoom. After logging in the user will see an eRoom as displayed in Figure A-1 below (there will be more items in the state eRooms, this is just for demonstration). Click the <add file> button.

Next the Add File page will appear (see Figure A-2 below); the user can browse their desktop/server to find the location where the data files are located, select the control file and then click the <OK> button. Then repeat this for the provider data file.

APPENDIX B: Entry of Group Practice and Federally Qualified Health Centers Provider Data

Many Federally Qualified Health Centers (FQHCs) provide dental services through contracts with local private practices. It is understood that many of these oral health providers supplying these services through these contractual arrangements may not want their practice information listed on the IKN website. It is not necessary to provide the name and address of individual oral health providers that are seeing clients through contracts with FQHCs, assuming that the billing is done through the FQHC’s National Provider Identifier (NPI). Instead, it is requested that when providing information for FQHCs, that the addresses of all clinic locations that provide oral health services are listed separately. For entries identified as an FQHC, only the name, address and phone number will be listed on the IKN website and not the provider name.

If your data include group practices, it is strongly preferred that each member of the practice be identified (with the applicable NPI) if possible. In cases where some providers who are members of a group practice do not wish to have their individual names listed on the website, it is acceptable to submit one record for each location where members of a group practice see patients, using only the group practice name for the listing. Please include a unique identifier for these practices just as you would when identifying a FQHC. As with FQHCs this identifier should NOT be the National Provider Identifier number for an individual.

APPENDIX C: Format for Text Data File Submission

Based on feedback from State Health Officials during the initial data submission process, the data submission format has been adapted to accommodate States that make extensive use of managed care plans. The current format allows State Health Officials to submit provider information specific to a health plan, which allows for more accurate information for the public. For example, if a provider is accepting new patients under one health plan but not the other, the submitted data will reflect that.

Under this format, State Health Officials submit multiple records (potentially in multiple files, one for each health plan) for a given provider. Each record should be a unique combination of:

• Provider (individual, group practice, or facility)

• “Coverage Plan”, which is a combination of:

  • Program name, and

  • Health Plan name under that program, or Fee for Service

• Service Location

(NOTE: You will not see a data element named “Coverage Plan”. This is something that will be created from the combined values in the Program_Name and Health_Plan_Name fields.)

Data Element Name	Description	Required	Comments
Provider_ID	Unique Provider Identifier	Required	Must be unique to a provider in your State. For individual providers, National provider ID is strongly preferred, but an alternate (e.g. State Medicaid Provider ID) is acceptable. For group practices and health centers, an alternate ID that uniquely identifies the practice or facility is required. This data element will not be displayed on the website, but may be used for “behind-the-scenes” activities such as data cleansing and statistics.
Prov_Aff	Provider Affiliation	Optional	Select one or more from the following list: PP = Private Practice CHC = Community Health Center FQHC = Federally-Qualified Health Center HD = Health Department OTH = Other NOTE: Use a comma (,) to separate multiple entries
First_Nm	Provider First Name	Required	Note FQHC exception specified in Appendix B
Middle_Nm	Provider Middle Name	Optional	Note FQHC exception specified in Appendix B
Last_Nm	Provider Last Name	Required	Note FQHC exception specified in Appendix B
Grp_Prac_Nm	Group Practice Name	Required if applicable	Only if applicable.
Fac_Nm	Facility Name	Required if applicable	Applies in cases where the practice location is associated with or contained in a facility such as a hospital, school, or community health center
Lang_Spoken	Languages Spoken	Optional	Only enter languages other than English that are spoken at the facility. A blank entry indicates that only English is spoken. NOTE: Use a comma (,) to separate multiple entries
Specialty	Provider Specialty	Required	Select one or more from the following list: General Dentist; Pediatric Dentist; Oral Surgeon; Orthodontist; Endodontist; Periodontist; Prosthodontist. Please add other values to the list as required by your data. Please standardize them, though, to avoid typographical differences and mis-spellings. NOTE: Use a comma (,) to separate multiple entries.
Website	Website address of provider	Optional	Provider’s website, if any
Program_Type	Type of Program	Required	Select from: CHIP (i.e. CHIP Standalone/Separate) Medicaid (i.e. Medicaid or Medicaid Expansion)
Program_Name	Name of Program	Optional	The name by which a Medicaid or CHIP program is known to beneficiaries (e.g. TennCare, Kids First, Medicaid, CHIP, etc.)
Health_Plan_Name	Name of entity providing coverage	Required	Enter name of managed care organization, or “Fee For Service” if no other name applies.
Phy_Street_Addr	Provider Physical Site Street Address	Required	Enter physical location where services are provided. Please include Floor Number and Room Number where applicable. No P.O. Box or R.R. Box.
City	Provider City	Required
State_Abbr	Provider State	Required	Two character postal abbreviation.
ZIP	Provider ZIP Code	Required	99999-9999 (last four digits optional)
Phone_Num	Phone Number	Required	999-999-9999 x999 (extension optional)
FAX_Num	FAX Number	Optional	999-999-9999 x999 (extension optional)
New_Patients	Accepts New Patients	Required	Enter Y or N.
Special_Needs	Can Accommodate Special Needs	Required	Enter Y or N. (NOTE: This data element is due to be re-defined in the future to provide more specific information on the types of special needs that a provider can accommodate.)
Active_Ind	Active Status	Required	Enter the provider’s status as of the date of the update. Use “Y” to indicate that the provider is currently active and “N” if inactive. Only active providers will be displayed on the national providers website. Note: If a given provider will remain inactive for the entire reporting cycle, they do not need to be included at all.
Active_Dt	Active Date	Optional	Enter date at which provider will become active in the specified health plan, in mm/dd/yyyy format. This field is only needed if the provider is currently inactive (i.e. Active_Ind is “N”) and will become active during the upcoming reporting period.
Inactive_Dt	Inactive Date	Optional	Enter date at which provider will become inactive in the specified health plan, in mm/dd/yyyy format. This field is only used if the provider is currently active (i.e. Active_Ind is “Y”) and will become inactive during the upcoming reporting period.

1 A qualified oral health provider is one who provides dental services to children enrolled in the State plan (or waiver) under Medicaid or the State child health plan (or waiver) under the Children's Health Insurance Program (CHIP).

2 The term State refers to U.S. States, the District of Columbia, and Territories throughout the remainder of the document.

October 1, 2009 - i - Provider Data Submission Technical Information