| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | name(+) | 0;1 | FREE TEXT | B | This is the name of either an individual NON-VA provider or a NON-VA or another VA facility that provides services to the V.A. for which the V.A. can in turn bill an insurance company for reimbursement. For individual type entries: The name should be entered in LAST,FIRST MIDDLE format. Enter only data that is actually part of the provider's name. Do not include extra titles, identification, flags, local information, etc. All individual provider names will be converted to the 'standardized' format. 'Standardized' for individuals means all punctuation except '-' and space are removed, the name is changed to all uppercase, 2 or more successive '-' or spaces are converted to a single '-' or space and any words for birth position (1ST-10TH) are changed to their Roman numeral equivalents. For facility type entries: The name MUST start with an Alpha character. The name may contain numerals, spaces, commas, periods, and a hyphen or dash. No other punctuation characters are allowed in the name. | |
| .02 | provider type | 0;2 | SET OF CODES | 1:FACILITY/GROUP 2:INDIVIDUAL | This field identifies the type of provider being defined. Facility providers can be used to fill in the name and address of the non-VA facility where services were rendered (box 32 on the CMS-1500). An individual provider can be selected as the rendering, attending, referring or operating provider on a bill. | |
| .03 | credentials | 0;3 | FREE TEXT | This is the 1 to 3 digits that represents the credentials for this provider. This field is only valid for INDIVIDUAL providers. | ||
| .04 | specialty | 0;4 | FREE TEXT | This is the 2 digits that represent the specialty for this provider. This field is only valid for INDIVIDUAL providers. | ||
| .05 | street address(+) | 0;5 | FREE TEXT | This is the street address of the non-VA facility that rendered the care that is being billed by the VA. It is only valid for FACILITY providers. It cannot be a post office box. | ||
| .06 | city | 0;6 | FREE TEXT | This is the city of the non-VA facility that rendered the care that is being billed by the VA. It is only valid for FACILITY providers. | ||
| .07 | state | 0;7 | POINTER | 5 | This is the state of the non-VA facility that rendered the care that is being billed by the VA. It is only valid for FACILITY providers. | |
| .08 | zip code(+) | 0;8 | FREE TEXT | This is the zip code of the non-VA facility that rendered the care that is being billed by the VA. It is only valid for FACILITY providers. The ZIP code must be a nine digit ZIP code number and not ending in "0000" (four consecutive zeros). | ||
| .09 | facility default id number | 0;9 | FREE TEXT | Enter the Federal Tax ID of the outside facility. | ||
| .1 | street address line 2 | 0;10 | FREE TEXT | This is line 2 of the street address of the non-VA facility that rendered the care that is being billed by the VA. It is only valid for FACILITY providers. | ||
| .11 | x12 type of facility | 0;11 | SET OF CODES | 77:SERVICE LOCATION FA:FACILITY LI:INDEPENDENT LAB TL:TESTING LAB | This is the code for the type of facility as identified in the X12 documents. It is used to describe the type of facility for professional claims. Facility (FA) will automatically be sent on institutional claims. | |
| .12 | state license # | 0;12 | FREE TEXT | This is the State license # for the non-VA provider. Note, there can be only 1 state license # on file for non-VA/other VA providers. Enter multiple entries for the provider if multiple state license numbers are required (one for each state). | ||
| .13 | primary id qualifier | 0;13 | POINTER | 355.97 | This is the Qualifier associated with the FACILITY DEFAULT ID NUMBER. | |
| .15 | mammography certification # | 0;15 | FREE TEXT | This is the mammography certification number for the non-VA facility which is used as a default on the claim when mammography services are performed. It is required by some insurance companies. | ||
| .16 | license state | 0;16 | POINTER | 5 | This is the state which issued the STATE LICENSE #(#.12) field of the non-VA individual or facility that rendered the care that is being billed by the VA. | |
| .17 | sole proprietorship | 0;17 | BOOLEAN | Y:YES N:NO | A sole proprietorship is a Non-VA facility that is owned by a single Non-VA provider. | |
| .18 | non-va provider | 0;18 | POINTER | 355.93 | Non-VA provider associated with this facility. | |
| 1.01 | p&c contact name | 1;1 | FREE TEXT | For use with property and casualty claims, this is the name of the contact person at this Lab/Facility (Last Name, First Name). | ||
| 1.02 | p&c contact phone number | 1;2 | FREE TEXT | For use with property and casualty claims, this is the area code and phone number of the contact person at this facility. | ||
| 1.03 | p&c contact phone extension | 1;3 | NUMERIC | For use with property and casualty claims, this is the phone extension of the contact person at this facility, if known. | ||
| 40 | date/time of last npi change | NPISTATUS;0 | MULTIPLE | 355.9301 | ||
| 41.01 | npi | 0;14 | FREE TEXT | NPI | Unique National Provider Identifier. A unique integer assigned to a provider by CMS. This field contains the current NPI for this provider. | |
| 42 | taxonomy code | TAXONOMY;0 | MULTIPLE | 355.9342 | ||
| 50 | date/time last fb update | 4;0 | MULTIPLE | 355.935 | This multiple tracks updates to this file that are made by the FEE BASIS PAID TO IB background job. | |
| 51 | date/time allow fb update | 3;0 | MULTIPLE | 355.9351 | This multiple stores information that the Fee Basis interface uses to control whether updates to this record should be allowed. Historical information is saved, and the most recent entry is used by the interface. |