| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | name(+) | 0;1 | FREE TEXT | B | This is the name used to describe the provider id type. | |
| .02 | source level minimum(+) | 0;2 | SET OF CODES | 0:NONE 1:LICENSING/GOVT AGENCY - EACH PROV 2:FACILITY - ALL PROV 3:INSURANCE CO - ALL PROV 4:INSURANCE CO - EACH PROV 5:INSURANCE CO - ALL PROV BY CARE UNIT | This is the minimum level or criteria of data that MUST be used to search for this type of ID number for a provider. If this field is zero or blank, there are no minimum data requirements to search for an ID for this id type. | |
| .03 | x12 code | 0;3 | FREE TEXT | C | This is the X12 code that determines the qualifier to be output in the X12 data stream when reporting this type of provider ID number. | |
| .04 | facility's default id # | 0;4 | FREE TEXT | This is the number that will be the default for all providers for the id type at the facility if no number exists for the specific provider/ins. co/care unit combination. | ||
| .05 | restrict editing | 0;5 | BOOLEAN | 0:NO 1:YES | This field controls whether or not users may edit the id #'s for the provider type at the facility level. | |
| .06 | valid for performing provider | 0;6 | BOOLEAN | 0:NO 1:YES | This field indicates whether the id type is valid for performing provider ids. | |
| .07 | allowable form type | 0;7 | SET OF CODES | I:INSTITUTIONAL P:PROFESSIONAL B:BOTH INSTITUTIONAL AND PROFESSIONAL | This is a flag used to determine what type of form this qualifier is valid for. It is used to validate provider id file set-up. | |
| .08 | active | 0;8 | BOOLEAN | 1:YES 0:NO | This field must be set to YES to allow this qualifier to be selected. Old entries that are no longer allowed should be set to NO. | |
| 1.01 | state dea# | 1;1 | BOOLEAN | 0:NO 1:YES | This is the flag that tells the system this id type is a state DEA # and the data is stored in the NEW PERSON file by state. | |
| 1.02 | federal dea# | 1;2 | BOOLEAN | 0:NO 1:YES | This is the flag that tells the system this id type is a federal DEA # and the data is stored in the NEW PERSON file. | |
| 1.03 | state license # | 1;3 | BOOLEAN | 0:NO 1:YES | This is the flag that tells the system this id type is a state license # and the data is stored in the NEW PERSON file by state. | |
| 1.04 | federal tax # - facility | 1;4 | BOOLEAN | 0:NO 1:YES | This is the flag that tells the system this id type is a facility federal tax id and the data is stored in the IB SITE PARAMETERS file. | |
| 1.05 | emc id type | 1;5 | BOOLEAN | 0:NO 1:YES | This is a flag to indicate if the record is for an EMC ID # | |
| 1.06 | network id type | 1;6 | BOOLEAN | 0:NO 1:YES | This is a flag to indicate if the record is for a network id #. | |
| 1.07 | provider's own id | 1;7 | BOOLEAN | 0:NO 1:YES | This is the flag that designates an id type is a personal # for the provider, not assigned by the facility or an insurance co | |
| 1.08 | stored outside of billing | 1;8 | BOOLEAN | 0:NO 1:YES | This is the flag that specifies the provider id data is not stored in an IB file. | |
| 1.09 | billing provider primary id | 1;9 | BOOLEAN | 0:NO 1:YES | This field is a 1 (YES) if this is the provider id type that represents the billing provider's primary id. |