1 ********************************************* * * * A T T E N T I O N * * * * THESE POS RECORD SPECIFICATIONS WERE * * PRODUCED FROM OUR DICTIONARY AT THE * * SAME TIME AS THE POS DATA FILE THAT * * YOU REQUESTED. YOU MAY WISH TO CHECK * * THESE SPECIFICATIONS TO SEE IF ANY * * CHANGES HAVE OCCURED SINCE YOUR RECEIPT * * OF ANY PRIOR DOCUMENTATION. * * * * FILE CREATION DATE = 01/01/2010 * * * ********************************************* 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 1 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 SHORT TERM 02 LONG TERM 03 RELIGIOUS NONMEDICAL HEALTH CARE INSTITUTIONS 04 PSYCHIATRIC 05 REHABILITATION 06 CHILDRENS 07 DISTINCT PART PSYCH HOSPITAL 11 CRITICAL ACCESS HOSPITALS CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 01 HOSPITALS CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 2 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 NATIONAL GOVERNMENT SERVICES 00180 NATIONAL GOVERNMENT SERVICES 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 3 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01101 PALMETTO (CALIFORNIA) 01201 PALMETTO (HAWAII) 01301 PALMETTO (NEVADA) 01390 AETNA (WASHINGTON) 02101 NATIONAL HERITAGE (ALASKA) 02201 NATIONAL HERITAGE (IDAHO) 02301 NATIONAL HERITAGE (OREGON) 02401 NATIONAL HERITAGE (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03101 NORIDIAN (ARIZONA) 03201 NORIDIAN (MONTANA) 03301 NORIDIAN (NORTH DAKOTA) 03401 NORIDIAN (SOUTH DAKOTA) 03501 NORIDIAN (UTAH) 03601 NORIDIAN (WYOMING) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 4 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 04101 TRAILBLAZER (COLORADO) 04201 TRAILBLAZER (NEW MEXICO) 04301 TRAILBLAZER (OKLAHOMA) 04401 TRAILBLAZER (TEXAS) 05101 WPS (IOWA) 05201 WPS (KANSAS) 05301 WPS (MISSOURI) 05401 WPS (NEBRASKA) 07101 PINNACLE (ARKANSAS) 07201 PINNACLE (LOUISIANA) 07301 PINNACLE (MISSISSIPPI) 08101 PINNACLE (INDIANA) 08201 PINNACLE (MICHIGAN) 09101 FIRST COAST (FLORIDA) 09201 FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 12101 HIGHMARK (DELAWARE) 12201 HIGHMARK (DISTRICT OF COLUMBIA) 12301 HIGHMARK (MARYLAND) 12401 HIGHMARK NEW JERSEY) 12501 HIGHMARK (PENNSYLVANIA) 13101 NATL GOVT SERVICES (CONNECTICUT) 13201 NATL GOVT SERVICES (NEW YORK) 14101 NATIONAL HERITAGE (MAINE) 14201 NATIONAL HERITAGE (MASSACHUSETTS) 14301 NATIONAL HERITAGE (NEW HAMPSHIRE) 14401 NATIONAL HERITAGE (RHODE ISLAND) 14501 NATIONAL HERITAGE (VERMONT) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 5 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 6 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN ADMIN SERVICES (ARIZONA) 03202 NORIDIAN ADMIN SERVICES (MONTANA) 03302 NORIDIAN ADMIN SERVICES (NORTH DAKOTA) 03402 NORIDIAN ADMIN SERVICES (MONTANA) 03502 NORIDIAN ADMIN SERVICES (UTAH) 03602 NORIDIAN ADMIN SERVICES (WYOMING) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 7 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 8 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 9 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 10 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATE REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 11 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 3 TERMINATION 4 CHANGE OF OWNERSHIP 5 VALIDATION (ACCRD) 8 FULL SURVEY AFTER COMPLAINT TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 VOLUNTARY NON-PROFIT - CHURCH 02 VOLUNTARY NON-PROFIT - PRIVATE 03 VOLUNTARY NON-PROFIT - OTHER 04 PROPRIETARY 05 GOVERNMENT - FEDERAL 06 GOVERNMENT - STATE 07 GOVERNMENT - LOCAL 08 GOV. - HOSP. DIST. OR AUTH. ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD ACCREDITATION EFFECTIVE DATE 8 274 281 C PROV0000 THE EFFECTIVE DATE OF THE CURRENT PERIOD OF ACCREDITATION BY THE JOINT COMMISSION ON ACCREDITATION OF HEALTH CARE ORGANIZATIONS (JCAHO) OR THE AMERICAN OSTEOPATHIC ASSOCIATION (AOA). COBOL NAME: ACCRED-EFF-DT ACCREDITATION EXPIRATION DATE 8 282 289 C PROV0005 THE EXPIRATION DATE OF THE CURRENT PERIOD OF ACCREDITATION BY THE JOINT COMMITTEE ON ACCREDITATION OF HEALTH CARE ORGANIZATIONS (JCAHO) OR THE AMERICAN OSTEOPATHIC ASSOCIATION (AOA). COBOL NAME: ACCRED-EXP-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 12 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ACCREDITATION INDICATOR 1 290 290 C PROV0010 INDICATES THE ORGANIZATION THAT IS RESPONSIBLE FOR THE ACCREDITATION OF THE PROVIDER. COBOL NAME: ACCRED-STAT VALUES: 0 NONE 1 JCAHO 2 AOA 4 BOTH 5 DNV 6 DNV & TJC 7 DNV & AOA 8 DNV, TJC, & AOA BEDS - TOTAL 4 291 294 N PROV0740 TOTAL NUMBER OF BEDS IN A FACILITY, INCLUDING THOSE IN NON-PARTICIPATING OR NON-LICENSED AREAS. COBOL NAME: NUM-BEDS BEDS - TOTAL CERTIFIED 4 295 298 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS CERTIFIED RN ANESTHETISTS 7.2 299 305 N PROV0760 NUMBER OF FULL-TIME EQUIVALENT CERTIFIED REGISTERED NURSE ANESTHETISTS (CRNA) EMPLOYED BY A HOSPITAL. COBOL NAME: NUM-CERT-RN-ANEST CLIA - HOSP LAB ID #1 10 306 315 C PROV0130 NUMBER ASSIGNED TO A HOSPITAL LABORATORY LICENSED IN ACCORDANCE WITH THE CLINICAL LABORATORY IMPROVEMENT ACT (CLIA). COBOL NAME: CLIA-ID-NUM-A CLIA - HOSP LAB ID #2 10 316 325 C PROV0135 NUMBER ASSIGNED TO A HOSPITAL LABORATORY LICENSED IN ACCORDANCE WITH THE CLINICAL LABORATORY IMPROVEMENT ACT (CLIA). COBOL NAME: CLIA-ID-NUM-B CLIA - HOSP LAB ID #3 10 326 335 C PROV0140 NUMBER ASSIGNED TO A HOSPITAL LABORATORY LICENSED IN ACCORDANCE WITH THE CLINICAL LABORATORY IMPROVEMENT ACT (CLIA). COBOL NAME: CLIA-ID-NUM-C CLIA - HOSP LAB ID #4 10 336 345 C PROV0145 NUMBER ASSIGNED TO A HOSPITAL LABORATORY LICENSED IN ACCORDANCE WITH THE CLINICAL LABORATORY IMPROVEMENT ACT (CLIA). COBOL NAME: CLIA-ID-NUM-D * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 13 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CLIA - HOSP LAB ID #5 10 346 355 C PROV0150 NUMBER ASSIGNED TO A HOSPITAL LABORATORY LICENSED IN ACCORDANCE WITH THE CLINICAL LABORATORY IMPROVEMENT ACT (CLIA). COBOL NAME: CLIA-ID-NUM-E COMPLIANCE: LIFE SAFETY CODE 1 356 356 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: 1 WAIVER RECOMMENDED COMPLIANCE: SCOPE OF SERVICE 1 357 357 C PROV0280 INDICATES IF A WAIVER OF THE SCOPE OF SERVICES REQUIREMENT HAS BEEN RECOMMENDED FOR A HOSPITAL. COBOL NAME: COMPL-SCOPE-OF-SERV VALUES: 1 WAIVER RECOMMENDED COMPLIANCE: TECHNICAL PERSONNEL 1 358 358 C PROV0285 INDICATES IF A WAIVER OF THE TECHNICAL PERSONNEL REQUIREMENT HAS BEEN RECOMMENDED FOR A HOSPITAL. COBOL NAME: COMPL-TECH-PERSNL VALUES: 1 WAIVER RECOMMENDED COMPLIANCE: 24 HR REGISTERED NURSE 1 359 359 C PROV0290 INDICATES IF A WAIVER OF THE 24 HOUR REGISTERED NURSE REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-24-HR-RN VALUES: 1 WAIVER RECOMMENDED CURRENT SURVEY EVER ACCREDITED 1 360 360 C PROV3545 INDICATES IF THIS PROVIDER WAS AN ACCREDITED HOSPITAL ANYTIME DURING THE CURRENT SURVEY. COBOL NAME: CURRENT-EVER-ACCRED VALUES: N NO Y YES CURRENT SURVEY EVER NON-ACCRED 1 361 361 C PROV3555 INDICATES IF THIS PROVIDER WAS A NON-ACCREDITED HOSPITAL ANYTINE DURING THE CURRENT SURVEY. COBOL NAME: CURRENT-EVER-NON-ACCRED VALUES: N NO Y YES CURRENT SURVEY EVER SWINGBED 1 362 362 C PROV3550 INDICATES IF THIS PROVIDER WAS A SWINGBED HOSPITAL ANYTIME DURING THE CURRENT SURVEY. COBOL NAME: CURRENT-EVER-SWINGBED VALUES: N NO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 14 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME Y YES DATE OF LAST VALIDATION SURVEY 8 363 370 C PROV0450 DATE THE LAST VALIDATION SURVEY WAS PERFORMED BY THE STATE AGENCY FOR A JCAH, AOA ACCREDITED HOSPITAL OR OTHER PROVIDER TYPE. COBOL NAME: DT-VALID-SURVEY DIETICIANS 7.2 371 377 N PROV0820 NUMBER OF FULL-TIME EQUIVALENT DIETICIANS EMPLOYED BY A FACILITY. COBOL NAME: NUM-DIETICIANS FISCAL YEAR ENDING DATE 4 378 381 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT LICENSED PRACT/VOCAT NURSES 7.2 382 388 N PROV0955 NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL OR VOCATIONAL NURSES EMPLOYED BY A FACILITY. COBOL NAME: NUM-LPN-LVN MEDICAL SCHOOL AFFILIATION 1 389 389 C PROV0645 THE TYPE OF AFFILIATION THAT A HOSPITAL MAY HAVE WITH A MEDICAL SCHOOL. COBOL NAME: MED-SCHL-AFF VALUES: 1 MAJOR 2 LIMITED 3 GRADUATE 4 NO AFFILIATION MEDICAL TECHNOLOGISTS (LAB) 7.2 390 396 N PROV6290 NUMBER OF FULL TIME EQUIVALENT MEDICAL LABORATORY TECHNOLOGISTS EMPLOYED BY A HOSPITAL COBOL NAME: NUM-LAB-MED-TECHS MEETS 1861 DEFINITION 1 397 397 C PROV0670 INDICATES IF AN EMERGENCY HOSPITAL MEETS THE DEFINITION OF "HOSPITAL" CONTAINED IN SECTION 1861 OF THE SOCIAL SECURITY ACT. COBOL NAME: MEETS-1861 VALUES: Y MEETS 1861(E)(1) NUCLEAR MEDICINE TECHNICIANS 7.2 398 404 N PROV6295 NUMBER OF FULL TIME EQUIVALENT NUCLEAR MEDICINE TECHNICIANS EMPLOYED BY A HOSPITAL. COBOL NAME: NUM-NUCL-MED-TECHS OCCUPATIONAL THERAPISTS 7.2 405 411 N PROV1050 THE NUMBER OF FULL TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-OCCUP-THERAPISTS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 15 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OTHER PERSONNEL 7.2 412 418 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL PARTICIPATING CODE (Y,N) 1 419 419 C PROV1575 THIS CODE INDICATES WHETHER A PROVIDER IS PARTICIPATING IN THE MEDICAID OR MEDICARE PROGRAM. COBOL NAME: PARTICIPATING-CD VALUES: N NON-PARTICIPATING PROVIDER Y PARTICIPATING PROVIDER PHYSICAL THERAPISTS 7.2 420 426 N PROV1125 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS-THERAPY PHYSICIAN ASSISTANTS 7.2 427 433 N PROV1115 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIAN ASSISTANTS EMPLOYED BY A HOSPITAL OR RURAL HEALTH CLINIC. COBOL NAME: NUM-PHYS-ASSIST PROGRAM PARTICIPATION 1 434 434 C PROV1670 INDICATES IF THE PROVIDER PARTICIPATES IN MEDICARE, MEDICAID, OR BOTH PROGRAMS. COBOL NAME: PROG-PARTCI VALUES: 1 MEDICARE ONLY 3 MEDICARE AND MEDICAID PSYCHIATRIC UNIT BEDS 3 435 437 N PROV1690 THE NUMBER OF BEDS IN A PPS EXEMPT PSYCHIATRIC UNIT OF A HOSPITAL. COBOL NAME: PSY-UNIT-BED-SZ PSYCHIATRIC UNIT EFFECTIVE DATE 8 438 445 C PROV1695 THE DATE A PSYCHIATRIC UNIT BECAME EXEMPT FROM THE PROSPECTIVE PAYMENT SYSTEM (PPS). COBOL NAME: PSY-UNIT-EFF-DT PSYCHIATRIC UNIT INDICATOR 1 446 446 C PROV1700 INDICATES IF A HOSPITAL HAS A PPS EXEMPT PSYCHIATRIC UNIT. COBOL NAME: PSY-UNIT-IND VALUES: Y PSYCH UNIT PSYCHIATRIC UNIT TERMINATION CODE 1 447 447 C PROV1705 INDICATES THE REASON THAT A PSYCHIATRIC UNIT IS NO LONGER EXEMPT FROM PPS. COBOL NAME: PSY-UNIT-TERM-CD VALUES: 0 ACTIVE 1 VOLUNTARY-MERGER OR CLOSURE 2 VOLUNTARY-DISSATISFIED WITH REIMBURSEMENT 3 RISK OF INVOLUNTARY TERMINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 16 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 4 VOLUNTARY-OTHER 5 FAILURE TO MEET HEALTH/SAFETY 6 FAILURE TO MEET AGREEMENT 7 PROVIDER STATUS CHANGE PSYCHIATRIC UNIT TERMINATION DATE 8 448 455 C PROV1710 THE DATE A PSYCHIATRIC UNIT IS NO LONGER EXEMPT FROM THE PROSPECTIVE PAYMENT SYSTEM. COBOL NAME: PSY-UNIT-TERM-DT PSYCHOLOGISTS 7.2 456 462 N PROV6300 NUMBER OF FULL TIME EQUIVALENT PSYCHOLOGISTS EMPLOYED BY A HOSPITAL. COBOL NAME: NUM-PSYCHOL RADIOLOGY TECHNICIANS (DIAGNOSTIC) 7.2 463 469 N PROV6305 NUMBER OF FULL TIME EQUIVALENT DIAGNOSTIC RADIOLOGY TECHNICIANS EMPLOYED BY A HOSPITAL. COBOL NAME: NUM-RADIO-TECHS REGIONAL OVERRIDE #1 (NUMBER BEDS) 1 470 470 C PROV1545 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-1 VALUES: Y RECORD HAS BEEN APPROVED REGIONAL OVERRIDE #2 (STAFFING) 1 471 471 C PROV1550 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-2 VALUES: Y RECORD HAS BEEN APPROVED REGIONAL OVERRIDE #3 (NURSE - BED) 1 472 472 C PROV1555 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-3 VALUES: Y RECORD HAS BEEN APPROVED REGISTERED NURSES 7.2 473 479 N PROV1145 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PROFESSIONAL NURSES EMPLOYED BY A PROVIDER. COBOL NAME: NUM-REG-NURS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 17 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME REGISTERED PHARMACISTS 7.2 480 486 N PROV1100 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PHARMACISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHARMACIST-REG REHABILITATION UNIT BEDS 3 487 489 N PROV1730 THE NUMBER OF BEDS IN A PPS EXEMPT REHABILITATION UNIT OF A HOSPITAL. COBOL NAME: REHAB-UNIT-BED-SZ REHABILITATION UNIT EFFECT DATE 8 490 497 C PROV1735 THE DATE A REHABILITATION UNIT BECAME EXEMPT FROM THE PROSPECTIVE PAYMENT SYSTEM. COBOL NAME: REHAB-UNIT-EFF-DT REHABILITATION UNIT INDICATOR 1 498 498 C PROV1740 INDICATES IF A HOSPITAL HAS A PPS EXEMPT REHABILITATION UNIT. COBOL NAME: REHAB-UNIT-IND VALUES: Y REHAB UNIT REHABILITATION UNIT TERMINAT CODE 1 499 499 C PROV1745 THIS ELEMENT INDICATES THE REASON FOR A HOSPITAL REHABILITATION UNIT'S TERMINATION OF ITS EXCLUSION STATUS UNDER PROSPECTIVE PAYMENT SYSTEM. COBOL NAME: REHAB-UNIT-TERM-CD VALUES: 0 ACTIVE 1 VOLUNTARY-MERGER OR CLOSURE 2 VOLUNTARY-DISSATISFIED WITH REIMBURSEMENT 3 RISK OF INVOLUNTARY TERMINATION 4 VOLUNTARY-OTHER 5 FAILURE TO MEET HEALTH/SAFETY 6 FAILURE TO MEET AGREEMENT 7 PROVIDER STATUS CHANGE REHABILITATION UNIT TERMINAT DATE 8 500 507 C PROV1750 THIS ELEMENT IS THE DATE THE HOSPITAL'S PSYCHIATRIC UNIT IS NO LONGER EXCLUDED FROM PROSPECTIVE PAYMENT SYSTEM. COBOL NAME: REHAB-UNIT-TERM-DT RESIDENT PROGRAM APPROVED BY ADA 1 508 508 C PROV1805 INDICATES IF THE RESIDENT PROGRAM AT A HOSPITAL IS APPROVED BY THE AMERICAN DENTAL ASSOCIATION COBOL NAME: RES-PGM-APPR-ADA VALUES: N NOT APPROVED Y APPROVED RESIDENT PROGRAM APPROVED BY AMA 1 509 509 C PROV1810 INDICATES IF THE RESIDENT PROGRAM AT A HOSPITAL IS APPROVED BY THE AMERICAN MEDICAL ASSOCIATION. COBOL NAME: RES-PGM-APPR-AMA VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 18 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME N NOT APPROVED Y APPROVED RESIDENT PROGRAM APPROVED BY AOA 1 510 510 C PROV1815 INDICATES IF THE RESIDENT PROGRAM AT A HOSPITAL IS APPROVED BY THE AMERICAN OSTEOPATHIC ASSOCIATION. COBOL NAME: RES-PGM-APPR-AOA VALUES: N NOT APPROVED Y APPROVED RESIDENT PROGRAM APPROVED BY OTHER 1 511 511 C PROV1820 INDICATES IF THE RESIDENT PROGRAM AT A HOSPITAL IS APPROVED BY OTHER PROFESSIONAL ORGANIZATIONS. COBOL NAME: RES-PGM-APPR-OTHER VALUES: N NOT APPROVED Y APPROVED RESIDENTS (PHYSICIANS) 7.2 512 518 N PROV1165 THE NUMBER OF FULL-TIME EQUIVALENT RESIDENTS (PHYSICIANS) EMPLOYED BY A HOSPITAL. COBOL NAME: NUM-RESID-PHYS RESPIRATORY THERAPISTS 7.2 519 525 N PROV0950 NUMBER OF FULLTIME EQUIVALENT RESPIRATORY THERAPISTS EMPLOYED BY A HOSPITAL. COBOL NAME: NUM-INHAL-THERAPY SRV: ACUTE RENAL DIALYSIS 1 526 526 C PROV2055 INDICATES HOW ACUTE RENAL DIALYSIS SERVICES ARE PROVIDED IN A HOSPITAL. COBOL NAME: SP-ACUTE-REN-DIAL VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: ALCOHOL AND/OR DRUG 1 527 527 C PROV2065 INDICATES HOW ALCOHOL AND/OR DRUG SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-ALCOH-DRUG VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: AMBULANCE (OWNED) 1 528 528 C PROV6155 INDICATES HOW AMBULANCE (OWNED) SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-AMBUL-OWNED VALUES: 0 NOT PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 19 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: ANESTHESIA 1 529 529 C PROV2070 INDICATES HOW ANESTHESIA SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-ANESTH VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: AUDIOLOGY 1 530 530 C PROV6160 INDICATES HOW AUDIOLOGY SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-AUDIO VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: BLOOD BANK 1 531 531 C PROV5675 INDICIATES HOW BLOOD BANK SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-BLOOD-BANK VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: BURN CARE UNIT 1 532 532 C PROV2090 INDICATES HOW BURN CARE UNIT SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-BURN-UNIT VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: CARDIAC CATHETERIZATION LAB 1 533 533 C PROV6165 INDICATES HOW CARDIAC CATHETERIZATION LABORATORY SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-CARD-CATH-LAB VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 20 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: CARDIO-THORACIC SURGERY 1 534 534 C PROV2285 INDICATES HOW CARDIO-THORACIC SURGERY SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-OPEN-HEART-SURG VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: CHEMOTHERAPY SERVICE 1 535 535 C PROV6170 INDICATES HOW CHEMOTHERAPY SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-CHEMOTHER VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: CHIROPRACTIC 1 536 536 C PROV2100 INDICATES HOW CHIROPRACTICE SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-CHIROPRATIC VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: CT SCANNER 1 537 537 C PROV6175 INDICATES HOW CT SCANNER SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-CT-SCAN VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: DENTAL 1 538 538 C PROV2120 INDICATES HOW DENTAL SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-DENTAL VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 21 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: DIETARY 1 539 539 C PROV2130 INDICATES HOW DIETARY SERVICES ARE PROVIDED BY A HOSPITAL COBOL NAME: SP-DIETARY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: EMERGENCY DEPT (DEDICATED) 1 540 540 C PROV6180 INDICATES HOW DEDICATED EMERGENCY DEPARTMENT SERVICES ARE PROVIDED BY A HOSPITAL COBOL NAME: SP-EMERG-DEDICATED VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: EMERGENCY SERVICES 1 541 541 C PROV2140 INDICATES HOW EMERGENCY SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-EMERG-DEPT VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: GERONTOLOGICAL SPECIALTY 1 542 542 C PROV6190 INDICATES HOW GERONTOLOGICAL SPECIALTY SERVICES ARE PROVIDED IN A HOSPITAL. COBOL NAME: SP-GERON-SPEC VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: HOME HEALTH SERVICES 1 543 543 C PROV2160 INDICATES HOW HOME HEALTH SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-HOME-CARE-UNIT VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 22 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: HOSPICE 1 544 544 C PROV2175 INDICATES HOW HOSPICE SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-HOSPICE VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: ICU - CARDIAC (NON-SURGICAL) 1 545 545 C PROV2110 INDICATES HOW ICU - CARDIAC (NON-SURGICAL)SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-CORONARY-CARE VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: ICU - MEDICAL/SURGICAL 1 546 546 C PROV2185 INDICATES HOW ICU - MEDICAL/SURGICAL SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-ICU VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: ICU - NEONATAL 1 547 547 C PROV6195 INDICATES HOW ICU - NEONATAL SERVICES ARE PROVIDED IN A HOSPITAL. COBOL NAME: SP-ICU-NEONATAL VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: ICU - PEDIATRIC 1 548 548 C PROV6200 INDICATES HOW ICU - PEDIATRIC SERVICES ARE PROVIDED IN A HOSPITAL. COBOL NAME: SP-ICU-PEDIATRIC VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 23 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: ICU - SURGICAL 1 549 549 C PROV6205 INDICATES HOW ICU - SURGICAL SERVICES ARE PROVIDED IN A HOSPITAL. COBOL NAME: SP-ICU-SURG VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: LABORATORY (ANATOMICAL) 1 550 550 C PROV2205 INDICATES HOW ANATOMICAL LABORATORY SERVICES ARE PROVIDED IN A HOSPITAL. COBOL NAME: SP-LABORATORY-ANATOM VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: LABORATORY (CLINICAL) 1 551 551 C PROV2210 INDICATES HOW CLINICAL LABORATORY SERVICES ARE PROVIDED IN A HOSPITAL. COBOL NAME: SP-LABORATORY-CLINIC VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: LONG TERM CARE (SWING-BEDS) 1 552 552 C PROV2215 INDICATES HOW LONG TERM CARE (SWING-BEDS) SERVICES ARE PROVIDED IN A HOSPITAL COBOL NAME: SP-LTC-UNIT VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: MAGNETIC RESONANCE IMAGING 1 553 553 C PROV6210 INDICATES HOW MAGNETIC RESONANCE IMAGING (MRI) SERVICES ARE PROVIDED IN A HOSPITAL. COBOL NAME: SP-MRI VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 24 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: NEONATAL NURSERY 1 554 554 C PROV2235 INDICATES HOW NEONATAL NURSERY SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-NEONATAL-NURS VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: NEUROSURGICAL SERVICES 1 555 555 C PROV6215 INDICATES HOW NEUROSURGICAL SERVICES ARE PROVIDED IN A HOSPITAL. COBOL NAME: SP-NEURO-SURG VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: NUCLEAR MEDICINE 1 556 556 C PROV2245 INDICATES HOW NUCLEAR MEDICINE SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-NUCLEAR-MED VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: OBSTETRICS 1 557 557 C PROV2265 INDICATES HOW OBSTETRIC SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-OBSTETRICS VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: OCCUPATIONAL THERAPY 1 558 558 C PROV2270 INDICATES HOW OCCUPATIONAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-OCCUP-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 25 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: OPERATING ROOMS 1 559 559 C PROV2300 INDICATES HOW OPERATING ROOM SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-OR-ROOMS VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: OPTHALMIC SURGERY 1 560 560 C PROV6220 INDICATES HOW OPTHALMIC SURGERY SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-OPTHALMIC-SURG VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: OPTOMETRIC 1 561 561 C PROV2295 INDICATES HOW OPTOMETRIC SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-OPTOMETRIC VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: ORGAN BANK 1 562 562 C PROV2310 INDICATES HOW ORGAN BANK SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-ORGAN-BANK VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: ORGAN TRANSPLANT 1 563 563 C PROV2315 INDICATES HOW ORGAN TRANSPLANT SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-ORGAN-TRANS VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 26 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: ORTHOPEDIC SURGERY 1 564 564 C PROV6225 INDICATES HOW ORTHOPEDIC SURGERY SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-ORTHOPEDIC-SURG VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: OUTPATIENT 1 565 565 C PROV2350 INDICATES HOW OUTPATIENT SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-OUTPAT VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: OUTPATIENT SURGERY UNIT 1 566 566 C PROV2355 INDICATES HOW OUTPATIENT SURGERY UNIT SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-OUTPAT-SURG VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: PEDIATRIC 1 567 567 C PROV2360 INDICATES HOW PEDIATRIC SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-PEDIATRIC VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: PET SCAN SERVICES 1 568 568 C PROV6230 INDICATES HOW POSITRON EMISSION TOMOGRAPHY (PET) SCAN SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-POS-EMIS-TOM-SCAN VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 27 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHARMACY 1 569 569 C PROV2365 INDICATES HOW PHARMACY SERVICES ARE PROVIDED. COBOL NAME: SP-PHARMACY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: PHYSICAL THERAPY 1 570 570 C PROV2370 INDICATES HOW PHYSICAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICAL-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: POSTOPERATIVE RECOVERY ROOM 1 571 571 C PROV2410 INDICATES HOW POSTOPERATIVE RECOVERY ROOM SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-POSTOP-REC-RM VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: PSYCHIATRIC 1 572 572 C PROV2415 INDICATES HOW PSYCHIATRIC SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-PSYCHIATRIC VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: PSYCHIATRIC - FORENSIC 1 573 573 C PROV6245 INDICATES HOW FORENSIC PSYCHIATRIC SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-PSY-FORENSIC VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: PSYCHIATRIC - GERIATRIC 1 574 574 C PROV6250 INDICATES HOW GERIATRIC PSYCHIATRIC SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-PSY-GERIATRIC VALUES: 0 NOT PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 28 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: PSYCHIATRIC - OUTPATIENT 1 575 575 C PROV6255 INDICATES HOW OUTPPATIENT PSYCHIATRIC SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-PSY-OUTPAT VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: PSYCHIATRIC CHILD/ADOLESCENT 1 576 576 C PROV6240 INDICATES HOW CHILD/ADOLESCENT PSYCHIATRIC SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-PSY-CHILD-ADOL VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: PSYCHIATRIC-EMERGENCY 1 577 577 C PROV6235 INDICATES HOW EMERGENCY PSYCHIATRIC SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-PSY-EMERG VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: RADIOLOGY (DIAGNOSTIC) 1 578 578 C PROV2440 INDICATES HOW DIAGNOSTIC RADIOLOGY SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-RADIOLOGY-DIAG VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: RADIOLOGY (THERAPEUTIC) 1 579 579 C PROV2445 INDICATES HOW THERAPEUTIC RADIOLOGY SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-RADIOLOGY-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 29 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: RECONSTRUCTIVE SURGERY 1 580 580 C PROV6260 INDICATES HOW RECONSTRUCTIVE SURGERY SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-RECON-SURG VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: REHAB - INPATIENT (CARF) 1 581 581 C PROV6270 INDICATES HOW INPATIENT REHABILITATION (CARF ACCREDITED) SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-REHABIL-CARF VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: REHAB - OUTPATIENT 1 582 582 C PROV6265 INDICATES HOW OUTPATIENT REHABILITATION SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-REHABIL-OUTPAT VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: REHAB INPATIENT (NOT CARF) 1 583 583 C PROV2450 INDICATES HOW INPATIENT REHABILITIATION (NOT CARF ACCREDITED) SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-REHABIL VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: SHOCK WAVE LITHOTRIPTER 1 584 584 C PROV6185 INDICATES HOW EXTRACORPOREAL SHOCK WAVE LITHOTRIPTER SERVICES ARE PROVIDED IN A HOSPITAL. COBOL NAME: SP-EXTRAC-SHOCK-WAVE VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 30 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: SOCIAL 1 585 585 C PROV2485 INDICATES HOW SOCIAL SERVICES ARE PROVIDED. COBOL NAME: SP-SOCIAL VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: SPEECH PATHOLOGY 1 586 586 C PROV2505 INDICATES HOW SPEECH PATHOLOGY SERVICES ARE PROVIDED. COBOL NAME: SP-SPEECH-PATH VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT OR AGREEMENT 3 COMBINATION SRV: SURGICAL SERVICES-INPATIENT 1 587 587 C PROV2190 INDICATES HOW INPATIENT SURGICAL SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-INPAT-SURG VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: TRANSPLANT CENTER, MEDICARE 1 588 588 C PROV6275 INDICATES HOW MEDICARE CERTIFIED TRANSPLANT CENTER SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-TRANS-MEDICARE VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: TRAUMA CENTER (CERTIFIED) 1 589 589 C PROV2475 INDICATES HOW CERTIFIED TRAUMA CENTER SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-SHOCK-TRAUMA VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SRV: URGENT CARE CENTER SERVICES 1 590 590 C PROV6280 INDICATES HOW URGENT CARE CENTER SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-URGENT-CARE VALUES: 0 NOT PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 31 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT SWING BED INDICATOR 1 591 591 C PROV2795 INDICATES IF A HOSPITAL PROVIDES SWING BED SERVICES - BEDS CAN BE USED FOR EITHER HOSPITAL OR LONG TERM CARE SERVICES. COBOL NAME: SWINGBED-IND VALUES: N NO Y YES SWING BED SIZE CODE 1 592 592 C PROV2800 INDICATES THE SIZE OF A HOSPITAL PROVIDING SWING BED SERVICES. COBOL NAME: SWINGBED-SIZE-CD VALUES: 1 49 OR FEWER BEDS 2 50 TO 99 BEDS TYPE OF FACILITY 2 593 594 C PROV2890 INDICATES THE CATEGORY WHICH REPRESENTS THE TYPE OF FACILITY. COBOL NAME: TYPE-FACILITY VALUES: 01 SHORT - TERM 02 LONG - TERM 03 RELIGIOUS NONMEDICAL HEALTH CARE INSTITUTION 04 PSYCHIATRIC 05 REHABILITATION 06 CHILDRENS 07 DISTINCT PART PSYCH HOSPITAL 11 CRITICAL ACCESS HOSPITALS TYPE OF NON-PARTICIPATING PROVIDER 1 595 595 C PROV0690 INDICATES WHETHER A NON-PARTICIPATING HOSPITAL IS FEDERAL OR OTHER THAN FEDERAL. COBOL NAME: NON-PARTICIPATING-TYPE VALUES: E EMERGENCY HOSPITAL NON-FEDERAL F EMERGENCY HOSPITAL FEDERAL SPEECH PATHOLOGISTS, AUDIOLOGISTS 7.2 1446 1452 N PROV1220 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS OR AUDIOLOGISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-SPEECH-PATH-AUDIO NURSE PRACTITIONERS 7.2 1622 1628 N PROV1015 NUMBER OF FULL-TIME EQUIVALENT NURSE PRACTITIONERS. COBOL NAME: NUM-NURSE-PRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 32 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PHYSICIANS 7.2 1639 1645 N PROV1110 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIANS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS SRV: RESPIRATORY CARE 1 1688 1688 C PROV2455 INDICATES HOW RESPIRATORY CARE SERVICES ARE PROVIDED. COBOL NAME: SP-RESP-CARE VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY STAFF AND THROUGH AGREEMENT MEDICAL SOCIAL WORKERS 7.2 1765 1771 N PROV0975 NUMBER OF FULL-TIME EQUIVALENT MEDICAL SOCIAL WORKERS EMPLOYED BY A HOSPITAL OR HOSPICE. COBOL NAME: NUM-MED-SOCIAL-WRKS FAX PHONE NUMBER 10 2039 2048 C PROV5800 THE 10 DIGIT FAX PHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF THE LABORATORY OR HOSPITAL COBOL NAME: FAX-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 1 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 03 TITLE 18/19 CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 02 SNF/NF (DUALLY CERTIFIED) CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 2 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 NATIONAL GOVERNMENT SERVICES 00180 NATIONAL GOVERNMENT SERVICES 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 3 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01101 PALMETTO (CALIFORNIA) 01201 PALMETTO (HAWAII) 01301 PALMETTO (NEVADA) 01390 AETNA (WASHINGTON) 02101 NATIONAL HERITAGE (ALASKA) 02201 NATIONAL HERITAGE (IDAHO) 02301 NATIONAL HERITAGE (OREGON) 02401 NATIONAL HERITAGE (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03101 NORIDIAN (ARIZONA) 03201 NORIDIAN (MONTANA) 03301 NORIDIAN (NORTH DAKOTA) 03401 NORIDIAN (SOUTH DAKOTA) 03501 NORIDIAN (UTAH) 03601 NORIDIAN (WYOMING) 04101 TRAILBLAZER (COLORADO) 04201 TRAILBLAZER (NEW MEXICO) 04301 TRAILBLAZER (OKLAHOMA) 04401 TRAILBLAZER (TEXAS) 05101 WPS (IOWA) 05201 WPS (KANSAS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 4 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 05301 WPS (MISSOURI) 05401 WPS (NEBRASKA) 07101 PINNACLE (ARKANSAS) 07201 PINNACLE (LOUISIANA) 07301 PINNACLE (MISSISSIPPI) 08101 PINNACLE (INDIANA) 08201 PINNACLE (MICHIGAN) 09101 FIRST COAST (FLORIDA) 09201 FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 12101 HIGHMARK (DELAWARE) 12201 HIGHMARK (DISTRICT OF COLUMBIA) 12301 HIGHMARK (MARYLAND) 12401 HIGHMARK NEW JERSEY) 12501 HIGHMARK (PENNSYLVANIA) 13101 NATL GOVT SERVICES (CONNECTICUT) 13201 NATL GOVT SERVICES (NEW YORK) 14101 NATIONAL HERITAGE (MAINE) 14201 NATIONAL HERITAGE (MASSACHUSETTS) 14301 NATIONAL HERITAGE (NEW HAMPSHIRE) 14401 NATIONAL HERITAGE (RHODE ISLAND) 14501 NATIONAL HERITAGE (VERMONT) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 5 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 6 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN ADMIN SERVICES (ARIZONA) 03202 NORIDIAN ADMIN SERVICES (MONTANA) 03302 NORIDIAN ADMIN SERVICES (NORTH DAKOTA) 03402 NORIDIAN ADMIN SERVICES (MONTANA) 03502 NORIDIAN ADMIN SERVICES (UTAH) 03602 NORIDIAN ADMIN SERVICES (WYOMING) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 7 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 8 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 9 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 10 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATE REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 11 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 FOR PROFIT - INDIVIDUAL 02 FOR PROFIT - PARTNERSHIP 03 FOR PROFIT - CORPORATION 04 NONPROFIT - CHURCH RELATED 05 NONPROFIT - CORPORATION 06 NONPROFIT - OTHER 07 GOVERNMENT - STATE 08 GOVERNMENT - COUNTY 09 GOVERNMENT - CITY 10 GOVERNMENT - CITY/COUNTY 11 GOVERNMENT - HOSPITAL DISTRICT 12 GOVERNMENT - FEDERAL 13 LIMITED LIABILITY CORPORATION ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD BEDS - TOTAL 4 291 294 N PROV0740 TOTAL NUMBER OF BEDS IN A FACILITY, INCLUDING THOSE IN NON-PARTICIPATING OR NON-LICENSED AREAS. COBOL NAME: NUM-BEDS BEDS - TOTAL CERTIFIED 4 295 298 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS COMPLIANCE: LIFE SAFETY CODE 1 356 356 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 12 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 1 WAIVER RECOMMENDED COMPLIANCE: 24 HR REGISTERED NURSE 1 359 359 C PROV0290 INDICATES IF A WAIVER OF THE 24 HOUR REGISTERED NURSE REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-24-HR-RN VALUES: 1 WAIVER RECOMMENDED FISCAL YEAR ENDING DATE 4 378 381 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT PROGRAM PARTICIPATION 1 434 434 C PROV1670 INDICATES IF THE PROVIDER PARTICIPATES IN MEDICARE, MEDICAID, OR BOTH PROGRAMS. COBOL NAME: PROG-PARTCI VALUES: 1 MEDICARE ONLY 2 MEDICAID ONLY 3 MEDICARE AND MEDICAID REGIONAL OVERRIDE #1 (NUMBER BEDS) 1 470 470 C PROV1545 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-1 VALUES: Y RECORD HAS BEEN APPROVED REGIONAL OVERRIDE #2 (STAFFING) 1 471 471 C PROV1550 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-2 VALUES: Y RECORD HAS BEEN APPROVED ACTIVITY PROFESSIONAL - CONTRACT 7.2 596 602 N PROV0695 THE NUMBER OF FULL TIME EQUIVALENT ACTIVITIES PROFESSIONALS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-ACT-THER-CONTRACT ACTIVITY PROFESSIONAL - FULL TIME 7.2 603 609 N PROV0700 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES PROFESSIONALS EMPLOYED FULL TIME BY A FACILITY. COBOL NAME: NUM-ACT-THER-FULL-TIME ACTIVITY PROFESSIONAL - PART TIME 7.2 610 616 N PROV0705 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES PROFESSIONALS EMPLOYED PART TIME BY A FACILITY. COBOL NAME: NUM-ACT-THER-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 13 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ADMINISTRATION - CONTRACT 7.2 617 623 N PROV0710 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-ADMN-CONTRACT ADMINISTRATOR - FULL TIME 7.2 624 630 N PROV0715 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF EMPLOYED ON A FULL TIME BASIS BY A FACILITY. COBOL NAME: NUM-ADMN-FULL-TIME ADMINISTRATOR - PART TIME 7.2 631 637 N PROV0720 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF EMPLOYED ON A PART-TIME BASIS BY A FACILITY. COBOL NAME: NUM-ADMN-PART-TIME BEDS - MEDICARE SNF 4 638 641 N PROV1445 NUMBER OF MEDICARE CERTIFIED SNF BEDS IN A FACILITY. COBOL NAME: NUM-T18-SNF-BEDS BEDS - NURSING FACILITY 4 642 645 N PROV1455 NUMBER OF MEDICAID CERTIFIED SKILLED NURSING CARE BEDS IN A FACILITY. COBOL NAME: NUM-T19-SNF-BEDS BEDS - SNF/NF 4 646 649 N PROV1450 NUMBER OF BEDS CERTIFIED FOR BOTH MEDICARE AND MEDICAID SKILLED NURSING CARE IN A LONG TERM CARE FACILITY. COBOL NAME: NUM-T1819-SNF-BEDS CERT NURSE AIDES - CONTRACT 7.2 650 656 N PROV1000 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-NURSE-AID-CONTRACT CERT NURSE AIDES - FULL TIME 7.2 657 663 N PROV1005 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-AID-FULL-TIME CERT NURSE AIDES - PART TIME 7.2 664 670 N PROV1010 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-AID-PART-TIME CHRISTIAN SCIENCE INDICATOR 1 671 671 C PROV0110 INDICATES IF A PROVIDER IS A CHRISTIAN SCIENCE FACILITY COBOL NAME: CHRISTIAN-SCIENCE-IND VALUES: Y CHRISTIAN SCIENCE COMPLIANCE: BEDS PER ROOM WAIVER 1 672 672 C PROV0225 INDICATES IF A WAIVER OF THE BEDS PER ROOM REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-BEDS-PER-ROOM VALUES: 1 WAIVER RECOMMENDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 14 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COMPLIANCE: PATIENT ROOM SIZE 1 673 673 C PROV0270 INDICATES IF A WAIVER OF PATIENT ROOM SIZE HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-PATIENT-ROOM-SZ VALUES: 1 WAIVER RECOMMENDED COMPLIANCE: 7 DAY REGISTERED NURSE 1 674 674 C PROV0295 INDICATES IF A WAIVER OF THE 7 DAY REGISTERED NURSE REQUIREMENTS HAS BEEN RECOMMENDED FOR A SNF OR NF. COBOL NAME: COMPL-7-DAY-RN VALUES: 1 WAIVER RECOMMENDED DENTISTS - CONTRACT 7.2 675 681 N PROV0785 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DENTIST-CONTRACT DENTISTS - FULL TIME 7.2 682 688 N PROV0790 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-DENTIST-FULL-TIME DENTISTS - PART TIME 7.2 689 695 N PROV0795 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-DENTIST-PART-TIME DIETITIANS - CONTRACT 7.2 696 702 N PROV0805 THE NUMBER OF FULL-TIME EQUIVALENT UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DIET-CONTRACT DIETITIANS - FULL TIME 7.2 703 709 N PROV0810 THE NUMBER OF FULL-TIME EQUIVALENT DIETITIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-DIET-FULL-TIME DIETITIANS - PART TIME 7.2 710 716 N PROV0815 THE NUMBER OF FULL-TIME EQUIVALENT DIETITIANS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-DIET-PART-TIME EXPERIMENTAL RESEARCH CONDUCTED 1 717 717 C PROV0465 INDICATES IF A FACILITY USES RESIDENTS TO DEVELOP AND TEST CLINICAL TREATMENTS. COBOL NAME: EXPER-RESEARCH VALUES: Y YES FOOD SERVICE - CONTRACT 7.2 718 724 N PROV0860 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-FOOD-SRV-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 15 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FOOD SERVICE - FULL TIME 7.2 725 731 N PROV0865 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-FOOD-SRV-FULL-TIME FOOD SERVICE - PART TIME 7.2 732 738 N PROV0870 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-FOOD-SRV-PART-TIME HOUSEKEEPING - CONTRACT 7.2 739 745 N PROV0925 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-HOUSE-CONTRACT HOUSEKEEPING - FULL TIME 7.2 746 752 N PROV0930 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-HOUSE-FULL-TIME HOUSEKEEPING - PART TIME 7.2 753 759 N PROV0935 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-HOUSE-PART-TIME LPN/LVN - CONTRACT 7.2 760 766 N PROV1465 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-VOC-NURSE-CONTRACT LPN/LVN - FULL TIME 7.2 767 773 N PROV1470 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-VOC-NURSE-FULL-TIME LPN/LVN - PART TIME 7.2 774 780 N PROV1475 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-VOC-NURSE-PART-TIME LTC CROSS REFERENCE PROVIDER # 6 781 786 C PROV0640 THIS CROSS REFERENCE NUMBER IDENTIFIES LTC PROVIDER NUMBERS THAT WERE TERMINATED IN 1985 BECAUSE OF POLICY CHANGES WHICH STATES THAT SNF/ICF DISTINCT PARTS OR DUA LLY CERTIFIED PORTIONS ARE ASSIGNED SINGLE SNF PROV NO. COBOL NAME: LTC-CROSS-REF-PROV-NUM MEDICAL DIRECTOR - CONTRACT 7.2 787 793 N PROV0960 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS UNDER CONTRCAT TO A FACILITY. COBOL NAME: NUM-MED-CONTRACT MEDICAL DIRECTOR - FULL TIME 7.2 794 800 N PROV0965 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MED-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 16 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MEDICAL DIRECTOR - PART TIME 7.2 801 807 N PROV0970 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MED-PART-TIME MEDICATION AIDES/TECHS-CONTRACT 7.2 808 814 N PROV5180 THE NUMBER OF FULL-TIMR EQUIVALENT MEDICATION AIDES/ TECHNICIANS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-MED-AID-CONTRACT MEDICATION AIDES/TECHS-FULL TIME 7.2 815 821 N PROV5170 THE NUMBER OF FULL-TIME EQUIVALENT MEDICATION AIDES/ TECHNICIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MED-AID-FULL-TIME MEDICATION AIDES/TECHS-PART TIME 7.2 822 828 N PROV5175 THE NUMBER OF FULL-TIME EQUIVALENT MEDICATION AIDES/ TECHNICIANS EMPLOYED BYA FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MED-AID-PART-TIME MENTAL HEALTH SERVICES - CONTRACT 7.2 829 835 N PROV0980 THE NUMBER OF FULL-TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-MEN-HLTH-CONTRACT MENTAL HEALTH SERVICES - FULL TIME 7.2 836 842 N PROV0985 THE NUMBER OF FULL-TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MEN-HLTH-FULL-TIME MENTAL HEALTH SERVICES - PART TIME 7.2 843 849 N PROV0990 THE NUMBER OF FULL TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MEN-HLTH-PART-TIME MULTI-FACILITY ORGANIZATION NAME 38 850 887 C PROV0680 THE NAME OF THE MULTI-FACILITY ORGANIZATION THAT OWNS THE FACILITY. COBOL NAME: NAME-MULT-FACL-ORG MULTI-FACILITY ORGANIZATION OWNED 1 888 888 C PROV0675 INDICATES IF A FACILITY IS OWNED BY AN ORGANIZATION THAT OWNS (OR LEASES) TWO OR MORE NURSING FACILITIES. COBOL NAME: MULT-FACL-ORG VALUES: Y YES NURSE AIDES IN TRNG - CONTRACT 7.2 889 895 N PROV5165 NUMBER OF FULL TIME EQUIVALENT NURSE AIDES IN TRAINING UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-AID-TRNG-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 17 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME NURSE AIDES IN TRNG-FULL TIME 7.2 896 902 N PROV5155 THE NUMBER OF FULL-TIME EQUIVALENT NURSE AIDES IN TRAINING EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-AID-TRNG-FULL-TIME NURSE AIDES IN TRNG-PART TIME 7.2 903 909 N PROV5160 THE NUMBER OF FULL-TIME EQUIVALENT NURSE AIDES IN TRAINING EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-AID-TRNG-PART-TIME NURSES WITH ADMIN DUTIES-CONTRACT 7.2 910 916 N PROV5150 THE NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-NURSE-ADM-CONTRACT NURSES WITH ADMIN DUTIES-FULL TIME 7.2 917 923 N PROV5135 THE NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-ADM-FULL-TIME NURSES WITH ADMIN DUTIES-PART TIME 7.2 924 930 N PROV5145 NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-ADM-PART-TIME OCCUP THERAPIST, FULL TIME, STAFF 7.2 931 937 N PROV1040 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-THER-FULL-TIME OCCUP THERAPISTS, CONTRACT/ARRANGE 7.2 938 944 N PROV1035 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-THER-CONTRACT OCCUP THERAPY AIDE - CONTRACT 7.2 945 951 N PROV1020 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-AID-CONTRACT OCCUP THERAPY AIDE - FULL TIME 7.2 952 958 N PROV1025 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-AID-FULL-TIME OCCUP THERAPY AIDE - PART TIME 7.2 959 965 N PROV1030 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-AID-PART-TIME OCCUP THERAPY ASST - CONTRACT 7.2 966 972 N PROV5195 THE NUMBER OF FULL TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS UNDER CONTRCAT TO A FACILITY. COBOL NAME: NUM-OCC-ASST-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 18 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OCCUP THERAPY ASST - FULL TIME 7.2 973 979 N PROV5185 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-ASST-FULL-TIME OCCUP THERAPY ASST - PART TIME 7.2 980 986 N PROV5190 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-ASST-PART-TIME OCCUPATIONAL THERAPIST - PART TIME 7.2 987 993 N PROV1045 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-THER-PART-TIME ORGANIZED FAMILY GROUP 1 994 994 C PROV1535 INDICATES IF THE FACILITY HAS AN ORGANIZED GROUP OF FAMILY MEMBERS OF RESIDENTS. COBOL NAME: ORG-FAMILY-GRP VALUES: Y YES ORGANIZED RESIDENT GROUP 1 995 995 C PROV1540 INDICATES IF THE FACILITY HAS AN ORGANIZED RESIDENTS GROUP. COBOL NAME: ORG-RESID-GRP VALUES: Y YES OTHER - CONTRACT 7.2 996 1002 N PROV3265 THE NUMBER OF FULL-TIME EQUIVALENT PERSONS NOT INCLUDED IN ANY OTHER CATEGORIES UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-OTH-CONTRACT OTHER - FULL TIME 7.2 1003 1009 N PROV3245 THE NUMBER OF FULL-TIME EQUIVALENT PERSONS NOT INCLUDED IN ANY OTHER CATEGORIES EMPLOYED BY THE FACILITY ON A FULL-TIME BASIS. COBOL NAME: NUM-OTH-FULL-TIME OTHER - PART TIME 7.2 1010 1016 N PROV3255 THE NUMBER OF FULL-TIME EQUIVALENT PERSONS NOT INCLUDED IN ANY OTHER CATEGORIES EMPLOYED BY THE FACILITY ON A PART-TIME BASIS. COBOL NAME: NUM-OTH-PART-TIME OTHER ACTIVITIES STAFF-CONTRACT 7.2 1017 1023 N PROV5270 NUMBER OF CONTRACT STAFF HOURS FOR OTHER ACTIVITIES. COBOL NAME: NUM-OTH-ACT-CONTRACT OTHER ACTIVITIES STAFF-FULL TIME 7.2 1024 1030 N PROV5260 NUMBER OF FULL-TIME STAFF HOURS FOR OTHER ACTIVITIES. COBOL NAME: NUM-OTH-ACT-FULL-TIME OTHER ACTIVITIES STAFF-PART TIME 7.2 1031 1037 N PROV5305 NUMBER OF PART TIME STAFF HOURS PROVIDED BY OTHER ACTIV ITIES STAFF. COBOL NAME: NUM-OTH-ACT-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 19 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OTHER PHYSICIAN - CONTRACT 7.2 1038 1044 N PROV1060 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS UNDER CONTRACT TO A FACILITY COBOL NAME: NUM-OTH-PHY-CONTRACT OTHER PHYSICIAN - FULL TIME 7.2 1045 1051 N PROV1065 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OTH-PHY-FULL-TIME OTHER PHYSICIAN - PART TIME 7.2 1052 1058 N PROV1070 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OTH-PHY-PART-TIME OTHR SOCIAL SERV STAFF-CONTRACT 7.2 1059 1065 N PROV5300 NUMBER OF CONTRACT STAFF HOURS PROVIDED BY OTHER SOCIAL SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-CONTRACT OTHR SOCIAL SERV STAFF-FULL TIME 7.2 1066 1072 N PROV5290 NUMBER OF FULL-TIME STAFF HOURS PROVIDED BY OTHER SOCIA L SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-FULL-TIME OTHR SOCIAL SERV STAFF-PART TIME 7.2 1073 1079 N PROV5295 NUMBER OF PART-TIME STAFF HOURS PROVIDED BY OTHER SOCIA L SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-PART-TIME PHARMACISTS - CONTRACT 7.2 1080 1086 N PROV1085 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-PHAR-CONTRACT PHARMACISTS - FULL TIME 7.2 1087 1093 N PROV1090 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-PHAR-FULL-TIME PHARMACISTS - PART TIME 7.2 1094 1100 N PROV1095 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-PHAR-PART-TIME PHYS THER ASST - CONTRACT 7.2 1101 1107 N PROV5210 NUMBER OF CONTRACT STAFF HOURS FOR PHYSICAL THERAPY ASS ISTANTS. COBOL NAME: NUM-THER-ASST-CONTRACT PHYS THER ASST - FULL TIME 7.2 1108 1114 N PROV5200 NUMBER OF FULL-TIME STAFF HOURS FOR PHYSICAL THERAPY AS SISTANTS. COBOL NAME: NUM-THER-ASST-FULL-TIME PHYS THER ASST - PART TIME 7.2 1115 1121 N PROV5205 NUMBER OF PART-TIME STAFF HOURS FOR PHYSICAL THERAPY AS SISTANTS. COBOL NAME: NUM-THER-ASST-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 20 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PHYSICAL THERAPISTS - CONTRACT 7.2 1122 1128 N PROV1430 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-CONTRACT PHYSICAL THERAPISTS - FULL TIME 7.2 1129 1135 N PROV1435 THE NUMBER OF FULL TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-FULL-TIME PHYSICAL THERAPISTS - PART TIME 7.2 1136 1142 N PROV1440 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-PART-TIME PHYSICAL THERAPY AIDE - CONTRACT 7.2 1143 1149 N PROV1415 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-AID-CONTRACT PHYSICAL THERAPY AIDE - FULL TIME 7.2 1150 1156 N PROV1420 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-AID-FULL-TIME PHYSICAL THERAPY AIDE - PART TIME 7.2 1157 1163 N PROV1425 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-AID-PART-TIME PHYSICIAN EXTENDER - CONTRACT 7.2 1164 1170 N PROV3270 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIAN EXTENDERS UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-PHYS-EXT-CONTRACT PHYSICIAN EXTENDER - FULL TIME 7.2 1171 1177 N PROV3250 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIAN EXTENDERS EMPLOYED BY THE FACILITY ON A FULL-TIME BASIS. COBOL NAME: NUM-PHYS-EXT-FULL-TIME PHYSICIAN EXTENDER - PART TIME 7.2 1178 1184 N PROV3260 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIAN EXTENDERS EMPLOYED BY THE FACILITY ON A PART-TIME BASIS. COBOL NAME: NUM-PHYS-EXT-PART-TIME PODIATRISTS - CONTRACT 7.2 1185 1191 N PROV1130 THE NUMBER OF FULL TIME EQUIVALENT PODIATRISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-POD-CONTRACT PODIATRISTS - FULL TIME 7.2 1192 1198 N PROV1135 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A AFCILITY ON A FULL TIME BASIS. COBOL NAME: NUM-POD-FULL-TIME PODIATRISTS - PART TIME 7.2 1199 1205 N PROV1140 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-POD-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 21 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PROVIDER BASED FACILITY 1 1206 1206 C PROV1675 INDICATES IF A LONG TERM CARE FACILITY IS PROVIDER BASED. COBOL NAME: PROV-BASED-FACILITY VALUES: Y HOSPITAL BASED REGISTERED NURSE - CONTRACT 7.2 1207 1213 N PROV1150 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-REG-NURSE-CONTRACT REGISTERED NURSE - FULL TIME 7.2 1214 1220 N PROV1155 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-REG-NURSE-FULL-TIME REGISTERED NURSE - PART TIME 7.2 1221 1227 N PROV1160 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-REG-NURSE-PART-TIME RELATED PROVIDER NUMBER 10 1228 1237 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM RN DIRECTOR OF NURSING - CONTRACT 7.2 1238 1244 N PROV5130 THE NUMBER OF FULL TIME EQUIVALENT RN DIRECTOR OF NURSI NG UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-RN-DON-CONTRACT RN DIRECTOR OF NURSING - FULL TIME 7.2 1245 1251 N PROV5120 THE NUMBER OF FULL-TIME EQUIVALENT RN DIRECTOR OF NURSING EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-RN-DON-FULL-TIME RN DIRECTOR OF NURSING - PART TIME 7.2 1252 1258 N PROV5140 THE NUMBER OF FULL-TIME EQUIVALENT RN DIRECTOR OF NURSING EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-RN-DON-PART-TIME SOCIAL WORKER - CONTRACT 7.2 1259 1265 N PROV1170 THE NUMBER OF FULL-TIME EQUIVALENT SOCIAL WORKERS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-SOCIAL-CONTRACT SOCIAL WORKER - FULL TIME 7.2 1266 1272 N PROV1175 THE NUMBER OF FULL-TIME EQUIVALENT SOCIAL WORKERS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-SOCIAL-FULL-TIME SOCIAL WORKER - PART TIME 7.2 1273 1279 N PROV1180 THE NUMBER OF FULL-TIME EQUIVALENT SOCIAL WORKERS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-SOCIAL-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 22 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPECIAL CARE BEDS-AIDS 3 1280 1282 N PROV0725 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH AIDS. COBOL NAME: NUM-AIDS-BEDS SPECIAL CARE BEDS-ALZHEIMERS 3 1283 1285 N PROV0730 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH ALZEHEIMERS. COBOL NAME: NUM-ALZHEIMERS-BEDS SPECIAL CARE BEDS-DIALYSIS 3 1286 1288 N PROV0800 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS NEEDING DIALYSIS. COBOL NAME: NUM-DIAL-BEDS SPECIAL CARE BEDS-DISABLED CHILD 3 1289 1291 N PROV0855 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR DEISCABLED CHILDREN. COBOL NAME: NUM-DIS-CHILD-BEDS SPECIAL CARE BEDS-HEAD TRAUMA 3 1292 1294 N PROV0905 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILTY FOR RESIDENTS WITH HEAD TRAUMA. COBOL NAME: NUM-HEAD-TRAUMA-BEDS SPECIAL CARE BEDS-HOSPICE 3 1295 1297 N PROV0920 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY A FACILITY FOR RESIDENTS NEEDING HOSPICE SERVICES. COBOL NAME: NUM-HOSPICE-BEDS SPECIAL CARE BEDS-HUNTINGTONS 3 1298 1300 N PROV0940 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH HUNTINGTON'S DISEASE COBOL NAME: NUM-HUNTING-DIS-BEDS SPECIAL CARE BEDS-SPEC REHAB 3 1301 1303 N PROV1205 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH SPECIALIZED REHAB NEEDS. COBOL NAME: NUM-SPEC-REHAB-BEDS SPECIAL CARE BEDS-VENTILATOR 3 1304 1306 N PROV1460 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH VENTILATOR/ RESIPIRATORY CARE NEEDS. COBOL NAME: NUM-VENT-RESP-BEDS SPEECH PATHOLOGIST - CONTRACT 7.2 1307 1313 N PROV1190 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-SPCH-PATH-CONTRACT SPEECH PATHOLOGIST - FULL TIME 7.2 1314 1320 N PROV1195 THE NUMBER OF FULL-TIME EQUIVALENT SPPECH PATHOLOGISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-SPCH-PATH-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 23 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPEECH PATHOLOGIST - PART TIME 7.2 1321 1327 N PROV1200 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-SPCH-PATH-PART-TIME SRV: ACTIVITIES-OFFSITE-RESIDENTS 1 1328 1328 C PROV3390 INDICATES IF ACTIVITIES SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-ACT-THER-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: ACTIVITIES-ONSITE-NON RES 1 1329 1329 C PROV3385 INDICATES IF ACTIVITIES SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-ACT-THER-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: ACTIVITIES-ONSITE-RESIDENTS 1 1330 1330 C PROV3380 INDICATES IF ACTIVITIES SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-ACT-THER-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: BLOOD ADMIN-OFFSITE-RESIDENTS 1 1331 1331 C PROV3525 INDICATES IF ADMINISTRATION AND STORAGE OF BLOOD SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-ADM-BLOOD-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: BLOOD ADMIN-ONSITE-NONRES 1 1332 1332 C PROV3520 INDICATES IF ADMINISTRATION AND STORAGE OF BLOOD SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-ADM-BLOOD-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: BLOOD ADMIN-ONSITE-RESIDENTS 1 1333 1333 C PROV3515 INDICATES IF ADMINISTRATION AND STORAGE OF BLOOD SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-ADM-BLOOD-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 24 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: CLINICAL LAB-OFFSITE-RESIDENT 1 1334 1334 C PROV3495 INDICATES IF CLINICAL LABORATORY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-CLIN-LAB-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: CLINICAL LAB-ONSITE-NON RES 1 1335 1335 C PROV3490 INDICATES IF CLINICAL LABORATORY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-CLIN-LAB-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: CLINICAL LAB-ONSITE-RESIDENTS 1 1336 1336 C PROV3485 INDICATES IF CLINICAL LABORATORY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-CLIN-LAB-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DENTAL-OFFSITE-RESIDENTS 1 1337 1337 C PROV3435 INDICATES IF DENTAL SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-DENTAL-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DENTAL-ONSITE-NON RESIDENTS 1 1338 1338 C PROV3430 INDICATES IF DENTAL SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-DENTAL-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DENTAL-ONSITE-RESIDENTS 1 1339 1339 C PROV3425 INDICATES IF DENTAL SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-DENTAL-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DIETARY-OFFSITE-RESIDENTS 1 1340 1340 C PROV3345 INDICATES IF DIETARY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-DIETARY-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 25 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: DIETARY-ONSITE-NON RESIDENTS 1 1341 1341 C PROV3340 INDICATES IF DIETARY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-DIETARY-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DIETARY-ONSITE-RESIDENTS 1 1342 1342 C PROV3335 INDICATES IF DIETARY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-DIETARY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: HOUSEKEEPING ONSITE-NON RES 1 1343 1343 C PROV3535 INDICATES IF HOUSEKEEPING SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-HOUSE-KP-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: HOUSEKEEPING-OFFSITE-RES 1 1344 1344 C PROV3540 INDICATES IF HOUSEKEEPING SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-HOUSE-KP-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: HOUSEKEEPING-ONSITE-RESIDENTS 1 1345 1345 C PROV3530 INDICATES IF HOUSEKEEPING SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-HOUSE-KP-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: MENTAL HEALTH-OFFSITE-RES 1 1346 1346 C PROV3465 INDICATES IF MENTAL HEALTH SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-MEN-HLTH-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: MENTAL HEALTH-ONSITE-NON RES 1 1347 1347 C PROV3460 INDICATES IF MENTAL HEALTH SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-MEN-HLTH-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 26 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: MENTAL HEALTH-ONSITE-RESID 1 1348 1348 C PROV3455 INDICATES IF MENTAL HEALTH SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-MEN-HLTH-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: NURSING-OFFSITE-RESIDENTS 1 1349 1349 C PROV3315 INDICATES IF NURSING SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-NURSING-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: NURSING-ONSITE-NON RESIDENTS 1 1350 1350 C PROV3310 INDICATES IF NURSING SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-NURSING-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: NURSING-ONSITE-RESIDENTS 1 1351 1351 C PROV3305 INDICATES IF NURSING SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-NURSING-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OCCUP THER-OFFSITE-RESIDENTS 1 1352 1352 C PROV3360 INDICATES IF OCCUPATIONAL THERAPY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-OCC-THER-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OCCUP THER-ONSITE-NON RESID 1 1353 1353 C PROV3355 INDICATES IF OCCUPATIONAL THERAPY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-OCC-THER-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OCCUP THER-ONSITE-RESIDENTS 1 1354 1354 C PROV3350 INDICATES IF OCCUPATIONAL THERAPY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-OCC-THER-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 27 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: OTH ACTIVITIES-OFFSITE TO RES 1 1355 1355 C PROV5255 FIELD 3 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF OFFSITE TO RESIDENTS. COBOL NAME: SP-OTH-ACT-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH ACTIVITIES-ONSITE NONRES 1 1356 1356 C PROV5250 FIELD 2 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF ONSITE TO NONRESIDENTS. COBOL NAME: SP-OTH-ACT-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH ACTIVITIES-ONSITE RES 1 1357 1357 C PROV5245 FIELD 1 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF ONSITE TO RESIDENTS. COBOL NAME: SP-OTH-ACT-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-OFFSITE TO RES 1 1358 1358 C PROV5285 FIELD 3 - INDICATES SERVICES PROVIDED BY OTHER SOCIAL S ERVICES STAFF OFFSITE TO RESIDENTS. COBOL NAME: SP-OTH-SOC-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-ONSITE TO NONRES 1 1359 1359 C PROV5280 INDICATES IF OTHER SOCIAL SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-OTH-SOC-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-ONSITE TO RES 1 1360 1360 C PROV5275 FIELD 1 - INDICATES SERVICES PROVIDED BY SOCIAL SERVICE S STAFF ONSITE TO RESIDENTS. COBOL NAME: SP-OTH-SOC-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHARMACY-OFFSITE-RESIDENTS 1 1361 1361 C PROV3330 INDICATES IF PHARMACY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PHARMACY-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 28 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHARMACY-ONSITE-NON RESIDENTS 1 1362 1362 C PROV3325 INDICATES IF PHARMACY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PHARMACY-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHARMACY-ONSITE-RESIDENTS 1 1363 1363 C PROV3320 INDICATES IF PHARMACY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PHARMACY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYS EXTENDER-OFFSITE-RESID 1 1364 1364 C PROV3300 INDICATES IF PHYSICIAN EXTENDER SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PHYS-EXT-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYS EXTENDER-ONSITE-NON RES 1 1365 1365 C PROV3295 INDICATES IF PHYSICIAN EXTENDER SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PHYS-EXT-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYS EXTENDER-ONSITE-RESIDENT 1 1366 1366 C PROV3290 INDICATES IF PHYSICIAN EXTENDER SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PHYS-EXT-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYS THER-OFFSITE-RESIDENTS 1 1367 1367 C PROV3375 INDICATES IF PHYSICAL THERAPY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PHYS-THER-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYS THER-ONSITE-NON RESIDENT 1 1368 1368 C PROV3370 INDICATES IF PHYSICAL THERAPY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PHYS-THER-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 29 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHYS THER-ONSITE-RESIDENTS 1 1369 1369 C PROV3365 INDICATES IF PHYSICAL THERAPY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PHYS-THER-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYSICIAN-OFFSITE-RESIDENTS 1 1370 1370 C PROV3285 INDICATES IF PHYSICIAN SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PHYS-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYSICIAN-ONSITE-NON RESIDENT 1 1371 1371 C PROV3280 INDICATES IF PHYSICIAN SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PHYS-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYSICIAN-ONSITE-RESIDENTS 1 1372 1372 C PROV3275 INDICATES IF PHYSICIAN SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PHYS-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PODIATRY-OFFSITE-RESIDENTS 1 1373 1373 C PROV3450 INDICATES IF PODIATRY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PODIATRY-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PODIATRY-ONSITE-NON RESIDENTS 1 1374 1374 C PROV3445 INDICATES IF PODIATRY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PODIATRY-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PODIATRY-ONSITE-RESIDENTS 1 1375 1375 C PROV3440 INDICATES IF PODIATRY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PODIATRY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 30 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: SOCIAL WORK-OFFSITE-RESIDENTS 1 1376 1376 C PROV3405 INDICATES IF SOCIAL WORK SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-MED-SOC-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: SOCIAL WORK-ONSITE-NON RESID 1 1377 1377 C PROV3400 INDICATES IF SOCIAL WORK SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-MED-SOC-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: SOCIAL WORK-ONSITE-RESIDENTS 1 1378 1378 C PROV3395 INDICATES IF SOCIAL WORK SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-MED-SOC-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: SPEECH PATH-OFFSITE-RESIDEN 1 1379 1379 C PROV3420 INDICATES IF SPEECH/LANGUAGE PATHOLOGY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-SPEECH-PH-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: SPEECH PATH-ONSITE-NON RESID 1 1380 1380 C PROV3415 INDICATES IF SPEECH/LANGUAGE PATHOLOGY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-SPEECH-PH-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: SPEECH PATH-ONSITE-RESIDENTS 1 1381 1381 C PROV3410 INDICATES IF SPEECH/LANGUAGE PATHOLOGY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-SPEECH-PH-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: THER REC SPEC-OFFSITE TO RES 1 1382 1382 C PROV5225 INDICATES IF THERAPEUTIC RECRECATION SPECIALIST SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-THER-REC-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 31 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: THER REC SPEC-ONSITE-NONRES 1 1383 1383 C PROV5220 INDICATES IF THERAPEUTIC RECREATION SPECIALIST SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-THER-REC-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: THER REC SPEC-ONSITE-RESIDENT 1 1384 1384 C PROV5215 INDICATES IF THERAPEUTIC RECREATION SPECIALIST SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-THER-REC-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: VOCATIONAL-OFFSITE-RESIDENTS 1 1385 1385 C PROV3480 INDICATES IF VOCATIONAL SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-VOC-GUID-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: VOCATIONAL-ONSITE-NON RESID 1 1386 1386 C PROV3475 INDICATES IF VOCATIONAL SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-VOC-GUID-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: VOCATIONAL-ONSITE-RESIDENTS 1 1387 1387 C PROV3470 INDICATES IF VOCATIONAL SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-VOC-GUID-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: XRAY-OFFSITE-RESIDENTS 1 1388 1388 C PROV3510 INDICATES IF DIAGNOSTIC XRAY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-DIAG-XRAY-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: XRAY-ONSITE-NON RESIDENTS 1 1389 1389 C PROV3505 INDICATES IF DIAGNOSTIC XRAY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-DIAG-XRAY-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 32 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: XRAY-ONSITE-RESIDENTS 1 1390 1390 C PROV3500 INDICATES IF DIAGNOSTIC XRAY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-DIAG-XRAY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED THER REC SPEC - CONTRACT 7.2 1391 1397 N PROV5240 NUMBER OF CONTRACT STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-CONTRACT THER REC SPEC - FULL TIME 7.2 1398 1404 N PROV5230 NUMBER OF FULL-TIME STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-FULL-TIME THER REC SPEC - PART TIME 7.2 1405 1411 N PROV5235 NUMBER OF PART-TIME STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 1 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 03 TITLE 18/19 CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 03 SNF/NF (DISTINCT PART) CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 2 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 NATIONAL GOVERNMENT SERVICES 00180 NATIONAL GOVERNMENT SERVICES 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 3 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01101 PALMETTO (CALIFORNIA) 01201 PALMETTO (HAWAII) 01301 PALMETTO (NEVADA) 01390 AETNA (WASHINGTON) 02101 NATIONAL HERITAGE (ALASKA) 02201 NATIONAL HERITAGE (IDAHO) 02301 NATIONAL HERITAGE (OREGON) 02401 NATIONAL HERITAGE (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03101 NORIDIAN (ARIZONA) 03201 NORIDIAN (MONTANA) 03301 NORIDIAN (NORTH DAKOTA) 03401 NORIDIAN (SOUTH DAKOTA) 03501 NORIDIAN (UTAH) 03601 NORIDIAN (WYOMING) 04101 TRAILBLAZER (COLORADO) 04201 TRAILBLAZER (NEW MEXICO) 04301 TRAILBLAZER (OKLAHOMA) 04401 TRAILBLAZER (TEXAS) 05101 WPS (IOWA) 05201 WPS (KANSAS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 4 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 05301 WPS (MISSOURI) 05401 WPS (NEBRASKA) 07101 PINNACLE (ARKANSAS) 07201 PINNACLE (LOUISIANA) 07301 PINNACLE (MISSISSIPPI) 08101 PINNACLE (INDIANA) 08201 PINNACLE (MICHIGAN) 09101 FIRST COAST (FLORIDA) 09201 FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 12101 HIGHMARK (DELAWARE) 12201 HIGHMARK (DISTRICT OF COLUMBIA) 12301 HIGHMARK (MARYLAND) 12401 HIGHMARK NEW JERSEY) 12501 HIGHMARK (PENNSYLVANIA) 13101 NATL GOVT SERVICES (CONNECTICUT) 13201 NATL GOVT SERVICES (NEW YORK) 14101 NATIONAL HERITAGE (MAINE) 14201 NATIONAL HERITAGE (MASSACHUSETTS) 14301 NATIONAL HERITAGE (NEW HAMPSHIRE) 14401 NATIONAL HERITAGE (RHODE ISLAND) 14501 NATIONAL HERITAGE (VERMONT) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 5 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 6 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN ADMIN SERVICES (ARIZONA) 03202 NORIDIAN ADMIN SERVICES (MONTANA) 03302 NORIDIAN ADMIN SERVICES (NORTH DAKOTA) 03402 NORIDIAN ADMIN SERVICES (MONTANA) 03502 NORIDIAN ADMIN SERVICES (UTAH) 03602 NORIDIAN ADMIN SERVICES (WYOMING) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 7 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 8 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 9 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 10 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATE REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 11 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 FOR PROFIT - INDIVIDUAL 02 FOR PROFIT - PARTNERSHIP 03 FOR PROFIT - CORPORATION 04 NONPROFIT - CHURCH RELATED 05 NONPROFIT - CORPORATION 06 NONPROFIT - OTHER 07 GOVERNMENT - STATE 08 GOVERNMENT - COUNTY 09 GOVERNMENT - CITY 10 GOVERNMENT - CITY/COUNTY 11 GOVERNMENT - HOSPITAL DISTRICT 12 GOVERNMENT - FEDERAL 13 LIMITED LIABILITY CORPORATION ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD BEDS - TOTAL 4 291 294 N PROV0740 TOTAL NUMBER OF BEDS IN A FACILITY, INCLUDING THOSE IN NON-PARTICIPATING OR NON-LICENSED AREAS. COBOL NAME: NUM-BEDS BEDS - TOTAL CERTIFIED 4 295 298 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS COMPLIANCE: LIFE SAFETY CODE 1 356 356 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 12 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 1 WAIVER RECOMMENDED COMPLIANCE: 24 HR REGISTERED NURSE 1 359 359 C PROV0290 INDICATES IF A WAIVER OF THE 24 HOUR REGISTERED NURSE REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-24-HR-RN VALUES: 1 WAIVER RECOMMENDED FISCAL YEAR ENDING DATE 4 378 381 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT PROGRAM PARTICIPATION 1 434 434 C PROV1670 INDICATES IF THE PROVIDER PARTICIPATES IN MEDICARE, MEDICAID, OR BOTH PROGRAMS. COBOL NAME: PROG-PARTCI VALUES: 1 MEDICARE ONLY 2 MEDICAID ONLY 3 MEDICARE AND MEDICAID REGIONAL OVERRIDE #1 (NUMBER BEDS) 1 470 470 C PROV1545 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-1 VALUES: Y RECORD HAS BEEN APPROVED REGIONAL OVERRIDE #2 (STAFFING) 1 471 471 C PROV1550 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-2 VALUES: Y RECORD HAS BEEN APPROVED ACTIVITY PROFESSIONAL - CONTRACT 7.2 596 602 N PROV0695 THE NUMBER OF FULL TIME EQUIVALENT ACTIVITIES PROFESSIONALS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-ACT-THER-CONTRACT ACTIVITY PROFESSIONAL - FULL TIME 7.2 603 609 N PROV0700 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES PROFESSIONALS EMPLOYED FULL TIME BY A FACILITY. COBOL NAME: NUM-ACT-THER-FULL-TIME ACTIVITY PROFESSIONAL - PART TIME 7.2 610 616 N PROV0705 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES PROFESSIONALS EMPLOYED PART TIME BY A FACILITY. COBOL NAME: NUM-ACT-THER-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 13 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ADMINISTRATION - CONTRACT 7.2 617 623 N PROV0710 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-ADMN-CONTRACT ADMINISTRATOR - FULL TIME 7.2 624 630 N PROV0715 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF EMPLOYED ON A FULL TIME BASIS BY A FACILITY. COBOL NAME: NUM-ADMN-FULL-TIME ADMINISTRATOR - PART TIME 7.2 631 637 N PROV0720 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF EMPLOYED ON A PART-TIME BASIS BY A FACILITY. COBOL NAME: NUM-ADMN-PART-TIME BEDS - MEDICARE SNF 4 638 641 N PROV1445 NUMBER OF MEDICARE CERTIFIED SNF BEDS IN A FACILITY. COBOL NAME: NUM-T18-SNF-BEDS BEDS - NURSING FACILITY 4 642 645 N PROV1455 NUMBER OF MEDICAID CERTIFIED SKILLED NURSING CARE BEDS IN A FACILITY. COBOL NAME: NUM-T19-SNF-BEDS BEDS - SNF/NF 4 646 649 N PROV1450 NUMBER OF BEDS CERTIFIED FOR BOTH MEDICARE AND MEDICAID SKILLED NURSING CARE IN A LONG TERM CARE FACILITY. COBOL NAME: NUM-T1819-SNF-BEDS CERT NURSE AIDES - CONTRACT 7.2 650 656 N PROV1000 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-NURSE-AID-CONTRACT CERT NURSE AIDES - FULL TIME 7.2 657 663 N PROV1005 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-AID-FULL-TIME CERT NURSE AIDES - PART TIME 7.2 664 670 N PROV1010 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-AID-PART-TIME CHRISTIAN SCIENCE INDICATOR 1 671 671 C PROV0110 INDICATES IF A PROVIDER IS A CHRISTIAN SCIENCE FACILITY COBOL NAME: CHRISTIAN-SCIENCE-IND VALUES: Y CHRISTIAN SCIENCE COMPLIANCE: BEDS PER ROOM WAIVER 1 672 672 C PROV0225 INDICATES IF A WAIVER OF THE BEDS PER ROOM REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-BEDS-PER-ROOM VALUES: 1 WAIVER RECOMMENDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 14 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COMPLIANCE: PATIENT ROOM SIZE 1 673 673 C PROV0270 INDICATES IF A WAIVER OF PATIENT ROOM SIZE HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-PATIENT-ROOM-SZ VALUES: 1 WAIVER RECOMMENDED COMPLIANCE: 7 DAY REGISTERED NURSE 1 674 674 C PROV0295 INDICATES IF A WAIVER OF THE 7 DAY REGISTERED NURSE REQUIREMENTS HAS BEEN RECOMMENDED FOR A SNF OR NF. COBOL NAME: COMPL-7-DAY-RN VALUES: 1 WAIVER RECOMMENDED DENTISTS - CONTRACT 7.2 675 681 N PROV0785 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DENTIST-CONTRACT DENTISTS - FULL TIME 7.2 682 688 N PROV0790 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-DENTIST-FULL-TIME DENTISTS - PART TIME 7.2 689 695 N PROV0795 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-DENTIST-PART-TIME DIETITIANS - CONTRACT 7.2 696 702 N PROV0805 THE NUMBER OF FULL-TIME EQUIVALENT UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DIET-CONTRACT DIETITIANS - FULL TIME 7.2 703 709 N PROV0810 THE NUMBER OF FULL-TIME EQUIVALENT DIETITIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-DIET-FULL-TIME DIETITIANS - PART TIME 7.2 710 716 N PROV0815 THE NUMBER OF FULL-TIME EQUIVALENT DIETITIANS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-DIET-PART-TIME EXPERIMENTAL RESEARCH CONDUCTED 1 717 717 C PROV0465 INDICATES IF A FACILITY USES RESIDENTS TO DEVELOP AND TEST CLINICAL TREATMENTS. COBOL NAME: EXPER-RESEARCH VALUES: Y YES FOOD SERVICE - CONTRACT 7.2 718 724 N PROV0860 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-FOOD-SRV-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 15 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FOOD SERVICE - FULL TIME 7.2 725 731 N PROV0865 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-FOOD-SRV-FULL-TIME FOOD SERVICE - PART TIME 7.2 732 738 N PROV0870 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-FOOD-SRV-PART-TIME HOUSEKEEPING - CONTRACT 7.2 739 745 N PROV0925 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-HOUSE-CONTRACT HOUSEKEEPING - FULL TIME 7.2 746 752 N PROV0930 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-HOUSE-FULL-TIME HOUSEKEEPING - PART TIME 7.2 753 759 N PROV0935 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-HOUSE-PART-TIME LPN/LVN - CONTRACT 7.2 760 766 N PROV1465 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-VOC-NURSE-CONTRACT LPN/LVN - FULL TIME 7.2 767 773 N PROV1470 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-VOC-NURSE-FULL-TIME LPN/LVN - PART TIME 7.2 774 780 N PROV1475 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-VOC-NURSE-PART-TIME LTC CROSS REFERENCE PROVIDER # 6 781 786 C PROV0640 THIS CROSS REFERENCE NUMBER IDENTIFIES LTC PROVIDER NUMBERS THAT WERE TERMINATED IN 1985 BECAUSE OF POLICY CHANGES WHICH STATES THAT SNF/ICF DISTINCT PARTS OR DUA LLY CERTIFIED PORTIONS ARE ASSIGNED SINGLE SNF PROV NO. COBOL NAME: LTC-CROSS-REF-PROV-NUM MEDICAL DIRECTOR - CONTRACT 7.2 787 793 N PROV0960 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS UNDER CONTRCAT TO A FACILITY. COBOL NAME: NUM-MED-CONTRACT MEDICAL DIRECTOR - FULL TIME 7.2 794 800 N PROV0965 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MED-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 16 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MEDICAL DIRECTOR - PART TIME 7.2 801 807 N PROV0970 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MED-PART-TIME MEDICATION AIDES/TECHS-CONTRACT 7.2 808 814 N PROV5180 THE NUMBER OF FULL-TIMR EQUIVALENT MEDICATION AIDES/ TECHNICIANS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-MED-AID-CONTRACT MEDICATION AIDES/TECHS-FULL TIME 7.2 815 821 N PROV5170 THE NUMBER OF FULL-TIME EQUIVALENT MEDICATION AIDES/ TECHNICIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MED-AID-FULL-TIME MEDICATION AIDES/TECHS-PART TIME 7.2 822 828 N PROV5175 THE NUMBER OF FULL-TIME EQUIVALENT MEDICATION AIDES/ TECHNICIANS EMPLOYED BYA FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MED-AID-PART-TIME MENTAL HEALTH SERVICES - CONTRACT 7.2 829 835 N PROV0980 THE NUMBER OF FULL-TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-MEN-HLTH-CONTRACT MENTAL HEALTH SERVICES - FULL TIME 7.2 836 842 N PROV0985 THE NUMBER OF FULL-TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MEN-HLTH-FULL-TIME MENTAL HEALTH SERVICES - PART TIME 7.2 843 849 N PROV0990 THE NUMBER OF FULL TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MEN-HLTH-PART-TIME MULTI-FACILITY ORGANIZATION NAME 38 850 887 C PROV0680 THE NAME OF THE MULTI-FACILITY ORGANIZATION THAT OWNS THE FACILITY. COBOL NAME: NAME-MULT-FACL-ORG MULTI-FACILITY ORGANIZATION OWNED 1 888 888 C PROV0675 INDICATES IF A FACILITY IS OWNED BY AN ORGANIZATION THAT OWNS (OR LEASES) TWO OR MORE NURSING FACILITIES. COBOL NAME: MULT-FACL-ORG VALUES: Y YES NURSE AIDES IN TRNG - CONTRACT 7.2 889 895 N PROV5165 NUMBER OF FULL TIME EQUIVALENT NURSE AIDES IN TRAINING UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-AID-TRNG-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 17 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME NURSE AIDES IN TRNG-FULL TIME 7.2 896 902 N PROV5155 THE NUMBER OF FULL-TIME EQUIVALENT NURSE AIDES IN TRAINING EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-AID-TRNG-FULL-TIME NURSE AIDES IN TRNG-PART TIME 7.2 903 909 N PROV5160 THE NUMBER OF FULL-TIME EQUIVALENT NURSE AIDES IN TRAINING EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-AID-TRNG-PART-TIME NURSES WITH ADMIN DUTIES-CONTRACT 7.2 910 916 N PROV5150 THE NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-NURSE-ADM-CONTRACT NURSES WITH ADMIN DUTIES-FULL TIME 7.2 917 923 N PROV5135 THE NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-ADM-FULL-TIME NURSES WITH ADMIN DUTIES-PART TIME 7.2 924 930 N PROV5145 NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-ADM-PART-TIME OCCUP THERAPIST, FULL TIME, STAFF 7.2 931 937 N PROV1040 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-THER-FULL-TIME OCCUP THERAPISTS, CONTRACT/ARRANGE 7.2 938 944 N PROV1035 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-THER-CONTRACT OCCUP THERAPY AIDE - CONTRACT 7.2 945 951 N PROV1020 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-AID-CONTRACT OCCUP THERAPY AIDE - FULL TIME 7.2 952 958 N PROV1025 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-AID-FULL-TIME OCCUP THERAPY AIDE - PART TIME 7.2 959 965 N PROV1030 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-AID-PART-TIME OCCUP THERAPY ASST - CONTRACT 7.2 966 972 N PROV5195 THE NUMBER OF FULL TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS UNDER CONTRCAT TO A FACILITY. COBOL NAME: NUM-OCC-ASST-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 18 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OCCUP THERAPY ASST - FULL TIME 7.2 973 979 N PROV5185 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-ASST-FULL-TIME OCCUP THERAPY ASST - PART TIME 7.2 980 986 N PROV5190 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-ASST-PART-TIME OCCUPATIONAL THERAPIST - PART TIME 7.2 987 993 N PROV1045 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-THER-PART-TIME ORGANIZED FAMILY GROUP 1 994 994 C PROV1535 INDICATES IF THE FACILITY HAS AN ORGANIZED GROUP OF FAMILY MEMBERS OF RESIDENTS. COBOL NAME: ORG-FAMILY-GRP VALUES: Y YES ORGANIZED RESIDENT GROUP 1 995 995 C PROV1540 INDICATES IF THE FACILITY HAS AN ORGANIZED RESIDENTS GROUP. COBOL NAME: ORG-RESID-GRP VALUES: Y YES OTHER - CONTRACT 7.2 996 1002 N PROV3265 THE NUMBER OF FULL-TIME EQUIVALENT PERSONS NOT INCLUDED IN ANY OTHER CATEGORIES UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-OTH-CONTRACT OTHER - FULL TIME 7.2 1003 1009 N PROV3245 THE NUMBER OF FULL-TIME EQUIVALENT PERSONS NOT INCLUDED IN ANY OTHER CATEGORIES EMPLOYED BY THE FACILITY ON A FULL-TIME BASIS. COBOL NAME: NUM-OTH-FULL-TIME OTHER - PART TIME 7.2 1010 1016 N PROV3255 THE NUMBER OF FULL-TIME EQUIVALENT PERSONS NOT INCLUDED IN ANY OTHER CATEGORIES EMPLOYED BY THE FACILITY ON A PART-TIME BASIS. COBOL NAME: NUM-OTH-PART-TIME OTHER ACTIVITIES STAFF-CONTRACT 7.2 1017 1023 N PROV5270 NUMBER OF CONTRACT STAFF HOURS FOR OTHER ACTIVITIES. COBOL NAME: NUM-OTH-ACT-CONTRACT OTHER ACTIVITIES STAFF-FULL TIME 7.2 1024 1030 N PROV5260 NUMBER OF FULL-TIME STAFF HOURS FOR OTHER ACTIVITIES. COBOL NAME: NUM-OTH-ACT-FULL-TIME OTHER ACTIVITIES STAFF-PART TIME 7.2 1031 1037 N PROV5305 NUMBER OF PART TIME STAFF HOURS PROVIDED BY OTHER ACTIV ITIES STAFF. COBOL NAME: NUM-OTH-ACT-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 19 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OTHER PHYSICIAN - CONTRACT 7.2 1038 1044 N PROV1060 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS UNDER CONTRACT TO A FACILITY COBOL NAME: NUM-OTH-PHY-CONTRACT OTHER PHYSICIAN - FULL TIME 7.2 1045 1051 N PROV1065 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OTH-PHY-FULL-TIME OTHER PHYSICIAN - PART TIME 7.2 1052 1058 N PROV1070 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OTH-PHY-PART-TIME OTHR SOCIAL SERV STAFF-CONTRACT 7.2 1059 1065 N PROV5300 NUMBER OF CONTRACT STAFF HOURS PROVIDED BY OTHER SOCIAL SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-CONTRACT OTHR SOCIAL SERV STAFF-FULL TIME 7.2 1066 1072 N PROV5290 NUMBER OF FULL-TIME STAFF HOURS PROVIDED BY OTHER SOCIA L SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-FULL-TIME OTHR SOCIAL SERV STAFF-PART TIME 7.2 1073 1079 N PROV5295 NUMBER OF PART-TIME STAFF HOURS PROVIDED BY OTHER SOCIA L SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-PART-TIME PHARMACISTS - CONTRACT 7.2 1080 1086 N PROV1085 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-PHAR-CONTRACT PHARMACISTS - FULL TIME 7.2 1087 1093 N PROV1090 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-PHAR-FULL-TIME PHARMACISTS - PART TIME 7.2 1094 1100 N PROV1095 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-PHAR-PART-TIME PHYS THER ASST - CONTRACT 7.2 1101 1107 N PROV5210 NUMBER OF CONTRACT STAFF HOURS FOR PHYSICAL THERAPY ASS ISTANTS. COBOL NAME: NUM-THER-ASST-CONTRACT PHYS THER ASST - FULL TIME 7.2 1108 1114 N PROV5200 NUMBER OF FULL-TIME STAFF HOURS FOR PHYSICAL THERAPY AS SISTANTS. COBOL NAME: NUM-THER-ASST-FULL-TIME PHYS THER ASST - PART TIME 7.2 1115 1121 N PROV5205 NUMBER OF PART-TIME STAFF HOURS FOR PHYSICAL THERAPY AS SISTANTS. COBOL NAME: NUM-THER-ASST-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 20 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PHYSICAL THERAPISTS - CONTRACT 7.2 1122 1128 N PROV1430 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-CONTRACT PHYSICAL THERAPISTS - FULL TIME 7.2 1129 1135 N PROV1435 THE NUMBER OF FULL TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-FULL-TIME PHYSICAL THERAPISTS - PART TIME 7.2 1136 1142 N PROV1440 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-PART-TIME PHYSICAL THERAPY AIDE - CONTRACT 7.2 1143 1149 N PROV1415 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-AID-CONTRACT PHYSICAL THERAPY AIDE - FULL TIME 7.2 1150 1156 N PROV1420 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-AID-FULL-TIME PHYSICAL THERAPY AIDE - PART TIME 7.2 1157 1163 N PROV1425 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-AID-PART-TIME PHYSICIAN EXTENDER - CONTRACT 7.2 1164 1170 N PROV3270 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIAN EXTENDERS UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-PHYS-EXT-CONTRACT PHYSICIAN EXTENDER - FULL TIME 7.2 1171 1177 N PROV3250 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIAN EXTENDERS EMPLOYED BY THE FACILITY ON A FULL-TIME BASIS. COBOL NAME: NUM-PHYS-EXT-FULL-TIME PHYSICIAN EXTENDER - PART TIME 7.2 1178 1184 N PROV3260 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIAN EXTENDERS EMPLOYED BY THE FACILITY ON A PART-TIME BASIS. COBOL NAME: NUM-PHYS-EXT-PART-TIME PODIATRISTS - CONTRACT 7.2 1185 1191 N PROV1130 THE NUMBER OF FULL TIME EQUIVALENT PODIATRISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-POD-CONTRACT PODIATRISTS - FULL TIME 7.2 1192 1198 N PROV1135 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A AFCILITY ON A FULL TIME BASIS. COBOL NAME: NUM-POD-FULL-TIME PODIATRISTS - PART TIME 7.2 1199 1205 N PROV1140 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-POD-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 21 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PROVIDER BASED FACILITY 1 1206 1206 C PROV1675 INDICATES IF A LONG TERM CARE FACILITY IS PROVIDER BASED. COBOL NAME: PROV-BASED-FACILITY VALUES: Y HOSPITAL BASED REGISTERED NURSE - CONTRACT 7.2 1207 1213 N PROV1150 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-REG-NURSE-CONTRACT REGISTERED NURSE - FULL TIME 7.2 1214 1220 N PROV1155 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-REG-NURSE-FULL-TIME REGISTERED NURSE - PART TIME 7.2 1221 1227 N PROV1160 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-REG-NURSE-PART-TIME RELATED PROVIDER NUMBER 10 1228 1237 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM RN DIRECTOR OF NURSING - CONTRACT 7.2 1238 1244 N PROV5130 THE NUMBER OF FULL TIME EQUIVALENT RN DIRECTOR OF NURSI NG UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-RN-DON-CONTRACT RN DIRECTOR OF NURSING - FULL TIME 7.2 1245 1251 N PROV5120 THE NUMBER OF FULL-TIME EQUIVALENT RN DIRECTOR OF NURSING EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-RN-DON-FULL-TIME RN DIRECTOR OF NURSING - PART TIME 7.2 1252 1258 N PROV5140 THE NUMBER OF FULL-TIME EQUIVALENT RN DIRECTOR OF NURSING EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-RN-DON-PART-TIME SOCIAL WORKER - CONTRACT 7.2 1259 1265 N PROV1170 THE NUMBER OF FULL-TIME EQUIVALENT SOCIAL WORKERS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-SOCIAL-CONTRACT SOCIAL WORKER - FULL TIME 7.2 1266 1272 N PROV1175 THE NUMBER OF FULL-TIME EQUIVALENT SOCIAL WORKERS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-SOCIAL-FULL-TIME SOCIAL WORKER - PART TIME 7.2 1273 1279 N PROV1180 THE NUMBER OF FULL-TIME EQUIVALENT SOCIAL WORKERS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-SOCIAL-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 22 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPECIAL CARE BEDS-AIDS 3 1280 1282 N PROV0725 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH AIDS. COBOL NAME: NUM-AIDS-BEDS SPECIAL CARE BEDS-ALZHEIMERS 3 1283 1285 N PROV0730 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH ALZEHEIMERS. COBOL NAME: NUM-ALZHEIMERS-BEDS SPECIAL CARE BEDS-DIALYSIS 3 1286 1288 N PROV0800 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS NEEDING DIALYSIS. COBOL NAME: NUM-DIAL-BEDS SPECIAL CARE BEDS-DISABLED CHILD 3 1289 1291 N PROV0855 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR DEISCABLED CHILDREN. COBOL NAME: NUM-DIS-CHILD-BEDS SPECIAL CARE BEDS-HEAD TRAUMA 3 1292 1294 N PROV0905 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILTY FOR RESIDENTS WITH HEAD TRAUMA. COBOL NAME: NUM-HEAD-TRAUMA-BEDS SPECIAL CARE BEDS-HOSPICE 3 1295 1297 N PROV0920 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY A FACILITY FOR RESIDENTS NEEDING HOSPICE SERVICES. COBOL NAME: NUM-HOSPICE-BEDS SPECIAL CARE BEDS-HUNTINGTONS 3 1298 1300 N PROV0940 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH HUNTINGTON'S DISEASE COBOL NAME: NUM-HUNTING-DIS-BEDS SPECIAL CARE BEDS-SPEC REHAB 3 1301 1303 N PROV1205 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH SPECIALIZED REHAB NEEDS. COBOL NAME: NUM-SPEC-REHAB-BEDS SPECIAL CARE BEDS-VENTILATOR 3 1304 1306 N PROV1460 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH VENTILATOR/ RESIPIRATORY CARE NEEDS. COBOL NAME: NUM-VENT-RESP-BEDS SPEECH PATHOLOGIST - CONTRACT 7.2 1307 1313 N PROV1190 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-SPCH-PATH-CONTRACT SPEECH PATHOLOGIST - FULL TIME 7.2 1314 1320 N PROV1195 THE NUMBER OF FULL-TIME EQUIVALENT SPPECH PATHOLOGISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-SPCH-PATH-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 23 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPEECH PATHOLOGIST - PART TIME 7.2 1321 1327 N PROV1200 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-SPCH-PATH-PART-TIME SRV: ACTIVITIES-OFFSITE-RESIDENTS 1 1328 1328 C PROV3390 INDICATES IF ACTIVITIES SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-ACT-THER-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: ACTIVITIES-ONSITE-NON RES 1 1329 1329 C PROV3385 INDICATES IF ACTIVITIES SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-ACT-THER-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: ACTIVITIES-ONSITE-RESIDENTS 1 1330 1330 C PROV3380 INDICATES IF ACTIVITIES SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-ACT-THER-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: BLOOD ADMIN-OFFSITE-RESIDENTS 1 1331 1331 C PROV3525 INDICATES IF ADMINISTRATION AND STORAGE OF BLOOD SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-ADM-BLOOD-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: BLOOD ADMIN-ONSITE-NONRES 1 1332 1332 C PROV3520 INDICATES IF ADMINISTRATION AND STORAGE OF BLOOD SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-ADM-BLOOD-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: BLOOD ADMIN-ONSITE-RESIDENTS 1 1333 1333 C PROV3515 INDICATES IF ADMINISTRATION AND STORAGE OF BLOOD SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-ADM-BLOOD-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 24 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: CLINICAL LAB-OFFSITE-RESIDENT 1 1334 1334 C PROV3495 INDICATES IF CLINICAL LABORATORY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-CLIN-LAB-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: CLINICAL LAB-ONSITE-NON RES 1 1335 1335 C PROV3490 INDICATES IF CLINICAL LABORATORY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-CLIN-LAB-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: CLINICAL LAB-ONSITE-RESIDENTS 1 1336 1336 C PROV3485 INDICATES IF CLINICAL LABORATORY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-CLIN-LAB-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DENTAL-OFFSITE-RESIDENTS 1 1337 1337 C PROV3435 INDICATES IF DENTAL SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-DENTAL-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DENTAL-ONSITE-NON RESIDENTS 1 1338 1338 C PROV3430 INDICATES IF DENTAL SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-DENTAL-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DENTAL-ONSITE-RESIDENTS 1 1339 1339 C PROV3425 INDICATES IF DENTAL SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-DENTAL-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DIETARY-OFFSITE-RESIDENTS 1 1340 1340 C PROV3345 INDICATES IF DIETARY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-DIETARY-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 25 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: DIETARY-ONSITE-NON RESIDENTS 1 1341 1341 C PROV3340 INDICATES IF DIETARY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-DIETARY-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DIETARY-ONSITE-RESIDENTS 1 1342 1342 C PROV3335 INDICATES IF DIETARY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-DIETARY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: HOUSEKEEPING ONSITE-NON RES 1 1343 1343 C PROV3535 INDICATES IF HOUSEKEEPING SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-HOUSE-KP-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: HOUSEKEEPING-OFFSITE-RES 1 1344 1344 C PROV3540 INDICATES IF HOUSEKEEPING SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-HOUSE-KP-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: HOUSEKEEPING-ONSITE-RESIDENTS 1 1345 1345 C PROV3530 INDICATES IF HOUSEKEEPING SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-HOUSE-KP-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: MENTAL HEALTH-OFFSITE-RES 1 1346 1346 C PROV3465 INDICATES IF MENTAL HEALTH SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-MEN-HLTH-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: MENTAL HEALTH-ONSITE-NON RES 1 1347 1347 C PROV3460 INDICATES IF MENTAL HEALTH SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-MEN-HLTH-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 26 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: MENTAL HEALTH-ONSITE-RESID 1 1348 1348 C PROV3455 INDICATES IF MENTAL HEALTH SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-MEN-HLTH-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: NURSING-OFFSITE-RESIDENTS 1 1349 1349 C PROV3315 INDICATES IF NURSING SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-NURSING-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: NURSING-ONSITE-NON RESIDENTS 1 1350 1350 C PROV3310 INDICATES IF NURSING SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-NURSING-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: NURSING-ONSITE-RESIDENTS 1 1351 1351 C PROV3305 INDICATES IF NURSING SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-NURSING-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OCCUP THER-OFFSITE-RESIDENTS 1 1352 1352 C PROV3360 INDICATES IF OCCUPATIONAL THERAPY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-OCC-THER-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OCCUP THER-ONSITE-NON RESID 1 1353 1353 C PROV3355 INDICATES IF OCCUPATIONAL THERAPY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-OCC-THER-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OCCUP THER-ONSITE-RESIDENTS 1 1354 1354 C PROV3350 INDICATES IF OCCUPATIONAL THERAPY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-OCC-THER-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 27 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: OTH ACTIVITIES-OFFSITE TO RES 1 1355 1355 C PROV5255 FIELD 3 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF OFFSITE TO RESIDENTS. COBOL NAME: SP-OTH-ACT-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH ACTIVITIES-ONSITE NONRES 1 1356 1356 C PROV5250 FIELD 2 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF ONSITE TO NONRESIDENTS. COBOL NAME: SP-OTH-ACT-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH ACTIVITIES-ONSITE RES 1 1357 1357 C PROV5245 FIELD 1 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF ONSITE TO RESIDENTS. COBOL NAME: SP-OTH-ACT-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-OFFSITE TO RES 1 1358 1358 C PROV5285 FIELD 3 - INDICATES SERVICES PROVIDED BY OTHER SOCIAL S ERVICES STAFF OFFSITE TO RESIDENTS. COBOL NAME: SP-OTH-SOC-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-ONSITE TO NONRES 1 1359 1359 C PROV5280 INDICATES IF OTHER SOCIAL SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-OTH-SOC-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-ONSITE TO RES 1 1360 1360 C PROV5275 FIELD 1 - INDICATES SERVICES PROVIDED BY SOCIAL SERVICE S STAFF ONSITE TO RESIDENTS. COBOL NAME: SP-OTH-SOC-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHARMACY-OFFSITE-RESIDENTS 1 1361 1361 C PROV3330 INDICATES IF PHARMACY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PHARMACY-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 28 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHARMACY-ONSITE-NON RESIDENTS 1 1362 1362 C PROV3325 INDICATES IF PHARMACY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PHARMACY-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHARMACY-ONSITE-RESIDENTS 1 1363 1363 C PROV3320 INDICATES IF PHARMACY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PHARMACY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYS EXTENDER-OFFSITE-RESID 1 1364 1364 C PROV3300 INDICATES IF PHYSICIAN EXTENDER SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PHYS-EXT-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYS EXTENDER-ONSITE-NON RES 1 1365 1365 C PROV3295 INDICATES IF PHYSICIAN EXTENDER SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PHYS-EXT-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYS EXTENDER-ONSITE-RESIDENT 1 1366 1366 C PROV3290 INDICATES IF PHYSICIAN EXTENDER SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PHYS-EXT-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYS THER-OFFSITE-RESIDENTS 1 1367 1367 C PROV3375 INDICATES IF PHYSICAL THERAPY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PHYS-THER-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYS THER-ONSITE-NON RESIDENT 1 1368 1368 C PROV3370 INDICATES IF PHYSICAL THERAPY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PHYS-THER-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 29 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHYS THER-ONSITE-RESIDENTS 1 1369 1369 C PROV3365 INDICATES IF PHYSICAL THERAPY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PHYS-THER-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYSICIAN-OFFSITE-RESIDENTS 1 1370 1370 C PROV3285 INDICATES IF PHYSICIAN SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PHYS-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYSICIAN-ONSITE-NON RESIDENT 1 1371 1371 C PROV3280 INDICATES IF PHYSICIAN SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PHYS-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYSICIAN-ONSITE-RESIDENTS 1 1372 1372 C PROV3275 INDICATES IF PHYSICIAN SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PHYS-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PODIATRY-OFFSITE-RESIDENTS 1 1373 1373 C PROV3450 INDICATES IF PODIATRY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PODIATRY-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PODIATRY-ONSITE-NON RESIDENTS 1 1374 1374 C PROV3445 INDICATES IF PODIATRY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PODIATRY-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PODIATRY-ONSITE-RESIDENTS 1 1375 1375 C PROV3440 INDICATES IF PODIATRY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PODIATRY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 30 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: SOCIAL WORK-OFFSITE-RESIDENTS 1 1376 1376 C PROV3405 INDICATES IF SOCIAL WORK SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-MED-SOC-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: SOCIAL WORK-ONSITE-NON RESID 1 1377 1377 C PROV3400 INDICATES IF SOCIAL WORK SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-MED-SOC-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: SOCIAL WORK-ONSITE-RESIDENTS 1 1378 1378 C PROV3395 INDICATES IF SOCIAL WORK SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-MED-SOC-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: SPEECH PATH-OFFSITE-RESIDEN 1 1379 1379 C PROV3420 INDICATES IF SPEECH/LANGUAGE PATHOLOGY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-SPEECH-PH-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: SPEECH PATH-ONSITE-NON RESID 1 1380 1380 C PROV3415 INDICATES IF SPEECH/LANGUAGE PATHOLOGY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-SPEECH-PH-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: SPEECH PATH-ONSITE-RESIDENTS 1 1381 1381 C PROV3410 INDICATES IF SPEECH/LANGUAGE PATHOLOGY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-SPEECH-PH-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: THER REC SPEC-OFFSITE TO RES 1 1382 1382 C PROV5225 INDICATES IF THERAPEUTIC RECRECATION SPECIALIST SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-THER-REC-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 31 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: THER REC SPEC-ONSITE-NONRES 1 1383 1383 C PROV5220 INDICATES IF THERAPEUTIC RECREATION SPECIALIST SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-THER-REC-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: THER REC SPEC-ONSITE-RESIDENT 1 1384 1384 C PROV5215 INDICATES IF THERAPEUTIC RECREATION SPECIALIST SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-THER-REC-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: VOCATIONAL-OFFSITE-RESIDENTS 1 1385 1385 C PROV3480 INDICATES IF VOCATIONAL SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-VOC-GUID-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: VOCATIONAL-ONSITE-NON RESID 1 1386 1386 C PROV3475 INDICATES IF VOCATIONAL SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-VOC-GUID-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: VOCATIONAL-ONSITE-RESIDENTS 1 1387 1387 C PROV3470 INDICATES IF VOCATIONAL SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-VOC-GUID-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: XRAY-OFFSITE-RESIDENTS 1 1388 1388 C PROV3510 INDICATES IF DIAGNOSTIC XRAY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-DIAG-XRAY-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: XRAY-ONSITE-NON RESIDENTS 1 1389 1389 C PROV3505 INDICATES IF DIAGNOSTIC XRAY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-DIAG-XRAY-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 32 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: XRAY-ONSITE-RESIDENTS 1 1390 1390 C PROV3500 INDICATES IF DIAGNOSTIC XRAY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-DIAG-XRAY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED THER REC SPEC - CONTRACT 7.2 1391 1397 N PROV5240 NUMBER OF CONTRACT STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-CONTRACT THER REC SPEC - FULL TIME 7.2 1398 1404 N PROV5230 NUMBER OF FULL-TIME STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-FULL-TIME THER REC SPEC - PART TIME 7.2 1405 1411 N PROV5235 NUMBER OF PART-TIME STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 1 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 TITLE 18 ONLY CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 04 SKILLED NURSING FACILITIES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 2 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 NATIONAL GOVERNMENT SERVICES 00180 NATIONAL GOVERNMENT SERVICES 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 3 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01101 PALMETTO (CALIFORNIA) 01201 PALMETTO (HAWAII) 01301 PALMETTO (NEVADA) 01390 AETNA (WASHINGTON) 02101 NATIONAL HERITAGE (ALASKA) 02201 NATIONAL HERITAGE (IDAHO) 02301 NATIONAL HERITAGE (OREGON) 02401 NATIONAL HERITAGE (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03101 NORIDIAN (ARIZONA) 03201 NORIDIAN (MONTANA) 03301 NORIDIAN (NORTH DAKOTA) 03401 NORIDIAN (SOUTH DAKOTA) 03501 NORIDIAN (UTAH) 03601 NORIDIAN (WYOMING) 04101 TRAILBLAZER (COLORADO) 04201 TRAILBLAZER (NEW MEXICO) 04301 TRAILBLAZER (OKLAHOMA) 04401 TRAILBLAZER (TEXAS) 05101 WPS (IOWA) 05201 WPS (KANSAS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 4 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 05301 WPS (MISSOURI) 05401 WPS (NEBRASKA) 07101 PINNACLE (ARKANSAS) 07201 PINNACLE (LOUISIANA) 07301 PINNACLE (MISSISSIPPI) 08101 PINNACLE (INDIANA) 08201 PINNACLE (MICHIGAN) 09101 FIRST COAST (FLORIDA) 09201 FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 12101 HIGHMARK (DELAWARE) 12201 HIGHMARK (DISTRICT OF COLUMBIA) 12301 HIGHMARK (MARYLAND) 12401 HIGHMARK NEW JERSEY) 12501 HIGHMARK (PENNSYLVANIA) 13101 NATL GOVT SERVICES (CONNECTICUT) 13201 NATL GOVT SERVICES (NEW YORK) 14101 NATIONAL HERITAGE (MAINE) 14201 NATIONAL HERITAGE (MASSACHUSETTS) 14301 NATIONAL HERITAGE (NEW HAMPSHIRE) 14401 NATIONAL HERITAGE (RHODE ISLAND) 14501 NATIONAL HERITAGE (VERMONT) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 5 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 6 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN ADMIN SERVICES (ARIZONA) 03202 NORIDIAN ADMIN SERVICES (MONTANA) 03302 NORIDIAN ADMIN SERVICES (NORTH DAKOTA) 03402 NORIDIAN ADMIN SERVICES (MONTANA) 03502 NORIDIAN ADMIN SERVICES (UTAH) 03602 NORIDIAN ADMIN SERVICES (WYOMING) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 7 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 8 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 9 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 10 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATE REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 11 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 FOR PROFIT - INDIVIDUAL 02 FOR PROFIT - PARTNERSHIP 03 FOR PROFIT - CORPORATION 04 NONPROFIT - CHURCH RELATED 05 NONPROFIT - CORPORATION 06 NONPROFIT - OTHER 07 GOVERNMENT - STATE 08 GOVERNMENT - COUNTY 09 GOVERNMENT - CITY 10 GOVERNMENT - CITY/COUNTY 11 GOVERNMENT - HOSPITAL DISTRICT 12 GOVERNMENT - FEDERAL 13 LIMITED LIABILITY CORPORATION ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD BEDS - TOTAL 4 291 294 N PROV0740 TOTAL NUMBER OF BEDS IN A FACILITY, INCLUDING THOSE IN NON-PARTICIPATING OR NON-LICENSED AREAS. COBOL NAME: NUM-BEDS BEDS - TOTAL CERTIFIED 4 295 298 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS COMPLIANCE: LIFE SAFETY CODE 1 356 356 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 12 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 1 WAIVER RECOMMENDED COMPLIANCE: 24 HR REGISTERED NURSE 1 359 359 C PROV0290 INDICATES IF A WAIVER OF THE 24 HOUR REGISTERED NURSE REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-24-HR-RN VALUES: 1 WAIVER RECOMMENDED FISCAL YEAR ENDING DATE 4 378 381 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT PROGRAM PARTICIPATION 1 434 434 C PROV1670 INDICATES IF THE PROVIDER PARTICIPATES IN MEDICARE, MEDICAID, OR BOTH PROGRAMS. COBOL NAME: PROG-PARTCI VALUES: 1 MEDICARE ONLY 2 MEDICAID ONLY 3 MEDICARE AND MEDICAID REGIONAL OVERRIDE #1 (NUMBER BEDS) 1 470 470 C PROV1545 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-1 VALUES: Y RECORD HAS BEEN APPROVED REGIONAL OVERRIDE #2 (STAFFING) 1 471 471 C PROV1550 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-2 VALUES: Y RECORD HAS BEEN APPROVED ACTIVITY PROFESSIONAL - CONTRACT 7.2 596 602 N PROV0695 THE NUMBER OF FULL TIME EQUIVALENT ACTIVITIES PROFESSIONALS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-ACT-THER-CONTRACT ACTIVITY PROFESSIONAL - FULL TIME 7.2 603 609 N PROV0700 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES PROFESSIONALS EMPLOYED FULL TIME BY A FACILITY. COBOL NAME: NUM-ACT-THER-FULL-TIME ACTIVITY PROFESSIONAL - PART TIME 7.2 610 616 N PROV0705 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES PROFESSIONALS EMPLOYED PART TIME BY A FACILITY. COBOL NAME: NUM-ACT-THER-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 13 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ADMINISTRATION - CONTRACT 7.2 617 623 N PROV0710 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-ADMN-CONTRACT ADMINISTRATOR - FULL TIME 7.2 624 630 N PROV0715 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF EMPLOYED ON A FULL TIME BASIS BY A FACILITY. COBOL NAME: NUM-ADMN-FULL-TIME ADMINISTRATOR - PART TIME 7.2 631 637 N PROV0720 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF EMPLOYED ON A PART-TIME BASIS BY A FACILITY. COBOL NAME: NUM-ADMN-PART-TIME BEDS - MEDICARE SNF 4 638 641 N PROV1445 NUMBER OF MEDICARE CERTIFIED SNF BEDS IN A FACILITY. COBOL NAME: NUM-T18-SNF-BEDS BEDS - NURSING FACILITY 4 642 645 N PROV1455 NUMBER OF MEDICAID CERTIFIED SKILLED NURSING CARE BEDS IN A FACILITY. COBOL NAME: NUM-T19-SNF-BEDS BEDS - SNF/NF 4 646 649 N PROV1450 NUMBER OF BEDS CERTIFIED FOR BOTH MEDICARE AND MEDICAID SKILLED NURSING CARE IN A LONG TERM CARE FACILITY. COBOL NAME: NUM-T1819-SNF-BEDS CERT NURSE AIDES - CONTRACT 7.2 650 656 N PROV1000 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-NURSE-AID-CONTRACT CERT NURSE AIDES - FULL TIME 7.2 657 663 N PROV1005 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-AID-FULL-TIME CERT NURSE AIDES - PART TIME 7.2 664 670 N PROV1010 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-AID-PART-TIME CHRISTIAN SCIENCE INDICATOR 1 671 671 C PROV0110 INDICATES IF A PROVIDER IS A CHRISTIAN SCIENCE FACILITY COBOL NAME: CHRISTIAN-SCIENCE-IND VALUES: Y CHRISTIAN SCIENCE COMPLIANCE: BEDS PER ROOM WAIVER 1 672 672 C PROV0225 INDICATES IF A WAIVER OF THE BEDS PER ROOM REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-BEDS-PER-ROOM VALUES: 1 WAIVER RECOMMENDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 14 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COMPLIANCE: PATIENT ROOM SIZE 1 673 673 C PROV0270 INDICATES IF A WAIVER OF PATIENT ROOM SIZE HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-PATIENT-ROOM-SZ VALUES: 1 WAIVER RECOMMENDED COMPLIANCE: 7 DAY REGISTERED NURSE 1 674 674 C PROV0295 INDICATES IF A WAIVER OF THE 7 DAY REGISTERED NURSE REQUIREMENTS HAS BEEN RECOMMENDED FOR A SNF OR NF. COBOL NAME: COMPL-7-DAY-RN VALUES: 1 WAIVER RECOMMENDED DENTISTS - CONTRACT 7.2 675 681 N PROV0785 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DENTIST-CONTRACT DENTISTS - FULL TIME 7.2 682 688 N PROV0790 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-DENTIST-FULL-TIME DENTISTS - PART TIME 7.2 689 695 N PROV0795 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-DENTIST-PART-TIME DIETITIANS - CONTRACT 7.2 696 702 N PROV0805 THE NUMBER OF FULL-TIME EQUIVALENT UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DIET-CONTRACT DIETITIANS - FULL TIME 7.2 703 709 N PROV0810 THE NUMBER OF FULL-TIME EQUIVALENT DIETITIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-DIET-FULL-TIME DIETITIANS - PART TIME 7.2 710 716 N PROV0815 THE NUMBER OF FULL-TIME EQUIVALENT DIETITIANS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-DIET-PART-TIME EXPERIMENTAL RESEARCH CONDUCTED 1 717 717 C PROV0465 INDICATES IF A FACILITY USES RESIDENTS TO DEVELOP AND TEST CLINICAL TREATMENTS. COBOL NAME: EXPER-RESEARCH VALUES: Y YES FOOD SERVICE - CONTRACT 7.2 718 724 N PROV0860 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-FOOD-SRV-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 15 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FOOD SERVICE - FULL TIME 7.2 725 731 N PROV0865 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-FOOD-SRV-FULL-TIME FOOD SERVICE - PART TIME 7.2 732 738 N PROV0870 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-FOOD-SRV-PART-TIME HOUSEKEEPING - CONTRACT 7.2 739 745 N PROV0925 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-HOUSE-CONTRACT HOUSEKEEPING - FULL TIME 7.2 746 752 N PROV0930 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-HOUSE-FULL-TIME HOUSEKEEPING - PART TIME 7.2 753 759 N PROV0935 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-HOUSE-PART-TIME LPN/LVN - CONTRACT 7.2 760 766 N PROV1465 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-VOC-NURSE-CONTRACT LPN/LVN - FULL TIME 7.2 767 773 N PROV1470 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-VOC-NURSE-FULL-TIME LPN/LVN - PART TIME 7.2 774 780 N PROV1475 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-VOC-NURSE-PART-TIME LTC CROSS REFERENCE PROVIDER # 6 781 786 C PROV0640 THIS CROSS REFERENCE NUMBER IDENTIFIES LTC PROVIDER NUMBERS THAT WERE TERMINATED IN 1985 BECAUSE OF POLICY CHANGES WHICH STATES THAT SNF/ICF DISTINCT PARTS OR DUA LLY CERTIFIED PORTIONS ARE ASSIGNED SINGLE SNF PROV NO. COBOL NAME: LTC-CROSS-REF-PROV-NUM MEDICAL DIRECTOR - CONTRACT 7.2 787 793 N PROV0960 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS UNDER CONTRCAT TO A FACILITY. COBOL NAME: NUM-MED-CONTRACT MEDICAL DIRECTOR - FULL TIME 7.2 794 800 N PROV0965 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MED-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 16 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MEDICAL DIRECTOR - PART TIME 7.2 801 807 N PROV0970 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MED-PART-TIME MEDICATION AIDES/TECHS-CONTRACT 7.2 808 814 N PROV5180 THE NUMBER OF FULL-TIMR EQUIVALENT MEDICATION AIDES/ TECHNICIANS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-MED-AID-CONTRACT MEDICATION AIDES/TECHS-FULL TIME 7.2 815 821 N PROV5170 THE NUMBER OF FULL-TIME EQUIVALENT MEDICATION AIDES/ TECHNICIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MED-AID-FULL-TIME MEDICATION AIDES/TECHS-PART TIME 7.2 822 828 N PROV5175 THE NUMBER OF FULL-TIME EQUIVALENT MEDICATION AIDES/ TECHNICIANS EMPLOYED BYA FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MED-AID-PART-TIME MENTAL HEALTH SERVICES - CONTRACT 7.2 829 835 N PROV0980 THE NUMBER OF FULL-TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-MEN-HLTH-CONTRACT MENTAL HEALTH SERVICES - FULL TIME 7.2 836 842 N PROV0985 THE NUMBER OF FULL-TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MEN-HLTH-FULL-TIME MENTAL HEALTH SERVICES - PART TIME 7.2 843 849 N PROV0990 THE NUMBER OF FULL TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MEN-HLTH-PART-TIME MULTI-FACILITY ORGANIZATION NAME 38 850 887 C PROV0680 THE NAME OF THE MULTI-FACILITY ORGANIZATION THAT OWNS THE FACILITY. COBOL NAME: NAME-MULT-FACL-ORG MULTI-FACILITY ORGANIZATION OWNED 1 888 888 C PROV0675 INDICATES IF A FACILITY IS OWNED BY AN ORGANIZATION THAT OWNS (OR LEASES) TWO OR MORE NURSING FACILITIES. COBOL NAME: MULT-FACL-ORG VALUES: Y YES NURSE AIDES IN TRNG - CONTRACT 7.2 889 895 N PROV5165 NUMBER OF FULL TIME EQUIVALENT NURSE AIDES IN TRAINING UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-AID-TRNG-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 17 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME NURSE AIDES IN TRNG-FULL TIME 7.2 896 902 N PROV5155 THE NUMBER OF FULL-TIME EQUIVALENT NURSE AIDES IN TRAINING EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-AID-TRNG-FULL-TIME NURSE AIDES IN TRNG-PART TIME 7.2 903 909 N PROV5160 THE NUMBER OF FULL-TIME EQUIVALENT NURSE AIDES IN TRAINING EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-AID-TRNG-PART-TIME NURSES WITH ADMIN DUTIES-CONTRACT 7.2 910 916 N PROV5150 THE NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-NURSE-ADM-CONTRACT NURSES WITH ADMIN DUTIES-FULL TIME 7.2 917 923 N PROV5135 THE NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-ADM-FULL-TIME NURSES WITH ADMIN DUTIES-PART TIME 7.2 924 930 N PROV5145 NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-ADM-PART-TIME OCCUP THERAPIST, FULL TIME, STAFF 7.2 931 937 N PROV1040 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-THER-FULL-TIME OCCUP THERAPISTS, CONTRACT/ARRANGE 7.2 938 944 N PROV1035 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-THER-CONTRACT OCCUP THERAPY AIDE - CONTRACT 7.2 945 951 N PROV1020 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-AID-CONTRACT OCCUP THERAPY AIDE - FULL TIME 7.2 952 958 N PROV1025 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-AID-FULL-TIME OCCUP THERAPY AIDE - PART TIME 7.2 959 965 N PROV1030 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-AID-PART-TIME OCCUP THERAPY ASST - CONTRACT 7.2 966 972 N PROV5195 THE NUMBER OF FULL TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS UNDER CONTRCAT TO A FACILITY. COBOL NAME: NUM-OCC-ASST-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 18 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OCCUP THERAPY ASST - FULL TIME 7.2 973 979 N PROV5185 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-ASST-FULL-TIME OCCUP THERAPY ASST - PART TIME 7.2 980 986 N PROV5190 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-ASST-PART-TIME OCCUPATIONAL THERAPIST - PART TIME 7.2 987 993 N PROV1045 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-THER-PART-TIME ORGANIZED FAMILY GROUP 1 994 994 C PROV1535 INDICATES IF THE FACILITY HAS AN ORGANIZED GROUP OF FAMILY MEMBERS OF RESIDENTS. COBOL NAME: ORG-FAMILY-GRP VALUES: Y YES ORGANIZED RESIDENT GROUP 1 995 995 C PROV1540 INDICATES IF THE FACILITY HAS AN ORGANIZED RESIDENTS GROUP. COBOL NAME: ORG-RESID-GRP VALUES: Y YES OTHER - CONTRACT 7.2 996 1002 N PROV3265 THE NUMBER OF FULL-TIME EQUIVALENT PERSONS NOT INCLUDED IN ANY OTHER CATEGORIES UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-OTH-CONTRACT OTHER - FULL TIME 7.2 1003 1009 N PROV3245 THE NUMBER OF FULL-TIME EQUIVALENT PERSONS NOT INCLUDED IN ANY OTHER CATEGORIES EMPLOYED BY THE FACILITY ON A FULL-TIME BASIS. COBOL NAME: NUM-OTH-FULL-TIME OTHER - PART TIME 7.2 1010 1016 N PROV3255 THE NUMBER OF FULL-TIME EQUIVALENT PERSONS NOT INCLUDED IN ANY OTHER CATEGORIES EMPLOYED BY THE FACILITY ON A PART-TIME BASIS. COBOL NAME: NUM-OTH-PART-TIME OTHER ACTIVITIES STAFF-CONTRACT 7.2 1017 1023 N PROV5270 NUMBER OF CONTRACT STAFF HOURS FOR OTHER ACTIVITIES. COBOL NAME: NUM-OTH-ACT-CONTRACT OTHER ACTIVITIES STAFF-FULL TIME 7.2 1024 1030 N PROV5260 NUMBER OF FULL-TIME STAFF HOURS FOR OTHER ACTIVITIES. COBOL NAME: NUM-OTH-ACT-FULL-TIME OTHER ACTIVITIES STAFF-PART TIME 7.2 1031 1037 N PROV5305 NUMBER OF PART TIME STAFF HOURS PROVIDED BY OTHER ACTIV ITIES STAFF. COBOL NAME: NUM-OTH-ACT-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 19 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OTHER PHYSICIAN - CONTRACT 7.2 1038 1044 N PROV1060 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS UNDER CONTRACT TO A FACILITY COBOL NAME: NUM-OTH-PHY-CONTRACT OTHER PHYSICIAN - FULL TIME 7.2 1045 1051 N PROV1065 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OTH-PHY-FULL-TIME OTHER PHYSICIAN - PART TIME 7.2 1052 1058 N PROV1070 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OTH-PHY-PART-TIME OTHR SOCIAL SERV STAFF-CONTRACT 7.2 1059 1065 N PROV5300 NUMBER OF CONTRACT STAFF HOURS PROVIDED BY OTHER SOCIAL SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-CONTRACT OTHR SOCIAL SERV STAFF-FULL TIME 7.2 1066 1072 N PROV5290 NUMBER OF FULL-TIME STAFF HOURS PROVIDED BY OTHER SOCIA L SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-FULL-TIME OTHR SOCIAL SERV STAFF-PART TIME 7.2 1073 1079 N PROV5295 NUMBER OF PART-TIME STAFF HOURS PROVIDED BY OTHER SOCIA L SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-PART-TIME PHARMACISTS - CONTRACT 7.2 1080 1086 N PROV1085 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-PHAR-CONTRACT PHARMACISTS - FULL TIME 7.2 1087 1093 N PROV1090 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-PHAR-FULL-TIME PHARMACISTS - PART TIME 7.2 1094 1100 N PROV1095 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-PHAR-PART-TIME PHYS THER ASST - CONTRACT 7.2 1101 1107 N PROV5210 NUMBER OF CONTRACT STAFF HOURS FOR PHYSICAL THERAPY ASS ISTANTS. COBOL NAME: NUM-THER-ASST-CONTRACT PHYS THER ASST - FULL TIME 7.2 1108 1114 N PROV5200 NUMBER OF FULL-TIME STAFF HOURS FOR PHYSICAL THERAPY AS SISTANTS. COBOL NAME: NUM-THER-ASST-FULL-TIME PHYS THER ASST - PART TIME 7.2 1115 1121 N PROV5205 NUMBER OF PART-TIME STAFF HOURS FOR PHYSICAL THERAPY AS SISTANTS. COBOL NAME: NUM-THER-ASST-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 20 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PHYSICAL THERAPISTS - CONTRACT 7.2 1122 1128 N PROV1430 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-CONTRACT PHYSICAL THERAPISTS - FULL TIME 7.2 1129 1135 N PROV1435 THE NUMBER OF FULL TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-FULL-TIME PHYSICAL THERAPISTS - PART TIME 7.2 1136 1142 N PROV1440 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-PART-TIME PHYSICAL THERAPY AIDE - CONTRACT 7.2 1143 1149 N PROV1415 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-AID-CONTRACT PHYSICAL THERAPY AIDE - FULL TIME 7.2 1150 1156 N PROV1420 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-AID-FULL-TIME PHYSICAL THERAPY AIDE - PART TIME 7.2 1157 1163 N PROV1425 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-AID-PART-TIME PHYSICIAN EXTENDER - CONTRACT 7.2 1164 1170 N PROV3270 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIAN EXTENDERS UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-PHYS-EXT-CONTRACT PHYSICIAN EXTENDER - FULL TIME 7.2 1171 1177 N PROV3250 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIAN EXTENDERS EMPLOYED BY THE FACILITY ON A FULL-TIME BASIS. COBOL NAME: NUM-PHYS-EXT-FULL-TIME PHYSICIAN EXTENDER - PART TIME 7.2 1178 1184 N PROV3260 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIAN EXTENDERS EMPLOYED BY THE FACILITY ON A PART-TIME BASIS. COBOL NAME: NUM-PHYS-EXT-PART-TIME PODIATRISTS - CONTRACT 7.2 1185 1191 N PROV1130 THE NUMBER OF FULL TIME EQUIVALENT PODIATRISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-POD-CONTRACT PODIATRISTS - FULL TIME 7.2 1192 1198 N PROV1135 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A AFCILITY ON A FULL TIME BASIS. COBOL NAME: NUM-POD-FULL-TIME PODIATRISTS - PART TIME 7.2 1199 1205 N PROV1140 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-POD-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 21 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PROVIDER BASED FACILITY 1 1206 1206 C PROV1675 INDICATES IF A LONG TERM CARE FACILITY IS PROVIDER BASED. COBOL NAME: PROV-BASED-FACILITY VALUES: Y HOSPITAL BASED REGISTERED NURSE - CONTRACT 7.2 1207 1213 N PROV1150 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-REG-NURSE-CONTRACT REGISTERED NURSE - FULL TIME 7.2 1214 1220 N PROV1155 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-REG-NURSE-FULL-TIME REGISTERED NURSE - PART TIME 7.2 1221 1227 N PROV1160 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-REG-NURSE-PART-TIME RELATED PROVIDER NUMBER 10 1228 1237 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM RN DIRECTOR OF NURSING - CONTRACT 7.2 1238 1244 N PROV5130 THE NUMBER OF FULL TIME EQUIVALENT RN DIRECTOR OF NURSI NG UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-RN-DON-CONTRACT RN DIRECTOR OF NURSING - FULL TIME 7.2 1245 1251 N PROV5120 THE NUMBER OF FULL-TIME EQUIVALENT RN DIRECTOR OF NURSING EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-RN-DON-FULL-TIME RN DIRECTOR OF NURSING - PART TIME 7.2 1252 1258 N PROV5140 THE NUMBER OF FULL-TIME EQUIVALENT RN DIRECTOR OF NURSING EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-RN-DON-PART-TIME SOCIAL WORKER - CONTRACT 7.2 1259 1265 N PROV1170 THE NUMBER OF FULL-TIME EQUIVALENT SOCIAL WORKERS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-SOCIAL-CONTRACT SOCIAL WORKER - FULL TIME 7.2 1266 1272 N PROV1175 THE NUMBER OF FULL-TIME EQUIVALENT SOCIAL WORKERS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-SOCIAL-FULL-TIME SOCIAL WORKER - PART TIME 7.2 1273 1279 N PROV1180 THE NUMBER OF FULL-TIME EQUIVALENT SOCIAL WORKERS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-SOCIAL-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 22 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPECIAL CARE BEDS-AIDS 3 1280 1282 N PROV0725 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH AIDS. COBOL NAME: NUM-AIDS-BEDS SPECIAL CARE BEDS-ALZHEIMERS 3 1283 1285 N PROV0730 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH ALZEHEIMERS. COBOL NAME: NUM-ALZHEIMERS-BEDS SPECIAL CARE BEDS-DIALYSIS 3 1286 1288 N PROV0800 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS NEEDING DIALYSIS. COBOL NAME: NUM-DIAL-BEDS SPECIAL CARE BEDS-DISABLED CHILD 3 1289 1291 N PROV0855 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR DEISCABLED CHILDREN. COBOL NAME: NUM-DIS-CHILD-BEDS SPECIAL CARE BEDS-HEAD TRAUMA 3 1292 1294 N PROV0905 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILTY FOR RESIDENTS WITH HEAD TRAUMA. COBOL NAME: NUM-HEAD-TRAUMA-BEDS SPECIAL CARE BEDS-HOSPICE 3 1295 1297 N PROV0920 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY A FACILITY FOR RESIDENTS NEEDING HOSPICE SERVICES. COBOL NAME: NUM-HOSPICE-BEDS SPECIAL CARE BEDS-HUNTINGTONS 3 1298 1300 N PROV0940 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH HUNTINGTON'S DISEASE COBOL NAME: NUM-HUNTING-DIS-BEDS SPECIAL CARE BEDS-SPEC REHAB 3 1301 1303 N PROV1205 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH SPECIALIZED REHAB NEEDS. COBOL NAME: NUM-SPEC-REHAB-BEDS SPECIAL CARE BEDS-VENTILATOR 3 1304 1306 N PROV1460 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH VENTILATOR/ RESIPIRATORY CARE NEEDS. COBOL NAME: NUM-VENT-RESP-BEDS SPEECH PATHOLOGIST - CONTRACT 7.2 1307 1313 N PROV1190 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-SPCH-PATH-CONTRACT SPEECH PATHOLOGIST - FULL TIME 7.2 1314 1320 N PROV1195 THE NUMBER OF FULL-TIME EQUIVALENT SPPECH PATHOLOGISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-SPCH-PATH-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 23 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPEECH PATHOLOGIST - PART TIME 7.2 1321 1327 N PROV1200 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-SPCH-PATH-PART-TIME SRV: ACTIVITIES-OFFSITE-RESIDENTS 1 1328 1328 C PROV3390 INDICATES IF ACTIVITIES SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-ACT-THER-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: ACTIVITIES-ONSITE-NON RES 1 1329 1329 C PROV3385 INDICATES IF ACTIVITIES SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-ACT-THER-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: ACTIVITIES-ONSITE-RESIDENTS 1 1330 1330 C PROV3380 INDICATES IF ACTIVITIES SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-ACT-THER-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: BLOOD ADMIN-OFFSITE-RESIDENTS 1 1331 1331 C PROV3525 INDICATES IF ADMINISTRATION AND STORAGE OF BLOOD SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-ADM-BLOOD-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: BLOOD ADMIN-ONSITE-NONRES 1 1332 1332 C PROV3520 INDICATES IF ADMINISTRATION AND STORAGE OF BLOOD SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-ADM-BLOOD-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: BLOOD ADMIN-ONSITE-RESIDENTS 1 1333 1333 C PROV3515 INDICATES IF ADMINISTRATION AND STORAGE OF BLOOD SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-ADM-BLOOD-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 24 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: CLINICAL LAB-OFFSITE-RESIDENT 1 1334 1334 C PROV3495 INDICATES IF CLINICAL LABORATORY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-CLIN-LAB-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: CLINICAL LAB-ONSITE-NON RES 1 1335 1335 C PROV3490 INDICATES IF CLINICAL LABORATORY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-CLIN-LAB-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: CLINICAL LAB-ONSITE-RESIDENTS 1 1336 1336 C PROV3485 INDICATES IF CLINICAL LABORATORY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-CLIN-LAB-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DENTAL-OFFSITE-RESIDENTS 1 1337 1337 C PROV3435 INDICATES IF DENTAL SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-DENTAL-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DENTAL-ONSITE-NON RESIDENTS 1 1338 1338 C PROV3430 INDICATES IF DENTAL SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-DENTAL-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DENTAL-ONSITE-RESIDENTS 1 1339 1339 C PROV3425 INDICATES IF DENTAL SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-DENTAL-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DIETARY-OFFSITE-RESIDENTS 1 1340 1340 C PROV3345 INDICATES IF DIETARY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-DIETARY-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 25 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: DIETARY-ONSITE-NON RESIDENTS 1 1341 1341 C PROV3340 INDICATES IF DIETARY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-DIETARY-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DIETARY-ONSITE-RESIDENTS 1 1342 1342 C PROV3335 INDICATES IF DIETARY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-DIETARY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: HOUSEKEEPING ONSITE-NON RES 1 1343 1343 C PROV3535 INDICATES IF HOUSEKEEPING SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-HOUSE-KP-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: HOUSEKEEPING-OFFSITE-RES 1 1344 1344 C PROV3540 INDICATES IF HOUSEKEEPING SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-HOUSE-KP-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: HOUSEKEEPING-ONSITE-RESIDENTS 1 1345 1345 C PROV3530 INDICATES IF HOUSEKEEPING SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-HOUSE-KP-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: MENTAL HEALTH-OFFSITE-RES 1 1346 1346 C PROV3465 INDICATES IF MENTAL HEALTH SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-MEN-HLTH-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: MENTAL HEALTH-ONSITE-NON RES 1 1347 1347 C PROV3460 INDICATES IF MENTAL HEALTH SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-MEN-HLTH-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 26 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: MENTAL HEALTH-ONSITE-RESID 1 1348 1348 C PROV3455 INDICATES IF MENTAL HEALTH SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-MEN-HLTH-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: NURSING-OFFSITE-RESIDENTS 1 1349 1349 C PROV3315 INDICATES IF NURSING SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-NURSING-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: NURSING-ONSITE-NON RESIDENTS 1 1350 1350 C PROV3310 INDICATES IF NURSING SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-NURSING-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: NURSING-ONSITE-RESIDENTS 1 1351 1351 C PROV3305 INDICATES IF NURSING SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-NURSING-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OCCUP THER-OFFSITE-RESIDENTS 1 1352 1352 C PROV3360 INDICATES IF OCCUPATIONAL THERAPY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-OCC-THER-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OCCUP THER-ONSITE-NON RESID 1 1353 1353 C PROV3355 INDICATES IF OCCUPATIONAL THERAPY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-OCC-THER-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OCCUP THER-ONSITE-RESIDENTS 1 1354 1354 C PROV3350 INDICATES IF OCCUPATIONAL THERAPY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-OCC-THER-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 27 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: OTH ACTIVITIES-OFFSITE TO RES 1 1355 1355 C PROV5255 FIELD 3 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF OFFSITE TO RESIDENTS. COBOL NAME: SP-OTH-ACT-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH ACTIVITIES-ONSITE NONRES 1 1356 1356 C PROV5250 FIELD 2 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF ONSITE TO NONRESIDENTS. COBOL NAME: SP-OTH-ACT-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH ACTIVITIES-ONSITE RES 1 1357 1357 C PROV5245 FIELD 1 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF ONSITE TO RESIDENTS. COBOL NAME: SP-OTH-ACT-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-OFFSITE TO RES 1 1358 1358 C PROV5285 FIELD 3 - INDICATES SERVICES PROVIDED BY OTHER SOCIAL S ERVICES STAFF OFFSITE TO RESIDENTS. COBOL NAME: SP-OTH-SOC-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-ONSITE TO NONRES 1 1359 1359 C PROV5280 INDICATES IF OTHER SOCIAL SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-OTH-SOC-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-ONSITE TO RES 1 1360 1360 C PROV5275 FIELD 1 - INDICATES SERVICES PROVIDED BY SOCIAL SERVICE S STAFF ONSITE TO RESIDENTS. COBOL NAME: SP-OTH-SOC-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHARMACY-OFFSITE-RESIDENTS 1 1361 1361 C PROV3330 INDICATES IF PHARMACY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PHARMACY-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 28 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHARMACY-ONSITE-NON RESIDENTS 1 1362 1362 C PROV3325 INDICATES IF PHARMACY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PHARMACY-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHARMACY-ONSITE-RESIDENTS 1 1363 1363 C PROV3320 INDICATES IF PHARMACY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PHARMACY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYS EXTENDER-OFFSITE-RESID 1 1364 1364 C PROV3300 INDICATES IF PHYSICIAN EXTENDER SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PHYS-EXT-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYS EXTENDER-ONSITE-NON RES 1 1365 1365 C PROV3295 INDICATES IF PHYSICIAN EXTENDER SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PHYS-EXT-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYS EXTENDER-ONSITE-RESIDENT 1 1366 1366 C PROV3290 INDICATES IF PHYSICIAN EXTENDER SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PHYS-EXT-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYS THER-OFFSITE-RESIDENTS 1 1367 1367 C PROV3375 INDICATES IF PHYSICAL THERAPY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PHYS-THER-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYS THER-ONSITE-NON RESIDENT 1 1368 1368 C PROV3370 INDICATES IF PHYSICAL THERAPY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PHYS-THER-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 29 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHYS THER-ONSITE-RESIDENTS 1 1369 1369 C PROV3365 INDICATES IF PHYSICAL THERAPY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PHYS-THER-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYSICIAN-OFFSITE-RESIDENTS 1 1370 1370 C PROV3285 INDICATES IF PHYSICIAN SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PHYS-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYSICIAN-ONSITE-NON RESIDENT 1 1371 1371 C PROV3280 INDICATES IF PHYSICIAN SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PHYS-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYSICIAN-ONSITE-RESIDENTS 1 1372 1372 C PROV3275 INDICATES IF PHYSICIAN SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PHYS-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PODIATRY-OFFSITE-RESIDENTS 1 1373 1373 C PROV3450 INDICATES IF PODIATRY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PODIATRY-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PODIATRY-ONSITE-NON RESIDENTS 1 1374 1374 C PROV3445 INDICATES IF PODIATRY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PODIATRY-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PODIATRY-ONSITE-RESIDENTS 1 1375 1375 C PROV3440 INDICATES IF PODIATRY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PODIATRY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 30 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: SOCIAL WORK-OFFSITE-RESIDENTS 1 1376 1376 C PROV3405 INDICATES IF SOCIAL WORK SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-MED-SOC-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: SOCIAL WORK-ONSITE-NON RESID 1 1377 1377 C PROV3400 INDICATES IF SOCIAL WORK SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-MED-SOC-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: SOCIAL WORK-ONSITE-RESIDENTS 1 1378 1378 C PROV3395 INDICATES IF SOCIAL WORK SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-MED-SOC-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: SPEECH PATH-OFFSITE-RESIDEN 1 1379 1379 C PROV3420 INDICATES IF SPEECH/LANGUAGE PATHOLOGY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-SPEECH-PH-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: SPEECH PATH-ONSITE-NON RESID 1 1380 1380 C PROV3415 INDICATES IF SPEECH/LANGUAGE PATHOLOGY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-SPEECH-PH-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: SPEECH PATH-ONSITE-RESIDENTS 1 1381 1381 C PROV3410 INDICATES IF SPEECH/LANGUAGE PATHOLOGY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-SPEECH-PH-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: THER REC SPEC-OFFSITE TO RES 1 1382 1382 C PROV5225 INDICATES IF THERAPEUTIC RECRECATION SPECIALIST SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-THER-REC-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 31 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: THER REC SPEC-ONSITE-NONRES 1 1383 1383 C PROV5220 INDICATES IF THERAPEUTIC RECREATION SPECIALIST SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-THER-REC-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: THER REC SPEC-ONSITE-RESIDENT 1 1384 1384 C PROV5215 INDICATES IF THERAPEUTIC RECREATION SPECIALIST SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-THER-REC-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: VOCATIONAL-OFFSITE-RESIDENTS 1 1385 1385 C PROV3480 INDICATES IF VOCATIONAL SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-VOC-GUID-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: VOCATIONAL-ONSITE-NON RESID 1 1386 1386 C PROV3475 INDICATES IF VOCATIONAL SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-VOC-GUID-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: VOCATIONAL-ONSITE-RESIDENTS 1 1387 1387 C PROV3470 INDICATES IF VOCATIONAL SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-VOC-GUID-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: XRAY-OFFSITE-RESIDENTS 1 1388 1388 C PROV3510 INDICATES IF DIAGNOSTIC XRAY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-DIAG-XRAY-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: XRAY-ONSITE-NON RESIDENTS 1 1389 1389 C PROV3505 INDICATES IF DIAGNOSTIC XRAY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-DIAG-XRAY-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 32 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: XRAY-ONSITE-RESIDENTS 1 1390 1390 C PROV3500 INDICATES IF DIAGNOSTIC XRAY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-DIAG-XRAY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED THER REC SPEC - CONTRACT 7.2 1391 1397 N PROV5240 NUMBER OF CONTRACT STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-CONTRACT THER REC SPEC - FULL TIME 7.2 1398 1404 N PROV5230 NUMBER OF FULL-TIME STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-FULL-TIME THER REC SPEC - PART TIME 7.2 1405 1411 N PROV5235 NUMBER OF PART-TIME STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 1 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 HOME HEALTH AGENCY CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 05 HOME HEALTH AGENCIES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 2 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00000 DUMMY FOR MEDICAID HHA 00011 CAHABA 00040 BLUE CROSS (CALIFORNIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00180 NATIONAL GOVERNMENT SERVICES 00181 NATIONAL GOVERNMENT SERVICES 00230 BLUE CROSS (MISSISSIPPI) 00290 BLUE CROSS (NEW MEXICO) 00332 NATIONAL GOVERNMENT SERVICES 00362 BLUE CROSS (INDEPENDENCE) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 3 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 01101 PALMETTO (CALIFORNIA) 01201 PALMETTO (HAWAII) 01301 PALMETTO (NEVADA) 01390 AETNA (WASHINGTON) 02101 NATIONAL HERITAGE (ALASKA) 02201 NATIONAL HERITAGE (IDAHO) 02301 NATIONAL HERITAGE (OREGON) 02401 NATIONAL HERITAGE (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03101 NORIDIAN (ARIZONA) 03201 NORIDIAN (MONTANA) 03301 NORIDIAN (NORTH DAKOTA) 03401 NORIDIAN (SOUTH DAKOTA) 03501 NORIDIAN (UTAH) 03601 NORIDIAN (WYOMING) 04101 TRAILBLAZER (COLORADO) 04201 TRAILBLAZER (NEW MEXICO) 04301 TRAILBLAZER (OKLAHOMA) 04401 TRAILBLAZER (TEXAS) 05101 WPS (IOWA) 05201 WPS (KANSAS) 05301 WPS (MISSOURI) 05401 WPS (NEBRASKA) 07101 PINNACLE (ARKANSAS) 07201 PINNACLE (LOUISIANA) 07301 PINNACLE (MISSISSIPPI) 08101 PINNACLE (INDIANA) 08201 PINNACLE (MICHIGAN) 09101 FIRST COAST (FLORIDA) 09201 FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 12101 HIGHMARK (DELAWARE) 12201 HIGHMARK (DISTRICT OF COLUMBIA) 12301 HIGHMARK (MARYLAND) 12401 HIGHMARK NEW JERSEY) 12501 HIGHMARK (PENNSYLVANIA) 13101 NATL GOVT SERVICES (CONNECTICUT) 13201 NATL GOVT SERVICES (NEW YORK) 14004 NATIONAL HERITAGE (HHA) 14101 NATIONAL HERITAGE (MAINE) 14201 NATIONAL HERITAGE (MASSACHUSETTS) 14301 NATIONAL HERITAGE (NEW HAMPSHIRE) 14401 NATIONAL HERITAGE (RHODE ISLAND) 14501 NATIONAL HERITAGE (VERMONT) 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 4 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 51051 AETNA (PETALUMA) 51100 AETNA (CLEARWATER) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM VALUES: 00000 DUMMY FOR MEDICAID HHA 00011 CAHABA 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00180 BLUE CROSS (MAINE) 00181 NATIONAL GOVERNMENT SERVICES 00230 BLUE CROSS (MISSISSIPPI) 00290 BLUE CROSS (NEW MEXICO) 00332 NATIONAL GOVERNMENT SERVICES 00362 BLUE CROSS (INDEPENDENCE) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00511 CAHABA 00883 PALMETTO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 5 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN ADMIN SERVICES (ARIZONA) 03202 NORIDIAN ADMIN SERVICES (MONTANA) 03302 NORIDIAN ADMIN SERVICES (NORTH DAKOTA) 03402 NORIDIAN ADMIN SERVICES (MONTANA) 03502 NORIDIAN ADMIN SERVICES (UTAH) 03602 NORIDIAN ADMIN SERVICES (WYOMING) 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 51051 AETNA (PETALUMA) 51100 AETNA (CLEARWATER) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 6 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 7 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 8 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATE REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 9 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP 5 VALIDATION (ACCRD) 8 FULL SURVEY AFTER COMPLAINT TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 VOL. NON-PROF. - RELIGIOUS AFF. 02 VOLUNTARY NON-PROFIT - PRIVATE 03 VOLUNTARY NON-PROFIT - OTHER 04 PROPRIETARY 05 GOVERNMENT - STATE/COUNTY 06 GOVERNMENT - COMB. GOVT & VOL. 07 GOVERNMENT - LOCAL * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 10 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD ACCREDITATION INDICATOR 1 290 290 C PROV0010 INDICATES THE ORGANIZATION THAT IS RESPONSIBLE FOR THE ACCREDITATION OF THE PROVIDER. COBOL NAME: ACCRED-STAT VALUES: 0 NONE 1 JCAHO 2 CHAP 3 ACHC DATE OF LAST VALIDATION SURVEY 8 363 370 C PROV0450 DATE THE LAST VALIDATION SURVEY WAS PERFORMED BY THE STATE AGENCY FOR A JCAH, AOA ACCREDITED HOSPITAL OR OTHER PROVIDER TYPE. COBOL NAME: DT-VALID-SURVEY DIETICIANS 7.2 371 377 N PROV0820 NUMBER OF FULL-TIME EQUIVALENT DIETICIANS EMPLOYED BY A FACILITY. COBOL NAME: NUM-DIETICIANS FISCAL YEAR ENDING DATE 4 378 381 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT LICENSED PRACT/VOCAT NURSES 7.2 382 388 N PROV0955 NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL OR VOCATIONAL NURSES EMPLOYED BY A FACILITY. COBOL NAME: NUM-LPN-LVN OCCUPATIONAL THERAPISTS 7.2 405 411 N PROV1050 THE NUMBER OF FULL TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-OCCUP-THERAPISTS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 11 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OTHER PERSONNEL 7.2 412 418 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL PROGRAM PARTICIPATION 1 434 434 C PROV1670 INDICATES IF THE PROVIDER PARTICIPATES IN MEDICARE, MEDICAID, OR BOTH PROGRAMS. COBOL NAME: PROG-PARTCI VALUES: 1 MEDICARE ONLY 2 MEDICAID ONLY 3 MEDICARE AND MEDICAID REGIONAL OVERRIDE #2 (STAFFING) 1 471 471 C PROV1550 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-2 VALUES: Y RECORD HAS BEEN APPROVED REGISTERED NURSES 7.2 473 479 N PROV1145 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PROFESSIONAL NURSES EMPLOYED BY A PROVIDER. COBOL NAME: NUM-REG-NURS REGISTERED PHARMACISTS 7.2 480 486 N PROV1100 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PHARMACISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHARMACIST-REG SRV: OCCUPATIONAL THERAPY 1 558 558 C PROV2270 INDICATES HOW OCCUPATIONAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-OCCUP-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: PHARMACY 1 569 569 C PROV2365 INDICATES HOW PHARMACY SERVICES ARE PROVIDED. COBOL NAME: SP-PHARMACY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 12 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHYSICAL THERAPY 1 570 570 C PROV2370 INDICATES HOW PHYSICAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICAL-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION TYPE OF FACILITY 2 593 594 C PROV2890 INDICATES THE CATEGORY WHICH REPRESENTS THE TYPE OF FACILITY. COBOL NAME: TYPE-FACILITY VALUES: 01 VISITING NURSE ASSOCIATION 02 COMBINATION GOVERNMENT VOLUNTARY 03 OFFICIAL HEALTH AGENCY 04 REHABILITATION FACILITY BASED PROGRAM 05 HOSPITAL BASED PROGRAM 06 SKILLED NURSING FACILITY BASED PROGRAM 07 OTHER RELATED PROVIDER NUMBER 10 1228 1237 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM AIDE TRAINING/COMPETENCY PROGRAMS 1 1412 1412 C PROV0555 INDICATES HOW THE AGENCY PROVIDES HOME HEALTH AIDE TRAINING AND COMPETENCY EVALUATION PROGRAMS. COBOL NAME: HHA-PROVIDES-DIRECT VALUES: 1 AIDE TRAINING 2 COMPETENCY EVALUATION PROG. 3 AIDE TRAINING AND COMPETENCY PROG. 4 NEITHER BRANCH OPERATION INDICATOR 1 1413 1413 C PROV1525 INDICATES IF THE AGENCY OPERATES ANY BRANCHES. COBOL NAME: OPERS-BRANCHES VALUES: N NO Y YES BRANCHES 3 1414 1416 N PROV0745 THE NUMBER OF BRANCHES OPERATED BY THE AGENCY. COBOL NAME: NUM-BRANCHES CHANGE OF OWNERSHIP INDICATOR 1 1417 1417 C PROV0105 INDICATES IF A HOME HEALTH AGENCY HAS UNDERGONE A CHANGE OF OWNERSHIP SINCE THE LAST SURVEY. COBOL NAME: CHOW-IND VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 13 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME N NO Y YES HHA QUALIFIED FOR OPT 1 1418 1418 C PROV0560 INDICATES IF A HOME HEALTH AGENCY IS QUALIFIED TO PROVIDE OUTPATIENT PHYSICAL THERAPY/SPEECH SERVICES. COBOL NAME: HHA-QUAL-FOR-OPT VALUES: N NO Y YES HOME HEALTH AIDES 7.2 1419 1425 N PROV0910 NUMBER OF FULL-TIME EQUIVALENT HOME HEALTH AIDES EMPLOYED BY A HOME HEALTH AGENCY OR HOSPICE. COBOL NAME: NUM-HOME-HEALTH-AIDES HOSPICE INDICATOR 1 1426 1426 C PROV0665 INDICATES IF THE HOME HEALTH AGENCY ALSO PARTICIPATES IN THE MEDICARE PROGRAM AS A HOSPICE. COBOL NAME: MEDICARE-CERT-HOSPICE VALUES: N NO Y YES MEDICARE HOSPICE PROVIDER NUMBER 6 1427 1432 C PROV0570 IF THE AGENCY ALSO PARTICIPATES IN THE MEDICARE PROGRAM AS A HOSPICE, THE HOSPICE PROVIDER NUMBER. COBOL NAME: HOSPICE-PROV-NUM MEDICARE/MEDICAID PROVIDER NUMBER 6 1433 1438 C PROV0650 IF THE AGENCY IS BASED IN ANOTHER MEDICARE OR MEDICAID FACILITY, THE PROVIDER NUMBER OF THAT FACILITY. COBOL NAME: MEDICAID-CARE-VEND-NUM SOCIAL WORKERS 7.2 1439 1445 N PROV1185 THE NUMBER OF FULL TIME EQUIVALENT SOCIAL WORKERS EMPLOYED BY THE AGENCY. COBOL NAME: NUM-SOCIAL-WRKS SPEECH PATHOLOGISTS, AUDIOLOGISTS 7.2 1446 1452 N PROV1220 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS OR AUDIOLOGISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-SPEECH-PATH-AUDIO SRV: APPLIANCE AND EQUIPMENT 1 1453 1453 C PROV2075 INDICATES HOW APPLIANCE AND EQUIPMENT SERVICES ARE PROVIDED BY A HOME HEALTH AGENCY. COBOL NAME: SP-APPLIANCE-EQUIP VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 14 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: HOME HEALTH AIDE/HOMEMAKER 1 1454 1454 C PROV2155 INDICATES HOW HOME HEALTH AIDE SERVICES ARE PROVIDED BY A HOME HEALTH AGENCY. COBOL NAME: SP-HH-AIDE-HOMEMAKER VALUES: 0 NOT PROVIDED 1 PROVIDED BY AGENCY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: INTERNS AND RESIDENTS 1 1455 1455 C PROV2195 INDICATES HOW INTERN AND RESIDENT SERVICES ARE PROVIDED BY A HOME HEALTH AGENCY. COBOL NAME: SP-INTERNS-RESIDENTS VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: MEDICAL SOCIAL 1 1456 1456 C PROV2220 INDICATES HOW MEDICAL SOCIAL SERVICES ARE PROVIDED COBOL NAME: SP-MEDICAL-SOCIAL VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: NURSING 1 1457 1457 C PROV2250 INDICATES HOW NURSING SERVICES ARE PROVIDED. COBOL NAME: SP-NURSING VALUES: 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: NUTRITIONAL GUIDANCE 1 1458 1458 C PROV2255 INDICATES HOW NUTRITIONAL GUIDANCE SERVICES ARE PROVIDED. COBOL NAME: SP-NUTRITION-GUIDANCE VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: OTHER 1 1459 1459 C PROV2340 INDICATES HOW OTHER (NOT SPECIFIED) SERVICES ARE PROVIDED. COBOL NAME: SP-OTHER VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 15 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: SPEECH THERAPY 1 1460 1460 C PROV2520 INDICATES HOW SPEECH THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-SPEECH-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: VOCATIONAL GUIDANCE 1 1461 1461 C PROV2535 INDICATES HOW VOCATIONAL GUIDANCE SERVICES ARE PROVIDED COBOL NAME: SP-VOCAT-GUIDANCE VALUES: 0 NOT PROVIDED 1 PROVIDED BY AGENCY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SUBUNIT INDICATOR 1 1462 1462 C PROV2725 INDICATES IF THE AGENCY IS A SUBUNIT OF ANOTHER AGENCY. COBOL NAME: SUBUNIT-IND VALUES: N NO Y YES SUBUNIT OPERATION INDICATOR 1 1463 1463 C PROV1530 INDICATES IF THE AGENCY OPERATES ANY SUBUNITS. COBOL NAME: OPERS-SUBUNITS VALUES: N NO Y YES SUBUNITS 3 1464 1466 N PROV1240 THE NUMBER OF SUBUNITS OPERATED BY THE AGENCY. COBOL NAME: NUM-SUBUNITS SURETY BOND INDICATOR 1 1467 1467 C PROV5680 SURETY BOND INDICATOR, VALID VALUES ARE "N" OR "Y" OR "W" COBOL NAME: SURETY-BOND-IND VALUES: N NO W WAIVER Y YES PHYSICAL THERAPISTS ON STAFF 7.2 1497 1503 N PROV1120 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY AN OUTPATIENT PHYSICAL THERAPY PROVIDER OR A HOME HEALTH AGENCY PROVIDER. COBOL NAME: NUM-PHYS-THERAPISTS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 16 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: LABORATORY 1 1720 1720 C PROV2200 INDICATES HOW LABORATORY SERVICES ARE PROVIDED. COBOL NAME: SP-LABORATORY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 1 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 X-RAY CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 07 PORTABLE X-RAY SUPPLIERS CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 2 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00011 CAHABA 00122 HCSC - MICHIGAN 00131 NATIONAL GOVERNMENT SERVICES 00181 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00510 BLUE SHIELD (ALABAMA) 00511 CAHABA 00520 BLUE SHIELD (ARKANSAS) 00528 BLUE SHIELD (ARKANSAS/LOUISIANA) 00542 BLUE SHIELD (CALIFORNIA) 00550 BLUE SHIELD (COLORADO) 00570 BLUE SHIELD (DELAWARE) 00580 BLUE SHIELD (DISTRICT OF COLUMBIA) 00590 BLUE SHIELD (FLORIDA) 00621 BLUE SHIELD (ILLINOIS) 00630 NATIONAL GOVERNMENT SERVICES 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 NATIONAL GOVERNMENT SERVICES 00690 BLUE SHIELD (MARYLAND) 00700 BLUE SHIELD (MASSACHUSETTS) 00710 BLUE SHIELD (MICHIGAN) 00720 BLUE SHIELD (MINNESOTA) 00740 BLUE SHIELD (KANSAS CITY) 00770 BLUE SHIELD (NEW HAMPSHIRE/VERMONT) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 3 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00780 BLUE SHIELD (TRI-STATE) 00801 BLUE SHIELD (BUFFALO) 00803 NATIONAL GOVERNMENT SERVICES 00805 NATIONAL GOVERNMENT SERVICES 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865 BLUE SHIELD (PENNSYLVANIA) 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00883 PALMETTO 00900 BLUE SHIELD (TEXAS) 00901 TRAILBLAZERS HEALTH ENTERPRISES 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 00973 BLUE SHIELD (PUERTO RICO) 00974 BLUE SHIELD (VIRGIN ISLANDS) 01010 AETNA (PEORIA) 01020 AETNA (ALASKA) 01030 AETNA (ARIZONA) 01040 AETNA (GEORGIA) 01102 PALMETTO (CALIFORNIA NORTH) 01120 AETNA (HAWAII) 01192 PALMETTO (CALIFORNIA SOUTH) 01202 PALMETTO (HAWAII) 01290 AETNA (NEVADA) 01302 PALMETTO (NEVADA) 01360 AETNA (NEW MEXICO) 01370 AETNA (OKLAHOMA) 01380 AETNA (OREGON) 01390 AETNA (WASHINGTON) 02050 OCCIDENTAL (CALIFORNIA) 02102 NATIONAL HERITAGE (ALASKA) 02202 NATIONAL HERITAGE (IDAHO) 02302 NATIONAL HERITAGE (OREGON) 02402 NATIONAL HERITAGE (WASHINGTON) 03102 NORIDIAN (ARIZONA) 03202 NORIDIAN (MONTANA) 03302 NORIDIAN (NORTH DAKOTA) 03402 NORIDIAN (SOUTH DAKOTA) 03502 NORIDIAN (UTAH) 03602 NORIDIAN (WYOMING) 04102 TRAILBLAZER (COLORADO) 04202 TRAILBLAZER (NEW MEXICO) 04302 TRAILBLAZER (OKLAHOMA) 04402 TRAILBLAZER (TEXAS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 4 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 05102 WPS (IOWA) 05130 EQICOR (IDAHO) 05202 WPS (KANSAS) 05302 WPS (MISSOURI WEST) 05392 WPS (MISSOURI EAST) 05402 WPS (NEBRASKA) 05440 EQICOR (TENNESSEE) 05535 EQICOR (NORTH CAROLINA) 07102 PINNACLE (ARKANSAS) 07202 PINNACLE (LOUISIANA) 07302 PINNACLE (MISSISSIPPI) 08102 PINNACLE (INDIANA) 08202 PINNACLE (MICHIGAN) 09102 FIRST COAST (FLORIDA) 09202 FIRST COAST (PUERTO RICO) 09302 FIRST COAST (VIRGIN ISLANDS) 10071 TRAVELERS (RRB) 10230 TRAVELERS (CONNECTICUT) 10240 TRAVELERS (MINNESOTA) 10250 TRAVELERS (MISSISSIPPI) 10490 TRAVELERS (VIRGINIA) 10492 TRAVELERS - VIRGINIA SPECIAL PROJECT 11260 GENERAL AMERICAN 12102 HIGHMARK (DELAWARE) 12202 HIGHMARK (DISTRICT OF COLUMBIA) 12302 HIGHMARK (MARYLAND) 12402 HIGHMARK (NEW JERSEY) 12502 HIGHMARK (PENNSYLVANIA) 13102 NATL GOVT SERVICES (CONNECTICUT) 13202 NATL GOVT SERVICES (NEW YORK (EMPIRE)) 13282 NATL GOVT SERVICES (NEW YORK (HEALTHNOW)) 13292 NATL GOVT SERVICES (NEW YORK (GHI)) 14102 NATIONAL HERITAGE (MAINE) 14202 NATIONAL HERITAGE (MASSACHUSETTS) 14302 NATIONAL HERITAGE (NEW HAMPSHIRE) 14330 GROUP HEALTH INC (NEW YORK) 14402 NATIONAL HERITAGE (RHODE ISLAND) 14502 NATIONAL HERITAGE (VERMONT) 16360 NATIONWIDE (OHIO) 16510 NATIONWIDE (WEST VIRGINIA) 21200 MASSACHUSETTS/MAINE 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 5 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM VALUES: 00011 CAHABA 00122 HCSC - MICHIGAN 00131 NATIONAL GOVERNMENT SERVICES 00181 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00510 BLUE SHIELD (ALABAMA) 00511 CAHABA 00520 BLUE SHIELD (ARKANSAS) 00528 BLUE SHIELD (ARKANSAS/LOUISIANA) 00542 BLUE SHIELD (CALIFORNIA) 00550 BLUE SHIELD (COLORADO) 00570 BLUE SHIELD (DELAWARE) 00580 BLUE SHIELD (DISTRICT OF COLUMBIA) 00590 BLUE SHIELD (FLORIDA) 00621 BLUE SHIELD (ILLINOIS) 00630 NATIONAL GOVERNMENT SERVICES 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 NATIONAL GOVERNMENT SERVICES 00690 BLUE SHIELD (MARYLAND) 00700 BLUE SHIELD (MASSACHUSETTS) 00710 BLUE SHIELD (MICHIGAN) 00720 BLUE SHIELD (MINNESOTA) 00740 BLUE SHIELD (KANSAS CITY) 00751 BLUE SHIELD (MONTANA) 00770 BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780 BLUE SHIELD (TRI-STATE) 00801 BLUE SHIELD (BUFFALO) 00803 NATIONAL GOVERNMENT SERVICES 00805 NATIONAL GOVERNMENT SERVICES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 6 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00820 BLUE SHIELD (NORTH DAKOTA) 00825 BLUE SHIELD (NORTH DAKOTA/WYOMING) 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865 BLUE SHIELD (PENNSYLVANIA) 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00883 PALMETTO 00900 BLUE SHIELD (TEXAS) 00901 TRAILBLAZERS HEALTH ENTERPRISES 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 00973 BLUE SHIELD (PUERTO RICO) 00974 BLUE SHIELD (VIRGIN ISLANDS) 01010 AETNA (PEORIA) 01020 AETNA (ALASKA) 01030 AETNA (ARIZONA) 01040 AETNA (GEORGIA) 01120 AETNA (HAWAII) 01290 AETNA (NEVADA) 01360 AETNA (NEW MEXICO) 01370 AETNA (OKLAHOMA) 01380 AETNA (OREGON) 01390 AETNA (WASHINGTON) 02050 OCCIDENTAL (CALIFORNIA) 05130 EQICOR (IDAHO) 05440 EQICOR (TENNESSEE) 05535 EQICOR (NORTH CAROLINA) 10071 TRAVELERS (RRB) 10230 TRAVELERS (CONNECTICUT) 10240 TRAVELERS (MINNESOTA) 10250 TRAVELERS (MISSISSIPPI) 10490 TRAVELERS (VIRGINIA) 10492 TRAVELERS - VIRGINIA SPECIAL PROJECT 11260 GENERAL AMERICAN 14330 GROUP HEALTH INC (NEW YORK) 16360 NATIONWIDE (OHIO) 16510 NATIONWIDE (WEST VIRGINIA) 21200 MASSACHUSETTS/MAINE 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 7 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 8 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 9 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 10 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATE REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 11 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 INDIVIDUAL 02 PARTNERSHIP 03 CORPORATION 04 OTHER THAN PRIVATE ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD FISCAL YEAR ENDING DATE 4 378 381 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT OTHER PERSONNEL 7.2 412 418 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL DIRECTOR QUALIFICATIONS 1 1468 1468 C PROV1715 INDICATES THE QUALIFICATIONS OF THE DIRECTOR OF A SUPPLIER OF PORTABLE X-RAY SERVICES. COBOL NAME: QUAL-OF-DIRECTOR VALUES: 1 PHYSICIAN 2 PHD/SCD 3 MS/MA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 12 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 4 BS/BA 5 OTHER TECHNOLOGISTS - ASSOC DEGREE 7.2 1469 1475 N PROV0735 THE NUMBER OF TECHNOLOGISTS WITH ASSOCIATE DEGREES IN RADIOLOGIC TECHNOLOGY. COBOL NAME: NUM-AS-RADIO-TECH TECHNOLOGISTS - BS/BA DEGREE 7.2 1476 1482 N PROV0750 NUMBER OF TECHNOLOGISTS WITH BACHELOR OF SCIENCE OR BACHELOR OF ARTS DEGREES IN RADIOLOGIC TECHNOLOGY. COBOL NAME: NUM-BS-BA-RAD-TECH TECHNOLOGISTS - 2 YEAR RADIOLOGY 7.2 1483 1489 N PROV1515 THE NUMBER OF FULL-TIME EQUIVALENT TECHNOLOGISTS EMPLOYED BY A PORTABLE X-RAY PROVIDER WHO ARE GRADUATES OF A TWO YEAR APPROVED SCHOOL OF RADIOLOGIC TECHNOLOGY. COBOL NAME: NUM-2YR-RADIO-TECH * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 1 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 OPT OR SPECH PATHOLOGY CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 08 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 2 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 NATIONAL GOVERNMENT SERVICES 00180 NATIONAL GOVERNMENT SERVICES 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 3 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00510 BLUE SHIELD (ALABAMA) 00511 CAHABA 00520 BLUE SHIELD (ARKANSAS) 00528 BLUE SHIELD (ARKANSAS/LOUISIANA) 00542 BLUE SHIELD (CALIFORNIA) 00550 BLUE SHIELD (COLORADO) 00570 BLUE SHIELD (DELAWARE) 00580 BLUE SHIELD (DISTRICT OF COLUMBIA) 00590 BLUE SHIELD (FLORIDA) 00621 BLUE SHIELD (ILLINOIS) 00630 NATIONAL GOVERNMENT SERVICES 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 NATIONAL GOVERNMENT SERVICES 00690 BLUE SHIELD (MARYLAND) 00700 BLUE SHIELD (MASSACHUSETTS) 00710 BLUE SHIELD (MICHIGAN) 00720 BLUE SHIELD (MINNESOTA) 00740 BLUE SHIELD (KANSAS CITY) 00770 BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780 BLUE SHIELD (TRI-STATE) 00801 BLUE SHIELD (BUFFALO) 00803 NATIONAL GOVERNMENT SERVICES 00805 NATIONAL GOVERNMENT SERVICES 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 4 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 00865 BLUE SHIELD (PENNSYLVANIA) 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00883 PALMETTO 00900 BLUE SHIELD (TEXAS) 00901 TRAILBLAZERS HEALTH ENTERPRISES 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 00973 BLUE SHIELD (PUERTO RICO) 00974 BLUE SHIELD (VIRGIN ISLANDS) 01010 AETNA (PEORIA) 01020 AETNA (ALASKA) 01030 AETNA (ARIZONA) 01040 AETNA (GEORGIA) 01101 PALMETTO (CALIFORNIA) 01102 PALMETTO (CALIFORNIA NORTH) 01120 AETNA (HAWAII) 01192 PALMETTO (CALIFORNIA SOUTH) 01201 PALMETTO (HAWAII) 01202 PALMETTO (HAWAII) 01290 AETNA (NEVADA) 01301 PALMETTO (NEVADA) 01302 PALMETTO (NEVADA) 01360 AETNA (NEW MEXICO) 01370 AETNA (OKLAHOMA) 01380 AETNA (OREGON) 01390 AETNA (WASHINGTON) 02050 OCCIDENTAL (CALIFORNIA) 02101 NATIONAL HERITAGE (ALASKA) 02102 NATIONAL HERITAGE (ALASKA) 02201 NATIONAL HERITAGE (IDAHO) 02202 NATIONAL HERITAGE (IDAHO) 02301 NATIONAL HERITAGE (OREGON) 02302 NATIONAL HERITAGE (OREGON) 02401 NATIONAL HERITAGE (WASHINGTON) 02402 NATIONAL HERITAGE (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03101 NORIDIAN (ARIZONA) 03102 NORIDIAN (ARIZONA) 03201 NORIDIAN (MONTANA) 03202 NORIDIAN (MONTANA) 03301 NORIDIAN (NORTH DAKOTA) 03302 NORIDIAN (NORTH DAKOTA) 03401 NORIDIAN (SOUTH DAKOTA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 5 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 03402 NORIDIAN (SOUTH DAKOTA) 03501 NORIDIAN (UTAH) 03502 NORIDIAN (UTAH) 03601 NORIDIAN (WYOMING) 03602 NORIDIAN (WYOMING) 04101 TRAILBLAZER (COLORADO) 04102 TRAILBLAZER (COLORADO) 04201 TRAILBLAZER (NEW MEXICO) 04202 TRAILBLAZER (NEW MEXICO) 04301 TRAILBLAZER (OKLAHOMA) 04302 TRAILBLAZER (OKLAHOMA) 04401 TRAILBLAZER (TEXAS) 04402 TRAILBLAZER (TEXAS) 05101 WPS (IOWA) 05102 WPS (IOWA) 05130 EQICOR (IDAHO) 05201 WPS (KANSAS) 05202 WPS (KANSAS) 05301 WPS (MISSOURI) 05302 WPS (MISSOURI WEST) 05392 WPS (MISSOURI EAST) 05401 WPS (NEBRASKA) 05402 WPS (NEBRASKA) 05440 EQICOR (TENNESSEE) 05535 EQICOR (NORTH CAROLINA) 07101 PINNACLE (ARKANSAS) 07102 PINNACLE (ARKANSAS) 07201 PINNACLE (LOUISIANA) 07202 PINNACLE (LOUISIANA) 07301 PINNACLE (MISSISSIPPI) 07302 PINNACLE (MISSISSIPPI) 08101 PINNACLE (INDIANA) 08102 PINNACLE (INDIANA) 08201 PINNACLE (MICHIGAN) 08202 PINNACLE (MICHIGAN) 09101 FIRST COAST (FLORIDA) 09102 FIRST COAST (FLORIDA) 09201 FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202 FIRST COAST (PUERTO RICO) 09302 FIRST COAST (VIRGIN ISLANDS) 10071 TRAVELERS (RRB) 10230 TRAVELERS (CONNECTICUT) 10240 TRAVELERS (MINNESOTA) 10250 TRAVELERS (MISSISSIPPI) 10490 TRAVELERS (VIRGINIA) 10492 TRAVELERS - VIRGINIA SPECIAL PROJECT 11260 GENERAL AMERICAN 12101 HIGHMARK (DELAWARE) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 6 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 12102 HIGHMARK (DELAWARE) 12201 HIGHMARK (DISTRICT OF COLUMBIA) 12202 HIGHMARK (DISTRICT OF COLUMBIA) 12301 HIGHMARK (MARYLAND) 12302 HIGHMARK (MARYLAND) 12401 HIGHMARK NEW JERSEY) 12402 HIGHMARK (NEW JERSEY) 12501 HIGHMARK (PENNSYLVANIA) 12502 HIGHMARK (PENNSYLVANIA) 13101 NATL GOVT SERVICES (CONNECTICUT) 13102 NATL GOVT SERVICES (CONNECTICUT) 13201 NATL GOVT SERVICES (NEW YORK) 13202 NATL GOVT SERVICES (NEW YORK (EMPIRE)) 13282 NATL GOVT SERVICES (NEW YORK (HEALTHNOW)) 13292 NATL GOVT SERVICES (NEW YORK (GHI)) 14101 NATIONAL HERITAGE (MAINE) 14102 NATIONAL HERITAGE (MAINE) 14201 NATIONAL HERITAGE (MASSACHUSETTS) 14202 NATIONAL HERITAGE (MASSACHUSETTS) 14301 NATIONAL HERITAGE (NEW HAMPSHIRE) 14302 NATIONAL HERITAGE (NEW HAMPSHIRE) 14330 GROUP HEALTH INC (NEW YORK) 14401 NATIONAL HERITAGE (RHODE ISLAND) 14402 NATIONAL HERITAGE (RHODE ISLAND) 14501 NATIONAL HERITAGE (VERMONT) 14502 NATIONAL HERITAGE (VERMONT) 16360 NATIONWIDE (OHIO) 16510 NATIONWIDE (WEST VIRGINIA) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 21200 MASSACHUSETTS/MAINE 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 7 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 8 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00510 BLUE SHIELD (ALABAMA) 00511 CAHABA 00520 BLUE SHIELD (ARKANSAS) 00528 BLUE SHIELD (ARKANSAS/LOUISIANA) 00542 BLUE SHIELD (CALIFORNIA) 00550 BLUE SHIELD (COLORADO) 00570 BLUE SHIELD (DELAWARE) 00580 BLUE SHIELD (DISTRICT OF COLUMBIA) 00590 BLUE SHIELD (FLORIDA) 00621 BLUE SHIELD (ILLINOIS) 00630 NATIONAL GOVERNMENT SERVICES 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 NATIONAL GOVERNMENT SERVICES 00690 BLUE SHIELD (MARYLAND) 00700 BLUE SHIELD (MASSACHUSETTS) 00710 BLUE SHIELD (MICHIGAN) 00720 BLUE SHIELD (MINNESOTA) 00740 BLUE SHIELD (KANSAS CITY) 00751 BLUE SHIELD (MONTANA) 00770 BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780 BLUE SHIELD (TRI-STATE) 00801 BLUE SHIELD (BUFFALO) 00803 NATIONAL GOVERNMENT SERVICES 00805 NATIONAL GOVERNMENT SERVICES 00820 BLUE SHIELD (NORTH DAKOTA) 00825 BLUE SHIELD (NORTH DAKOTA/WYOMING) 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865 BLUE SHIELD (PENNSYLVANIA) 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 9 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 00883 PALMETTO 00900 BLUE SHIELD (TEXAS) 00901 TRAILBLAZERS HEALTH ENTERPRISES 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 00973 BLUE SHIELD (PUERTO RICO) 00974 BLUE SHIELD (VIRGIN ISLANDS) 01010 AETNA (PEORIA) 01020 AETNA (ALASKA) 01030 AETNA (ARIZONA) 01040 AETNA (GEORGIA) 01120 AETNA (HAWAII) 01290 AETNA (NEVADA) 01360 AETNA (NEW MEXICO) 01370 AETNA (OKLAHOMA) 01380 AETNA (OREGON) 01390 AETNA (WASHINGTON) 02050 OCCIDENTAL (CALIFORNIA) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN ADMIN SERVICES (ARIZONA) 03202 NORIDIAN ADMIN SERVICES (MONTANA) 03302 NORIDIAN ADMIN SERVICES (NORTH DAKOTA) 03402 NORIDIAN ADMIN SERVICES (MONTANA) 03502 NORIDIAN ADMIN SERVICES (UTAH) 03602 NORIDIAN ADMIN SERVICES (WYOMING) 05130 EQICOR (IDAHO) 05440 EQICOR (TENNESSEE) 05535 EQICOR (NORTH CAROLINA) 10071 TRAVELERS (RRB) 10230 TRAVELERS (CONNECTICUT) 10240 TRAVELERS (MINNESOTA) 10250 TRAVELERS (MISSISSIPPI) 10490 TRAVELERS (VIRGINIA) 10492 TRAVELERS - VIRGINIA SPECIAL PROJECT 11260 GENERAL AMERICAN 14330 GROUP HEALTH INC (NEW YORK) 16360 NATIONWIDE (OHIO) 16510 NATIONWIDE (WEST VIRGINIA) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 21200 MASSACHUSETTS/MAINE 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 10 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 11 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 12 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 13 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATE REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 14 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 VOL. NON-PROF. NOT CHURCH 02 VOLUNTARY NON PROFIT CHURCH 03 STATE GOVERNMENT 04 LOCAL GOVERNMENT 05 COMBINATION GOVERNMENT & VOL. 06 PROPRIETARY ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 15 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME FISCAL YEAR ENDING DATE 4 378 381 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT OCCUPATIONAL THERAPISTS 7.2 405 411 N PROV1050 THE NUMBER OF FULL TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-OCCUP-THERAPISTS PHYSICAL THERAPISTS 7.2 420 426 N PROV1125 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS-THERAPY PROGRAM PARTICIPATION 1 434 434 C PROV1670 INDICATES IF THE PROVIDER PARTICIPATES IN MEDICARE, MEDICAID, OR BOTH PROGRAMS. COBOL NAME: PROG-PARTCI SRV: OCCUPATIONAL THERAPY 1 558 558 C PROV2270 INDICATES HOW OCCUPATIONAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-OCCUP-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED SRV: PHYSICAL THERAPY 1 570 570 C PROV2370 INDICATES HOW PHYSICAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICAL-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED SRV: SPEECH PATHOLOGY 1 586 586 C PROV2505 INDICATES HOW SPEECH PATHOLOGY SERVICES ARE PROVIDED. COBOL NAME: SP-SPEECH-PATH VALUES: 0 NOT PROVIDED 1 PROVIDED TYPE OF FACILITY 2 593 594 C PROV2890 INDICATES THE CATEGORY WHICH REPRESENTS THE TYPE OF FACILITY. COBOL NAME: TYPE-FACILITY VALUES: 01 HOSPITAL 02 SKILLED NURSING FACILITY 03 HOME HEALTH AGENCY 04 REHABILITATION AGENCY 05 PUBLIC CLINIC 06 PRIVATE CLINIC 07 PUBLIC HEALTH AGENCY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 16 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME OCCUP THERAPIST, FULL TIME, STAFF 7.2 931 937 N PROV1040 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-THER-FULL-TIME OCCUP THERAPISTS, CONTRACT/ARRANGE 7.2 938 944 N PROV1035 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-THER-CONTRACT RELATED PROVIDER NUMBER 10 1228 1237 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM SPEECH PATHOLOGISTS, AUDIOLOGISTS 7.2 1446 1452 N PROV1220 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS OR AUDIOLOGISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-SPEECH-PATH-AUDIO PHYSICAL THERAPIST - ARRANGEMENT 7.2 1490 1496 N PROV1105 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY ARRANGEMENT IN AN OUTPATIENT PHYSICAL THERAPY FACILITY. COBOL NAME: NUM-PHY-THER-ARGNM PHYSICAL THERAPISTS ON STAFF 7.2 1497 1503 N PROV1120 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY AN OUTPATIENT PHYSICAL THERAPY PROVIDER OR A HOME HEALTH AGENCY PROVIDER. COBOL NAME: NUM-PHYS-THERAPISTS SPEECH PATHOLOGISTS - ARRANGEMENT 7.2 1504 1510 N PROV1215 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS EMPLOYED BY ARRANGEMENT IN AN OUTPATIENT PHYSICAL THERAPY FACILITY. COBOL NAME: NUM-SPEECH-PATH-AR SPEECH PATHOLOGISTS - TOTAL 7.2 1511 1517 N PROV1210 THE TOTAL NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS ON STAFF AND BY ARRANGEMENT IN AN OUTPATIENT PHYSICAL THERAPY FACILITY. COBOL NAME: NUM-SPEECH-PATH * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 1 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 END STAGE RENAL DISEASE CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 09 END STAGE RENAL DISEASE FACILITIES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 2 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 NATIONAL GOVERNMENT SERVICES 00180 NATIONAL GOVERNMENT SERVICES 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 3 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00901 TRAILBLAZERS HEALTH ENTERPRISES 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01102 PALMETTO (CALIFORNIA NORTH) 01192 PALMETTO (CALIFORNIA SOUTH) 01202 PALMETTO (HAWAII) 01302 PALMETTO (NEVADA) 01390 AETNA (WASHINGTON) 02102 NATIONAL HERITAGE (ALASKA) 02202 NATIONAL HERITAGE (IDAHO) 02302 NATIONAL HERITAGE (OREGON) 02402 NATIONAL HERITAGE (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN (ARIZONA) 03202 NORIDIAN (MONTANA) 03302 NORIDIAN (NORTH DAKOTA) 03402 NORIDIAN (SOUTH DAKOTA) 03502 NORIDIAN (UTAH) 03602 NORIDIAN (WYOMING) 04102 TRAILBLAZER (COLORADO) 04202 TRAILBLAZER (NEW MEXICO) 04302 TRAILBLAZER (OKLAHOMA) 04402 TRAILBLAZER (TEXAS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 4 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 05102 WPS (IOWA) 05202 WPS (KANSAS) 05302 WPS (MISSOURI WEST) 05392 WPS (MISSOURI EAST) 05402 WPS (NEBRASKA) 07102 PINNACLE (ARKANSAS) 07202 PINNACLE (LOUISIANA) 07302 PINNACLE (MISSISSIPPI) 08102 PINNACLE (INDIANA) 08202 PINNACLE (MICHIGAN) 09102 FIRST COAST (FLORIDA) 09202 FIRST COAST (PUERTO RICO) 09302 FIRST COAST (VIRGIN ISLANDS) 12102 HIGHMARK (DELAWARE) 12202 HIGHMARK (DISTRICT OF COLUMBIA) 12302 HIGHMARK (MARYLAND) 12402 HIGHMARK (NEW JERSEY) 12502 HIGHMARK (PENNSYLVANIA) 13102 NATL GOVT SERVICES (CONNECTICUT) 13202 NATL GOVT SERVICES (NEW YORK (EMPIRE)) 13282 NATL GOVT SERVICES (NEW YORK (HEALTHNOW)) 13292 NATL GOVT SERVICES (NEW YORK (GHI)) 14102 NATIONAL HERITAGE (MAINE) 14202 NATIONAL HERITAGE (MASSACHUSETTS) 14302 NATIONAL HERITAGE (NEW HAMPSHIRE) 14402 NATIONAL HERITAGE (RHODE ISLAND) 14502 NATIONAL HERITAGE (VERMONT) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 5 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 6 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00901 TRAILBLAZERS HEALTH ENTERPRISES 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN ADMIN SERVICES (ARIZONA) 03202 NORIDIAN ADMIN SERVICES (MONTANA) 03302 NORIDIAN ADMIN SERVICES (NORTH DAKOTA) 03402 NORIDIAN ADMIN SERVICES (MONTANA) 03502 NORIDIAN ADMIN SERVICES (UTAH) 03602 NORIDIAN ADMIN SERVICES (WYOMING) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 7 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 8 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 9 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 10 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATE REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 11 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 FOR PROFIT 02 NOT FOR PROFIT 03 PUBLIC ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD DIETICIANS 7.2 371 377 N PROV0820 NUMBER OF FULL-TIME EQUIVALENT DIETICIANS EMPLOYED BY A FACILITY. COBOL NAME: NUM-DIETICIANS FISCAL YEAR ENDING DATE 4 378 381 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT OTHER PERSONNEL 7.2 412 418 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL REGISTERED NURSES 7.2 473 479 N PROV1145 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PROFESSIONAL NURSES EMPLOYED BY A PROVIDER. COBOL NAME: NUM-REG-NURS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 12 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MULTI-FACILITY ORGANIZATION NAME 38 850 887 C PROV0680 THE NAME OF THE MULTI-FACILITY ORGANIZATION THAT OWNS THE FACILITY. COBOL NAME: NAME-MULT-FACL-ORG MULTI-FACILITY ORGANIZATION OWNED 1 888 888 C PROV0675 INDICATES IF A FACILITY IS OWNED BY AN ORGANIZATION THAT OWNS (OR LEASES) TWO OR MORE NURSING FACILITIES. COBOL NAME: MULT-FACL-ORG VALUES: Y YES RELATED PROVIDER NUMBER 10 1228 1237 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM SOCIAL WORKERS 7.2 1439 1445 N PROV1185 THE NUMBER OF FULL TIME EQUIVALENT SOCIAL WORKERS EMPLOYED BY THE AGENCY. COBOL NAME: NUM-SOCIAL-WRKS ESRD NETWORK # 2 1518 1519 C PROV0685 THE NUMBER OF THE NETWORK TO WHICH THE END STAGE RENAL DIALYSIS FACILITY IS ASSIGNED. COBOL NAME: NETWORK-NUM VALUES: 01 CONN-MAINE-MASS-NEW HAMP-RHODE ISLAND-VERMONT 02 NEW YORK 03 NEW JERSEY, PUERTO RICO AND VIRGIN ISLAND 04 DELAWARE AND PENNSYLVANIA 05 DIST OF COLUM-MARYLAND-VIRGINIA-WEST VIRGINIA 06 GEORGIA, SOUTH CAROLINA AND NORTH CAROLINA 07 FLORIDA 08 ALABAMA, MISSISSIPPI AND TENNESSEE 09 INDIANA, KENTUCKY AND OHIO 10 ILLINOIS 11 MICH-MINN-NORTH DAKOTA-SOUTH DAKOTA-WISCONSIN 12 IOWA, KANSAS, MISSOURI AND NEBRASKA 13 ARKANSAS, LOUISIANA AND OKLAHOMA 14 TEXAS 15 ARIZONA-COLO-NEVADA-NEW MEXI-UTAH AND WYOMING 16 ALASKA, IDAHO, MONTANA, OREGON AND WASHINGTON 17 COUNTIES IN NORTHERN CALIF, HAWAII, AS, GUAM 18 COUNTIES IN SOUTHERN CALIFORNIA NUMBER OF PATIENTS TUE. 4TH SHIFT 3 1520 1522 N PROV5540 NUMBER OF PATIENTS TUE. 4TH SHIFT COBOL NAME: NUM-PATIENT-TUE-SHIFT-4 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 13 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME STATIONS - HEMODIALYSIS 3 1523 1525 N PROV1230 THE TOTAL NUMBER OF HEMODIALYSIS STATIONS IN AN END STAGE RENAL DISEASE (ESRD) FACILITY. COBOL NAME: NUM-STATIONS-HEMO STATIONS - TOTAL 3 1526 1528 N PROV2855 THE TOTAL NUMBER OF APPROVED DIALYSIS STATIONS IN AN END STAGE RENAL DIALYSIS FACILITY. COBOL NAME: TOT-STATIONS HOSPITAL BASED INDICATOR 1 1704 1704 C PROV0565 HOSPITAL BASED INDICATOR COBOL NAME: HOSP-BASED-IND VALUES: Y HOSPITAL BASED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 1 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 02 TITLE 19 ONLY CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 10 NURSING FACILITIES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 2 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00452 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM VALUES: 00452 NATIONAL GOVERNMENT SERVICES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 3 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00454 NATIONAL GOVERNMENT SERVICES 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 4 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 5 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 6 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATE REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 7 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 FOR PROFIT - INDIVIDUAL 02 FOR PROFIT - PARTNERSHIP 03 FOR PROFIT - CORPORATION 04 NONPROFIT - CHURCH RELATED 05 NONPROFIT - CORPORATION 06 NONPROFIT - OTHER 07 GOVERNMENT - STATE 08 GOVERNMENT - COUNTY 09 GOVERNMENT - CITY 10 GOVERNMENT - CITY/COUNTY 11 GOVERNMENT - HOSPITAL DISTRICT 12 GOVERNMENT - FEDERAL 13 LIMITED LIABILITY CORPORATION ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 8 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD BEDS - TOTAL 4 291 294 N PROV0740 TOTAL NUMBER OF BEDS IN A FACILITY, INCLUDING THOSE IN NON-PARTICIPATING OR NON-LICENSED AREAS. COBOL NAME: NUM-BEDS BEDS - TOTAL CERTIFIED 4 295 298 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS COMPLIANCE: LIFE SAFETY CODE 1 356 356 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: 1 WAIVER RECOMMENDED COMPLIANCE: 24 HR REGISTERED NURSE 1 359 359 C PROV0290 INDICATES IF A WAIVER OF THE 24 HOUR REGISTERED NURSE REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-24-HR-RN VALUES: 1 WAIVER RECOMMENDED FISCAL YEAR ENDING DATE 4 378 381 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT PROGRAM PARTICIPATION 1 434 434 C PROV1670 INDICATES IF THE PROVIDER PARTICIPATES IN MEDICARE, MEDICAID, OR BOTH PROGRAMS. COBOL NAME: PROG-PARTCI VALUES: 2 MEDICAID ONLY REGIONAL OVERRIDE #1 (NUMBER BEDS) 1 470 470 C PROV1545 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-1 VALUES: Y RECORD HAS BEEN APPROVED REGIONAL OVERRIDE #2 (STAFFING) 1 471 471 C PROV1550 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-2 VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 9 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 10 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME Y RECORD HAS BEEN APPROVED ACTIVITY PROFESSIONAL - CONTRACT 7.2 596 602 N PROV0695 THE NUMBER OF FULL TIME EQUIVALENT ACTIVITIES PROFESSIONALS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-ACT-THER-CONTRACT ACTIVITY PROFESSIONAL - FULL TIME 7.2 603 609 N PROV0700 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES PROFESSIONALS EMPLOYED FULL TIME BY A FACILITY. COBOL NAME: NUM-ACT-THER-FULL-TIME ACTIVITY PROFESSIONAL - PART TIME 7.2 610 616 N PROV0705 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES PROFESSIONALS EMPLOYED PART TIME BY A FACILITY. COBOL NAME: NUM-ACT-THER-PART-TIME ADMINISTRATION - CONTRACT 7.2 617 623 N PROV0710 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-ADMN-CONTRACT ADMINISTRATOR - FULL TIME 7.2 624 630 N PROV0715 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF EMPLOYED ON A FULL TIME BASIS BY A FACILITY. COBOL NAME: NUM-ADMN-FULL-TIME ADMINISTRATOR - PART TIME 7.2 631 637 N PROV0720 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF EMPLOYED ON A PART-TIME BASIS BY A FACILITY. COBOL NAME: NUM-ADMN-PART-TIME BEDS - NURSING FACILITY 4 642 645 N PROV1455 NUMBER OF MEDICAID CERTIFIED SKILLED NURSING CARE BEDS IN A FACILITY. COBOL NAME: NUM-T19-SNF-BEDS CERT NURSE AIDES - CONTRACT 7.2 650 656 N PROV1000 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-NURSE-AID-CONTRACT CERT NURSE AIDES - FULL TIME 7.2 657 663 N PROV1005 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-AID-FULL-TIME CERT NURSE AIDES - PART TIME 7.2 664 670 N PROV1010 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-AID-PART-TIME COMPLIANCE: BEDS PER ROOM WAIVER 1 672 672 C PROV0225 INDICATES IF A WAIVER OF THE BEDS PER ROOM REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-BEDS-PER-ROOM VALUES: 1 WAIVER RECOMMENDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 11 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COMPLIANCE: PATIENT ROOM SIZE 1 673 673 C PROV0270 INDICATES IF A WAIVER OF PATIENT ROOM SIZE HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-PATIENT-ROOM-SZ VALUES: 1 WAIVER RECOMMENDED COMPLIANCE: 7 DAY REGISTERED NURSE 1 674 674 C PROV0295 INDICATES IF A WAIVER OF THE 7 DAY REGISTERED NURSE REQUIREMENTS HAS BEEN RECOMMENDED FOR A SNF OR NF. COBOL NAME: COMPL-7-DAY-RN VALUES: 1 WAIVER RECOMMENDED DENTISTS - CONTRACT 7.2 675 681 N PROV0785 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DENTIST-CONTRACT DENTISTS - FULL TIME 7.2 682 688 N PROV0790 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-DENTIST-FULL-TIME DENTISTS - PART TIME 7.2 689 695 N PROV0795 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-DENTIST-PART-TIME DIETITIANS - CONTRACT 7.2 696 702 N PROV0805 THE NUMBER OF FULL-TIME EQUIVALENT UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DIET-CONTRACT DIETITIANS - FULL TIME 7.2 703 709 N PROV0810 THE NUMBER OF FULL-TIME EQUIVALENT DIETITIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-DIET-FULL-TIME DIETITIANS - PART TIME 7.2 710 716 N PROV0815 THE NUMBER OF FULL-TIME EQUIVALENT DIETITIANS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-DIET-PART-TIME EXPERIMENTAL RESEARCH CONDUCTED 1 717 717 C PROV0465 INDICATES IF A FACILITY USES RESIDENTS TO DEVELOP AND TEST CLINICAL TREATMENTS. COBOL NAME: EXPER-RESEARCH VALUES: Y YES FOOD SERVICE - CONTRACT 7.2 718 724 N PROV0860 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-FOOD-SRV-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 12 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FOOD SERVICE - FULL TIME 7.2 725 731 N PROV0865 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-FOOD-SRV-FULL-TIME FOOD SERVICE - PART TIME 7.2 732 738 N PROV0870 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-FOOD-SRV-PART-TIME HOUSEKEEPING - CONTRACT 7.2 739 745 N PROV0925 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-HOUSE-CONTRACT HOUSEKEEPING - FULL TIME 7.2 746 752 N PROV0930 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-HOUSE-FULL-TIME HOUSEKEEPING - PART TIME 7.2 753 759 N PROV0935 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-HOUSE-PART-TIME LPN/LVN - CONTRACT 7.2 760 766 N PROV1465 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-VOC-NURSE-CONTRACT LPN/LVN - FULL TIME 7.2 767 773 N PROV1470 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-VOC-NURSE-FULL-TIME LPN/LVN - PART TIME 7.2 774 780 N PROV1475 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-VOC-NURSE-PART-TIME LTC CROSS REFERENCE PROVIDER # 6 781 786 C PROV0640 THIS CROSS REFERENCE NUMBER IDENTIFIES LTC PROVIDER NUMBERS THAT WERE TERMINATED IN 1985 BECAUSE OF POLICY CHANGES WHICH STATES THAT SNF/ICF DISTINCT PARTS OR DUA LLY CERTIFIED PORTIONS ARE ASSIGNED SINGLE SNF PROV NO. COBOL NAME: LTC-CROSS-REF-PROV-NUM MEDICAL DIRECTOR - CONTRACT 7.2 787 793 N PROV0960 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS UNDER CONTRCAT TO A FACILITY. COBOL NAME: NUM-MED-CONTRACT MEDICAL DIRECTOR - FULL TIME 7.2 794 800 N PROV0965 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MED-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 13 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MEDICAL DIRECTOR - PART TIME 7.2 801 807 N PROV0970 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MED-PART-TIME MEDICATION AIDES/TECHS-CONTRACT 7.2 808 814 N PROV5180 THE NUMBER OF FULL-TIMR EQUIVALENT MEDICATION AIDES/ TECHNICIANS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-MED-AID-CONTRACT MEDICATION AIDES/TECHS-FULL TIME 7.2 815 821 N PROV5170 THE NUMBER OF FULL-TIME EQUIVALENT MEDICATION AIDES/ TECHNICIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MED-AID-FULL-TIME MEDICATION AIDES/TECHS-PART TIME 7.2 822 828 N PROV5175 THE NUMBER OF FULL-TIME EQUIVALENT MEDICATION AIDES/ TECHNICIANS EMPLOYED BYA FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MED-AID-PART-TIME MENTAL HEALTH SERVICES - CONTRACT 7.2 829 835 N PROV0980 THE NUMBER OF FULL-TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-MEN-HLTH-CONTRACT MENTAL HEALTH SERVICES - FULL TIME 7.2 836 842 N PROV0985 THE NUMBER OF FULL-TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MEN-HLTH-FULL-TIME MENTAL HEALTH SERVICES - PART TIME 7.2 843 849 N PROV0990 THE NUMBER OF FULL TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MEN-HLTH-PART-TIME MULTI-FACILITY ORGANIZATION NAME 38 850 887 C PROV0680 THE NAME OF THE MULTI-FACILITY ORGANIZATION THAT OWNS THE FACILITY. COBOL NAME: NAME-MULT-FACL-ORG MULTI-FACILITY ORGANIZATION OWNED 1 888 888 C PROV0675 INDICATES IF A FACILITY IS OWNED BY AN ORGANIZATION THAT OWNS (OR LEASES) TWO OR MORE NURSING FACILITIES. COBOL NAME: MULT-FACL-ORG VALUES: Y YES NURSE AIDES IN TRNG - CONTRACT 7.2 889 895 N PROV5165 NUMBER OF FULL TIME EQUIVALENT NURSE AIDES IN TRAINING UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-AID-TRNG-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 14 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME NURSE AIDES IN TRNG-FULL TIME 7.2 896 902 N PROV5155 THE NUMBER OF FULL-TIME EQUIVALENT NURSE AIDES IN TRAINING EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-AID-TRNG-FULL-TIME NURSE AIDES IN TRNG-PART TIME 7.2 903 909 N PROV5160 THE NUMBER OF FULL-TIME EQUIVALENT NURSE AIDES IN TRAINING EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-AID-TRNG-PART-TIME NURSES WITH ADMIN DUTIES-CONTRACT 7.2 910 916 N PROV5150 THE NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-NURSE-ADM-CONTRACT NURSES WITH ADMIN DUTIES-FULL TIME 7.2 917 923 N PROV5135 THE NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-ADM-FULL-TIME NURSES WITH ADMIN DUTIES-PART TIME 7.2 924 930 N PROV5145 NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-ADM-PART-TIME OCCUP THERAPIST, FULL TIME, STAFF 7.2 931 937 N PROV1040 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-THER-FULL-TIME OCCUP THERAPISTS, CONTRACT/ARRANGE 7.2 938 944 N PROV1035 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-THER-CONTRACT OCCUP THERAPY AIDE - CONTRACT 7.2 945 951 N PROV1020 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-AID-CONTRACT OCCUP THERAPY AIDE - FULL TIME 7.2 952 958 N PROV1025 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-AID-FULL-TIME OCCUP THERAPY AIDE - PART TIME 7.2 959 965 N PROV1030 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-AID-PART-TIME OCCUP THERAPY ASST - CONTRACT 7.2 966 972 N PROV5195 THE NUMBER OF FULL TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS UNDER CONTRCAT TO A FACILITY. COBOL NAME: NUM-OCC-ASST-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 15 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OCCUP THERAPY ASST - FULL TIME 7.2 973 979 N PROV5185 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-ASST-FULL-TIME OCCUP THERAPY ASST - PART TIME 7.2 980 986 N PROV5190 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-ASST-PART-TIME OCCUPATIONAL THERAPIST - PART TIME 7.2 987 993 N PROV1045 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-THER-PART-TIME ORGANIZED FAMILY GROUP 1 994 994 C PROV1535 INDICATES IF THE FACILITY HAS AN ORGANIZED GROUP OF FAMILY MEMBERS OF RESIDENTS. COBOL NAME: ORG-FAMILY-GRP VALUES: Y YES ORGANIZED RESIDENT GROUP 1 995 995 C PROV1540 INDICATES IF THE FACILITY HAS AN ORGANIZED RESIDENTS GROUP. COBOL NAME: ORG-RESID-GRP VALUES: Y YES OTHER - CONTRACT 7.2 996 1002 N PROV3265 THE NUMBER OF FULL-TIME EQUIVALENT PERSONS NOT INCLUDED IN ANY OTHER CATEGORIES UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-OTH-CONTRACT OTHER - FULL TIME 7.2 1003 1009 N PROV3245 THE NUMBER OF FULL-TIME EQUIVALENT PERSONS NOT INCLUDED IN ANY OTHER CATEGORIES EMPLOYED BY THE FACILITY ON A FULL-TIME BASIS. COBOL NAME: NUM-OTH-FULL-TIME OTHER - PART TIME 7.2 1010 1016 N PROV3255 THE NUMBER OF FULL-TIME EQUIVALENT PERSONS NOT INCLUDED IN ANY OTHER CATEGORIES EMPLOYED BY THE FACILITY ON A PART-TIME BASIS. COBOL NAME: NUM-OTH-PART-TIME OTHER ACTIVITIES STAFF-CONTRACT 7.2 1017 1023 N PROV5270 NUMBER OF CONTRACT STAFF HOURS FOR OTHER ACTIVITIES. COBOL NAME: NUM-OTH-ACT-CONTRACT OTHER ACTIVITIES STAFF-FULL TIME 7.2 1024 1030 N PROV5260 NUMBER OF FULL-TIME STAFF HOURS FOR OTHER ACTIVITIES. COBOL NAME: NUM-OTH-ACT-FULL-TIME OTHER ACTIVITIES STAFF-PART TIME 7.2 1031 1037 N PROV5305 NUMBER OF PART TIME STAFF HOURS PROVIDED BY OTHER ACTIV ITIES STAFF. COBOL NAME: NUM-OTH-ACT-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 16 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OTHER PHYSICIAN - CONTRACT 7.2 1038 1044 N PROV1060 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS UNDER CONTRACT TO A FACILITY COBOL NAME: NUM-OTH-PHY-CONTRACT OTHER PHYSICIAN - FULL TIME 7.2 1045 1051 N PROV1065 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OTH-PHY-FULL-TIME OTHER PHYSICIAN - PART TIME 7.2 1052 1058 N PROV1070 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OTH-PHY-PART-TIME OTHR SOCIAL SERV STAFF-CONTRACT 7.2 1059 1065 N PROV5300 NUMBER OF CONTRACT STAFF HOURS PROVIDED BY OTHER SOCIAL SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-CONTRACT OTHR SOCIAL SERV STAFF-FULL TIME 7.2 1066 1072 N PROV5290 NUMBER OF FULL-TIME STAFF HOURS PROVIDED BY OTHER SOCIA L SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-FULL-TIME OTHR SOCIAL SERV STAFF-PART TIME 7.2 1073 1079 N PROV5295 NUMBER OF PART-TIME STAFF HOURS PROVIDED BY OTHER SOCIA L SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-PART-TIME PHARMACISTS - CONTRACT 7.2 1080 1086 N PROV1085 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-PHAR-CONTRACT PHARMACISTS - FULL TIME 7.2 1087 1093 N PROV1090 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-PHAR-FULL-TIME PHARMACISTS - PART TIME 7.2 1094 1100 N PROV1095 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-PHAR-PART-TIME PHYS THER ASST - CONTRACT 7.2 1101 1107 N PROV5210 NUMBER OF CONTRACT STAFF HOURS FOR PHYSICAL THERAPY ASS ISTANTS. COBOL NAME: NUM-THER-ASST-CONTRACT PHYS THER ASST - FULL TIME 7.2 1108 1114 N PROV5200 NUMBER OF FULL-TIME STAFF HOURS FOR PHYSICAL THERAPY AS SISTANTS. COBOL NAME: NUM-THER-ASST-FULL-TIME PHYS THER ASST - PART TIME 7.2 1115 1121 N PROV5205 NUMBER OF PART-TIME STAFF HOURS FOR PHYSICAL THERAPY AS SISTANTS. COBOL NAME: NUM-THER-ASST-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 17 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PHYSICAL THERAPISTS - CONTRACT 7.2 1122 1128 N PROV1430 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-CONTRACT PHYSICAL THERAPISTS - FULL TIME 7.2 1129 1135 N PROV1435 THE NUMBER OF FULL TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-FULL-TIME PHYSICAL THERAPISTS - PART TIME 7.2 1136 1142 N PROV1440 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-PART-TIME PHYSICAL THERAPY AIDE - CONTRACT 7.2 1143 1149 N PROV1415 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-AID-CONTRACT PHYSICAL THERAPY AIDE - FULL TIME 7.2 1150 1156 N PROV1420 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-AID-FULL-TIME PHYSICAL THERAPY AIDE - PART TIME 7.2 1157 1163 N PROV1425 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-AID-PART-TIME PHYSICIAN EXTENDER - CONTRACT 7.2 1164 1170 N PROV3270 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIAN EXTENDERS UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-PHYS-EXT-CONTRACT PHYSICIAN EXTENDER - FULL TIME 7.2 1171 1177 N PROV3250 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIAN EXTENDERS EMPLOYED BY THE FACILITY ON A FULL-TIME BASIS. COBOL NAME: NUM-PHYS-EXT-FULL-TIME PHYSICIAN EXTENDER - PART TIME 7.2 1178 1184 N PROV3260 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIAN EXTENDERS EMPLOYED BY THE FACILITY ON A PART-TIME BASIS. COBOL NAME: NUM-PHYS-EXT-PART-TIME PODIATRISTS - CONTRACT 7.2 1185 1191 N PROV1130 THE NUMBER OF FULL TIME EQUIVALENT PODIATRISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-POD-CONTRACT PODIATRISTS - FULL TIME 7.2 1192 1198 N PROV1135 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A AFCILITY ON A FULL TIME BASIS. COBOL NAME: NUM-POD-FULL-TIME PODIATRISTS - PART TIME 7.2 1199 1205 N PROV1140 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-POD-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 18 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PROVIDER BASED FACILITY 1 1206 1206 C PROV1675 INDICATES IF A LONG TERM CARE FACILITY IS PROVIDER BASED. COBOL NAME: PROV-BASED-FACILITY VALUES: Y HOSPITAL BASED REGISTERED NURSE - CONTRACT 7.2 1207 1213 N PROV1150 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-REG-NURSE-CONTRACT REGISTERED NURSE - FULL TIME 7.2 1214 1220 N PROV1155 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-REG-NURSE-FULL-TIME REGISTERED NURSE - PART TIME 7.2 1221 1227 N PROV1160 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-REG-NURSE-PART-TIME RELATED PROVIDER NUMBER 10 1228 1237 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM RN DIRECTOR OF NURSING - CONTRACT 7.2 1238 1244 N PROV5130 THE NUMBER OF FULL TIME EQUIVALENT RN DIRECTOR OF NURSI NG UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-RN-DON-CONTRACT RN DIRECTOR OF NURSING - FULL TIME 7.2 1245 1251 N PROV5120 THE NUMBER OF FULL-TIME EQUIVALENT RN DIRECTOR OF NURSING EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-RN-DON-FULL-TIME RN DIRECTOR OF NURSING - PART TIME 7.2 1252 1258 N PROV5140 THE NUMBER OF FULL-TIME EQUIVALENT RN DIRECTOR OF NURSING EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-RN-DON-PART-TIME SOCIAL WORKER - CONTRACT 7.2 1259 1265 N PROV1170 THE NUMBER OF FULL-TIME EQUIVALENT SOCIAL WORKERS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-SOCIAL-CONTRACT SOCIAL WORKER - FULL TIME 7.2 1266 1272 N PROV1175 THE NUMBER OF FULL-TIME EQUIVALENT SOCIAL WORKERS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-SOCIAL-FULL-TIME SOCIAL WORKER - PART TIME 7.2 1273 1279 N PROV1180 THE NUMBER OF FULL-TIME EQUIVALENT SOCIAL WORKERS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-SOCIAL-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 19 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPECIAL CARE BEDS-AIDS 3 1280 1282 N PROV0725 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH AIDS. COBOL NAME: NUM-AIDS-BEDS SPECIAL CARE BEDS-ALZHEIMERS 3 1283 1285 N PROV0730 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH ALZEHEIMERS. COBOL NAME: NUM-ALZHEIMERS-BEDS SPECIAL CARE BEDS-DIALYSIS 3 1286 1288 N PROV0800 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS NEEDING DIALYSIS. COBOL NAME: NUM-DIAL-BEDS SPECIAL CARE BEDS-DISABLED CHILD 3 1289 1291 N PROV0855 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR DEISCABLED CHILDREN. COBOL NAME: NUM-DIS-CHILD-BEDS SPECIAL CARE BEDS-HEAD TRAUMA 3 1292 1294 N PROV0905 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILTY FOR RESIDENTS WITH HEAD TRAUMA. COBOL NAME: NUM-HEAD-TRAUMA-BEDS SPECIAL CARE BEDS-HOSPICE 3 1295 1297 N PROV0920 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY A FACILITY FOR RESIDENTS NEEDING HOSPICE SERVICES. COBOL NAME: NUM-HOSPICE-BEDS SPECIAL CARE BEDS-HUNTINGTONS 3 1298 1300 N PROV0940 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH HUNTINGTON'S DISEASE COBOL NAME: NUM-HUNTING-DIS-BEDS SPECIAL CARE BEDS-SPEC REHAB 3 1301 1303 N PROV1205 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH SPECIALIZED REHAB NEEDS. COBOL NAME: NUM-SPEC-REHAB-BEDS SPECIAL CARE BEDS-VENTILATOR 3 1304 1306 N PROV1460 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH VENTILATOR/ RESIPIRATORY CARE NEEDS. COBOL NAME: NUM-VENT-RESP-BEDS SPEECH PATHOLOGIST - CONTRACT 7.2 1307 1313 N PROV1190 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-SPCH-PATH-CONTRACT SPEECH PATHOLOGIST - FULL TIME 7.2 1314 1320 N PROV1195 THE NUMBER OF FULL-TIME EQUIVALENT SPPECH PATHOLOGISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-SPCH-PATH-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 20 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPEECH PATHOLOGIST - PART TIME 7.2 1321 1327 N PROV1200 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-SPCH-PATH-PART-TIME SRV: ACTIVITIES-OFFSITE-RESIDENTS 1 1328 1328 C PROV3390 INDICATES IF ACTIVITIES SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-ACT-THER-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: ACTIVITIES-ONSITE-NON RES 1 1329 1329 C PROV3385 INDICATES IF ACTIVITIES SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-ACT-THER-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: ACTIVITIES-ONSITE-RESIDENTS 1 1330 1330 C PROV3380 INDICATES IF ACTIVITIES SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-ACT-THER-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: BLOOD ADMIN-OFFSITE-RESIDENTS 1 1331 1331 C PROV3525 INDICATES IF ADMINISTRATION AND STORAGE OF BLOOD SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-ADM-BLOOD-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: BLOOD ADMIN-ONSITE-NONRES 1 1332 1332 C PROV3520 INDICATES IF ADMINISTRATION AND STORAGE OF BLOOD SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-ADM-BLOOD-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: BLOOD ADMIN-ONSITE-RESIDENTS 1 1333 1333 C PROV3515 INDICATES IF ADMINISTRATION AND STORAGE OF BLOOD SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-ADM-BLOOD-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 21 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: CLINICAL LAB-OFFSITE-RESIDENT 1 1334 1334 C PROV3495 INDICATES IF CLINICAL LABORATORY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-CLIN-LAB-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: CLINICAL LAB-ONSITE-NON RES 1 1335 1335 C PROV3490 INDICATES IF CLINICAL LABORATORY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-CLIN-LAB-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: CLINICAL LAB-ONSITE-RESIDENTS 1 1336 1336 C PROV3485 INDICATES IF CLINICAL LABORATORY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-CLIN-LAB-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DENTAL-OFFSITE-RESIDENTS 1 1337 1337 C PROV3435 INDICATES IF DENTAL SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-DENTAL-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DENTAL-ONSITE-NON RESIDENTS 1 1338 1338 C PROV3430 INDICATES IF DENTAL SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-DENTAL-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DENTAL-ONSITE-RESIDENTS 1 1339 1339 C PROV3425 INDICATES IF DENTAL SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-DENTAL-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DIETARY-OFFSITE-RESIDENTS 1 1340 1340 C PROV3345 INDICATES IF DIETARY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-DIETARY-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 22 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: DIETARY-ONSITE-NON RESIDENTS 1 1341 1341 C PROV3340 INDICATES IF DIETARY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-DIETARY-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DIETARY-ONSITE-RESIDENTS 1 1342 1342 C PROV3335 INDICATES IF DIETARY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-DIETARY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: HOUSEKEEPING ONSITE-NON RES 1 1343 1343 C PROV3535 INDICATES IF HOUSEKEEPING SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-HOUSE-KP-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: HOUSEKEEPING-OFFSITE-RES 1 1344 1344 C PROV3540 INDICATES IF HOUSEKEEPING SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-HOUSE-KP-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: HOUSEKEEPING-ONSITE-RESIDENTS 1 1345 1345 C PROV3530 INDICATES IF HOUSEKEEPING SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-HOUSE-KP-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: MENTAL HEALTH-OFFSITE-RES 1 1346 1346 C PROV3465 INDICATES IF MENTAL HEALTH SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-MEN-HLTH-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: MENTAL HEALTH-ONSITE-NON RES 1 1347 1347 C PROV3460 INDICATES IF MENTAL HEALTH SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-MEN-HLTH-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 23 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: MENTAL HEALTH-ONSITE-RESID 1 1348 1348 C PROV3455 INDICATES IF MENTAL HEALTH SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-MEN-HLTH-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: NURSING-OFFSITE-RESIDENTS 1 1349 1349 C PROV3315 INDICATES IF NURSING SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-NURSING-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: NURSING-ONSITE-NON RESIDENTS 1 1350 1350 C PROV3310 INDICATES IF NURSING SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-NURSING-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: NURSING-ONSITE-RESIDENTS 1 1351 1351 C PROV3305 INDICATES IF NURSING SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-NURSING-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OCCUP THER-OFFSITE-RESIDENTS 1 1352 1352 C PROV3360 INDICATES IF OCCUPATIONAL THERAPY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-OCC-THER-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OCCUP THER-ONSITE-NON RESID 1 1353 1353 C PROV3355 INDICATES IF OCCUPATIONAL THERAPY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-OCC-THER-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OCCUP THER-ONSITE-RESIDENTS 1 1354 1354 C PROV3350 INDICATES IF OCCUPATIONAL THERAPY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-OCC-THER-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 24 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: OTH ACTIVITIES-OFFSITE TO RES 1 1355 1355 C PROV5255 FIELD 3 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF OFFSITE TO RESIDENTS. COBOL NAME: SP-OTH-ACT-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH ACTIVITIES-ONSITE NONRES 1 1356 1356 C PROV5250 FIELD 2 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF ONSITE TO NONRESIDENTS. COBOL NAME: SP-OTH-ACT-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH ACTIVITIES-ONSITE RES 1 1357 1357 C PROV5245 FIELD 1 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF ONSITE TO RESIDENTS. COBOL NAME: SP-OTH-ACT-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-OFFSITE TO RES 1 1358 1358 C PROV5285 FIELD 3 - INDICATES SERVICES PROVIDED BY OTHER SOCIAL S ERVICES STAFF OFFSITE TO RESIDENTS. COBOL NAME: SP-OTH-SOC-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-ONSITE TO NONRES 1 1359 1359 C PROV5280 INDICATES IF OTHER SOCIAL SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-OTH-SOC-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-ONSITE TO RES 1 1360 1360 C PROV5275 FIELD 1 - INDICATES SERVICES PROVIDED BY SOCIAL SERVICE S STAFF ONSITE TO RESIDENTS. COBOL NAME: SP-OTH-SOC-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHARMACY-OFFSITE-RESIDENTS 1 1361 1361 C PROV3330 INDICATES IF PHARMACY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PHARMACY-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 25 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHARMACY-ONSITE-NON RESIDENTS 1 1362 1362 C PROV3325 INDICATES IF PHARMACY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PHARMACY-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHARMACY-ONSITE-RESIDENTS 1 1363 1363 C PROV3320 INDICATES IF PHARMACY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PHARMACY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYS EXTENDER-OFFSITE-RESID 1 1364 1364 C PROV3300 INDICATES IF PHYSICIAN EXTENDER SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PHYS-EXT-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYS EXTENDER-ONSITE-NON RES 1 1365 1365 C PROV3295 INDICATES IF PHYSICIAN EXTENDER SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PHYS-EXT-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYS EXTENDER-ONSITE-RESIDENT 1 1366 1366 C PROV3290 INDICATES IF PHYSICIAN EXTENDER SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PHYS-EXT-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYS THER-OFFSITE-RESIDENTS 1 1367 1367 C PROV3375 INDICATES IF PHYSICAL THERAPY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PHYS-THER-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYS THER-ONSITE-NON RESIDENT 1 1368 1368 C PROV3370 INDICATES IF PHYSICAL THERAPY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PHYS-THER-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 26 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHYS THER-ONSITE-RESIDENTS 1 1369 1369 C PROV3365 INDICATES IF PHYSICAL THERAPY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PHYS-THER-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYSICIAN-OFFSITE-RESIDENTS 1 1370 1370 C PROV3285 INDICATES IF PHYSICIAN SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PHYS-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYSICIAN-ONSITE-NON RESIDENT 1 1371 1371 C PROV3280 INDICATES IF PHYSICIAN SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PHYS-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHYSICIAN-ONSITE-RESIDENTS 1 1372 1372 C PROV3275 INDICATES IF PHYSICIAN SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PHYS-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PODIATRY-OFFSITE-RESIDENTS 1 1373 1373 C PROV3450 INDICATES IF PODIATRY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PODIATRY-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PODIATRY-ONSITE-NON RESIDENTS 1 1374 1374 C PROV3445 INDICATES IF PODIATRY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PODIATRY-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PODIATRY-ONSITE-RESIDENTS 1 1375 1375 C PROV3440 INDICATES IF PODIATRY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PODIATRY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 27 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: SOCIAL WORK-OFFSITE-RESIDENTS 1 1376 1376 C PROV3405 INDICATES IF SOCIAL WORK SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-MED-SOC-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: SOCIAL WORK-ONSITE-NON RESID 1 1377 1377 C PROV3400 INDICATES IF SOCIAL WORK SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-MED-SOC-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: SOCIAL WORK-ONSITE-RESIDENTS 1 1378 1378 C PROV3395 INDICATES IF SOCIAL WORK SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-MED-SOC-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: SPEECH PATH-OFFSITE-RESIDEN 1 1379 1379 C PROV3420 INDICATES IF SPEECH/LANGUAGE PATHOLOGY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-SPEECH-PH-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: SPEECH PATH-ONSITE-NON RESID 1 1380 1380 C PROV3415 INDICATES IF SPEECH/LANGUAGE PATHOLOGY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-SPEECH-PH-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: SPEECH PATH-ONSITE-RESIDENTS 1 1381 1381 C PROV3410 INDICATES IF SPEECH/LANGUAGE PATHOLOGY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-SPEECH-PH-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: THER REC SPEC-OFFSITE TO RES 1 1382 1382 C PROV5225 INDICATES IF THERAPEUTIC RECRECATION SPECIALIST SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-THER-REC-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 28 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: THER REC SPEC-ONSITE-NONRES 1 1383 1383 C PROV5220 INDICATES IF THERAPEUTIC RECREATION SPECIALIST SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-THER-REC-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: THER REC SPEC-ONSITE-RESIDENT 1 1384 1384 C PROV5215 INDICATES IF THERAPEUTIC RECREATION SPECIALIST SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-THER-REC-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: VOCATIONAL-OFFSITE-RESIDENTS 1 1385 1385 C PROV3480 INDICATES IF VOCATIONAL SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-VOC-GUID-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: VOCATIONAL-ONSITE-NON RESID 1 1386 1386 C PROV3475 INDICATES IF VOCATIONAL SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-VOC-GUID-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: VOCATIONAL-ONSITE-RESIDENTS 1 1387 1387 C PROV3470 INDICATES IF VOCATIONAL SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-VOC-GUID-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: XRAY-OFFSITE-RESIDENTS 1 1388 1388 C PROV3510 INDICATES IF DIAGNOSTIC XRAY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-DIAG-XRAY-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: XRAY-ONSITE-NON RESIDENTS 1 1389 1389 C PROV3505 INDICATES IF DIAGNOSTIC XRAY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-DIAG-XRAY-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 29 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: XRAY-ONSITE-RESIDENTS 1 1390 1390 C PROV3500 INDICATES IF DIAGNOSTIC XRAY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-DIAG-XRAY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED THER REC SPEC - CONTRACT 7.2 1391 1397 N PROV5240 NUMBER OF CONTRACT STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-CONTRACT THER REC SPEC - FULL TIME 7.2 1398 1404 N PROV5230 NUMBER OF FULL-TIME STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-FULL-TIME THER REC SPEC - PART TIME 7.2 1405 1411 N PROV5235 NUMBER OF PART-TIME STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 1 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 02 TITLE 19 ONLY CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 11 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 2 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00452 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM VALUES: 00452 NATIONAL GOVERNMENT SERVICES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 3 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 00454 NATIONAL GOVERNMENT SERVICES 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 4 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 5 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 6 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATE REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 7 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 PRIVATE NON PROFIT 02 PRIVATE PROPRIETARY 03 STATE 04 CITY/TOWN 05 COUNTY 06 CITY/COUNTY 07 OTHER ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 8 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME BEDS - TOTAL 4 291 294 N PROV0740 TOTAL NUMBER OF BEDS IN A FACILITY, INCLUDING THOSE IN NON-PARTICIPATING OR NON-LICENSED AREAS. COBOL NAME: NUM-BEDS BEDS - TOTAL CERTIFIED 4 295 298 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS COMPLIANCE: LIFE SAFETY CODE 1 356 356 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: 1 WAIVER RECOMMENDED FISCAL YEAR ENDING DATE 4 378 381 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT LICENSED PRACT/VOCAT NURSES 7.2 382 388 N PROV0955 NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL OR VOCATIONAL NURSES EMPLOYED BY A FACILITY. COBOL NAME: NUM-LPN-LVN PROGRAM PARTICIPATION 1 434 434 C PROV1670 INDICATES IF THE PROVIDER PARTICIPATES IN MEDICARE, MEDICAID, OR BOTH PROGRAMS. COBOL NAME: PROG-PARTCI VALUES: 2 MEDICAID ONLY REGIONAL OVERRIDE #1 (NUMBER BEDS) 1 470 470 C PROV1545 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-1 VALUES: Y RECORD HAS BEEN APPROVED REGISTERED NURSES 7.2 473 479 N PROV1145 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PROFESSIONAL NURSES EMPLOYED BY A PROVIDER. COBOL NAME: NUM-REG-NURS COMPLIANCE: BEDS PER ROOM WAIVER 1 672 672 C PROV0225 INDICATES IF A WAIVER OF THE BEDS PER ROOM REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-BEDS-PER-ROOM VALUES: 1 WAIVER RECOMMENDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 9 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME COMPLIANCE: PATIENT ROOM SIZE 1 673 673 C PROV0270 INDICATES IF A WAIVER OF PATIENT ROOM SIZE HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-PATIENT-ROOM-SZ VALUES: 1 WAIVER RECOMMENDED PROVIDER BASED FACILITY 1 1206 1206 C PROV1675 INDICATES IF A LONG TERM CARE FACILITY IS PROVIDER BASED. COBOL NAME: PROV-BASED-FACILITY VALUES: Y DISTINCT PART OF A HOSPITAL, SNF OR ICF RELATED PROVIDER NUMBER 10 1228 1237 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM ADMISSION SUSPENSION DATE 8 1529 1536 C PROV0030 THE DATE THAT PAYMENTS FOR NEW ADMISSIONS IN A LONG TERM CARE FACILITY WILL BE DENIED IF AN INTERMEDIATE SANCTION IS TAKEN AGAINST THE FACILITY. COBOL NAME: ADMIN-SUSP-DT BEDS - ICF/MR 4 1537 1540 N PROV0945 NUMBER OF CERTIFIED BEDS IN AN INTERMEDIATE CARE FACILITY FOR THE MENTALLY RETARDED. COBOL NAME: NUM-ICF-MR-BEDS DIRECT CARE PERSONNEL 7.2 1541 1547 N PROV0780 NUMBER OF FULL-TIME EQUIVALENT DIRECT CARE PERSONNEL EMPLOYED BY AN INTERMEDIATE CARE FACILITY FOR THE MENTALLY RETARDED. COBOL NAME: NUM-DCARE-PERSNL LTC AGREEMENT BEGINNING DATE 8 1548 1555 C PROV0620 THE BEGINNING DATE OF A CERTIFIED LONG TERM CARE FACILI TY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-BEGIN-DT LTC AGREEMENT ENDING DATE 8 1556 1563 C PROV0625 THE ENDING DATE OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-END-DT LTC AGREEMENT EXTENSION DATE 8 1564 1571 C PROV0630 THE LAST DATE OF AN EXTENSION OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-EXT-DT PRIOR ADMISSION SUSPENSION DATE 8 1572 1579 C PROV1610 PREVIOUS DATE A SUSPENSION OF ADMISSIONS WAS INVOKED FOR A PROVIDER. COBOL NAME: PRIOR-ADMIN-SUSP-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 10 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR LTC END DATE 8 1580 1587 C PROV1630 THE LAST DATE OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT FOR A PRIOR SURVEY. COBOL NAME: PRIOR-LTC-END-DT PRIOR LTC EXTENSION DATE 8 1588 1595 C PROV1635 THE LAST DATE OF AN EXTENSION OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT FOR A PRIOR SURVEY. COBOL NAME: PRIOR-LTC-EXT-DT PRIOR RESCIND SUSPENSION DATE 8 1596 1603 C PROV1640 THE EFFECTIVE DATE OF A PREVIOUS SUSPENSION OF ADMISSIONS TO A LTC FACILITY. COBOL NAME: PRIOR-RESC-SUSP-DT RESCIND SUSPENSION DATE 8 1604 1611 C PROV1825 DATE THAT THE SUPENSION OF PAYMENTS FOR NEW ADMISSIONS TO A LONG TERM CARE FACILITY (LTC) IS RESCINDED. COBOL NAME: RESC-SUSP-DT TOTAL # OF EMPLOYEES 9.2 1612 1620 N PROV2850 THE TOTAL NUMBER OF FULL-TIME EMPLOYEES IN A HOSPICE OR AN INTERMEDIATE CARE FACILITY/MENTAL RETARDATION FACILITY. COBOL NAME: TOT-EMPLOYEES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 1 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 RURAL HEALTH CLINICS CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 12 RURAL HEALTH CLINICS CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 2 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 NATIONAL GOVERNMENT SERVICES 00180 NATIONAL GOVERNMENT SERVICES 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 3 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01102 PALMETTO (CALIFORNIA NORTH) 01192 PALMETTO (CALIFORNIA SOUTH) 01202 PALMETTO (HAWAII) 01302 PALMETTO (NEVADA) 01390 AETNA (WASHINGTON) 02102 NATIONAL HERITAGE (ALASKA) 02202 NATIONAL HERITAGE (IDAHO) 02302 NATIONAL HERITAGE (OREGON) 02402 NATIONAL HERITAGE (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN (ARIZONA) 03202 NORIDIAN (MONTANA) 03302 NORIDIAN (NORTH DAKOTA) 03402 NORIDIAN (SOUTH DAKOTA) 03502 NORIDIAN (UTAH) 03602 NORIDIAN (WYOMING) 04102 TRAILBLAZER (COLORADO) 04202 TRAILBLAZER (NEW MEXICO) 04302 TRAILBLAZER (OKLAHOMA) 04402 TRAILBLAZER (TEXAS) 05102 WPS (IOWA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 4 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 05202 WPS (KANSAS) 05302 WPS (MISSOURI WEST) 05392 WPS (MISSOURI EAST) 05402 WPS (NEBRASKA) 07102 PINNACLE (ARKANSAS) 07202 PINNACLE (LOUISIANA) 07302 PINNACLE (MISSISSIPPI) 08102 PINNACLE (INDIANA) 08202 PINNACLE (MICHIGAN) 09102 FIRST COAST (FLORIDA) 09202 FIRST COAST (PUERTO RICO) 09302 FIRST COAST (VIRGIN ISLANDS) 12102 HIGHMARK (DELAWARE) 12202 HIGHMARK (DISTRICT OF COLUMBIA) 12302 HIGHMARK (MARYLAND) 12402 HIGHMARK (NEW JERSEY) 12502 HIGHMARK (PENNSYLVANIA) 13102 NATL GOVT SERVICES (CONNECTICUT) 13202 NATL GOVT SERVICES (NEW YORK (EMPIRE)) 13282 NATL GOVT SERVICES (NEW YORK (HEALTHNOW)) 13292 NATL GOVT SERVICES (NEW YORK (GHI)) 14102 NATIONAL HERITAGE (MAINE) 14202 NATIONAL HERITAGE (MASSACHUSETTS) 14302 NATIONAL HERITAGE (NEW HAMPSHIRE) 14402 NATIONAL HERITAGE (RHODE ISLAND) 14502 NATIONAL HERITAGE (VERMONT) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 5 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 6 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN ADMIN SERVICES (ARIZONA) 03202 NORIDIAN ADMIN SERVICES (MONTANA) 03302 NORIDIAN ADMIN SERVICES (NORTH DAKOTA) 03402 NORIDIAN ADMIN SERVICES (MONTANA) 03502 NORIDIAN ADMIN SERVICES (UTAH) 03602 NORIDIAN ADMIN SERVICES (WYOMING) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 7 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 8 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 9 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 10 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATE REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 11 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 03 STATE GOVERNMENT 04 LOCAL GOVERNMENT 05 FEDERAL GOVERNMENT 1A FOR PROFIT INDIVIDUAL 1B FOR PROFIT CORPORATION 1C FOR PROFIT PARTNERSHIP 2A NON PROFIT INDIVIDUAL 2B NON PROFIT CORPORATION 2C NON PROFIT PARTNERSHIP ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD FISCAL YEAR ENDING DATE 4 378 381 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT OTHER PERSONNEL 7.2 412 418 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL PHYSICIAN ASSISTANTS 7.2 427 433 N PROV1115 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIAN ASSISTANTS EMPLOYED BY A HOSPITAL OR RURAL HEALTH CLINIC. COBOL NAME: NUM-PHYS-ASSIST FEDERAL PROGRAM SUPPORT 1 1621 1621 C PROV0480 INDICATES IF A CLINIC IS RECEIVING SUPPORT FROM A FEDERAL PROGRAM TO PROVIDE HEALTH SERVICES IN A MEDICALLY UNDERSERVED AREA OR IN AN AREA WITH A SHORTAGE OF PRIMARY CARE HEALTH MANPOWER. COBOL NAME: FED-PROG-SUPPORT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 12 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME VALUES: N NO Y YES NURSE PRACTITIONERS 7.2 1622 1628 N PROV1015 NUMBER OF FULL-TIME EQUIVALENT NURSE PRACTITIONERS. COBOL NAME: NUM-NURSE-PRACT PARENT PROVIDER NUMBER 10 1629 1638 C PROV1560 THE IDENTIFICATION NUMBER OF THE PARENT PROVIDER WHEN A PROVIDER IS PART OF AN EXISTING MEDICARE PROVIDER. COBOL NAME: PARENT-PROV-NUM PHYSICIANS 7.2 1639 1645 N PROV1110 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIANS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS TITLE OF FEDERAL PROGRAM 26 1646 1671 C PROV2845 THE NAME OF A FEDERAL PROGRAM WHICH PROVIDES SUPPORT TO A RURAL HEALTH CLINIC TO PROVIDE SERVICES IN A MEDICALLY UNDERSERVED AREA OR AN AREA WITH A SHORTAGE OF PRIMARY CARE HEALTH MANPOWER. COBOL NAME: TITL-FED-PROGR VALUES: COMM HLTH PRG (330)COMMUNITY HEALTH PROGRAM (330) INDIAN HEALTH SERV INDIAN HEALTH SERVICE MIGRT HLTH PRG (329)MIGRANT HEALTH PROGRAM (329) NATNL HEALTH SRV DELNATIONAL HEALTH SERVICE DELIVERY PROGRAM RURAL OUTREACH DEMORURAL OUTREACH DEMO GRANT PROGRAM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 1 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 13 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 2 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00011 CAHABA 00122 HCSC - MICHIGAN 00452 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00510 BLUE SHIELD (ALABAMA) 00511 CAHABA 00520 BLUE SHIELD (ARKANSAS) 00528 BLUE SHIELD (ARKANSAS/LOUISIANA) 00542 BLUE SHIELD (CALIFORNIA) 00550 BLUE SHIELD (COLORADO) 00570 BLUE SHIELD (DELAWARE) 00580 BLUE SHIELD (DISTRICT OF COLUMBIA) 00590 BLUE SHIELD (FLORIDA) 00621 BLUE SHIELD (ILLINOIS) 00630 NATIONAL GOVERNMENT SERVICES 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 NATIONAL GOVERNMENT SERVICES 00690 BLUE SHIELD (MARYLAND) 00700 BLUE SHIELD (MASSACHUSETTS) 00710 BLUE SHIELD (MICHIGAN) 00720 BLUE SHIELD (MINNESOTA) 00740 BLUE SHIELD (KANSAS CITY) 00770 BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780 BLUE SHIELD (TRI-STATE) 00801 BLUE SHIELD (BUFFALO) 00803 NATIONAL GOVERNMENT SERVICES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 3 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME 00805 NATIONAL GOVERNMENT SERVICES 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865 BLUE SHIELD (PENNSYLVANIA) 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00883 PALMETTO 00900 BLUE SHIELD (TEXAS) 00901 TRAILBLAZERS HEALTH ENTERPRISES 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 00973 BLUE SHIELD (PUERTO RICO) 00974 BLUE SHIELD (VIRGIN ISLANDS) 01010 AETNA (PEORIA) 01020 AETNA (ALASKA) 01030 AETNA (ARIZONA) 01040 AETNA (GEORGIA) 01120 AETNA (HAWAII) 01290 AETNA (NEVADA) 01360 AETNA (NEW MEXICO) 01370 AETNA (OKLAHOMA) 01380 AETNA (OREGON) 01390 AETNA (WASHINGTON) 02050 OCCIDENTAL (CALIFORNIA) 05130 EQICOR (IDAHO) 05440 EQICOR (TENNESSEE) 05535 EQICOR (NORTH CAROLINA) 10071 TRAVELERS (RRB) 10230 TRAVELERS (CONNECTICUT) 10240 TRAVELERS (MINNESOTA) 10250 TRAVELERS (MISSISSIPPI) 10490 TRAVELERS (VIRGINIA) 10492 TRAVELERS - VIRGINIA SPECIAL PROJECT 11260 GENERAL AMERICAN 14330 GROUP HEALTH INC (NEW YORK) 16360 NATIONWIDE (OHIO) 16510 NATIONWIDE (WEST VIRGINIA) 21200 MASSACHUSETTS/MAINE 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 4 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM VALUES: 00011 CAHABA 00122 HCSC - MICHIGAN 00452 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00510 BLUE SHIELD (ALABAMA) 00511 CAHABA 00520 BLUE SHIELD (ARKANSAS) 00528 BLUE SHIELD (ARKANSAS/LOUISIANA) 00542 BLUE SHIELD (CALIFORNIA) 00550 BLUE SHIELD (COLORADO) 00570 BLUE SHIELD (DELAWARE) 00580 BLUE SHIELD (DISTRICT OF COLUMBIA) 00590 BLUE SHIELD (FLORIDA) 00621 BLUE SHIELD (ILLINOIS) 00630 NATIONAL GOVERNMENT SERVICES 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 NATIONAL GOVERNMENT SERVICES 00690 BLUE SHIELD (MARYLAND) 00700 BLUE SHIELD (MASSACHUSETTS) 00710 BLUE SHIELD (MICHIGAN) 00720 BLUE SHIELD (MINNESOTA) 00740 BLUE SHIELD (KANSAS CITY) 00751 BLUE SHIELD (MONTANA) 00770 BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780 BLUE SHIELD (TRI-STATE) 00801 BLUE SHIELD (BUFFALO) 00803 NATIONAL GOVERNMENT SERVICES 00805 NATIONAL GOVERNMENT SERVICES 00820 BLUE SHIELD (NORTH DAKOTA) 00825 BLUE SHIELD (NORTH DAKOTA/WYOMING) 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 5 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME 00865 BLUE SHIELD (PENNSYLVANIA) 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00883 PALMETTO 00900 BLUE SHIELD (TEXAS) 00901 TRAILBLAZERS HEALTH ENTERPRISES 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 00973 BLUE SHIELD (PUERTO RICO) 00974 BLUE SHIELD (VIRGIN ISLANDS) 01010 AETNA (PEORIA) 01020 AETNA (ALASKA) 01030 AETNA (ARIZONA) 01040 AETNA (GEORGIA) 01120 AETNA (HAWAII) 01290 AETNA (NEVADA) 01360 AETNA (NEW MEXICO) 01370 AETNA (OKLAHOMA) 01380 AETNA (OREGON) 01390 AETNA (WASHINGTON) 02050 OCCIDENTAL (CALIFORNIA) 05130 EQICOR (IDAHO) 05440 EQICOR (TENNESSEE) 05535 EQICOR (NORTH CAROLINA) 10071 TRAVELERS (RRB) 10230 TRAVELERS (CONNECTICUT) 10240 TRAVELERS (MINNESOTA) 10250 TRAVELERS (MISSISSIPPI) 10490 TRAVELERS (VIRGINIA) 10492 TRAVELERS - VIRGINIA SPECIAL PROJECT 11260 GENERAL AMERICAN 14330 GROUP HEALTH INC (NEW YORK) 16360 NATIONWIDE (OHIO) 16510 NATIONWIDE (WEST VIRGINIA) 21200 MASSACHUSETTS/MAINE 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 6 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 7 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 8 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 9 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATE REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 10 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 1 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 COMPREHENSIVE OUTPATIENT CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 14 COMPREHENSIVE OUTPATIENT REHAB FACILITIES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 2 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 NATIONAL GOVERNMENT SERVICES 00180 NATIONAL GOVERNMENT SERVICES 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 3 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01101 PALMETTO (CALIFORNIA) 01201 PALMETTO (HAWAII) 01301 PALMETTO (NEVADA) 01390 AETNA (WASHINGTON) 02101 NATIONAL HERITAGE (ALASKA) 02201 NATIONAL HERITAGE (IDAHO) 02301 NATIONAL HERITAGE (OREGON) 02401 NATIONAL HERITAGE (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03101 NORIDIAN (ARIZONA) 03201 NORIDIAN (MONTANA) 03301 NORIDIAN (NORTH DAKOTA) 03401 NORIDIAN (SOUTH DAKOTA) 03501 NORIDIAN (UTAH) 03601 NORIDIAN (WYOMING) 04101 TRAILBLAZER (COLORADO) 04201 TRAILBLAZER (NEW MEXICO) 04301 TRAILBLAZER (OKLAHOMA) 04401 TRAILBLAZER (TEXAS) 05101 WPS (IOWA) 05201 WPS (KANSAS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 4 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 05301 WPS (MISSOURI) 05401 WPS (NEBRASKA) 07101 PINNACLE (ARKANSAS) 07201 PINNACLE (LOUISIANA) 07301 PINNACLE (MISSISSIPPI) 08101 PINNACLE (INDIANA) 08201 PINNACLE (MICHIGAN) 09101 FIRST COAST (FLORIDA) 09201 FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 12101 HIGHMARK (DELAWARE) 12201 HIGHMARK (DISTRICT OF COLUMBIA) 12301 HIGHMARK (MARYLAND) 12401 HIGHMARK NEW JERSEY) 12501 HIGHMARK (PENNSYLVANIA) 13101 NATL GOVT SERVICES (CONNECTICUT) 13201 NATL GOVT SERVICES (NEW YORK) 14101 NATIONAL HERITAGE (MAINE) 14201 NATIONAL HERITAGE (MASSACHUSETTS) 14301 NATIONAL HERITAGE (NEW HAMPSHIRE) 14401 NATIONAL HERITAGE (RHODE ISLAND) 14501 NATIONAL HERITAGE (VERMONT) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 5 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 6 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN ADMIN SERVICES (ARIZONA) 03202 NORIDIAN ADMIN SERVICES (MONTANA) 03302 NORIDIAN ADMIN SERVICES (NORTH DAKOTA) 03402 NORIDIAN ADMIN SERVICES (MONTANA) 03502 NORIDIAN ADMIN SERVICES (UTAH) 03602 NORIDIAN ADMIN SERVICES (WYOMING) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 7 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 8 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 9 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 10 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATE REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 11 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 PROPRIETARY 02 NON PROFIT CHURCH 03 NON PROFIT OTHER 04 GOVERNMENT ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD FISCAL YEAR ENDING DATE 4 378 381 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT SRV: OCCUPATIONAL THERAPY 1 558 558 C PROV2270 INDICATES HOW OCCUPATIONAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-OCCUP-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: PHYSICAL THERAPY 1 570 570 C PROV2370 INDICATES HOW PHYSICAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICAL-THERAPY VALUES: 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 12 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: SOCIAL 1 585 585 C PROV2485 INDICATES HOW SOCIAL SERVICES ARE PROVIDED. COBOL NAME: SP-SOCIAL VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT OR AGREEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: SPEECH PATHOLOGY 1 586 586 C PROV2505 INDICATES HOW SPEECH PATHOLOGY SERVICES ARE PROVIDED. COBOL NAME: SP-SPEECH-PATH VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT OR AGREEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR RELATED PROVIDER NUMBER 10 1228 1237 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM SRV: NURSING 1 1457 1457 C PROV2250 INDICATES HOW NURSING SERVICES ARE PROVIDED. COBOL NAME: SP-NURSING VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION PARENT PROVIDER NUMBER 10 1629 1638 C PROV1560 THE IDENTIFICATION NUMBER OF THE PARENT PROVIDER WHEN A PROVIDER IS PART OF AN EXISTING MEDICARE PROVIDER. COBOL NAME: PARENT-PROV-NUM PARTICIPATION MEDICARE OPT/SP 1 1672 1672 C PROV1570 INDICATES IF A COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY ALSO PARTICIPATES IN MEDICARE AS A PROVIDER OF OUTPATIENT PHYSICAL THERAPY AND/OR SPEECH PATHOLOGY. COBOL NAME: PARTIC-OPT-SP VALUES: N NO Y YES SRV: NURSING #2 1 1673 1673 C PROV6140 INDICATES HOW NURSING SERVICES ARE PROVIDED COBOL NAME: SP-NURSING-2 VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 13 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 3 COMBINATION SRV: NURSING #3 1 1674 1674 C PROV6145 INDICATES HOW NURSING SERVICES ARE PROVIDED COBOL NAME: SP-NURSING-3 VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: OCCUPATIONAL THERAPY #2 1 1675 1675 C PROV2275 INDICATES HOW OCCUPATIONAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-OCCUP-THERAPY-2 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: OCCUPATIONAL THERAPY #3 1 1676 1676 C PROV2280 INDICATES HOW OCCUPATIONAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-OCCUP-THERAPY-3 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: ORTHOTIC/PROSTHETIC 1 1677 1677 C PROV2325 INDICATES HOW ORTHOTIC/PROSTHETIC SERVICES ARE PROVIDED BY A COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY. COBOL NAME: SP-ORTHOTIC-PROSTHET VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: ORTHOTIC/PROSTHETIC #2 1 1678 1678 C PROV2330 INDICATES HOW ORTHOTIC/PROSTHETIC SERVICES ARE PROVIDED BY A COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY. COBOL NAME: SP-ORTHOTIC-PROSTHET-2 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 14 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: ORTHOTIC/PROSTHETIC #3 1 1679 1679 C PROV2335 INDICATES HOW ORTHOTIC/PROSTHETIC SERVICES ARE PROVIDED BY A COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY. COBOL NAME: SP-ORTHOTIC-PROSTHET-3 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: PHYSICAL THERAPY #2 1 1680 1680 C PROV2375 INDICATES HOW PHYSICAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICAL-THERAPY-2 VALUES: 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: PHYSICAL THERAPY #3 1 1681 1681 C PROV2380 INDICATES HOW PHYSICAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICAL-THERAPY-3 VALUES: 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: PHYSICIAN 1 1682 1682 C PROV2385 INDICATES HOW PHYSICIAN SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICIAN VALUES: 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: PHYSICIAN #2 1 1683 1683 C PROV2390 INDICATES HOW PHYSICIAN SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICIAN-2 VALUES: 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: PHYSICIAN #3 1 1684 1684 C PROV2395 INDICATES HOW PHYSICIAN SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICIAN-3 VALUES: 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: PSYCHOLOGICAL 1 1685 1685 C PROV2420 INDICATES HOW PSYCHOLOGICAL SERVICES ARE PROVIDED. COBOL NAME: SP-PSYCHOLOGICAL VALUES: 0 NOT PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 15 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: PSYCHOLOGICAL #2 1 1686 1686 C PROV2425 INDICATES HOW PSYCHOLOGICAL SERVICES ARE PROVIDED. COBOL NAME: SP-PSYCHOLOGICAL-2 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: PSYCHOLOGICAL #3 1 1687 1687 C PROV2430 INDICATES HOW PSYCHOLOGICAL SERVICES ARE PROVIDED. COBOL NAME: SP-PSYCHOLOGICAL-3 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: RESPIRATORY CARE 1 1688 1688 C PROV2455 INDICATES HOW RESPIRATORY CARE SERVICES ARE PROVIDED. COBOL NAME: SP-RESP-CARE VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED BY ARRANGEMENT OR AGREEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: RESPIRATORY CARE #2 1 1689 1689 C PROV2460 INDICATES HOW RESPIRATORY CARE SERVICES ARE PROVIDED. COBOL NAME: SP-RESP-CARE-2 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: RESPIRATORY CARE #3 1 1690 1690 C PROV2465 INDICATES HOW RESPIRATORY CARE SERVICES ARE PROVIDED. COBOL NAME: SP-RESP-CARE-3 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: SOCIAL #2 1 1691 1691 C PROV2490 INDICATES HOW SOCIAL SERVICES ARE PROVIDED. COBOL NAME: SP-SOCIAL-2 VALUES: 0 NOT PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 16 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: SOCIAL #3 1 1692 1692 C PROV2495 INDICATES HOW SOCIAL SERVICES ARE PROVIDED. COBOL NAME: SP-SOCIAL-3 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: SPEECH PATHOLOGY #2 1 1693 1693 C PROV2510 INDICATES HOW SPEECH PATHOLOGY SERVICES ARE PROVIDED. COBOL NAME: SP-SPEECH-PATH-2 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: SPEECH PATHOLOGY #3 1 1694 1694 C PROV2515 INDICATES HOW SPEECH PATHOLOGY SERVICES ARE PROVIDED. COBOL NAME: SP-SPEECH-PATH-3 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 1 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 AMBULATORY SURGICAL CENTER CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 15 AMBULATORY SURGICAL CENTERS CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 2 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 NATIONAL GOVERNMENT SERVICES 00180 NATIONAL GOVERNMENT SERVICES 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 3 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00510 BLUE SHIELD (ALABAMA) 00511 CAHABA 00520 BLUE SHIELD (ARKANSAS) 00528 BLUE SHIELD (ARKANSAS/LOUISIANA) 00542 BLUE SHIELD (CALIFORNIA) 00550 BLUE SHIELD (COLORADO) 00570 BLUE SHIELD (DELAWARE) 00580 BLUE SHIELD (DISTRICT OF COLUMBIA) 00590 BLUE SHIELD (FLORIDA) 00621 BLUE SHIELD (ILLINOIS) 00630 NATIONAL GOVERNMENT SERVICES 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 NATIONAL GOVERNMENT SERVICES 00690 BLUE SHIELD (MARYLAND) 00700 BLUE SHIELD (MASSACHUSETTS) 00710 BLUE SHIELD (MICHIGAN) 00720 BLUE SHIELD (MINNESOTA) 00740 BLUE SHIELD (KANSAS CITY) 00770 BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780 BLUE SHIELD (TRI-STATE) 00801 BLUE SHIELD (BUFFALO) 00803 NATIONAL GOVERNMENT SERVICES 00805 NATIONAL GOVERNMENT SERVICES 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 4 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00865 BLUE SHIELD (PENNSYLVANIA) 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00883 PALMETTO 00900 BLUE SHIELD (TEXAS) 00901 TRAILBLAZERS HEALTH ENTERPRISES 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 00973 BLUE SHIELD (PUERTO RICO) 00974 BLUE SHIELD (VIRGIN ISLANDS) 01010 AETNA (PEORIA) 01020 AETNA (ALASKA) 01030 AETNA (ARIZONA) 01040 AETNA (GEORGIA) 01102 PALMETTO (CALIFORNIA NORTH) 01120 AETNA (HAWAII) 01192 PALMETTO (CALIFORNIA SOUTH) 01202 PALMETTO (HAWAII) 01290 AETNA (NEVADA) 01302 PALMETTO (NEVADA) 01360 AETNA (NEW MEXICO) 01370 AETNA (OKLAHOMA) 01380 AETNA (OREGON) 01390 AETNA (WASHINGTON) 02050 OCCIDENTAL (CALIFORNIA) 02102 NATIONAL HERITAGE (ALASKA) 02202 NATIONAL HERITAGE (IDAHO) 02302 NATIONAL HERITAGE (OREGON) 02402 NATIONAL HERITAGE (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN (ARIZONA) 03202 NORIDIAN (MONTANA) 03302 NORIDIAN (NORTH DAKOTA) 03402 NORIDIAN (SOUTH DAKOTA) 03502 NORIDIAN (UTAH) 03602 NORIDIAN (WYOMING) 04102 TRAILBLAZER (COLORADO) 04202 TRAILBLAZER (NEW MEXICO) 04302 TRAILBLAZER (OKLAHOMA) 04402 TRAILBLAZER (TEXAS) 05102 WPS (IOWA) 05130 EQICOR (IDAHO) 05202 WPS (KANSAS) 05302 WPS (MISSOURI WEST) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 5 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 05392 WPS (MISSOURI EAST) 05402 WPS (NEBRASKA) 05440 EQICOR (TENNESSEE) 05535 EQICOR (NORTH CAROLINA) 07102 PINNACLE (ARKANSAS) 07202 PINNACLE (LOUISIANA) 07302 PINNACLE (MISSISSIPPI) 08102 PINNACLE (INDIANA) 08202 PINNACLE (MICHIGAN) 09102 FIRST COAST (FLORIDA) 09202 FIRST COAST (PUERTO RICO) 09302 FIRST COAST (VIRGIN ISLANDS) 10071 TRAVELERS (RRB) 10230 TRAVELERS (CONNECTICUT) 10240 TRAVELERS (MINNESOTA) 10250 TRAVELERS (MISSISSIPPI) 10490 TRAVELERS (VIRGINIA) 10492 TRAVELERS - VIRGINIA SPECIAL PROJECT 11260 GENERAL AMERICAN 12102 HIGHMARK (DELAWARE) 12202 HIGHMARK (DISTRICT OF COLUMBIA) 12302 HIGHMARK (MARYLAND) 12402 HIGHMARK (NEW JERSEY) 12502 HIGHMARK (PENNSYLVANIA) 13102 NATL GOVT SERVICES (CONNECTICUT) 13202 NATL GOVT SERVICES (NEW YORK (EMPIRE)) 13282 NATL GOVT SERVICES (NEW YORK (HEALTHNOW)) 13292 NATL GOVT SERVICES (NEW YORK (GHI)) 14102 NATIONAL HERITAGE (MAINE) 14202 NATIONAL HERITAGE (MASSACHUSETTS) 14302 NATIONAL HERITAGE (NEW HAMPSHIRE) 14330 GROUP HEALTH INC (NEW YORK) 14402 NATIONAL HERITAGE (RHODE ISLAND) 14502 NATIONAL HERITAGE (VERMONT) 16360 NATIONWIDE (OHIO) 16510 NATIONWIDE (WEST VIRGINIA) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 21200 MASSACHUSETTS/MAINE 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 6 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 7 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00510 BLUE SHIELD (ALABAMA) 00511 CAHABA 00520 BLUE SHIELD (ARKANSAS) 00528 BLUE SHIELD (ARKANSAS/LOUISIANA) 00542 BLUE SHIELD (CALIFORNIA) 00550 BLUE SHIELD (COLORADO) 00570 BLUE SHIELD (DELAWARE) 00580 BLUE SHIELD (DISTRICT OF COLUMBIA) 00590 BLUE SHIELD (FLORIDA) 00621 BLUE SHIELD (ILLINOIS) 00630 NATIONAL GOVERNMENT SERVICES 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 NATIONAL GOVERNMENT SERVICES 00690 BLUE SHIELD (MARYLAND) 00700 BLUE SHIELD (MASSACHUSETTS) 00710 BLUE SHIELD (MICHIGAN) 00720 BLUE SHIELD (MINNESOTA) 00740 BLUE SHIELD (KANSAS CITY) 00751 BLUE SHIELD (MONTANA) 00770 BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780 BLUE SHIELD (TRI-STATE) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 8 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00801 BLUE SHIELD (BUFFALO) 00803 NATIONAL GOVERNMENT SERVICES 00805 NATIONAL GOVERNMENT SERVICES 00820 BLUE SHIELD (NORTH DAKOTA) 00825 BLUE SHIELD (NORTH DAKOTA/WYOMING) 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865 BLUE SHIELD (PENNSYLVANIA) 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00883 PALMETTO 00900 BLUE SHIELD (TEXAS) 00901 TRAILBLAZERS HEALTH ENTERPRISES 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 00973 BLUE SHIELD (PUERTO RICO) 00974 BLUE SHIELD (VIRGIN ISLANDS) 01010 AETNA (PEORIA) 01020 AETNA (ALASKA) 01030 AETNA (ARIZONA) 01040 AETNA (GEORGIA) 01120 AETNA (HAWAII) 01290 AETNA (NEVADA) 01360 AETNA (NEW MEXICO) 01370 AETNA (OKLAHOMA) 01380 AETNA (OREGON) 01390 AETNA (WASHINGTON) 02050 OCCIDENTAL (CALIFORNIA) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN ADMIN SERVICES (ARIZONA) 03202 NORIDIAN ADMIN SERVICES (MONTANA) 03302 NORIDIAN ADMIN SERVICES (NORTH DAKOTA) 03402 NORIDIAN ADMIN SERVICES (MONTANA) 03502 NORIDIAN ADMIN SERVICES (UTAH) 03602 NORIDIAN ADMIN SERVICES (WYOMING) 05130 EQICOR (IDAHO) 05440 EQICOR (TENNESSEE) 05535 EQICOR (NORTH CAROLINA) 10071 TRAVELERS (RRB) 10230 TRAVELERS (CONNECTICUT) 10240 TRAVELERS (MINNESOTA) 10250 TRAVELERS (MISSISSIPPI) 10490 TRAVELERS (VIRGINIA) 10492 TRAVELERS - VIRGINIA SPECIAL PROJECT 11260 GENERAL AMERICAN * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 9 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 14330 GROUP HEALTH INC (NEW YORK) 16360 NATIONWIDE (OHIO) 16510 NATIONWIDE (WEST VIRGINIA) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 21200 MASSACHUSETTS/MAINE 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 10 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 11 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 12 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATE REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 13 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP 5 VALIDATION (ACCRD) 8 FULL SURVEY AFTER COMPLAINT TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 PROPRIETARY 02 NON PROFIT 03 GOVERNMENT ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 14 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD ACCREDITATION INDICATOR 1 290 290 C PROV0010 INDICATES THE ORGANIZATION THAT IS RESPONSIBLE FOR THE ACCREDITATION OF THE PROVIDER. COBOL NAME: ACCRED-STAT VALUES: 0 NONE 1 JCAHO 2 AAAHC 3 AAAASF 4 AOA COMPLIANCE: LIFE SAFETY CODE 1 356 356 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: 1 WAIVER RECOMMENDED DATE OF LAST VALIDATION SURVEY 8 363 370 C PROV0450 DATE THE LAST VALIDATION SURVEY WAS PERFORMED BY THE STATE AGENCY FOR A JCAH, AOA ACCREDITED HOSPITAL OR OTHER PROVIDER TYPE. COBOL NAME: DT-VALID-SURVEY FISCAL YEAR ENDING DATE 4 378 381 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT SRV: PHARMACY 1 569 569 C PROV2365 INDICATES HOW PHARMACY SERVICES ARE PROVIDED. COBOL NAME: SP-PHARMACY VALUES: 1 PROVIDED DIRECTLY BY THE FACILITY 2 PROVIDED THROUGH AN OUTSIDE SOURCE 3 COMBINATION RELATED PROVIDER NUMBER 10 1228 1237 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM SRV: OTHER 1 1459 1459 C PROV2340 INDICATES HOW OTHER (NOT SPECIFIED) SERVICES ARE PROVIDED. COBOL NAME: SP-OTHER VALUES: N NOT OFFERED Y OFFERED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 15 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME DATE CENTER BEGAN PROVIDING SERV 8 1695 1702 C PROV0415 THE DATE AN AMBULATORY SURGICAL CENTER (ASC) BEGAN PROVIDING HEALTH CARE SERVICES. COBOL NAME: DT-SERVICE-BEGAN FREE STANDING INDICATOR (ASC) 1 1703 1703 C PROV0550 INDICATES IF THE AMBULATORY SURGICAL CENTER IS FREE STANDING. THIS INDICATOR IS USED BY SOME STANDARD REPORTS TO GET CERTAIN PROVIDER RANGES. COBOL NAME: FREE-STAND-IND VALUES: Y YES FREE STANDING HOSPITAL BASED INDICATOR 1 1704 1704 C PROV0565 HOSPITAL BASED INDICATOR COBOL NAME: HOSP-BASED-IND VALUES: 1 HOSPITAL BASED OPERATING ROOMS 2 1705 1706 N PROV1055 THE NUMBER OF OPERATING ROOMS IN AN AMBULATORY SURGICAL CENTER. COBOL NAME: NUM-OPERATING-ROOMS SPEC: CARDIOVASCULAR 1 1707 1707 C PROV2095 INDICATES IF CARDIOVASCULAR SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-CARDIOVASCULAR VALUES: N NOT OFFERED Y OFFERED SPEC: FOOT 1 1708 1708 C PROV2145 INDICATES IF FOOT SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-FOOT VALUES: N NOT OFFERED Y OFFERED SPEC: GENERAL 1 1709 1709 C PROV2150 INDICATES IF GENERAL SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-GENERAL VALUES: N NOT OFFERED Y OFFERED SPEC: NEUROLOGICAL 1 1710 1710 C PROV2240 INDICATES IF NEUROLOGICAL SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-NEUROLOGICAL VALUES: N NOT OFFERED Y OFFERED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 16 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPEC: OBSTETRICS/GYNECOLOGY 1 1711 1711 C PROV2260 INDICATES IF OBSTETRICS/GYNECOLOGY SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-OBSTETR-GYNECOL VALUES: N NOT OFFERED Y OFFERED SPEC: OPTHAMOLOGY 1 1712 1712 C PROV2290 INDICATES IF OPTHAMOLOGY SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-OPTHAMOLOGY-SURG VALUES: N NOT OFFERED Y OFFERED SPEC: ORAL 1 1713 1713 C PROV2305 INDICATES IF ORAL SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-ORAL VALUES: N NOT OFFERED Y OFFERED SPEC: ORTHOPEDIC 1 1714 1714 C PROV2320 INDICATES IF ORTHOPEDIC SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-ORTHOPEDIC VALUES: N NOT OFFERED Y OFFERED SPEC: OTOLARYNGOLOGY 1 1715 1715 C PROV2345 INDICATES IF OTOLARYNGOLOGY SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-OTOLARYRGOLOGY VALUES: N NOT OFFERED Y OFFERED SPEC: PLASTIC 1 1716 1716 C PROV2400 INDICATES IF PLASTIC SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-PLASTIC VALUES: N NOT OFFERED Y OFFERED SPEC: THORACIC 1 1717 1717 C PROV2525 INDICATES IF THORACIC SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-THORACIC VALUES: N NOT OFFERED Y OFFERED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 17 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPEC: UROLOGY 1 1718 1718 C PROV2530 INDICATES IF UROLOGY SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-UROLOGY VALUES: N NOT OFFERED Y OFFERED SRV: EKG 1 1719 1719 C PROV2135 INDICATES IF EKG SERVICES ARE PROVIDED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-EKG VALUES: 0 NOT PROVIDED 1 PROVIDED DIRECTLY BY THE FACILITY 2 PROVIDED THROUGH AN OUTSIDE SOURCE 3 COMBINATION SRV: LABORATORY 1 1720 1720 C PROV2200 INDICATES HOW LABORATORY SERVICES ARE PROVIDED. COBOL NAME: SP-LABORATORY VALUES: 1 PROVIDED DIRECTLY BY THE FACILITY 2 PROVIDED THROUGH AN OUTSIDE SOURCE 3 COMBINATION SRV: RADIOLOGY 1 1721 1721 C PROV2435 INDICATES HOW RADIOLOGY SERVICES ARE PROVIDED. COBOL NAME: SP-RADIOLOGY VALUES: 1 PROVIDED DIRECTLY BY THE FACILITY 2 PROVIDED THROUGH AN OUTSIDE SOURCE 3 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 1 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 HOSPICE CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 16 HOSPICES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 2 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 NATIONAL GOVERNMENT SERVICES 00180 NATIONAL GOVERNMENT SERVICES 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 3 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01101 PALMETTO (CALIFORNIA) 01201 PALMETTO (HAWAII) 01301 PALMETTO (NEVADA) 01390 AETNA (WASHINGTON) 02101 NATIONAL HERITAGE (ALASKA) 02201 NATIONAL HERITAGE (IDAHO) 02301 NATIONAL HERITAGE (OREGON) 02401 NATIONAL HERITAGE (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03101 NORIDIAN (ARIZONA) 03201 NORIDIAN (MONTANA) 03301 NORIDIAN (NORTH DAKOTA) 03401 NORIDIAN (SOUTH DAKOTA) 03501 NORIDIAN (UTAH) 03601 NORIDIAN (WYOMING) 04101 TRAILBLAZER (COLORADO) 04201 TRAILBLAZER (NEW MEXICO) 04301 TRAILBLAZER (OKLAHOMA) 04401 TRAILBLAZER (TEXAS) 05101 WPS (IOWA) 05201 WPS (KANSAS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 4 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 05301 WPS (MISSOURI) 05401 WPS (NEBRASKA) 07101 PINNACLE (ARKANSAS) 07201 PINNACLE (LOUISIANA) 07301 PINNACLE (MISSISSIPPI) 08101 PINNACLE (INDIANA) 08201 PINNACLE (MICHIGAN) 09101 FIRST COAST (FLORIDA) 09201 FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 12101 HIGHMARK (DELAWARE) 12201 HIGHMARK (DISTRICT OF COLUMBIA) 12301 HIGHMARK (MARYLAND) 12401 HIGHMARK NEW JERSEY) 12501 HIGHMARK (PENNSYLVANIA) 13101 NATL GOVT SERVICES (CONNECTICUT) 13201 NATL GOVT SERVICES (NEW YORK) 14101 NATIONAL HERITAGE (MAINE) 14201 NATIONAL HERITAGE (MASSACHUSETTS) 14301 NATIONAL HERITAGE (NEW HAMPSHIRE) 14401 NATIONAL HERITAGE (RHODE ISLAND) 14501 NATIONAL HERITAGE (VERMONT) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 5 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 6 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN ADMIN SERVICES (ARIZONA) 03202 NORIDIAN ADMIN SERVICES (MONTANA) 03302 NORIDIAN ADMIN SERVICES (NORTH DAKOTA) 03402 NORIDIAN ADMIN SERVICES (MONTANA) 03502 NORIDIAN ADMIN SERVICES (UTAH) 03602 NORIDIAN ADMIN SERVICES (WYOMING) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 7 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 8 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 9 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 10 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATE REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 11 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 3 TERMINATION 4 CHANGE OF OWNERSHIP 5 VALIDATION (ACCRD) 8 FULL SURVEY AFTER COMPLAINT TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 VOLUNTARY NON-PROFIT - CHURCH 02 VOLUNTARY NON-PROFIT - PRIVATE 03 VOLUNTARY NON-PROFIT - OTHER 04 PROPRIETARY - INDIVIDUAL 05 PROPRIETARY - PARTNERSHIP 06 PROPRIETARY - CORPORATION 07 PROPRIETARY - OTHER 08 GOVERNMENT - STATE 09 GOVERNMENT - COUNTY 10 GOVERNMENT - CITY 11 GOVERNMENT - CITY-COUNTY 12 COMBINATION GOV. & NONPROFIT 13 OTHER ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD ACCREDITATION INDICATOR 1 290 290 C PROV0010 INDICATES THE ORGANIZATION THAT IS RESPONSIBLE FOR THE ACCREDITATION OF THE PROVIDER. COBOL NAME: ACCRED-STAT VALUES: 0 NONE 1 JCAHO 2 CHAP 3 ACHC * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 12 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COMPLIANCE: LIFE SAFETY CODE 1 356 356 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: 1 WAIVER RECOMMENDED DATE OF LAST VALIDATION SURVEY 8 363 370 C PROV0450 DATE THE LAST VALIDATION SURVEY WAS PERFORMED BY THE STATE AGENCY FOR A JCAH, AOA ACCREDITED HOSPITAL OR OTHER PROVIDER TYPE. COBOL NAME: DT-VALID-SURVEY FISCAL YEAR ENDING DATE 4 378 381 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT LICENSED PRACT/VOCAT NURSES 7.2 382 388 N PROV0955 NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL OR VOCATIONAL NURSES EMPLOYED BY A FACILITY. COBOL NAME: NUM-LPN-LVN OTHER PERSONNEL 7.2 412 418 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL REGISTERED NURSES 7.2 473 479 N PROV1145 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PROFESSIONAL NURSES EMPLOYED BY A PROVIDER. COBOL NAME: NUM-REG-NURS SRV: OCCUPATIONAL THERAPY 1 558 558 C PROV2270 INDICATES HOW OCCUPATIONAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-OCCUP-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: PHYSICAL THERAPY 1 570 570 C PROV2370 INDICATES HOW PHYSICAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICAL-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: SPEECH PATHOLOGY 1 586 586 C PROV2505 INDICATES HOW SPEECH PATHOLOGY SERVICES ARE PROVIDED. COBOL NAME: SP-SPEECH-PATH VALUES: 0 NOT PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 13 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT OR AGREEMENT 3 COMBINATION TYPE OF FACILITY 2 593 594 C PROV2890 INDICATES THE CATEGORY WHICH REPRESENTS THE TYPE OF FACILITY. COBOL NAME: TYPE-FACILITY VALUES: 01 HOSPITAL 02 SKILLED NURSING FACILITY 03 NURSING FACILITY 04 HOME HEALTH AGENCY 05 FREESTANDING HOSPICE RELATED PROVIDER NUMBER 10 1228 1237 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM HOME HEALTH AIDES 7.2 1419 1425 N PROV0910 NUMBER OF FULL-TIME EQUIVALENT HOME HEALTH AIDES EMPLOYED BY A HOME HEALTH AGENCY OR HOSPICE. COBOL NAME: NUM-HOME-HEALTH-AIDES SRV: MEDICAL SOCIAL 1 1456 1456 C PROV2220 INDICATES HOW MEDICAL SOCIAL SERVICES ARE PROVIDED COBOL NAME: SP-MEDICAL-SOCIAL VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: NURSING 1 1457 1457 C PROV2250 INDICATES HOW NURSING SERVICES ARE PROVIDED. COBOL NAME: SP-NURSING VALUES: 1 PROVIDED BY STAFF 3 COMBINATION SRV: OTHER 1 1459 1459 C PROV2340 INDICATES HOW OTHER (NOT SPECIFIED) SERVICES ARE PROVIDED. COBOL NAME: SP-OTHER VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 14 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TOTAL # OF EMPLOYEES 9.2 1612 1620 N PROV2850 THE TOTAL NUMBER OF FULL-TIME EMPLOYEES IN A HOSPICE OR AN INTERMEDIATE CARE FACILITY/MENTAL RETARDATION FACILITY. COBOL NAME: TOT-EMPLOYEES PHYSICIANS 7.2 1639 1645 N PROV1110 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIANS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS SRV: PHYSICIAN 1 1682 1682 C PROV2385 INDICATES HOW PHYSICIAN SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICIAN VALUES: 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION ACUTE/RESPITE CARE INDICATOR 1 1722 1722 C PROV0015 INDICATES IF THE HOSPICE PROVIDES ACUTE AND/OR RESPITE SHORT TERM INPATIENT CARE. COBOL NAME: ACUTE-RESPITE VALUES: A SHORT TERM INPATIENT ACUTE CARE PROV'D IN HSP B SHORT TERM INPATIENT RESPITE CARE PROV IN HSP C ST INPATIENT ACUTE & RESPITE CARE PROV IN HSP COUNSELORS - STAFF 7.2 1723 1729 N PROV1225 THE NUMBER OF FULL-TIME EQUIVALENT COUNSELORS EMPLOYED BY A HOSPICE. COBOL NAME: NUM-STAFF-COUNSL COUNSELORS - VOLUNTEER 7.2 1730 1736 N PROV1480 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER COUNSELORS IN A HOSPICE. COBOL NAME: NUM-VOL-COUNSL HOME HEALTH AIDES - VOLUNTEER 7.2 1737 1743 N PROV1485 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER HOME HEALTH AIDES IN A HOSPICE. COBOL NAME: NUM-VOL-HHA HOMEMAKERS - STAFF 7.2 1744 1750 N PROV0915 THE NUMBER OF FULL-TIME EQUIVALENT HOMEMAKERS EMPLOYED BY A HOSPICE. COBOL NAME: NUM-HOMEMAKERS HOMEMAKERS - VOLUNTEER 7.2 1751 1757 N PROV1490 THE NUMBER OF FULL-TIME EQUIVALENT HOMEMAKERS IN A HOSPICE. COBOL NAME: NUM-VOL-HOMEMKR LPNS/LVNS - VOLUNTEER 7.2 1758 1764 N PROV1495 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER LICENSED PRACTICAL/VOCATIONAL NURSES IN A HOSPICE. COBOL NAME: NUM-VOL-LPN-LVN * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 15 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MEDICAL SOCIAL WORKERS 7.2 1765 1771 N PROV0975 NUMBER OF FULL-TIME EQUIVALENT MEDICAL SOCIAL WORKERS EMPLOYED BY A HOSPITAL OR HOSPICE. COBOL NAME: NUM-MED-SOCIAL-WRKS MEDICAL SOCIAL WORKERS - VOLUNTEER 7.2 1772 1778 N PROV1510 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER MEDICAL SOCIAL WORKERS IN A HOSPICE. COBOL NAME: NUM-VOL-SOC-WORK PHYSICIANS - VOLUNTEER 7.2 1779 1785 N PROV1500 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER PHYSICIANS IN A HOSPICE. COBOL NAME: NUM-VOL-PHYS REGISTERED NURSES - VOLUNTEER 7.2 1786 1792 N PROV1505 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER REGISTERED NURSES IN A HOSPICE. COBOL NAME: NUM-VOL-REG-NURS SRV: COUNSELING 1 1793 1793 C PROV2115 INDICATES HOW COUNSELING SERVICES ARE PROVIDED BY A HOSPICE. COBOL NAME: SP-COUNSELING VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: HOME HEALTH AIDE 1 1794 1794 C PROV2165 INDICATES HOW HOME HEALTH AIDE SERVICES ARE PROVIDED BY A HOSPICE. COBOL NAME: SP-HOME-HEALTH-AIDE VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: HOMEMAKER 1 1795 1795 C PROV2170 INDICATES HOW HOMEMAKER SERVICES ARE PROVIDED BY A HOSPICE. COBOL NAME: SP-HOMEMAKER VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: MEDICAL SUPPLIES 1 1796 1796 C PROV2225 INDICATES HOW MEDICAL SUPPLIES SERVICES ARE PROVIDED BY A HOSPICE. COBOL NAME: SP-MEDICAL-SUPPLIES VALUES: 0 NOT PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 16 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: SHORT TERM INPATIENT CARE 1 1797 1797 C PROV2480 INDICATES HOW SHORT TERM INPATIENT CARE SERVICES ARE PROVIDED BY A HOSPICE. COBOL NAME: SP-SHORT-TERM-INCARE VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION VOLUNTEERS - OTHER 7.2 1798 1804 N PROV1080 THE NUMBER OF FULL-TIME EQUIVALENT OTHER VOLUNTEERS IN A HOSPICE. COBOL NAME: NUM-OTHER-VOLS VOLUNTEERS - TOTAL 9.2 1805 1813 N PROV2860 THE NUMBER OF FULL-TIME VOLUNTEERS IN A HOSPICE. COBOL NAME: TOT-VOLS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 1 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 ORGAN PROCUREMENT CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 17 ORGAN PROCUREMENT ORGANIZATIONS CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 2 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 NATIONAL GOVERNMENT SERVICES 00180 NATIONAL GOVERNMENT SERVICES 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 3 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01102 PALMETTO (CALIFORNIA NORTH) 01192 PALMETTO (CALIFORNIA SOUTH) 01202 PALMETTO (HAWAII) 01302 PALMETTO (NEVADA) 01390 AETNA (WASHINGTON) 02102 NATIONAL HERITAGE (ALASKA) 02202 NATIONAL HERITAGE (IDAHO) 02302 NATIONAL HERITAGE (OREGON) 02402 NATIONAL HERITAGE (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN (ARIZONA) 03202 NORIDIAN (MONTANA) 03302 NORIDIAN (NORTH DAKOTA) 03402 NORIDIAN (SOUTH DAKOTA) 03502 NORIDIAN (UTAH) 03602 NORIDIAN (WYOMING) 04102 TRAILBLAZER (COLORADO) 04202 TRAILBLAZER (NEW MEXICO) 04302 TRAILBLAZER (OKLAHOMA) 04402 TRAILBLAZER (TEXAS) 05102 WPS (IOWA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 4 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 05202 WPS (KANSAS) 05302 WPS (MISSOURI WEST) 05392 WPS (MISSOURI EAST) 05402 WPS (NEBRASKA) 07102 PINNACLE (ARKANSAS) 07202 PINNACLE (LOUISIANA) 07302 PINNACLE (MISSISSIPPI) 08102 PINNACLE (INDIANA) 08202 PINNACLE (MICHIGAN) 09102 FIRST COAST (FLORIDA) 09202 FIRST COAST (PUERTO RICO) 09302 FIRST COAST (VIRGIN ISLANDS) 12102 HIGHMARK (DELAWARE) 12202 HIGHMARK (DISTRICT OF COLUMBIA) 12302 HIGHMARK (MARYLAND) 12402 HIGHMARK (NEW JERSEY) 12502 HIGHMARK (PENNSYLVANIA) 13102 NATL GOVT SERVICES (CONNECTICUT) 13202 NATL GOVT SERVICES (NEW YORK (EMPIRE)) 13282 NATL GOVT SERVICES (NEW YORK (HEALTHNOW)) 13292 NATL GOVT SERVICES (NEW YORK (GHI)) 14102 NATIONAL HERITAGE (MAINE) 14202 NATIONAL HERITAGE (MASSACHUSETTS) 14302 NATIONAL HERITAGE (NEW HAMPSHIRE) 14402 NATIONAL HERITAGE (RHODE ISLAND) 14502 NATIONAL HERITAGE (VERMONT) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 5 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 6 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN ADMIN SERVICES (ARIZONA) 03202 NORIDIAN ADMIN SERVICES (MONTANA) 03302 NORIDIAN ADMIN SERVICES (NORTH DAKOTA) 03402 NORIDIAN ADMIN SERVICES (MONTANA) 03502 NORIDIAN ADMIN SERVICES (UTAH) 03602 NORIDIAN ADMIN SERVICES (WYOMING) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 7 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 8 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 9 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 10 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATE REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 11 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD FISCAL YEAR ENDING DATE 4 378 381 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 1 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 COMMUNITY MENTAL HEALTH CENTERS CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 19 COMMUNITY MENTAL HEALTH CENTERS CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 2 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 NATIONAL GOVERNMENT SERVICES 00180 NATIONAL GOVERNMENT SERVICES 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 3 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01101 PALMETTO (CALIFORNIA) 01201 PALMETTO (HAWAII) 01301 PALMETTO (NEVADA) 01390 AETNA (WASHINGTON) 02101 NATIONAL HERITAGE (ALASKA) 02201 NATIONAL HERITAGE (IDAHO) 02301 NATIONAL HERITAGE (OREGON) 02401 NATIONAL HERITAGE (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03101 NORIDIAN (ARIZONA) 03201 NORIDIAN (MONTANA) 03301 NORIDIAN (NORTH DAKOTA) 03401 NORIDIAN (SOUTH DAKOTA) 03501 NORIDIAN (UTAH) 03601 NORIDIAN (WYOMING) 04101 TRAILBLAZER (COLORADO) 04201 TRAILBLAZER (NEW MEXICO) 04301 TRAILBLAZER (OKLAHOMA) 04401 TRAILBLAZER (TEXAS) 05101 WPS (IOWA) 05201 WPS (KANSAS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 4 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 05301 WPS (MISSOURI) 05401 WPS (NEBRASKA) 07101 PINNACLE (ARKANSAS) 07201 PINNACLE (LOUISIANA) 07301 PINNACLE (MISSISSIPPI) 08101 PINNACLE (INDIANA) 08201 PINNACLE (MICHIGAN) 09101 FIRST COAST (FLORIDA) 09201 FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 12101 HIGHMARK (DELAWARE) 12201 HIGHMARK (DISTRICT OF COLUMBIA) 12301 HIGHMARK (MARYLAND) 12401 HIGHMARK NEW JERSEY) 12501 HIGHMARK (PENNSYLVANIA) 13101 NATL GOVT SERVICES (CONNECTICUT) 13201 NATL GOVT SERVICES (NEW YORK) 14101 NATIONAL HERITAGE (MAINE) 14201 NATIONAL HERITAGE (MASSACHUSETTS) 14301 NATIONAL HERITAGE (NEW HAMPSHIRE) 14401 NATIONAL HERITAGE (RHODE ISLAND) 14501 NATIONAL HERITAGE (VERMONT) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 5 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 6 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN ADMIN SERVICES (ARIZONA) 03202 NORIDIAN ADMIN SERVICES (MONTANA) 03302 NORIDIAN ADMIN SERVICES (NORTH DAKOTA) 03402 NORIDIAN ADMIN SERVICES (MONTANA) 03502 NORIDIAN ADMIN SERVICES (UTAH) 03602 NORIDIAN ADMIN SERVICES (WYOMING) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 7 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 8 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 9 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 10 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATE REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 3 TERMINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 11 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 PROPRIETARY 02 CHURCH RELATED 03 NONPROFIT CORPORATION 04 OTHER NONPROFIT 05 STATE 06 LOCAL 07 FEDERAL ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD RELATED PROVIDER NUMBER 10 1228 1237 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 1 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 FEDERALLY QUALIFIED HEALTH CENTERS CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 21 FEDERALLY QUALIFIED HEALTH CENTERS CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 2 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 NATIONAL GOVERNMENT SERVICES 00180 NATIONAL GOVERNMENT SERVICES 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 3 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01102 PALMETTO (CALIFORNIA NORTH) 01192 PALMETTO (CALIFORNIA SOUTH) 01202 PALMETTO (HAWAII) 01302 PALMETTO (NEVADA) 01390 AETNA (WASHINGTON) 02102 NATIONAL HERITAGE (ALASKA) 02202 NATIONAL HERITAGE (IDAHO) 02302 NATIONAL HERITAGE (OREGON) 02402 NATIONAL HERITAGE (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN (ARIZONA) 03202 NORIDIAN (MONTANA) 03302 NORIDIAN (NORTH DAKOTA) 03402 NORIDIAN (SOUTH DAKOTA) 03502 NORIDIAN (UTAH) 03602 NORIDIAN (WYOMING) 04102 TRAILBLAZER (COLORADO) 04202 TRAILBLAZER (NEW MEXICO) 04302 TRAILBLAZER (OKLAHOMA) 04402 TRAILBLAZER (TEXAS) 05102 WPS (IOWA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 4 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 05202 WPS (KANSAS) 05302 WPS (MISSOURI WEST) 05392 WPS (MISSOURI EAST) 05402 WPS (NEBRASKA) 07102 PINNACLE (ARKANSAS) 07202 PINNACLE (LOUISIANA) 07302 PINNACLE (MISSISSIPPI) 08102 PINNACLE (INDIANA) 08202 PINNACLE (MICHIGAN) 09102 FIRST COAST (FLORIDA) 09202 FIRST COAST (PUERTO RICO) 09302 FIRST COAST (VIRGIN ISLANDS) 12102 HIGHMARK (DELAWARE) 12202 HIGHMARK (DISTRICT OF COLUMBIA) 12302 HIGHMARK (MARYLAND) 12402 HIGHMARK (NEW JERSEY) 12502 HIGHMARK (PENNSYLVANIA) 13102 NATL GOVT SERVICES (CONNECTICUT) 13202 NATL GOVT SERVICES (NEW YORK (EMPIRE)) 13282 NATL GOVT SERVICES (NEW YORK (HEALTHNOW)) 13292 NATL GOVT SERVICES (NEW YORK (GHI)) 14102 NATIONAL HERITAGE (MAINE) 14202 NATIONAL HERITAGE (MASSACHUSETTS) 14302 NATIONAL HERITAGE (NEW HAMPSHIRE) 14402 NATIONAL HERITAGE (RHODE ISLAND) 14502 NATIONAL HERITAGE (VERMONT) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 5 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 6 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN ADMIN SERVICES (ARIZONA) 03202 NORIDIAN ADMIN SERVICES (MONTANA) 03302 NORIDIAN ADMIN SERVICES (NORTH DAKOTA) 03402 NORIDIAN ADMIN SERVICES (MONTANA) 03502 NORIDIAN ADMIN SERVICES (UTAH) 03602 NORIDIAN ADMIN SERVICES (WYOMING) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 7 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 8 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 9 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 10 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATE REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 3 TERMINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 11 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 RELIGIOUS AFFILIATION 02 PRIVATE 03 OTHER 04 PROPRIETARY 05 GOVERNMENT - STATE/COUNTY 06 GOVERNMENT - COMB. GOVT & VOL. ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD RELATED PROVIDER NUMBER 10 1228 1237 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM FEDERALLY FUNDED HEALTH CENTER 1 1814 1814 C PROV3710 INDICATED WHETHER THIS FQHC IS FEDERALLY FUNDED. COBOL NAME: FED-FUNDED-FFHC VALUES: N NO Y YES FQHC APPROVED RHC PROVIDER # 6 1815 1820 C PROV3705 APPROVED FQHC'S RELATED RHC PROVIDER NUMBER. COBOL NAME: APPROVED-RHC-PROV-NUM FQHC APPROVED RURAL HEALTH CLINIC 1 1821 1821 C PROV3700 INDICATES IF THE FQHC WAS A MEDICARE CERTIFIED RURAL HEALTH CLINIC. COBOL NAME: APPROVED-MEDICARE-RHC VALUES: N NO Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 1 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 CLIA88 LABORATORY CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 22 CLIA88 LABORATORIES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 2 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 NATIONAL GOVERNMENT SERVICES 00180 NATIONAL GOVERNMENT SERVICES 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES 00280 BLUE CROSS (NEW JERSEY) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 3 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00510 BLUE SHIELD (ALABAMA) 00511 CAHABA 00520 BLUE SHIELD (ARKANSAS) 00528 BLUE SHIELD (ARKANSAS/LOUISIANA) 00542 BLUE SHIELD (CALIFORNIA) 00550 BLUE SHIELD (COLORADO) 00570 BLUE SHIELD (DELAWARE) 00580 BLUE SHIELD (DISTRICT OF COLUMBIA) 00590 BLUE SHIELD (FLORIDA) 00621 BLUE SHIELD (ILLINOIS) 00630 NATIONAL GOVERNMENT SERVICES 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 NATIONAL GOVERNMENT SERVICES 00690 BLUE SHIELD (MARYLAND) 00700 BLUE SHIELD (MASSACHUSETTS) 00710 BLUE SHIELD (MICHIGAN) 00720 BLUE SHIELD (MINNESOTA) 00740 BLUE SHIELD (KANSAS CITY) 00770 BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780 BLUE SHIELD (TRI-STATE) 00801 BLUE SHIELD (BUFFALO) 00803 NATIONAL GOVERNMENT SERVICES 00805 NATIONAL GOVERNMENT SERVICES 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 4 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00865 BLUE SHIELD (PENNSYLVANIA) 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00883 PALMETTO 00900 BLUE SHIELD (TEXAS) 00901 TRAILBLAZERS HEALTH ENTERPRISES 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 00973 BLUE SHIELD (PUERTO RICO) 00974 BLUE SHIELD (VIRGIN ISLANDS) 01010 AETNA (PEORIA) 01020 AETNA (ALASKA) 01030 AETNA (ARIZONA) 01040 AETNA (GEORGIA) 01102 PALMETTO (CALIFORNIA NORTH) 01120 AETNA (HAWAII) 01192 PALMETTO (CALIFORNIA SOUTH) 01202 PALMETTO (HAWAII) 01290 AETNA (NEVADA) 01302 PALMETTO (NEVADA) 01360 AETNA (NEW MEXICO) 01370 AETNA (OKLAHOMA) 01380 AETNA (OREGON) 01390 AETNA (WASHINGTON) 02050 OCCIDENTAL (CALIFORNIA) 02102 NATIONAL HERITAGE (ALASKA) 02202 NATIONAL HERITAGE (IDAHO) 02302 NATIONAL HERITAGE (OREGON) 02402 NATIONAL HERITAGE (WASHINGTON) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN (ARIZONA) 03202 NORIDIAN (MONTANA) 03302 NORIDIAN (NORTH DAKOTA) 03402 NORIDIAN (SOUTH DAKOTA) 03502 NORIDIAN (UTAH) 03602 NORIDIAN (WYOMING) 04102 TRAILBLAZER (COLORADO) 04202 TRAILBLAZER (NEW MEXICO) 04302 TRAILBLAZER (OKLAHOMA) 04402 TRAILBLAZER (TEXAS) 05102 WPS (IOWA) 05130 EQICOR (IDAHO) 05202 WPS (KANSAS) 05302 WPS (MISSOURI WEST) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 5 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 05392 WPS (MISSOURI EAST) 05402 WPS (NEBRASKA) 05440 EQICOR (TENNESSEE) 05535 EQICOR (NORTH CAROLINA) 07102 PINNACLE (ARKANSAS) 07202 PINNACLE (LOUISIANA) 07302 PINNACLE (MISSISSIPPI) 08102 PINNACLE (INDIANA) 08202 PINNACLE (MICHIGAN) 09102 FIRST COAST (FLORIDA) 09202 FIRST COAST (PUERTO RICO) 09302 FIRST COAST (VIRGIN ISLANDS) 10071 TRAVELERS (RRB) 10230 TRAVELERS (CONNECTICUT) 10240 TRAVELERS (MINNESOTA) 10250 TRAVELERS (MISSISSIPPI) 10490 TRAVELERS (VIRGINIA) 10492 TRAVELERS - VIRGINIA SPECIAL PROJECT 11260 GENERAL AMERICAN 12102 HIGHMARK (DELAWARE) 12202 HIGHMARK (DISTRICT OF COLUMBIA) 12302 HIGHMARK (MARYLAND) 12402 HIGHMARK (NEW JERSEY) 12502 HIGHMARK (PENNSYLVANIA) 13102 NATL GOVT SERVICES (CONNECTICUT) 13202 NATL GOVT SERVICES (NEW YORK (EMPIRE)) 13282 NATL GOVT SERVICES (NEW YORK (HEALTHNOW)) 13292 NATL GOVT SERVICES (NEW YORK (GHI)) 14102 NATIONAL HERITAGE (MAINE) 14202 NATIONAL HERITAGE (MASSACHUSETTS) 14302 NATIONAL HERITAGE (NEW HAMPSHIRE) 14330 GROUP HEALTH INC (NEW YORK) 14402 NATIONAL HERITAGE (RHODE ISLAND) 14502 NATIONAL HERITAGE (VERMONT) 16360 NATIONWIDE (OHIO) 16510 NATIONWIDE (WEST VIRGINIA) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 21200 MASSACHUSETTS/MAINE 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 6 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 NATIONAL GOVERNMENT SERVICES 00131 NATIONAL GOVERNMENT SERVICES 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00181 NATIONAL GOVERNMENT SERVICES 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NATIONAL GOVERNMENT SERVICES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 7 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 NATIONAL GOVERNMENT SERVICES 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 NATIONAL GOVERNMENT SERVICES 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00366 HIGHMARK MEDICARE SERVICES 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 NATIONAL GOVERNMENT SERVICES 00452 NATIONAL GOVERNMENT SERVICES 00453 NATIONAL GOVERNMENT SERVICES 00454 NATIONAL GOVERNMENT SERVICES 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00510 BLUE SHIELD (ALABAMA) 00511 CAHABA 00520 BLUE SHIELD (ARKANSAS) 00528 BLUE SHIELD (ARKANSAS/LOUISIANA) 00542 BLUE SHIELD (CALIFORNIA) 00550 BLUE SHIELD (COLORADO) 00570 BLUE SHIELD (DELAWARE) 00580 BLUE SHIELD (DISTRICT OF COLUMBIA) 00590 BLUE SHIELD (FLORIDA) 00621 BLUE SHIELD (ILLINOIS) 00630 NATIONAL GOVERNMENT SERVICES 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 NATIONAL GOVERNMENT SERVICES 00690 BLUE SHIELD (MARYLAND) 00700 BLUE SHIELD (MASSACHUSETTS) 00710 BLUE SHIELD (MICHIGAN) 00720 BLUE SHIELD (MINNESOTA) 00740 BLUE SHIELD (KANSAS CITY) 00751 BLUE SHIELD (MONTANA) 00770 BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780 BLUE SHIELD (TRI-STATE) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 8 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00801 BLUE SHIELD (BUFFALO) 00803 NATIONAL GOVERNMENT SERVICES 00805 NATIONAL GOVERNMENT SERVICES 00820 BLUE SHIELD (NORTH DAKOTA) 00825 BLUE SHIELD (NORTH DAKOTA/WYOMING) 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865 BLUE SHIELD (PENNSYLVANIA) 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00883 PALMETTO 00900 BLUE SHIELD (TEXAS) 00901 TRAILBLAZERS HEALTH ENTERPRISES 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 00973 BLUE SHIELD (PUERTO RICO) 00974 BLUE SHIELD (VIRGIN ISLANDS) 01010 AETNA (PEORIA) 01020 AETNA (ALASKA) 01030 AETNA (ARIZONA) 01040 AETNA (GEORGIA) 01120 AETNA (HAWAII) 01290 AETNA (NEVADA) 01360 AETNA (NEW MEXICO) 01370 AETNA (OKLAHOMA) 01380 AETNA (OREGON) 01390 AETNA (WASHINGTON) 02050 OCCIDENTAL (CALIFORNIA) 03001 NORIDIAN ADMIN SERVICES 03102 NORIDIAN ADMIN SERVICES (ARIZONA) 03202 NORIDIAN ADMIN SERVICES (MONTANA) 03302 NORIDIAN ADMIN SERVICES (NORTH DAKOTA) 03402 NORIDIAN ADMIN SERVICES (MONTANA) 03502 NORIDIAN ADMIN SERVICES (UTAH) 03602 NORIDIAN ADMIN SERVICES (WYOMING) 05130 EQICOR (IDAHO) 05440 EQICOR (TENNESSEE) 05535 EQICOR (NORTH CAROLINA) 10071 TRAVELERS (RRB) 10230 TRAVELERS (CONNECTICUT) 10240 TRAVELERS (MINNESOTA) 10250 TRAVELERS (MISSISSIPPI) 10490 TRAVELERS (VIRGINIA) 10492 TRAVELERS - VIRGINIA SPECIAL PROJECT 11260 GENERAL AMERICAN * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 9 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 14330 GROUP HEALTH INC (NEW YORK) 16360 NATIONWIDE (OHIO) 16510 NATIONWIDE (WEST VIRGINIA) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 21200 MASSACHUSETTS/MAINE 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 31146 NATIONAL HERTAGE INSURANCE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED D DELETED N NOT-A-LAB P PENDING T TEMPORARY (CLIA ONLY) W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 10 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA FN FOREIGN GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 11 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 12 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN 99 FOREIGN STATE REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 13 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG 08 NONPAYMENT OF FEES 09 REV/UNSUCCESSFUL PARTICIPATION IN PT 10 REV/OTHER REASON 11 INCOMPLETE CLIA APPLICATION INFORMATION 12 NO LONGER PERFORMING TESTS 13 MULTIPLE TO SINGLE SITE CERTIFICATE 14 SHARED LABORATORY 15 FAILURE TO RENEW WAIVER PPMP CERTIFICATE 16 DUPLICATE CLIA NUMBER 17 UNDELIVERABLE 20 NOTIFICATION BANKRUPTCY 33 LAB NOT AFFILIATED WITH ACCRED ORGANIZATION 80 AWAITING STATE APPROVAL 99 OIG ACTION - DO NOT ACTIVATE TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP 5 CLIA VALIDATION 6 ONSITE SURVEY DUE TO FLEXIBLE SURVEY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 14 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 RELIGIOUS AFFILIATION 02 PRIVATE 03 OTHER 04 PROPRIETARY 05 GOVERNMENT - CITY 06 GOVERNMENT - COUNTY 07 GOVERNMENT - STATE 08 GOVERNMENT - FEDERAL 09 GOVERNMENT - OTHER 10 UNKNOWN ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD DATE OF LAST VALIDATION SURVEY 8 363 370 C PROV0450 DATE THE LAST VALIDATION SURVEY WAS PERFORMED BY THE STATE AGENCY FOR A JCAH, AOA ACCREDITED HOSPITAL OR OTHER PROVIDER TYPE. COBOL NAME: DT-VALID-SURVEY FISCAL YEAR ENDING DATE 4 378 381 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT TYPE OF FACILITY 2 593 594 C PROV2890 INDICATES THE CATEGORY WHICH REPRESENTS THE TYPE OF FACILITY. COBOL NAME: TYPE-FACILITY VALUES: 01 AMBULANCE 02 AMBULATORY SURGERY CENTER 03 ANCILLARY TEST SITE 04 ASSISTED LIVING FACILITY 05 BLOOD BANKS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 15 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 06 COMMUNITY CLINIC 07 COMPREHENSIVE OUTPATIENT REHAB 08 END STAGE RENAL DISEASE DIALYSIS 09 FEDERALLY QUALIFIED HEALTH CENTER 10 HEALTH FAIR 11 HEALTH MAINTENANCE ORGANIZATION 12 HOME HEALTH AGENCY 13 HOSPICE 14 HOSPITAL 15 INDEPENDENT 16 INDUSTRIAL 17 INSURANCE 18 ICF FOR MENTALLY RETARDED 19 MOBILE LAB 20 PHARMACY 21 PHYSICIAN OFFICE 22 OTHER PRACTITIONER 23 PRISON 24 PUBLIC HEALTH LABORATORY 25 RURAL HEALTH CLINIC 26 SCHOOL/STUDENT HEALTH SERVICE 27 SKILLED NURSING/NURSING FACILITY 28 TISSUE BANK/REPOSITORIES 29 OTHER ACCREDITED BY AABB 1 1822 1822 C PROV4205 INDICATES IF THE LAB IS ACCREDITED THE AMERICAN ASSOCIATION OF BLOOD BANKS. THIS INFORMATION IS FROM THE LABORATORY'S HCFA-116. COBOL NAME: ACCRED-AABB-IND VALUES: X YES ACCREDITED BY AOA 1 1823 1823 C PROV4200 INDICATES IF THE LAB IS ACCREDITED BY THE AMERICAN OSTEOPATHIC ASSOCIATION. THIS INFORMATION IS FROM THE LABORATORY'S HCFA-116. COBOL NAME: ACCRED-AOA-IND VALUES: X YES ACCREDITED BY ASHI 1 1824 1824 C PROV4225 INDICATES IF THE LAB IS ACCREDITED BY THE AMERICAN SOCIETY FOR HISTOCOMPATIBILITY AND IMMUNOGENETICS. THIS INFORMATION IS FROM THE LABORATORY'S HCFA-116. COBOL NAME: ACCRED-ASHI-IND VALUES: X YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 16 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ACCREDITED BY A2LA 1 1825 1825 C PROV6535 INDICATES IF THE LAB IS ACCREDITED THE AMERICAN ASSOCIATION OF LAB ACCRED. THIS INFORMATION IS FROM THE LABORATORY'S CMS-116. COBOL NAME: ACCRED-A2LA-IND VALUES: X YES ACCREDITED BY CAP 1 1826 1826 C PROV4210 INDICATES IF THE LAB IS ACCREDITED BY THE COLLEGE OF AMERICAN PATHOLOGISTS. THIS INFORMATION IS FROM THE LABORATORY'S HCFA-116. COBOL NAME: ACCRED-CAP-IND VALUES: X YES ACCREDITED BY COLA 1 1827 1827 C PROV4215 INDICATES IF THE LAB IS ACCREDITED BY THE COMMISSION ON OFFICE LABORATORY ACCREDITATION. THIS INFORMATION IS FROM THE LABORATORY'S HCFA-116. COBOL NAME: ACCRED-COLA-IND VALUES: X YES ACCREDITED BY JCAHO 1 1828 1828 C PROV4195 INDICATES IF THE LAB IS ACCREDITED BY THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATION. THIS INFORMATION IS FROM THE LABORATORY'S HCFA-116. COBOL NAME: ACCRED-JCAHO-IND VALUES: X YES ACCREDITED Y MATCH DATE AABB 8 1829 1836 C PROV5040 THE DATE THE AMERICAN ASSOCIATION OF BLOOD BANKS NOTIFIES HCFA THAT LAB IS ACCREDITED WITH AABB. THE EARLIEST Y MATCH DATE INITIATES THE BILLING OF THE CERTIFICATE OF ACCREDITATION FEES. COBOL NAME: ACCRED-AABB-DT ACCREDITED Y MATCH DATE AOA 8 1837 1844 C PROV5045 THE DATE THE LAB WAS ACCREDITED BY THE AMERICAN OSTEOPATHIC ASSOCIATION. THIS INFORMATION IS SUPPLIED BY THE ACCREDITING ORGANIZATION. COBOL NAME: ACCRED-AOA-DT ACCREDITED Y MATCH DATE ASHI 8 1845 1852 C PROV5055 THE DATE THE LAB WAS ACCREDITED BY THE AMERICAN SOCIETY FOR HISTOCOMPATIBILITY AND IMMUNOGENETICS. THIS INFORMATION IS SUPPLIED BY THE ACCREDITING ORGANIZATION COBOL NAME: ACCRED-ASHI-DT ACCREDITED Y MATCH DATE A2LA 8 1853 1860 C PROV6530 THE DATE THE AMERICAN ASSOCIATION OF LABORATORY ACCRED. NOTIFIES CMS THAT LAB IS ACCREDITED WITH A2LA. THE EARLIEST Y MATCH DATE INITIATES THE BILLING OF THE CERTIFICATE OF ACCREDITATION FEES. COBOL NAME: ACCRED-A2LA-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 17 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ACCREDITED Y MATCH DATE CAP 8 1861 1868 C PROV5060 THE DATE THE COLLEGE OF AMERICAN PATHOLOGIST NOTIFIES HCFA THAT LAB IS ACCREDITED BY CAP. THE EARLIEST Y MATCH DATE INITIATES THE BILLING FOR THE CERTIFICATE OF ACCREDITATION FEES. COBOL NAME: ACCRED-CAP-DT ACCREDITED Y MATCH DATE COLA 8 1869 1876 C PROV5065 THE DATE THE COMMISSION ON OFFICE LABORATORY ACCREDITATION NOTIFIES HCFA THAT LAB IS ACCREDITED WITH COLA. THE EARLIEST Y MATCH DATE INITIATES THE BILLING OF THE CERTIFICATE OF ACCREDITATION FEES COBOL NAME: ACCRED-COLA-DT ACCREDITED Y MATCH DATE JCAHO 8 1877 1884 C PROV5070 THE DATE THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS NOTIFIES HCFA THAT LAB IS ACCREDITED. THE EARLIEST Y MATCH DATE INITIATES THE BILLING OF THE CERTIFICATE OF ACCREDITATION FEES COBOL NAME: ACCRED-JCAHO-DT ACCREDITED Y MATCH IND AABB 1 1885 1885 C PROV4970 INDICATES IF THE LAB IS ACCREDITED BY THE AMERICAN ASSOCIATION OF BLOOD BANKS. THIS INFORMATION IS SUPPLIED BY THE ACCREDITING ORGANIZATION. COBOL NAME: ACCRED-AABB-MATCH-IND VALUES: Y YES ACCREDITED Y MATCH IND AOA 1 1886 1886 C PROV4975 INDICATES IF THE LAB IS ACCREDITED BY THE AMERICAN OSTEOPATHIC ASSOCIATION. THIS INFORMATION IS SUPPLIED BY THE ACCREDITING ORGANIZATION. COBOL NAME: ACCRED-AOA-MATCH-IND VALUES: Y YES ACCREDITED Y MATCH IND ASHI 1 1887 1887 C PROV4985 INDICATES IF THE LAB IS ACCREDITED BY THE AMERICAN SOCIETY FOR HISTOCOMPATIBILITY AND IMMUNOGENETICS. THIS INFORMATION IS SUPPLIED BY THE ACCREDITING ORGANIZATION. COBOL NAME: ACCRED-ASHI-MATCH-IND VALUES: Y YES ACCREDITED Y MATCH IND A2LA 1 1888 1888 C PROV6540 INDICATES IF THE LAB IS ACCREDITED BY THE AMERICAN ASSOCIATION OF LAB ACCRED. THIS INFORMATION IS SUPPLIED BY THE ACCREDITING ORGANIZATION. COBOL NAME: ACCRED-A2LA-MATCH-IND VALUES: Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 18 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ACCREDITED Y MATCH IND CAP 1 1889 1889 C PROV4990 INDICATES IF THE LAB IS ACCREDITED BY COLLEGE OF AMERICAN PATHOLOGISTS. THIS INFORMATION IS SUPPLIED BY THE ACCREDITING ORGANIZATION. COBOL NAME: ACCRED-CAP-MATCH-IND VALUES: Y YES ACCREDITED Y MATCH IND COLA 1 1890 1890 C PROV4960 INDICATES IF THE LAB IS ACCREDITED BY THE COMMISSION ON OFFICE LABORATORY ACCREDITATION. THIS INFORMATION IS SUPPLIED BY THE ACCREDITING ORGANIZATION. COBOL NAME: ACCRED-COLA-MATCH-IND VALUES: Y YES ACCREDITED Y MATCH IND JCAHO 1 1891 1891 C PROV4995 INDICATES IF LAB IS ACCREDITED BY THE JOINT COMMISSION ON ACCREDITAION OF HEALTHCARE ORGANIZATIONS. THIS INFORMATION IS SUPPLIED BY THE ACCREDITING ORGANIZATION. COBOL NAME: ACCRED-JCAHO-MATCH-IND VALUES: Y YES AFFILIATED PROVIDER #1 10 1892 1901 C PROV4240 AFFILIATED PROVIDER #1 COBOL NAME: AFFIL-PROV-NUM-1 AFFILIATED PROVIDER #2 10 1902 1911 C PROV4245 AFFILIATED PROVIDER #2 COBOL NAME: AFFIL-PROV-NUM-2 AFFILIATED PROVIDER #3 10 1912 1921 C PROV4250 AFFILIATED PROVIDER #3 COBOL NAME: AFFIL-PROV-NUM-3 AFFILIATED PROVIDER #4 10 1922 1931 C PROV4255 AFFILIATED PROVIDER #4 COBOL NAME: AFFIL-PROV-NUM-4 AFFILIATED PROVIDER #5 10 1932 1941 C PROV4260 AFFILIATED PROVIDER #5 COBOL NAME: AFFIL-PROV-NUM-5 AFFILIATED PROVIDER #6 10 1942 1951 C PROV4265 AFFILIATED PROVIDER #6 COBOL NAME: AFFIL-PROV-NUM-6 AFFILIATED PROVIDER #7 10 1952 1961 C PROV4270 AFFILIATED PROVIDER #7 COBOL NAME: AFFIL-PROV-NUM-7 AFFILIATED PROVIDER #8 10 1962 1971 C PROV4275 AFFILIATED PROVIDER #8 COBOL NAME: AFFIL-PROV-NUM-8 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 19 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME APPLICATION ACCRED ANNUAL TEST VOL 13 1972 1984 N PROV4390 ACCREDITED ANNUAL TEST VOLUME. THIS FIELD IS CALCULATED USING THE CLIA APPLICATION DATA. COBOL NAME: APPL-ACCR-ANN-TEST-VOL APPLICATION ACCRED SCHEDULE CODE 1 1985 1985 C PROV4365 ACCREDITATION SCHEDULE CODE. THIS SCHEDULE IS FIGURED USING THE CLIA APPLICATION DATA. COBOL NAME: APPL-ACCRED-SCHED-CD VALUES: A SPEC COUNT < 4 (2,001 TO 10,000 TOT. VOL.) B SPEC COUNT > 3 (2,001 T0 10,000 TOT. VOL.) C SPEC COUNT < 4 (10,001 TO 25,000 TOT. VOL.) D SPEC COUNT > 3 (10,001 TO 25,000 TOT. VOL.) E SPEC COUNT > 0 (25,001 TO 50,000 TOT. VOL.) F SPEC COUNT > 0 (50,001 TO 75,000 TOT. VOL.) G SPEC COUNT > 0 (75,001 TO 100,000 TOT. VOL.) H SPEC COUNT > 0 (100,001 TO 500,000 TOT. VOL.) I SPEC COUNT > 0 (500,001 TO 1,000,000 TOT VOL) J SPEC COUNT > 0 (1,000,001 OR MORE TOT. VOL.) V TOTAL VOLUME: 1 TO 2,000 APPLICATION RECEIVED DATE 8 1986 1993 C PROV4340 APPLICATION RECEIVED DATE. THE DATE THE APPLICATION WAS ADDED OR THE 109 DATA WAS UPDATED WITH APPLICATION DATA COBOL NAME: APPL-RECEIVED-DT APPLICATION TOTAL ANNUAL TEST VOL 13 1994 2006 N PROV4325 APPLICATION TOTAL ANNUAL TEST VOLUME. THIS FIELD IS CALCULATED USING CLIA APPLICATION DATA. COBOL NAME: APPL-TOT-ANN-TEST-VOL APPLICATION TYPE 1 2007 2007 C PROV4695 THE TYPE OF CLIA CERTIFICATE APPLIED FOR BY A LAB COBOL NAME: TYPE-APPLICATION VALUES: 1 COMP 2 WAIV 3 ACCR 4 PPMP CERT TYPE CODE # 1 1 2008 2008 C PROV3810 A CODE THAT IDENTIFIES THE TYPE OF LABORATORY CERTIFICATE CURRENTLY IN EFFECT COBOL NAME: CERT-TYPE-CD-1 VALUES: 1 COMPLIANCE 2 WAIVER 3 ACCREDITATION 4 MICROSCOPY 5 PARTIAL ACC 9 REGISTRATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 20 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CERTIFICATE MAILED DATE 1 8 2009 2016 C PROV4700 CERTIFICATE MAILED DATE 1 COBOL NAME: CERT-MAILED-DT-1 CLIA CERT. EFFECTIVE DATE # 1 8 2017 2024 C PROV3860 DATE THE CURRENT LABORATORY CERTIFICATE IS EFFECTIVE, DETERMINED BY THE APPROVAL DATE OF THE CERTIFICATE APPLICATION UNLESS OVERRIDDEN. COBOL NAME: EFF-DT-1 CLIA MEDICARE NUMBER 12 2025 2036 C PROV4885 CLIA MEDICARE NUMBER COBOL NAME: CLIA-MEDICARE-NUM CURRENT LABORATORY CLASSSIFICATION 2 2037 2038 C PROV5935 CLIA LABORATORY CLASSIFICATION DETERMINES IF LAB IS CLIA EXEMPT, VA LABORATORY OR STANDARD LABORATORY COBOL NAME: CLIA-LAB-CLASS-CD VALUES: 00 CLIA LABORATORY 05 CLIA EXEMPT 10 VA LABORATORY FAX PHONE NUMBER 10 2039 2048 C PROV5800 THE 10 DIGIT FAX PHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF THE LABORATORY OR HOSPITAL COBOL NAME: FAX-NUM LABORATORY CLASSIFICATION 1 2 2049 2050 C PROV5945 CLIA LABORATORY CLASSIFICATION DETERMINES IF LAB IS CLIA EXEMPT, VA LABORATORY OR STANDARD LABORATORY COBOL NAME: CLIA-LAB-CLASS-CD-1 VALUES: 00 NON EXEMPT LAB 05 EXEMPT LAB 10 VA LAB LABORATORY CLASSIFICATION 10 2 2051 2052 C PROV5940 CLIA LABORTORY CLASSIFICATION DETERMINES IF LAB IS CLIA EXEMPT, VA LABORATORY OR STANDARD LABORATORY COBOL NAME: CLIA-LAB-CLASS-CD-10 VALUES: 00 CLIA LABORATORY 05 CLIA EXEMPT 10 VA LABORATORY LABORATORY CLASSIFICATION 2 2 2053 2054 C PROV5955 CLIA LABORATORY CLASSIFICATION DETERMINES IF LAB IS CLIA EXEMPT, VA LABORATORY OR STANDARD LABORATORY COBOL NAME: CLIA-LAB-CLASS-CD-2 VALUES: 00 CLIA LABORATORY 05 CLIA EXEMPT 10 VA LABORATORY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 21 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME LABORATORY CLASSIFICATION 3 2 2055 2056 C PROV5965 CLIA LABORATORY CLASSIFICATION DETERMINES IF LAB IS CLIA EXEMPT, VA LABORATORY OR STANDARD LABORATORY COBOL NAME: CLIA-LAB-CLASS-CD-3 VALUES: 00 CLIA LABORATORY 05 CLIA EXEMPT 10 VA LABORATORY LABORATORY CLASSIFICATION 4 2 2057 2058 C PROV5990 CLIA LABORATORY CLASSIFICATION DETERMINES IF LAB IS CLIA EXEMPT, VA LABORATORY OR STANDARD LABORATORY COBOL NAME: CLIA-LAB-CLASS-CD-4 VALUES: 00 CLIA LABORATORY 05 CLIA EXEMPT 10 VA LABORATORY LABORATORY CLASSIFICATION 5 2 2059 2060 C PROV5985 CLIA LABORATORY CLASSIFICATION DETERMINES IF LAB IS CLIA EXEMPT, VA LABORATORY OR STANDARD LABORATARY COBOL NAME: CLIA-LAB-CLASS-CD-5 VALUES: 00 CLIA LABORATORY 05 CLIA EXEMPT 10 VA LABORATORY LABORATORY CLASSIFICATION 6 2 2061 2062 C PROV5975 CLIA LABORATORY CLASSIFICATION DETERMINES IF LAB IS CLIA EXEMPT, VA LABORATORY OR STANDARD LABORATORY COBOL NAME: CLIA-LAB-CLASS-CD-6 VALUES: 00 CLIA LABORATORY 05 CLIA EXEMPT 10 VA LABORATORY LABORATORY CLASSIFICATION 7 2 2063 2064 C PROV5970 CLIA LABORATORY CLASSIFICATION DETERMINES IF LAB IS CLIA EXEMPT, VA LABORATORY OR STANDARD LABORATORY COBOL NAME: CLIA-LAB-CLASS-CD-7 VALUES: 00 CLIA LABORATORY 05 CLIA EXEMPT 10 VA LABORATORY LABORATORY CLASSIFICATION 8 2 2065 2066 C PROV5960 CLIA LABORATORY CLASSIFICATION DETERMINES IS LAB IS CLIA EXEMPT, VA LABORATORY OR STANDARD LABORATORY COBOL NAME: CLIA-LAB-CLASS-CD-8 VALUES: 00 CLIA LABORATORY 05 CLIA EXEMPT 10 VA LABORATORY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 22 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME LABORATORY CLASSIFICATION 9 2 2067 2068 C PROV5950 CLIA LABORATORY CLASSIFICATION DETERMINES IF LAB IS CLIA EXEMPT, VA LABORATORY OR STANDARD LABORATORY COBOL NAME: CLIA-LAB-CLASS-CD-9 VALUES: 00 CLIA LABORATORY 05 CLIA EXEMPT 10 VA LABORATORY MULTIPLE SITE CERTIFICATE IND 1 2069 2069 C PROV4175 INDICATES IF A LAB HAS APPLIED FOR ONE CERTIFICATE FOR MULTIPLE SITES. COBOL NAME: MULTI-SITE-IND VALUES: N NO Y YES NON-PROFIT CODE 1 2070 2070 C PROV4190 ONE TYPE OF MULTIPLE SITE EXCEPTION (MORE THAN ONE SITE UNDER ONE CERTIFICATE) AS DESCRIBED IN CLIA REQUIREMENTS 42 CFR 493. COBOL NAME: NON-PROFIT-IND VALUES: N NO Y YES NUMBER OF LAB SITES 4 2071 2074 N PROV4180 THE TOTAL NUMBER OF LAB SITES FOR WHICH A LAB HAS APPLIED FOR A SINGLE CERTIFICATE. COBOL NAME: TOT-NUM-SITES NUMBER OF LABS DIRECTLY AFFILIATED 1 2075 2075 N PROV4235 NUMBER OF LABORATORIES DIRECTLY AFFILIATED COBOL NAME: NUM-AFFIL-LABS PENDING LABORATORY CLASSIFICATION 2 2076 2077 C PROV5980 CLIA LABORATORY CLASSIFICATION DETERMINES IF LAB IS CLIA EXEMPT, VA LABORATORY OR STANDARD LABORATORY COBOL NAME: PEND-CLIA-LAB-CLASS-CD PREVIOUSLY REGULATED INDICATOR 1 2078 2078 C PROV3610 INDICATES IF THE LABORATORY WAS LICENSED UNDER CLIA 67 OR PARTICPATED IN THE MEDICARE/MEDICAID PROGRAMS. COBOL NAME: CLIA67-IND VALUES: N NO Y YES SHARED LAB CROSS REFERENCE # 10 2079 2088 C PROV4890 SHARED LAB CROSS REFERENCE # COBOL NAME: SHARED-LAB-XREF-NUM SHARED LAB INDICATOR 1 2089 2089 C PROV4880 SHARED LAB INDICATOR COBOL NAME: SHARED-LAB-IND VALUES: N NO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 23 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME Y YES SURVEY CERTIFICATE SCHEDULE CODE 1 2090 2090 C PROV4470 1557 CERTIFICATE SCHEDULE CODE. THIS CODE IS SYSTEM GENERATED AND IS BASED ON THE TEST VOLUME AND SPECIAL TIES ENTERED INTO ODIE FOLLOWING THE SURVEY. CLIA FEES ARE BASED ON THE SCHEDULE CODES. COBOL NAME: SURV-CERT-SCHED-CD VALUES: A SPEC COUNT < 4 (2,001 TO 10,000 TOT. VOL.) B SPEC COUNT > 3 (2,001 T0 10,000 TOT. VOL.) C SPEC COUNT < 4 (10,001 TO 25,000 TOT. VOL.) D SPEC COUNT > 3 (10,001 TO 25,000 TOT. VOL.) E SPEC COUNT > 0 (25,001 TO 50,000 TOT. VOL.) F SPEC COUNT > 0 (50,001 TO 75,000 TOT. VOL.) G SPEC COUNT > 0 (75,001 TO 100,000 TOT. VOL.) H SPEC COUNT > 0 (100,001 TO 500,000 TOT. VOL.) I SPEC COUNT > 0 (500,001 TO 1,000,000 TOT VOL) J SPEC COUNT > 0 (1,000,001 OR MORE TOT. VOL.) V TOTAL VOLUME: 1 TO 2,000 SURVEY COMPLIANCE SCHEDULE CODE 1 2091 2091 C PROV4475 1557 COMPLIANCE SCHEDULE CODE THIS CODE IS SYSTEM GENERATED AND IS BASED ON THE NUMBER OF TESTS AND SPECIALTIES ENTERED INTO ODIE FOLLOWING THE SURVEY. CLIA FEES ARE BASED ON THE SCHEDULE CODES. COBOL NAME: SURV-COMPL-SCHED-CD VALUES: A SPEC COUNT < 4 (2,001 TO 10,000 TOT. VOL.) B SPEC COUNT > 3 (2,001 T0 10,000 TOT. VOL.) C SPEC COUNT < 4 (10,001 TO 25,000 TOT. VOL.) D SPEC COUNT > 3 (10,001 TO 25,000 TOT. VOL.) E SPEC COUNT > 0 (25,001 TO 50,000 TOT. VOL.) F SPEC COUNT > 0 (50,001 TO 75,000 TOT. VOL.) G SPEC COUNT > 0 (75,001 TO 100,000 TOT. VOL.) H SPEC COUNT > 0 (100,001 TO 500,000 TOT. VOL.) I SPEC COUNT > 0 (500,001 TO 1,000,000 TOT VOL) J SPEC COUNT > 0 (1,000,001 OR MORE TOT. VOL.) V TOTAL VOLUME: 1 TO 2,000 SURVEY TEST VOLUME TOTAL 13 2092 2104 N PROV4460 SURVEY TEST VOLUME TOTAL. THE NUMBER OF TESTS PERFORMED ANNUALLY IN A LABORATORY. THIS INFORMATION IS COLLECTED AT THE TIME OF THE STATE SURVEY AGENCY INSPECTION. COBOL NAME: SURV-TOT-ANN-TEST-VOL TERMINATION CODE 2 2105 2106 C PROV5805 THE REASON A LABORATORY'S CLIA CERTIFICATE HAS ENDED COBOL NAME: TERM-CD VALUES: 00 ACTIVE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009 1DATE: 01/01/2010 POS RECORD LAYOUT PAGE: 24 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG 08 NONPAYMENT OF FEES 09 REV/UNSUCCESSFUL PARTICIPATION IN PT 10 REV/OTHER REASON 11 INCOMPLETE CLIA APPLICATION INFORMATION 12 NO LONGER PERFORMING TESTS 13 MULTIPLE TO SINGLE SITE CERTIFICATE 14 SHARED LABORATORY 15 FAILURE TO RENEW WAIVER PPMP CERTIFICATE 16 DUPLICATE CLIA NUMBER 17 UNDELIVERABLE 20 NOTIFICATION BANKRUPTCY 33 LAB NOT AFFILIATED WITH ACCRED ORGANIZATION 80 AWAITING STATE APPROVAL 99 OIG ACTION - DO NOT ACTIVATE TOTAL PPM TEST VOLUMES 13 2107 2119 N PROV6430 NUMBER OF ESTIMATED ANNUAL TEST VOLUME FOR ALL PROVIDER PERFORMED MICROSCOPY TESTS PERFORMED IN A LAB. TEST VOLUME MAY BE PRESENT FOR LABS HOLDING PPM, COMPLIANCE AND ACCREDITATION CERTIFICATES. COBOL NAME: TOT-ANN-TEST-VOL-PPM TOTAL WAIVED TEST VOL 13 2120 2132 N PROV4280 THE NUMBER OF ESTIMATED TOTAL ANNUAL TEST VOLUME FOR ALL WAIVED TESTS PERFORMED IN A LAB HOLDING A CERTIFI- CATE OF WAIVER, PPM, COMPLIANCE OR ACCREDITATION. COBOL NAME: TOT-ANN-TEST-VOL-WAIVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/03/2009