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 = 01/02/95 * * * ********************************************* 1DATE: 01/02/95 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 CHRISTIAN SCIENCE 04 PSYCHIATRIC 05 REHABILITATION 06 CHILDRENS' 07 ALCOHOL/DRUG 08 PPS EXEMPT REHABILITATION 09 PPS EXEMPT PSYCHIATRIC 10 PPS EXEMPT ALCOHOL/DRUG 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 2 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COUNTY CODE 3 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 CURRENT SURVEY DATE 6 62 67 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 68 68 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 38 69 106 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 5 107 111 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) 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 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 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: 10/04/94 1DATE: 01/02/95 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) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 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 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 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) PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 129 138 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 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 140 141 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 1 142 142 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 2 143 144 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 145 146 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 206 206 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 (ACCRED HOSPITAL) TYPE OF CONTROL 2 207 208 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 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE ACCREDITATION EFFECTIVE DATE 6 223 228 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 9 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ACCREDITATION EXPIRATION DATE 6 229 234 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 ACCREDITATION INDICATOR 1 235 235 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 ALCOHOL/DRUG UNIT BEDS 3 236 238 N PROV0040 THE NUMBER OF BEDS IN A PPS EXEMPT ALCOHOL/DRUG UNIT OF A HOSPITAL. COBOL NAME: ALCOH-DRG-UNIT-BED-SZ ALCOHOL/DRUG UNIT EFFECTIVE DATE 6 239 244 C PROV0045 THE DATE AN ALCOHOL/DRUG UNIT BECAME EXEMPT FROM THE PROSPECTIVE PAYMENT SYSTEM (PPS). COBOL NAME: ALCOH-DRG-UNIT-EFF-DT ALCOHOL/DRUG UNIT INDICATOR 1 245 245 C PROV0050 INDICATES IF A HOSPITAL HAS A PPS EXEMPT ALCOHOL/DRUG UNIT. COBOL NAME: ALCOH-DRG-UNIT-IND VALUES: Y ALC/DRG UNIT ALCOHOL/DRUG UNIT TERMINATION CODE 1 246 246 C PROV0055 INDICATES THE REASON THAT AN ALCOHOL/DRUG UNIT IS NO LONGER EXEMPT FROM THE PROSPECTIVE PAYMENT SYSTEM. COBOL NAME: ALCOH-DRG-UNIT-TERM-CD VALUES: 0 ACTIVE 1 VOLUNTARY-MERGER OR CLOSURE 2 VOLUNTARY-DISSATISFACTION WITH REIMBURSEMENT 3 RISK OF INVOLUNTARY TERMINATION 4 VOLUNTARY-OTHER 5 FAILURE TO MEET HEALTH/SAFETY 6 FAILURE TO MEET AGREEMENT ALCOHOL/DRUG UNIT TERMINATION DATE 6 247 252 C PROV0060 THE DATE AN ALCOHOL/DRUG UNIT'S EXEMPTION FROM THE PROSPECTIVE PAYMENT SYSTEM IS TERMINATED. COBOL NAME: ALCOH-DRG-UNIT-TERM-DT BEDS - TOTAL 5 253 257 N PROV0740 TOTAL NUMBER OF BEDS IN A FACILITY, INCLUDING THOSE IN NON-PARTICIPATING OR NON-LICENSED AREAS. COBOL NAME: NUM-BEDS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 10 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME BEDS - TOTAL CERTIFIED 5 258 262 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS CERTIFIED RN ANESTHETISTS 7.2 263 269 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 10 270 279 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 10 280 289 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 10 290 299 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 10 300 309 C PROV0145 NUMBER ASSIGNED TO A HOSPITAL LABORATORY LICENSED IN ACCORDANCE WITH THE CLINICAL LABORATORY IMPROVEMENT ACT (CLIA). COBOL NAME: CLIA-ID-NUM-D CLIA - HOSP LAB ID #5 10 310 319 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 1 320 320 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 1 321 321 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 11 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COMPLIANCE: TECHNICAL PERSONNEL 1 322 322 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 1 323 323 C PROV0290 INDICATES IF A WAIVER OF THE 24 HOUR REGISTERED NURSE REQUIREMENT HAS BEEN RECOMMENDED FOR A HOSPITAL. COBOL NAME: COMPL-24-HR-RN VALUES: 1 WAIVER RECOMMENDED CURRENT SURVEY EVER ACCREDITED 1 324 324 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 1 325 325 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 1 326 326 C PROV3550 INDICATES IF THIS PROVIDER WAS A SWINGBED HOSPITAL ANYTIME DURING THE CURRENT SURVEY. COBOL NAME: CURRENT-EVER-SWINGBED VALUES: N NO Y YES DATE OF VALIDATION SURVEY 6 327 332 C PROV0450 DATE A VALIDATION SURVEY IS PERFORMED BY THE STATE AGENCY IN A JCAH OR AOA ACCREDITED HOSPITAL. COBOL NAME: DT-VALID-SURVEY DIETITIANS 7.2 333 339 N PROV0820 NUMBER OF FULL-TIME EQUIVALENT DIETITIANS EMPLOYED BY A FACILITY. COBOL NAME: NUM-DIETICIANS FISCAL YEAR ENDING DATE 4 340 343 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 12 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME INHALATION THERAPISTS 7.2 344 350 N PROV0950 NUMBER OF FULLTIME EQUIVALENT INHALATION THERAPISTS EMPLOYED BY A HOSPITAL. COBOL NAME: NUM-INHAL-THERAPY LICENSED PRACTICAL NURSES 7.2 351 357 N PROV0955 NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL OR VOCATIONAL NURSES EMPLOYED BY A FACILITY. COBOL NAME: NUM-LPN-LVN MEDICAL SCHOOL AFFILIATION 1 358 358 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 MEDICARE OR MEDICAID VENDOR NUMBER 12 359 370 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 MEETS 1861 DEFINITION 1 371 371 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) OCCUPATIONAL THERAPISTS 7.2 372 378 N PROV1050 THE NUMBER OF FULL TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-OCCUP-THERAPISTS OTHER PERSONNEL 7.2 379 385 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL PARTICIPATING CODE (Y,N) 1 386 386 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 7.2 387 393 N PROV1125 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS-THERAPY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 13 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PHYSICIAN ASSISTANTS 7.2 394 400 N PROV1115 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIAN ASSISTANTS EMPLOYED BY A HOSPITAL OR RURAL HEALTH CLINIC. COBOL NAME: NUM-PHYS-ASSIST PPS PREVIOUS PROVIDER NUMBER 6 401 406 C PROV1520 A PROVIDER NUMBER PREVIOUSLY ASSIGNED TO A PPS EXEMPT PROVIDER OR UNIT. COBOL NAME: OLD-PROV-NUM PROGRAM PARTICIPATION 1 407 407 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 3 408 410 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 6 411 416 C PROV1695 THE DATE A PSYCHIATRIC UNIT BECAME EXEMPT FROM THE PROSPECTIVE PAYMENT SYSTEM (PPS). COBOL NAME: PSY-UNIT-EFF-DT PSYCHIATRIC UNIT INDICATOR 1 417 417 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 1 418 418 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 4 VOLUNTARY-OTHER 5 FAILURE TO MEET HEALTH/SAFETY 6 FAILURE TO MEET AGREEMENT 7 PROVIDER STATUS CHANGE PSYCHIATRIC UNIT TERMINATION DATE 6 419 424 C PROV1710 THE DATE A PSYCHIATRIC UNIT IS NO LONGER EXEMPT FROM THE PROSPECTIVE PAYMENT SYSTEM. COBOL NAME: PSY-UNIT-TERM-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 14 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME REGIONAL OVERRIDE #1 (NUMBER BEDS) 1 425 425 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) 1 426 426 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) 1 427 427 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 7.2 428 434 N PROV1145 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PROFESSIONAL NURSES EMPLOYED BY A PROVIDER. COBOL NAME: NUM-REG-NURS REGISTERED PHARMACISTS 7.2 435 441 N PROV1100 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PHARMACISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHARMACIST-REG REHABILITATION UNIT BEDS 3 442 444 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 6 445 450 C PROV1735 THE DATE A REHABILITATION UNIT BECAME EXEMPT FROM THE PROSPECTIVE PAYMENT SYSTEM. COBOL NAME: REHAB-UNIT-EFF-DT REHABILITATION UNIT INDICATOR 1 451 451 C PROV1740 INDICATES IF A HOSPITAL HAS A PPS EXEMPT REHABILITATION UNIT. COBOL NAME: REHAB-UNIT-IND VALUES: Y REHAB UNIT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 15 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME REHABILITATION UNIT TERMINAT CODE 1 452 452 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 6 453 458 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 RELATED PROVIDER NUMBER 10 459 468 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 RESIDENT PROGRAM APPROVED BY ADA 1 469 469 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 1 470 470 C PROV1810 INDICATES IF THE RESIDENT PROGRAM AT A HOSPITAL IS APPROVED BY THE AMERICAN MEDICAL ASSOCIATION. COBOL NAME: RES-PGM-APPR-AMA VALUES: N NOT APPROVED Y APPROVED RESIDENT PROGRAM APPROVED BY AOA 1 471 471 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 16 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RESIDENT PROGRAM APPROVED BY OTHER 1 472 472 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) 7.2 473 479 N PROV1165 THE NUMBER OF FULL-TIME EQUIVALENT RESIDENTS (PHYSICIANS) EMPLOYED BY A HOSPITAL. COBOL NAME: NUM-RESID-PHYS SEPARATE COST ENTITY INDICATOR 1 480 480 C PROV2040 INDICATES IF A HOSPITAL HAS A UNIT IDENTIFIED AS A SEPARATE COST ENTITY. COBOL NAME: SEP-COST-ENTITY-IND VALUES: Y SEPARATE COST ENTITY SRV: ACUTE RENAL DIALYSIS 1 481 481 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 UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: ALCOHOL AND/OR DRUG 1 482 482 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 UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: ANESTHESIA 1 483 483 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 UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: BLOOD BANK 1 484 484 C PROV2080 INDICATES HOW BLOOD BANK SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-BLOOD-BANK VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 17 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: BURN CARE UNIT 1 485 485 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 UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: CHIROPRACTIC 1 486 486 C PROV2100 INDICATES HOW CHIROPRACTIC SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-CHIROPRATIC VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: CORONARY CARE UNIT 1 487 487 C PROV2110 INDICATES HOW CORONARY CARE UNIT SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-CORONARY-CARE VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: DENTAL 1 488 488 C PROV2120 INDICATES HOW DENTAL SERVICES ARE PROVIDED. COBOL NAME: SP-DENTAL VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: DIETARY 1 489 489 C PROV2130 INDICATES HOW DIETARY SERVICES ARE PROVIDED. COBOL NAME: SP-DIETARY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 18 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: EMERGENCY SERVICES(ORGANIZED) 1 490 490 C PROV2140 INDICATES HOW ORGANIZED EMERGENCY SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-EMERG-DEPT VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: HOME CARE UNIT 1 491 491 C PROV2160 INDICATES HOW HOME CARE SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-HOME-CARE-UNIT VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: HOSPICE 1 492 492 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 UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: INPATIENT SURGICAL 1 493 493 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 UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: INTENSIVE CARE UNIT 1 494 494 C PROV2185 INDICATES HOW INTENSIVE CARE UNIT SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-ICU VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 19 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: LABORATORY (ANATOMICAL) 1 495 495 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 UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: LABORATORY (CLINICAL) 1 496 496 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 UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: LONG TERM CARE UNIT 1 497 497 C PROV2215 INDICATES HOW LONG TERM CARE UNIT SERVICES ARE PROVIDED IN A HOSPITAL. COBOL NAME: SP-LTC-UNIT VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: NEONATAL NURSERY 1 498 498 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 UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: NUCLEAR MEDICINE 1 499 499 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 UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 20 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: OBSTETRICS 1 500 500 C PROV2265 INDICATES HOW OBSTETRICS SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-OBSTETRICS VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: OCCUPATIONAL THERAPY 1 501 501 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: OPEN HEART SURGERY FACILITY 1 502 502 C PROV2285 INDICATES HOW OPEN HEART SURGERY FACILITY SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-OPEN-HEART-SURG VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: OPERATING ROOMS 1 503 503 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 UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: OPTOMETRIC 1 504 504 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 UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 21 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: ORGAN BANK 1 505 505 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 UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: ORGAN TRANSPLANT 1 506 506 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 UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: OUTPATIENT 1 507 507 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 UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: OUTPATIENT SURGERY UNIT 1 508 508 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 UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: PEDIATRIC 1 509 509 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 UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 22 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHARMACY 1 510 510 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 UNDER ARRANGEMENT SRV: PHYSICAL THERAPY 1 511 511 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 1 512 512 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 UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: PSYCHIATRIC 1 513 513 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 UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: RADIOLOGY (DIAGNOSTIC) 1 514 514 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 UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: RADIOLOGY (THERAPEUTIC) 1 515 515 C PROV2445 INDICATES HOW THERAPEUTIC RADIOLOGY SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-RADIOLOGY-THERAPY VALUES: 0 NOT PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 23 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: REHABILITATION 1 516 516 C PROV2450 INDICATES HOW REHABILITATION SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-REHABIL VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: SELF CARE UNIT 1 517 517 C PROV2470 INDICATES HOW SELF CARE UNIT SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-SELF-CARE VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: SHOCK TRAUMA 1 518 518 C PROV2475 INDICATES HOW SHOCK TRAUMA SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-SHOCK-TRAUMA VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: SOCIAL 1 519 519 C PROV2485 INDICATES HOW SOCIAL SERVICES ARE PROVIDED. COBOL NAME: SP-SOCIAL VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: SPEECH PATHOLOGY 1 520 520 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 3 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 24 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SWING BED INDICATOR 1 521 521 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 1 522 522 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 (CLIA LAB TYPE) 2 523 524 C PROV2890 INDICATES THE CATEGORY WHICH REPRESENTS THE TYPE OF FACILITY. COBOL NAME: TYPE-FACILITY VALUES: 01 SHORT - TERM 02 LONG - TERM 03 CHRISTIAN SCIENCE SANITORIUM 04 PSYCHIATRIC 05 REHABILITATION 06 CHILDRENS 07 ALCOHOL AND/OR DRUG HOSPITAL TYPE OF NON-PARTICIPATING PROVIDER 1 525 525 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 PHYSICAL THERAPISTS 7.2 1182 1188 N PROV1120 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS-THERAPISTS SPEECH PATHOLOGISTS, AUDIOLOGISTS 7.2 1196 1202 N PROV1220 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS OR AUDIOLOGISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-SPEECH-PATH-AUDIO PHYSICIANS 7.2 1565 1571 N PROV1110 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIANS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 25 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: RESPIRATORY CARE 1 1612 1612 C PROV2455 INDICATES HOW RESPIRATORY CARE SERVICES ARE PROVIDED. COBOL NAME: SP-RESP-CARE VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT MEDICAL SOCIAL WORKERS 7.2 1687 1693 N PROV0975 NUMBER OF FULL-TIME EQUIVALENT MEDICAL SOCIAL WORKERS EMPLOYED BY A HOSPITAL OR HOSPICE. COBOL NAME: NUM-MED-SOCIAL-WRKS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 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: 01 TITLE 18 ONLY 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 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 6 62 67 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 68 68 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 38 69 106 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 5 107 111 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) 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 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 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 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 3 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 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 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 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) PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 129 138 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 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME P PENDING W WORK REGION CODE 2 140 141 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 1 142 142 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 2 143 144 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 2 145 146 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 52 WISCONSIN 53 WYOMING * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 206 206 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF CONTROL 2 207 208 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 ZIP CODE 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE BEDS - TOTAL 5 253 257 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 5 258 262 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS COMPLIANCE: LIFE SAFETY CODE 1 320 320 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 9 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FISCAL YEAR ENDING DATE 4 340 343 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT MEDICARE OR MEDICAID VENDOR NUMBER 12 359 370 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 PROGRAM PARTICIPATION 1 407 407 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) 1 425 425 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) 1 426 426 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 RELATED PROVIDER NUMBER 10 459 468 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 ACTIVITY THERAPISTS - CONTRACT 7.2 526 532 N PROV0695 THE NUMBER OF FULL TIME EQUIVALENT ACTIVITIES THERAPISTS UNDER CONTRACT TO THE FACILITY COBOL NAME: NUM-ACT-THER-CONTRACT ACTIVITY THERAPISTS - FULL TIME 7.2 533 539 N PROV0700 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES THERAPISTS EMPLOYED FULL TIME BY THE FACILITY COBOL NAME: NUM-ACT-THER-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 10 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ACTIVITY THERAPISTS - PART TIME 7.2 540 546 N PROV0705 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES THERAPISTS EMPLOYED PART-TIME BY THE FACILITY. COBOL NAME: NUM-ACT-THER-PART-TIME ADMINISTRATOR - CONTRACT 7.2 547 553 N PROV0710 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-ADMN-CONTRACT ADMINISTRATOR - FULL TIME 7.2 554 560 N PROV0715 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS EMPLOYED ON A FULL TIME BASIS BY THE FACILITY. COBOL NAME: NUM-ADMN-FULL-TIME ADMINISTRATOR - PART TIME 7.2 561 567 N PROV0720 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS EMPLOYED ON A PART-TIME BASIS BY THE FACILITY. COBOL NAME: NUM-ADMN-PART-TIME ADMISSION SUSPENSION DATE 6 568 573 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 AIDES/ORDERLIES - CONTRACT 7.2 574 580 N PROV1000 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-NURSE-AID-CONTRACT AIDES/ORDERLIES - FULL TIME 7.2 581 587 N PROV1005 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES EMPLOYED BY THE FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-AID-FULL-TIME AIDES/ORDERLIES - PART TIME 7.2 588 594 N PROV1010 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES EMPLOYED BY THE FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-AID-PART-TIME BEDS - MEDICARE SNF 4 595 598 N PROV1445 NUMBER OF MEDICARE CERTIFIED SNF BEDS IN A FACILITY. COBOL NAME: NUM-T18-SNF-BEDS BEDS - NURSING FACILITY 4 599 602 N PROV1455 NUMBER OF MEDICAID CERTIFIED SKILLED NURSING CARE BEDS IN A FACILITY. COBOL NAME: NUM-T19-SNF-BEDS BEDS - SNF/NF 4 603 606 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 CHRISTIAN SCIENCE INDICATOR 1 607 607 C PROV0110 INDICATES IF A PROVIDER IS A CHRISTIAN SCIENCE FACILITY COBOL NAME: CHRISTIAN-SCIENCE-IND VALUES: Y CHRISTIAN SCIENCE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 11 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COMPLIANCE: BEDS PER ROOM WAIVER 1 608 608 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 COMPLIANCE: PATIENT ROOM SIZE 1 609 609 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 1 610 610 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 7.2 611 617 N PROV0785 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DENTIST-CONTRACT DENTISTS - FULL TIME 7.2 618 624 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 7.2 625 631 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 7.2 632 638 N PROV0805 THE NUMBER OF FULL-TIME EQUIVALENT UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DIET-CONTRACT DIETITIANS - FULL TIME 7.2 639 645 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 7.2 646 652 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 1 653 653 C PROV0465 INDICATES IF A FACILITY USES RESIDENTS TO DEVELOP AND TEST CLINICAL TREATMENTS. COBOL NAME: EXPER-RESEARCH VALUES: N NO Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 12 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FOOD SERVICE - CONTRACT 7.2 654 660 N PROV0860 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-FOOD-SRV-CONTRACT FOOD SERVICE - FULL TIME 7.2 661 667 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 7.2 668 674 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 7.2 675 681 N PROV0925 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-HOUSE-CONTRACT HOUSEKEEPING - FULL TIME 7.2 682 688 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 7.2 689 695 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 7.2 696 702 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 7.2 703 709 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 7.2 710 716 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 # 6 717 722 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 7.2 723 729 N PROV0960 NUMBER OF MEDICAL DIRECTORS UNDER CONTRACT. COBOL NAME: NUM-MED-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 13 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MEDICAL DIRECTOR - FULL TIME 7.2 730 736 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 MEDICAL DIRECTOR - PART TIME 7.2 737 743 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 MENTAL HEALTH SERVICES - CONTRACT 7.2 744 750 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 7.2 751 757 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 7.2 758 764 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 38 765 802 C PROV0680 THE NAME OF THE MULTI-FACILITY ORGANIZATION THAT OWNS THE FACILITY. COBOL NAME: NAME-MULT-FACL-ORG MULTI-FACILITY ORGANIZATION OWNED 1 803 803 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: N NO Y YES OCCUPATIONAL THERAPIST - CONTRACT 7.2 804 810 N PROV1035 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-THER-CONTRACT OCCUPATIONAL THERAPIST - FULL TIME 7.2 811 817 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 OCCUPATIONAL THERAPIST - PART TIME 7.2 818 824 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 14 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OCCUPATIONAL THERAPY ASST-CONTRACT 7.2 825 831 N PROV1020 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-AID-CONTRACT OCCUPATIONAL THERAPY ASST-FULL 7.2 832 838 N PROV1025 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-AID-FULL-TIME OCCUPATIONAL THERAPY ASST-PART 7.2 839 845 N PROV1030 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-AID-PART-TIME ORGANIZED FAMILY GROUP 1 846 846 C PROV1535 INDICATES IF THE FACILITY HAS AN ORGANIZED GROUP OF FAMILY MEMBERS OF RESIDENTS. COBOL NAME: ORG-FAMILY-GRP VALUES: N NO Y YES ORGANIZED RESIDENT GROUP 1 847 847 C PROV1540 INDICATES IF THE FACILITY HAS AN ORGANIZED RESIDENTS GROUP. COBOL NAME: ORG-RESID-GRP VALUES: N NO Y YES OTHER - CONTRACT 7.2 848 854 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 7.2 855 861 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 7.2 862 868 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 PHYSICIAN - CONTRACT 7.2 869 875 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 7.2 876 882 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 15 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OTHER PHYSICIAN - PART TIME 7.2 883 889 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 PHARMACISTS - CONTRACT 7.2 890 896 N PROV1085 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-PHAR-CONTRACT PHARMACISTS - FULL TIME 7.2 897 903 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 7.2 904 910 N PROV1095 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-PHAR-PART-TIME PHYSICAL THERAPISTS - CONTRACT 7.2 911 917 N PROV1430 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-CONTRACT PHYSICAL THERAPISTS - FULL TIME 7.2 918 924 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 7.2 925 931 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 ASST - CONTRACT 7.2 932 938 N PROV1415 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-AID-CONTRACT PHYSICAL THERAPY ASST - FULL TIME 7.2 939 945 N PROV1420 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-AID-FULL-TIME PHYSICAL THERAPY ASST - PART TIME 7.2 946 952 N PROV1425 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-AID-PART-TIME PHYSICIAN EXTENDER - CONTRACT 7.2 953 959 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 7.2 960 966 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 16 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PHYSICIAN EXTENDER - PART TIME 7.2 967 973 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 7.2 974 980 N PROV1130 THE NUMBER OF FULL TIME EQUIVALENT PODIATRISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-POD-CONTRACT PODIATRISTS - FULL TIME 7.2 981 987 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 7.2 988 994 N PROV1140 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-POD-PART-TIME PRIOR ADMISSION SUSPENSION DATE 6 995 1000 C PROV1610 PREVIOUS DATE A SUSPENSION OF ADMISSIONS WAS INVOKED FOR A PROVIDER. COBOL NAME: PRIOR-ADMIN-SUSP-DT PRIOR RESCIND SUSPENSION DATE 6 1001 1006 C PROV1640 THE EFFECTIVE DATE OF A PREVIOUS SUSPENSION OF ADMISSIONS TO A LTC FACILITY. COBOL NAME: PRIOR-RESC-SUSP-DT PROVIDER BASED FACILITY 1 1007 1007 C PROV1675 INDICATES IF A LONG TERM CARE FACILITY IS PROVIDER BASED. COBOL NAME: PROV-BASED-FACILITY VALUES: N NOT HOSPITAL BASED Y HOSPITAL BASED REGISTERED NURSE - CONTRACT 7.2 1008 1014 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 1015 1021 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 1022 1028 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 RESCIND SUSPENSION DATE 6 1029 1034 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 17 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SOCIAL WORKER - CONTRACT 7.2 1035 1041 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 1042 1048 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 1049 1055 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 SPECIAL CARE BEDS-AIDS 3 1056 1058 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 1059 1061 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 1062 1064 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 1065 1067 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 1068 1070 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 1071 1073 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 1074 1076 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 1077 1079 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 18 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPECIAL CARE BEDS-VENTILATOR 3 1080 1082 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 1083 1089 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 1090 1096 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 SPEECH PATHOLOGIST - PART TIME 7.2 1097 1103 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 1104 1104 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 1105 1105 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 1106 1106 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 1107 1107 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 19 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: BLOOD ADMIN-ONSITE-NONRES 1 1108 1108 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 1109 1109 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 SRV: CLINICAL LAB-OFFSITE-RESIDENT 1 1110 1110 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 1111 1111 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 1112 1112 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 1113 1113 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-RESIDENTS 1 1114 1114 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 20 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: DIETARY-OFFSITE-RESIDENTS 1 1115 1115 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 SRV: DIETARY-ONSITE-NON RESIDENTS 1 1116 1116 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 1117 1117 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 1118 1118 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 1119 1119 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 1120 1120 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 1121 1121 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 21 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: MENTAL HEALTH-ONSITE-NON RES 1 1122 1122 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 SRV: MENTAL HEALTH-ONSITE-RESID 1 1123 1123 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 1124 1124 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 1125 1125 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 1126 1126 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 1127 1127 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 1128 1128 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 22 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: OCCUP THER-ONSITE-RESIDENTS 1 1129 1129 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 SRV: PHARMACY-OFFSITE-RESIDENTS 1 1130 1130 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 SRV: PHARMACY-ONSITE-NON RESIDENTS 1 1131 1131 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 1132 1132 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 1133 1133 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 1134 1134 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 1135 1135 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 23 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHYS THER-OFFSITE-RESIDENTS 1 1136 1136 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 1137 1137 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 SRV: PHYS THER-ONSITE-RESIDENTS 1 1138 1138 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 1139 1139 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 1140 1140 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 1141 1141 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 1142 1142 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 24 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PODIATRY-ONSITE-NON RESIDENTS 1 1143 1143 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 1144 1144 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 SRV: SOCIAL WORK-OFFSITE-RESIDENTS 1 1145 1145 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 1146 1146 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 1147 1147 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 1148 1148 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 1149 1149 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 25 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: SPEECH PATH-ONSITE-RESIDENTS 1 1150 1150 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: VOCATIONAL-OFFSITE-RESIDENTS 1 1151 1151 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 1152 1152 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 1153 1153 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 1154 1154 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 1155 1155 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: 10/04/94 1DATE: 01/02/95 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: 01 TITLE 18 ONLY 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 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 6 62 67 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 68 68 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 38 69 106 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 5 107 111 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) 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 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 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 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 3 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 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 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 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) PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 129 138 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 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME P PENDING W WORK REGION CODE 2 140 141 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 1 142 142 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 2 143 144 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 2 145 146 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 52 WISCONSIN 53 WYOMING * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 206 206 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF CONTROL 2 207 208 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 ZIP CODE 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE BEDS - TOTAL 5 253 257 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 5 258 262 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS COMPLIANCE: LIFE SAFETY CODE 1 320 320 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 9 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FISCAL YEAR ENDING DATE 4 340 343 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT MEDICARE OR MEDICAID VENDOR NUMBER 12 359 370 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 PROGRAM PARTICIPATION 1 407 407 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) 1 425 425 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) 1 426 426 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 RELATED PROVIDER NUMBER 10 459 468 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 ACTIVITY THERAPISTS - CONTRACT 7.2 526 532 N PROV0695 THE NUMBER OF FULL TIME EQUIVALENT ACTIVITIES THERAPISTS UNDER CONTRACT TO THE FACILITY COBOL NAME: NUM-ACT-THER-CONTRACT ACTIVITY THERAPISTS - FULL TIME 7.2 533 539 N PROV0700 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES THERAPISTS EMPLOYED FULL TIME BY THE FACILITY COBOL NAME: NUM-ACT-THER-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 10 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ACTIVITY THERAPISTS - PART TIME 7.2 540 546 N PROV0705 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES THERAPISTS EMPLOYED PART-TIME BY THE FACILITY. COBOL NAME: NUM-ACT-THER-PART-TIME ADMINISTRATOR - CONTRACT 7.2 547 553 N PROV0710 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-ADMN-CONTRACT ADMINISTRATOR - FULL TIME 7.2 554 560 N PROV0715 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS EMPLOYED ON A FULL TIME BASIS BY THE FACILITY. COBOL NAME: NUM-ADMN-FULL-TIME ADMINISTRATOR - PART TIME 7.2 561 567 N PROV0720 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS EMPLOYED ON A PART-TIME BASIS BY THE FACILITY. COBOL NAME: NUM-ADMN-PART-TIME ADMISSION SUSPENSION DATE 6 568 573 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 AIDES/ORDERLIES - CONTRACT 7.2 574 580 N PROV1000 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-NURSE-AID-CONTRACT AIDES/ORDERLIES - FULL TIME 7.2 581 587 N PROV1005 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES EMPLOYED BY THE FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-AID-FULL-TIME AIDES/ORDERLIES - PART TIME 7.2 588 594 N PROV1010 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES EMPLOYED BY THE FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-AID-PART-TIME BEDS - MEDICARE SNF 4 595 598 N PROV1445 NUMBER OF MEDICARE CERTIFIED SNF BEDS IN A FACILITY. COBOL NAME: NUM-T18-SNF-BEDS BEDS - NURSING FACILITY 4 599 602 N PROV1455 NUMBER OF MEDICAID CERTIFIED SKILLED NURSING CARE BEDS IN A FACILITY. COBOL NAME: NUM-T19-SNF-BEDS BEDS - SNF/NF 4 603 606 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 CHRISTIAN SCIENCE INDICATOR 1 607 607 C PROV0110 INDICATES IF A PROVIDER IS A CHRISTIAN SCIENCE FACILITY COBOL NAME: CHRISTIAN-SCIENCE-IND VALUES: Y CHRISTIAN SCIENCE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 11 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COMPLIANCE: BEDS PER ROOM WAIVER 1 608 608 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 COMPLIANCE: PATIENT ROOM SIZE 1 609 609 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 1 610 610 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 7.2 611 617 N PROV0785 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DENTIST-CONTRACT DENTISTS - FULL TIME 7.2 618 624 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 7.2 625 631 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 7.2 632 638 N PROV0805 THE NUMBER OF FULL-TIME EQUIVALENT UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DIET-CONTRACT DIETITIANS - FULL TIME 7.2 639 645 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 7.2 646 652 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 1 653 653 C PROV0465 INDICATES IF A FACILITY USES RESIDENTS TO DEVELOP AND TEST CLINICAL TREATMENTS. COBOL NAME: EXPER-RESEARCH VALUES: N NO Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 12 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FOOD SERVICE - CONTRACT 7.2 654 660 N PROV0860 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-FOOD-SRV-CONTRACT FOOD SERVICE - FULL TIME 7.2 661 667 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 7.2 668 674 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 7.2 675 681 N PROV0925 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-HOUSE-CONTRACT HOUSEKEEPING - FULL TIME 7.2 682 688 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 7.2 689 695 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 7.2 696 702 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 7.2 703 709 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 7.2 710 716 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 # 6 717 722 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 7.2 723 729 N PROV0960 NUMBER OF MEDICAL DIRECTORS UNDER CONTRACT. COBOL NAME: NUM-MED-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 13 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MEDICAL DIRECTOR - FULL TIME 7.2 730 736 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 MEDICAL DIRECTOR - PART TIME 7.2 737 743 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 MENTAL HEALTH SERVICES - CONTRACT 7.2 744 750 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 7.2 751 757 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 7.2 758 764 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 38 765 802 C PROV0680 THE NAME OF THE MULTI-FACILITY ORGANIZATION THAT OWNS THE FACILITY. COBOL NAME: NAME-MULT-FACL-ORG MULTI-FACILITY ORGANIZATION OWNED 1 803 803 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: N NO Y YES OCCUPATIONAL THERAPIST - CONTRACT 7.2 804 810 N PROV1035 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-THER-CONTRACT OCCUPATIONAL THERAPIST - FULL TIME 7.2 811 817 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 OCCUPATIONAL THERAPIST - PART TIME 7.2 818 824 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 14 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OCCUPATIONAL THERAPY ASST-CONTRACT 7.2 825 831 N PROV1020 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-AID-CONTRACT OCCUPATIONAL THERAPY ASST-FULL 7.2 832 838 N PROV1025 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-AID-FULL-TIME OCCUPATIONAL THERAPY ASST-PART 7.2 839 845 N PROV1030 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-AID-PART-TIME ORGANIZED FAMILY GROUP 1 846 846 C PROV1535 INDICATES IF THE FACILITY HAS AN ORGANIZED GROUP OF FAMILY MEMBERS OF RESIDENTS. COBOL NAME: ORG-FAMILY-GRP VALUES: N NO Y YES ORGANIZED RESIDENT GROUP 1 847 847 C PROV1540 INDICATES IF THE FACILITY HAS AN ORGANIZED RESIDENTS GROUP. COBOL NAME: ORG-RESID-GRP VALUES: N NO Y YES OTHER - CONTRACT 7.2 848 854 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 7.2 855 861 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 7.2 862 868 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 PHYSICIAN - CONTRACT 7.2 869 875 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 7.2 876 882 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 15 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OTHER PHYSICIAN - PART TIME 7.2 883 889 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 PHARMACISTS - CONTRACT 7.2 890 896 N PROV1085 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-PHAR-CONTRACT PHARMACISTS - FULL TIME 7.2 897 903 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 7.2 904 910 N PROV1095 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-PHAR-PART-TIME PHYSICAL THERAPISTS - CONTRACT 7.2 911 917 N PROV1430 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-CONTRACT PHYSICAL THERAPISTS - FULL TIME 7.2 918 924 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 7.2 925 931 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 ASST - CONTRACT 7.2 932 938 N PROV1415 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-AID-CONTRACT PHYSICAL THERAPY ASST - FULL TIME 7.2 939 945 N PROV1420 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-AID-FULL-TIME PHYSICAL THERAPY ASST - PART TIME 7.2 946 952 N PROV1425 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-AID-PART-TIME PHYSICIAN EXTENDER - CONTRACT 7.2 953 959 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 7.2 960 966 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 16 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PHYSICIAN EXTENDER - PART TIME 7.2 967 973 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 7.2 974 980 N PROV1130 THE NUMBER OF FULL TIME EQUIVALENT PODIATRISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-POD-CONTRACT PODIATRISTS - FULL TIME 7.2 981 987 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 7.2 988 994 N PROV1140 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-POD-PART-TIME PRIOR ADMISSION SUSPENSION DATE 6 995 1000 C PROV1610 PREVIOUS DATE A SUSPENSION OF ADMISSIONS WAS INVOKED FOR A PROVIDER. COBOL NAME: PRIOR-ADMIN-SUSP-DT PRIOR RESCIND SUSPENSION DATE 6 1001 1006 C PROV1640 THE EFFECTIVE DATE OF A PREVIOUS SUSPENSION OF ADMISSIONS TO A LTC FACILITY. COBOL NAME: PRIOR-RESC-SUSP-DT PROVIDER BASED FACILITY 1 1007 1007 C PROV1675 INDICATES IF A LONG TERM CARE FACILITY IS PROVIDER BASED. COBOL NAME: PROV-BASED-FACILITY VALUES: N NOT HOSPITAL BASED Y HOSPITAL BASED REGISTERED NURSE - CONTRACT 7.2 1008 1014 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 1015 1021 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 1022 1028 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 RESCIND SUSPENSION DATE 6 1029 1034 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 17 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SOCIAL WORKER - CONTRACT 7.2 1035 1041 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 1042 1048 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 1049 1055 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 SPECIAL CARE BEDS-AIDS 3 1056 1058 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 1059 1061 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 1062 1064 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 1065 1067 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 1068 1070 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 1071 1073 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 1074 1076 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 1077 1079 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 18 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPECIAL CARE BEDS-VENTILATOR 3 1080 1082 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 1083 1089 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 1090 1096 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 SPEECH PATHOLOGIST - PART TIME 7.2 1097 1103 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 1104 1104 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 1105 1105 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 1106 1106 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 1107 1107 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 19 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: BLOOD ADMIN-ONSITE-NONRES 1 1108 1108 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 1109 1109 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 SRV: CLINICAL LAB-OFFSITE-RESIDENT 1 1110 1110 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 1111 1111 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 1112 1112 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 1113 1113 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-RESIDENTS 1 1114 1114 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 20 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: DIETARY-OFFSITE-RESIDENTS 1 1115 1115 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 SRV: DIETARY-ONSITE-NON RESIDENTS 1 1116 1116 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 1117 1117 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 1118 1118 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 1119 1119 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 1120 1120 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 1121 1121 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 21 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: MENTAL HEALTH-ONSITE-NON RES 1 1122 1122 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 SRV: MENTAL HEALTH-ONSITE-RESID 1 1123 1123 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 1124 1124 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 1125 1125 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 1126 1126 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 1127 1127 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 1128 1128 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 22 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: OCCUP THER-ONSITE-RESIDENTS 1 1129 1129 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 SRV: PHARMACY-OFFSITE-RESIDENTS 1 1130 1130 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 SRV: PHARMACY-ONSITE-NON RESIDENTS 1 1131 1131 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 1132 1132 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 1133 1133 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 1134 1134 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 1135 1135 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 23 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHYS THER-OFFSITE-RESIDENTS 1 1136 1136 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 1137 1137 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 SRV: PHYS THER-ONSITE-RESIDENTS 1 1138 1138 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 1139 1139 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 1140 1140 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 1141 1141 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 1142 1142 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 24 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PODIATRY-ONSITE-NON RESIDENTS 1 1143 1143 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 1144 1144 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 SRV: SOCIAL WORK-OFFSITE-RESIDENTS 1 1145 1145 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 1146 1146 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 1147 1147 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 1148 1148 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 1149 1149 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 25 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: SPEECH PATH-ONSITE-RESIDENTS 1 1150 1150 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: VOCATIONAL-OFFSITE-RESIDENTS 1 1151 1151 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 1152 1152 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 1153 1153 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 1154 1154 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 1155 1155 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: 10/04/94 1DATE: 01/02/95 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 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: 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 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 6 62 67 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 68 68 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 38 69 106 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 5 107 111 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) 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 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 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 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 3 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 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 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 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) PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 129 138 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 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME P PENDING W WORK REGION CODE 2 140 141 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 1 142 142 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 2 143 144 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 2 145 146 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 52 WISCONSIN 53 WYOMING * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 206 206 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF CONTROL 2 207 208 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 ZIP CODE 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE BEDS - TOTAL 5 253 257 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 5 258 262 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS COMPLIANCE: LIFE SAFETY CODE 1 320 320 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 9 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FISCAL YEAR ENDING DATE 4 340 343 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT MEDICARE OR MEDICAID VENDOR NUMBER 12 359 370 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 PROGRAM PARTICIPATION 1 407 407 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) 1 425 425 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) 1 426 426 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 RELATED PROVIDER NUMBER 10 459 468 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 ACTIVITY THERAPISTS - CONTRACT 7.2 526 532 N PROV0695 THE NUMBER OF FULL TIME EQUIVALENT ACTIVITIES THERAPISTS UNDER CONTRACT TO THE FACILITY COBOL NAME: NUM-ACT-THER-CONTRACT ACTIVITY THERAPISTS - FULL TIME 7.2 533 539 N PROV0700 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES THERAPISTS EMPLOYED FULL TIME BY THE FACILITY COBOL NAME: NUM-ACT-THER-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 10 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ACTIVITY THERAPISTS - PART TIME 7.2 540 546 N PROV0705 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES THERAPISTS EMPLOYED PART-TIME BY THE FACILITY. COBOL NAME: NUM-ACT-THER-PART-TIME ADMINISTRATOR - CONTRACT 7.2 547 553 N PROV0710 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-ADMN-CONTRACT ADMINISTRATOR - FULL TIME 7.2 554 560 N PROV0715 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS EMPLOYED ON A FULL TIME BASIS BY THE FACILITY. COBOL NAME: NUM-ADMN-FULL-TIME ADMINISTRATOR - PART TIME 7.2 561 567 N PROV0720 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS EMPLOYED ON A PART-TIME BASIS BY THE FACILITY. COBOL NAME: NUM-ADMN-PART-TIME ADMISSION SUSPENSION DATE 6 568 573 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 AIDES/ORDERLIES - CONTRACT 7.2 574 580 N PROV1000 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-NURSE-AID-CONTRACT AIDES/ORDERLIES - FULL TIME 7.2 581 587 N PROV1005 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES EMPLOYED BY THE FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-AID-FULL-TIME AIDES/ORDERLIES - PART TIME 7.2 588 594 N PROV1010 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES EMPLOYED BY THE FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-AID-PART-TIME BEDS - MEDICARE SNF 4 595 598 N PROV1445 NUMBER OF MEDICARE CERTIFIED SNF BEDS IN A FACILITY. COBOL NAME: NUM-T18-SNF-BEDS BEDS - NURSING FACILITY 4 599 602 N PROV1455 NUMBER OF MEDICAID CERTIFIED SKILLED NURSING CARE BEDS IN A FACILITY. COBOL NAME: NUM-T19-SNF-BEDS BEDS - SNF/NF 4 603 606 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 CHRISTIAN SCIENCE INDICATOR 1 607 607 C PROV0110 INDICATES IF A PROVIDER IS A CHRISTIAN SCIENCE FACILITY COBOL NAME: CHRISTIAN-SCIENCE-IND VALUES: Y CHRISTIAN SCIENCE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 11 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COMPLIANCE: BEDS PER ROOM WAIVER 1 608 608 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 COMPLIANCE: PATIENT ROOM SIZE 1 609 609 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 1 610 610 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 7.2 611 617 N PROV0785 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DENTIST-CONTRACT DENTISTS - FULL TIME 7.2 618 624 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 7.2 625 631 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 7.2 632 638 N PROV0805 THE NUMBER OF FULL-TIME EQUIVALENT UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DIET-CONTRACT DIETITIANS - FULL TIME 7.2 639 645 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 7.2 646 652 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 1 653 653 C PROV0465 INDICATES IF A FACILITY USES RESIDENTS TO DEVELOP AND TEST CLINICAL TREATMENTS. COBOL NAME: EXPER-RESEARCH VALUES: N NO Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 12 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FOOD SERVICE - CONTRACT 7.2 654 660 N PROV0860 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-FOOD-SRV-CONTRACT FOOD SERVICE - FULL TIME 7.2 661 667 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 7.2 668 674 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 7.2 675 681 N PROV0925 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-HOUSE-CONTRACT HOUSEKEEPING - FULL TIME 7.2 682 688 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 7.2 689 695 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 7.2 696 702 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 7.2 703 709 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 7.2 710 716 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 # 6 717 722 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 7.2 723 729 N PROV0960 NUMBER OF MEDICAL DIRECTORS UNDER CONTRACT. COBOL NAME: NUM-MED-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 13 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MEDICAL DIRECTOR - FULL TIME 7.2 730 736 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 MEDICAL DIRECTOR - PART TIME 7.2 737 743 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 MENTAL HEALTH SERVICES - CONTRACT 7.2 744 750 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 7.2 751 757 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 7.2 758 764 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 38 765 802 C PROV0680 THE NAME OF THE MULTI-FACILITY ORGANIZATION THAT OWNS THE FACILITY. COBOL NAME: NAME-MULT-FACL-ORG MULTI-FACILITY ORGANIZATION OWNED 1 803 803 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: N NO Y YES OCCUPATIONAL THERAPIST - CONTRACT 7.2 804 810 N PROV1035 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-THER-CONTRACT OCCUPATIONAL THERAPIST - FULL TIME 7.2 811 817 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 OCCUPATIONAL THERAPIST - PART TIME 7.2 818 824 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 14 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OCCUPATIONAL THERAPY ASST-CONTRACT 7.2 825 831 N PROV1020 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-AID-CONTRACT OCCUPATIONAL THERAPY ASST-FULL 7.2 832 838 N PROV1025 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-AID-FULL-TIME OCCUPATIONAL THERAPY ASST-PART 7.2 839 845 N PROV1030 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-AID-PART-TIME ORGANIZED FAMILY GROUP 1 846 846 C PROV1535 INDICATES IF THE FACILITY HAS AN ORGANIZED GROUP OF FAMILY MEMBERS OF RESIDENTS. COBOL NAME: ORG-FAMILY-GRP VALUES: N NO Y YES ORGANIZED RESIDENT GROUP 1 847 847 C PROV1540 INDICATES IF THE FACILITY HAS AN ORGANIZED RESIDENTS GROUP. COBOL NAME: ORG-RESID-GRP VALUES: N NO Y YES OTHER - CONTRACT 7.2 848 854 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 7.2 855 861 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 7.2 862 868 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 PHYSICIAN - CONTRACT 7.2 869 875 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 7.2 876 882 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 15 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OTHER PHYSICIAN - PART TIME 7.2 883 889 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 PHARMACISTS - CONTRACT 7.2 890 896 N PROV1085 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-PHAR-CONTRACT PHARMACISTS - FULL TIME 7.2 897 903 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 7.2 904 910 N PROV1095 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-PHAR-PART-TIME PHYSICAL THERAPISTS - CONTRACT 7.2 911 917 N PROV1430 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-CONTRACT PHYSICAL THERAPISTS - FULL TIME 7.2 918 924 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 7.2 925 931 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 ASST - CONTRACT 7.2 932 938 N PROV1415 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-AID-CONTRACT PHYSICAL THERAPY ASST - FULL TIME 7.2 939 945 N PROV1420 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-AID-FULL-TIME PHYSICAL THERAPY ASST - PART TIME 7.2 946 952 N PROV1425 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-AID-PART-TIME PHYSICIAN EXTENDER - CONTRACT 7.2 953 959 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 7.2 960 966 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 16 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PHYSICIAN EXTENDER - PART TIME 7.2 967 973 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 7.2 974 980 N PROV1130 THE NUMBER OF FULL TIME EQUIVALENT PODIATRISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-POD-CONTRACT PODIATRISTS - FULL TIME 7.2 981 987 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 7.2 988 994 N PROV1140 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-POD-PART-TIME PRIOR ADMISSION SUSPENSION DATE 6 995 1000 C PROV1610 PREVIOUS DATE A SUSPENSION OF ADMISSIONS WAS INVOKED FOR A PROVIDER. COBOL NAME: PRIOR-ADMIN-SUSP-DT PRIOR RESCIND SUSPENSION DATE 6 1001 1006 C PROV1640 THE EFFECTIVE DATE OF A PREVIOUS SUSPENSION OF ADMISSIONS TO A LTC FACILITY. COBOL NAME: PRIOR-RESC-SUSP-DT PROVIDER BASED FACILITY 1 1007 1007 C PROV1675 INDICATES IF A LONG TERM CARE FACILITY IS PROVIDER BASED. COBOL NAME: PROV-BASED-FACILITY VALUES: N NOT HOSPITAL BASED Y HOSPITAL BASED REGISTERED NURSE - CONTRACT 7.2 1008 1014 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 1015 1021 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 1022 1028 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 RESCIND SUSPENSION DATE 6 1029 1034 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 17 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SOCIAL WORKER - CONTRACT 7.2 1035 1041 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 1042 1048 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 1049 1055 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 SPECIAL CARE BEDS-AIDS 3 1056 1058 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 1059 1061 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 1062 1064 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 1065 1067 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 1068 1070 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 1071 1073 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 1074 1076 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 1077 1079 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 18 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPECIAL CARE BEDS-VENTILATOR 3 1080 1082 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 1083 1089 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 1090 1096 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 SPEECH PATHOLOGIST - PART TIME 7.2 1097 1103 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 1104 1104 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 1105 1105 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 1106 1106 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 1107 1107 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 19 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: BLOOD ADMIN-ONSITE-NONRES 1 1108 1108 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 1109 1109 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 SRV: CLINICAL LAB-OFFSITE-RESIDENT 1 1110 1110 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 1111 1111 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 1112 1112 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 1113 1113 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-RESIDENTS 1 1114 1114 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 20 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: DIETARY-OFFSITE-RESIDENTS 1 1115 1115 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 SRV: DIETARY-ONSITE-NON RESIDENTS 1 1116 1116 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 1117 1117 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 1118 1118 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 1119 1119 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 1120 1120 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 1121 1121 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 21 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: MENTAL HEALTH-ONSITE-NON RES 1 1122 1122 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 SRV: MENTAL HEALTH-ONSITE-RESID 1 1123 1123 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 1124 1124 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 1125 1125 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 1126 1126 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 1127 1127 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 1128 1128 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 22 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: OCCUP THER-ONSITE-RESIDENTS 1 1129 1129 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 SRV: PHARMACY-OFFSITE-RESIDENTS 1 1130 1130 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 SRV: PHARMACY-ONSITE-NON RESIDENTS 1 1131 1131 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 1132 1132 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 1133 1133 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 1134 1134 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 1135 1135 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 23 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHYS THER-OFFSITE-RESIDENTS 1 1136 1136 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 1137 1137 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 SRV: PHYS THER-ONSITE-RESIDENTS 1 1138 1138 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 1139 1139 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 1140 1140 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 1141 1141 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 1142 1142 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 24 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PODIATRY-ONSITE-NON RESIDENTS 1 1143 1143 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 1144 1144 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 SRV: SOCIAL WORK-OFFSITE-RESIDENTS 1 1145 1145 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 1146 1146 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 1147 1147 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 1148 1148 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 1149 1149 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 25 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: SPEECH PATH-ONSITE-RESIDENTS 1 1150 1150 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: VOCATIONAL-OFFSITE-RESIDENTS 1 1151 1151 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 1152 1152 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 1153 1153 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 1154 1154 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 1155 1155 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: 10/04/94 1DATE: 01/02/95 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 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 6 62 67 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 68 68 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 38 69 106 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 5 107 111 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00121 HEALTH CARE SERVICE CORPORATION 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00180 BLUE CROSS (MAINE) 00290 BLUE CROSS (NEW MEXICO) 00362 BLUE CROSS (INDEPENDENCE) 00380 BLUE CROSS (SOUTH CAROLINA) 00450 BLUE CROSS (WISCONSIN) 01390 AETNA (WASHINGTON) 51051 AETNA (PETALUMA) 51100 AETNA (CLEARWATER) 51390 AETNA (FORT WASHINGTON) 57400 COOPERATIVA (PUERTO RICO) PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 3 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PROVIDER NUMBER 10 129 138 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 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 140 141 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 1 142 142 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 2 143 144 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 HOME HEALTH AGENCIES, CATEGORY = "05" (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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME STATE CODE (SSA) 2 145 146 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 HOME HEALTH AGENCIES, CATEGORY = "05" (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 STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF ACTION 1 206 206 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 2 207 208 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 ZIP CODE 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE ACCREDITATION EXPIRATION DATE 6 229 234 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 DIETITIANS 7.2 333 339 N PROV0820 NUMBER OF FULL-TIME EQUIVALENT DIETITIANS EMPLOYED BY A FACILITY. COBOL NAME: NUM-DIETICIANS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FISCAL YEAR ENDING DATE 4 340 343 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT LICENSED PRACTICAL NURSES 7.2 351 357 N PROV0955 NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL OR VOCATIONAL NURSES EMPLOYED BY A FACILITY. COBOL NAME: NUM-LPN-LVN MEDICARE OR MEDICAID VENDOR NUMBER 12 359 370 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 OCCUPATIONAL THERAPISTS 7.2 372 378 N PROV1050 THE NUMBER OF FULL TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-OCCUP-THERAPISTS OTHER PERSONNEL 7.2 379 385 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL PROGRAM PARTICIPATION 1 407 407 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) 1 426 426 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 7.2 428 434 N PROV1145 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PROFESSIONAL NURSES EMPLOYED BY A PROVIDER. COBOL NAME: NUM-REG-NURS REGISTERED PHARMACISTS 7.2 435 441 N PROV1100 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PHARMACISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHARMACIST-REG * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 9 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RELATED PROVIDER NUMBER 10 459 468 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: OCCUPATIONAL THERAPY 1 501 501 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 1 510 510 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 SRV: PHYSICAL THERAPY 1 511 511 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 (CLIA LAB TYPE) 2 523 524 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 AIDE TRAINING/COMPETENCY PROGRAMS 1 1156 1156 C PROV0555 INDICATES HOW THE AGENCY PROVIDES HOME HEALTH AIDE TRAINING AND COMPETENCY EVALUATION PROGRAMS. COBOL NAME: HHA-PROVIDES-DIRECT VALUES: 1 AIDE TRAINING * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 10 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 2 COMPETENCY EVALUATION PROG. 3 BOTH 4 NEITHER BRANCH OPERATION INDICATOR 1 1157 1157 C PROV1525 INDICATES IF THE AGENCY OPERATES ANY BRANCHES. COBOL NAME: OPERS-BRANCHES VALUES: N NO Y YES BRANCHES 2 1158 1159 N PROV0745 THE NUMBER OF BRANCHES OPERATED BY THE AGENCY. COBOL NAME: NUM-BRANCHES CHANGE OF OWNERSHIP INDICATOR 1 1160 1160 C PROV0105 INDICATES IF A HOME HEALTH AGENCY HAS UNDERGONE A CHANGE OF OWNERSHIP SINCE THE LAST SURVEY. COBOL NAME: CHOW-IND VALUES: N NO Y YES HHA QUALIFIED FOR OPT 1 1161 1161 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 1162 1168 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 1169 1169 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 1170 1175 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 1176 1181 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 11 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PHYSICAL THERAPISTS 7.2 1182 1188 N PROV1120 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS-THERAPISTS SOCIAL WORKERS 7.2 1189 1195 N PROV1185 THE NUMBER OF FULL TIME EQUIVALENT SOCIAL WORKERS EMPLOYED BY THE AGENCY. COBOL NAME: NUM-SOCIAL-WRKS SPEECH PATHOLOGISTS, AUDIOLOGISTS 7.2 1196 1202 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 1203 1203 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 SRV: HOME HEALTH AIDE/HOMEMAKER 1 1204 1204 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 1205 1205 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 1206 1206 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 12 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: NURSING 1 1207 1207 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 SRV: NUTRITIONAL GUIDANCE 1 1208 1208 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 1209 1209 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 SRV: SPEECH THERAPY 1 1210 1210 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 1211 1211 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 1212 1212 C PROV2725 INDICATES IF THE AGENCY IS A SUBUNIT OF ANOTHER AGENCY. COBOL NAME: SUBUNIT-IND VALUES: N NO Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 13 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SUBUNIT OPERATION INDICATOR 1 1213 1213 C PROV1530 INDICATES IF THE AGENCY OPERATES ANY SUBUNITS. COBOL NAME: OPERS-SUBUNITS VALUES: N NO Y YES SUBUNITS 2 1214 1215 N PROV1240 THE NUMBER OF SUBUNITS OPERATED BY THE AGENCY. COBOL NAME: NUM-SUBUNITS SRV: LABORATORY 1 1642 1642 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 1 MEDICARE LABORATORIES, CATEGORY = "06" (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 MEDICARE 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: 06 MEDICARE 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 2 MEDICARE LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 6 62 67 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 68 68 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 38 69 106 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 5 107 111 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00510 BLUE SHIELD (ALABAMA) 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 BLUE SHIELD (INDIANA) 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 BLUE SHIELD (KENTUCKY) 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 BLUE SHIELD (EMPIRE) 00820 BLUE SHIELD (NORTH DAKOTA) 00825 BLUE SHIELD (NORTH DAKOTA/WYOMING) 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865 BLUE SHIELD (PENNSYLVANIA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 3 MEDICARE LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00900 BLUE SHIELD (TEXAS) 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 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 PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 129 138 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 MEDICARE LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RECORD TYPE 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 140 141 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 1 142 142 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 2 143 144 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 MEDICARE LABORATORIES, CATEGORY = "06" (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) 2 145 146 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 MEDICARE LABORATORIES, CATEGORY = "06" (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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 MEDICARE LABORATORIES, CATEGORY = "06" (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 STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 206 206 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 MEDICARE LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF CONTROL 2 207 208 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 - CITY 06 GOVERNMENT - COUNTY 07 GOVERNMENT - STATE 08 GOVERNMENT - FEDERAL 09 GOVERNMENT - OTHER 10 OTHER (SURVEYED PRIOR TO 040491) 11 UNKNOWN (PRIOR TO 040491 SURVEYS) ZIP CODE 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE MEDICARE OR MEDICAID VENDOR NUMBER 12 359 370 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 CALENDAR YEAR TEST VOLUME 2 1216 1217 C PROV2615 THE NUMBER OF TESTS PERFORMED BY A LAB FOR THE PRE- VIOUS CALENDAR YEAR FOR ALL SPECIALTIES AND SUB- SPECIALTIES COBOL NAME: SPEC-CALENDAR-YEAR CLIA LAB PROGRAM STATUS 1 1218 1218 C PROV0615 THE TYPE OF LABORATORY, I.E. HOSPITAL OR INDEPEDENT, AND THE PROGRAM(S) (MEDICARE, CLIA) IN WHICH THE LAB PARTICIPATES COBOL NAME: LAB-PROGRAM-STATUS VALUES: 1 INDEPENDENT MEDICARE LAB 3 INDEPENDENT MEDICARE/CLIA LAB * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 9 MEDICARE LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CYTOTECHNOLOGISTS-PROF EXAM 3 1219 1221 N PROV0775 NUMBER OF CYTOTECHNOLOGISTS QUALIFIED UNDER CFR 405.1437(B)(3) WHICH REQUIRES SATISFACTORY GRADES IN PROFICIENCY EXAMINATIONS. COBOL NAME: NUM-CYTOTECHS-3 CYTOTECHNOLOGISTS-2 YR COLL 3 1222 1224 N PROV0765 NUMBER OF CYTOTECHNOLOGISTS QUALIFIED UNDER CFR 493.1437(B)(1) WHICH REQUIRES TWO YEARS OF COLLEGE, TWELVE MONTHS OF CYTOTECHNOLOGY TRAINING AND SIX MONTHS OF FORMAL TRAINING. COBOL NAME: NUM-CYTOTECHS-1 CYTOTECHNOLOGISTS-6 MO TRAIN 3 1225 1227 N PROV0770 # OF CYTOTECHNOLOGISTS QUALIFIED UNDER CFR CFR 493.1437(B)(2) WHICH REQUIRES THAT PRIOR TO 1/1/69, THE CYTOTECH IS A HS GRAD WITH 6 MTHS TRNG IN CYTOTECH, AND 2 YRS FULLTIME SUPERVISORY EXPER IN CYTOTECHNOLOGY COBOL NAME: NUM-CYTOTECHS-2 GENERAL SUPERVISOR - CYTOTECH 3 1228 1230 N PROV0880 THE NUMBER OF LAB GENERAL SUPERVISORS, QUALIFIED UNDER CFR 493.1427(B)(5), WHO HAVE FOUR YEARS EXPERIENCE AS CYTOTECHNOLOGISTS. COBOL NAME: NUM-GN-SUP-CYTOTECH GENERAL SUPERVISOR - GRANDFATHERED 3 1231 1233 N PROV0885 THE NUMBER OF LAB GENERAL SUPERVISORS QUALIFIED PRIOR TO 7/1/71 WITH AT LEAST 15 YEARS FULL-TIME EXPERIENCE PRIOR TO 1/1/68. (SEE CFR 493.1427(B)(6). COBOL NAME: NUM-GN-SUP-GRFATHER GENERAL SUPERVISOR - MD/DOCTORATE 3 1234 1236 N PROV0895 THE NUMBER OF LAB GENERAL SUPERVISORS, QUALIFIED UNDER CFR 493.1427(B)(2) WHO ARE PHYSICIANS OR HAVE DOCTORAL DEGREES IN A CLINICAL, PHYSICAL OR BIOLOGICAL SCIENCE AND 2 YEARS EXPERIENCE IN A LABORATORY. COBOL NAME: NUM-GN-SUP-PHYS-DOCT GENERAL SUPERVISOR - QUALIFIED DIR 3 1237 1239 N PROV0900 THE NUMBER OF GENERAL SUPERVISORS QUALIFIED UNDER CFR 493.1427(B)(1) WHO MAY ALSO SERVE AS THE LABORATORY DIRECTOR COBOL NAME: NUM-GN-SUP-QUALIF GENERAL SUPERVISOR - 6 YRS EXP 3 1240 1242 N PROV0875 THE NUMBER OF LAB GENERAL SUPERVISORS, QUALIFIED UNDER CFR 493.1427(B)(4), WHO ARE LAB TECHNOLOGISTS WITH AT LEAST 6 YRS FULL-TIME LAB EXPERIENCE. COBOL NAME: NUM-GN-SUP-CLT-PLUS6 GENERAL SUPERVISOR-MASTERS DEGREE 3 1243 1245 N PROV0890 THE NUMBER OF LAB GENERAL SUPERVISORS QUALIFIED UNDER CFR 493.1427(B)32) WHO POSSESS MASTER'S DEGREES IN A CHEMICAL, PHYSICAL OR BIOLOGICAL SCIENCE AND HAVE AT LEAST 4 YEARS LAB EXPERIENCE. COBOL NAME: NUM-GN-SUP-MST-DEGREE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 10 MEDICARE LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME IMMUNOHEMATOLOGY TEST FOR TRANSFUS 1 1246 1246 C PROV2085 INDICATES IF A LABORATORY PERFORMS IMMUNOHEMATOLOGY TESTS FOR TRANSFUSION PURPOSES COBOL NAME: SP-BLOOD-BANK-IMMUN VALUES: N NO Y YES LAB DIRECTORS - DOCTORATES 3 1247 1249 N PROV0830 THE NUMBER OF LAB DIRECTORS QUALIFIED UNDER CFR 493.1415(B)(4), WHICH REQUIRES DOCTORAL DEGREES AND BOARD CERTIFICATION OR 4 OR MORE YEARS EXPERIENCE IN AN APPROVED CLINICAL LABORATORY. COBOL NAME: NUM-DIR-DOCT-DEGREE LAB DIRECTORS - GRANDFATHERED 3 1250 1252 N PROV0835 THE NUMBER OF LAB DIRECTORS QUALIFIED UNDER CFR 493.1415(B)(5) WHO QUALIFIED PRIOR TO JULY 1, 1971, UNDER THE GRANDFATHER CLAUSE. COBOL NAME: NUM-DIR-GRFATHER LAB DIRECTORS - MD PATHOLOGISTS 3 1253 1255 N PROV0840 THE NUMBER OF LAB DIRECTORS QUALIFIED UNDER CFR 493.1415(B)(1) WHO ARE PHYSICIANS BOARD CERTIFIED IN ANATOMICAL AND/OR CLINICAL PATHOLOGY OR POSSESS EQUIVALENT QUALIFICATIONS. COBOL NAME: NUM-DIR-PATHOLOGIST LAB DIRECTORS - MD SPECIALTY 3 1256 1258 N PROV0845 THE NUMBER OF LAB DIRECTORS QUALIFIED UNDER CFR 493.1415(B)(2), WHO ARE PHYSICIANS BOARD CERTIFIED IN ONE OF THE LAB SPECIALTIES OR WHO HAVE 4 YEARS OF FT EXPERIENCE IN A LAB, INCLUDING 2 YEARS SPECIALIZED TRNG COBOL NAME: NUM-DIR-PHYS-BOARD LAB DIRECTORS - ORAL PATHOLOGY 3 1259 1261 N PROV0825 NUMBER OF LABORATORY DIRECTORS WHO ARE BOARD CERTIFIED IN ORAL PATHOLOGY OR_WHO POSSESS EQUIVALENT QUALIFICATIONS._SEE CFR 493.1415(B)(3) COBOL NAME: NUM-DIR-DENTIST LAB DIRECTORS - STATE DEEMED 3 1262 1264 N PROV0850 NUMBER OF DIRECTORS THAT QUALIFY UNDER STATE LAW TO DIRECT THE LABORATORY (CFR 493.1415(B)(6)). COBOL NAME: NUM-DIR-STATE-DEEMED TECH SUPER - BA/BS CHEMISTRY 3 1265 1267 N PROV1275 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(S) TO PERFORM CHEMISTRY TESTS, WHO ARE DIRECTORS WITH A BS IN CHEMICAL SCIENCE AND 6 YEARS RELATED EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-CHEM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 11 MEDICARE LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TECH SUPER - BA/BS HEMATOLOGY 3 1268 1270 N PROV1285 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER_CFR 493.1421(O) TO PERFORM HEMATOLOGY TESTS, WHO ARE DIRECTORS WITH A BS IN BIOLOGY, IMMUNOLOGY OR MICRO- BIOLOGY, AND HAVE 6 YEARS EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-HEM TECH SUPER - BA/BS IMMUNOHEM 3 1271 1273 N PROV1290 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(R) TO PERFORM BLOOD GROUPING TESTS, WHO ARE DIRECTORS WITH A BS IN BIOLOGY, IMMUNOLOGY OR MICRO- BIOLOGY, AND 6 YEARS EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-IMHE TECH SUPER - BA/BS IMMUNOLOGY 3 1274 1276 N PROV1295 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(P) TO PERFORM DIAGNOSTIC IMMUNOLOGY TESTS, WHO ARE DIRECTORS WITH A BS IN BIOLOGY, CHEMISTRY, IMMU- NOLOGY OR MICROBIOLOGY, AND HAVE 6 YEARS EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-IMM TECH SUPER - BA/BS MICROBIO 3 1277 1279 N PROV1300 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(N) TO PERFORM MICROBIOLOGY TESTS WHO ARE DIRECTORS WITH A BS IN BIOLOGY AND 6 YEARS MICROBIOLOGY EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-MICR TECH SUPER - BA/BS RADIOBIO 3 1280 1282 N PROV1305 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(Q) TO PERFORM RADIOBIOASSAY TESTS WHO ARE DIRECTORS WITH A BS IN CHEMICAL, PHYSICAL OR BIOLOGICAL SCIENCE AND HAVE 6 YEARS EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-RADI TECH SUPER - BA/BS SPEC EXP 3 1283 1285 N PROV1280 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(T) TO PERFORM SPECIFIC LAB TESTS WHO ARE DIRECTORS WITH A BS IN MEDICAL TECHNOLOGY AND HAVE 6 YEARS SPECIALIZED EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-EXP TECH SUPER - CLINICAL CHEMISTRY 3 1286 1288 N PROV1310 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(D) TO PERFORM TESTS IN CHEM UNDER THE SUP OF A BOARD CERT MD OR HAVE EQUIV QUALIFS OR HAVE DOCT/MAST DEGREE IN CHEM AND 4 YRS EXP IN CLINICAL CHEMISTRY COBOL NAME: NUM-TECH-SUP-CHEMISTRY TECH SUPER - CYTOGENETICS 3 1289 1291 N PROV1315 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(K) TO PERFORM IN CLINICAL CYTOGENETICS WHO ARE DIRECTORS WITH A DOCTORAL DEGREE IN BIOLOGY OR PHYSICIANS AND HAVE 4 YEARS EXPERIENCE IN GENETICS COBOL NAME: NUM-TECH-SUP-CYTOGEN * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 12 MEDICARE LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TECH SUPER - CYTOLOGY 3 1292 1294 N PROV1320 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(F) TO PERFORM CYTOLOGY TESTS UNDER THE SUPERVISION OF A BOARD CERTIFIED PHYSICIAN OR WHO POSSESS EQUIVALENT QUALIFICATIONS COBOL NAME: NUM-TECH-SUP-CYTOLOGY TECH SUPER - DIAGNOSTIC IMMUN 3 1295 1297 N PROV1345 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(C) TO PERFORM TESTS IN DIAGNOSTIC IMMUN- OLOGY UNDER THE SUP OF A BOARD CERT MD OR HAVE EQUIV QUALIFS OR HAVE DOCT/MAST DEGREE IN RELATED SCIENCES COBOL NAME: NUM-TECH-SUP-IMMUNOL TECH SUPER - HEMATOLOGY 3 1298 1300 N PROV1330 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(E) TO PERFORM HEMATOLOGY TESTS UNDER SUPERVISION OF A BOARD CERT MD OR WHO POSSESS BS OR MS DEGREES IN RELATED SCIENCES AND 4 YRS HEMATOLOGY EXPER. COBOL NAME: NUM-TECH-SUP-HEMATOLOGY TECH SUPER - HISTO PATHOLOGY 3 1301 1303 N PROV1325 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(G) TO PERFORM TESTS IN HISTOPATHOLOGY UNDER THE SUPERVISION OF A BOARD CERTIFIED MD OR WHO POSSESS EQUIVALENT QUALIFICATIONS COBOL NAME: NUM-TECH-SUP-DERMATOLGY TECH SUPER - HISTOCOMPATIBILITY 3 1304 1306 N PROV1335 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(J)TO PERFORM TESTS IN HISTO UNDER SUP OF MD OR WHO POSSESS DOCT DEGREES OR ARE MD'S WITH 4 YRS EXP IN IMMUNOLOGY INCLUDING 2 YRS OF HISTO TESTING COBOL NAME: NUM-TECH-SUP-HISTOCOM TECH SUPER - IMMUNOHEMATOLOGY 3 1307 1309 N PROV1340 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(L) TO PERFORM TESTS IN IMMUNOHEMATOLOGY UNDER SUP OF A BOARD CERT MD OR HAVE EQUIV QUALIFS OR ARE PHYSICIANS WITH 2 YRS EXP IN IMMUNOHEMATOLOGY COBOL NAME: NUM-TECH-SUP-IMMUNOHEM TECH SUPER - MICROBIOLOGY 3 1310 1312 N PROV1350 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(B) TO PERFORM MICRO TESTS UNDER SUPERV OF A BOARD CERT MD, OR WHO HOLD DOCTORAL OR MASTER DEGREES IN MICRO AND HAVE 4 YRS EXP IN CLINICAL MICROBIOLOGY COBOL NAME: NUM-TECH-SUP-MICROBIO TECH SUPER - ORAL PATHOLOGY 3 1313 1315 N PROV1355 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(H) TO PERFORM TESTS IN ORAL PATHOLOGY UNDER SUPERVISION OF A BOARD CERT MD OR WHO HAVE EQUIVALENT QUALIFICATIONS COBOL NAME: NUM-TECH-SUP-ORAL-PATH * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 13 MEDICARE LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TECH SUPER - PATHOLOGIST 3 1316 1318 N PROV1360 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(A) TO PERFORM ALL BUT HISTOCOMPATIBILITY AND CLINICAL CYTOGENETICS WHO ARE MD'S CERT IN BOTH ANATOMICAL AND CLINICAL PATH OR HAVE EQUIV QUALIFICATNS COBOL NAME: NUM-TECH-SUP-PATHOLOGY TECH SUPER - PHS EXAM 3 1319 1321 N PROV1365 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(M) WITH SATISFACTORY GRADES IN EXAMINATIONS CONDUCTED BY THE PUBLIC HEALTH SERVICE. COBOL NAME: NUM-TECH-SUP-PHS-EXAM TECH SUPER - RADIOBIOASSAY 3 1322 1324 N PROV1370 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(I) WHO ARE BOARD CERT MD'S OR WHO HAVE A DOCTORATE/MASTERS/BACH DEGREE IN RELATED SCIENCES OR ARE PHYSICIANS WITH 4 YEARS EXP IN RADIOBIOASSAY COBOL NAME: NUM-TECH-SUP-RADIOBIO TECHNICIAN TRAINEES 3 1325 1327 N PROV1375 THE NUMBER OF TECHNICIAN TRAINEES IN LABORATORIES WHO ARE HIGH SCHOOL GRADUATES AND WHO ARE RECEIVING THE REQUIRED 2 YEARS LAB EXPERIENCE AND ARE PARTICIPATING IN A STRUCTURED TRAINING PROGRAM.(CFR 493.1402) COBOL NAME: NUM-TECH-TRAINEES TECHNICIANS - GRANDFATHERED 3 1328 1330 N PROV1245 THE NUMBER OF TECHNICIANS QUALIFIED UNDER CFR 493.1441(B)(5) WHO WAS PERFORMING THE DUTIES OF A LAB TECHNICIAN BETWEEN 7/1/61 & 1/1/68 AND HAS AT LEAST 5 YEARS EXPERIENCE PRIOR TO 1/1/68. COBOL NAME: NUM-TECH-GRFATHER TECHNICIANS - MILITARY 3 1331 1333 N PROV1260 THE NUMBER OF TECHNICIANS QUALIFIED UNDER CFR 493.1441(B)(4) WHO COMPLETED AN OFFICIAL MILITARY MEDICAL LABORATORY PROCEDURES COURSE OF AT LEAST 50 WEEKS DURATION. COBOL NAME: NUM-TECH-MILITARY TECHNICIANS - PROFICIENCY EXAM 3 1334 1336 N PROV1265 THE NUMBER OF TECHNICIANS QUALIFIED UNDER CFR 493.1441(B)(6) WHO ACHIEVED A SATISFACTORY GRADE IN AN APPROVED PROFICIENCY EXAMINATION PRIOR TO 12/31/77. COBOL NAME: NUM-TECH-PES-EXAM TECHNICIANS-AA PLUS 60 CREDIT HRS 3 1337 1339 N PROV1380 THE NUMBER OF LABORATORY TECHNICIANS WHO HAVE COMPLETED EITHER 60 HOURS OF ACADEMIC CREDIT OR HAVE ASSOCIATE DEGREES IN A COURSE OF STUDY THAT INCLUDES MEDICAL LABORATORY TECHNIQUES (CFR 493.1441(B)(1). COBOL NAME: NUM-TECH-60-CREDITS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 14 MEDICARE LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TECHNICIANS-HIGH SCH + EXPERIENCE 3 1340 1342 N PROV1255 THE NUMBER OF TECHNICIANS QUALIFIED UNDER CFR 493.1441(B)(3) WHO ARE HIGH SCHOOL GRADUATES AND HAVE TWO YEARS OF PERTINENT LABORATORY EXPERIENCE. COBOL NAME: NUM-TECH-HS-AND-2YR TECHNICIANS-HIGH SCH + TRAINING 3 1343 1345 N PROV1250 THE NUMBER OF TECHNICIANS QUALIFIED UNDER CFR 493.1441(B)(2) WHO COMPLETED HIGH SCHOOL AND ONE YEAR IN A TECHNICIAN TRAINING PROGRAM. COBOL NAME: NUM-TECH-HS-AND-1YR TECHNOLOGIST - BACHELORS DEGREE 3 1346 1348 N PROV1385 THE NUMBER OF LAB TECHNOLOGISTS WHO HAVE EARNED BACHELOR'S DEGREES IN CHEMICAL, BIOLOGICAL, OR PHYSICAL SCIENCE AND HAVE ONE YEAR EXPERIENCE/TRAINING IN RELATED SPECIALTY (CFR 493.1433(B)(3)). COBOL NAME: NUM-TECHNOLO-BS-BA TECHNOLOGIST - BS MED TECH 3 1349 1351 N PROV1390 THE NUMBER OF TECHNOLOGISTS WHO HAVE EARNED BACHELOR'S DEGREES IN MEDICAL TECHNOLOGY (CFR 493.1433(B)(1)). COBOL NAME: NUM-TECHNOLO-BS-MT TECHNOLOGIST - GRANDFATHERED 3 1352 1354 N PROV1395 THE NUMBER OF TECHNOLOGISTS WHO QUALIFIED PRIOR TO JULY 1, 1971 & WHO WERE PERFORMING AS TECHNOLOGISTS BETWEEN 7/1/61 & 1/1/68 & HAVE AT LEAST TEN YEARS LAB EXPERIENCE PRIOR TO 1/1/68 (CFR 493.1433(B)(5)). COBOL NAME: NUM-TECHNOLO-GRFATHER TECHNOLOGIST - PROFICIENCY EXAM 3 1355 1357 N PROV1400 THE NUMBER OF TECHNOLOGISTS WHO HAVE ACHIEVED A SATISFACTORY GRADE IN A PROFICIENCY EXAM APPROVED BY THE SECRETARY (CFR 493.1433(B)(6)). COBOL NAME: NUM-TECHNOLO-PES-EXAM TECHNOLOGIST - 90 HRS + EXP 3 1358 1360 N PROV1410 THE NUMBER OF TECHNOLOGISTS WHO HAVE COMPLETED THREE YEARS (90 SEMESTER HOURS) OF PERTINENT ACADEMIC STUDIES OUTLINED IN CFR 493.1433(B)(4) AND HAVE ONE YEAR OF LAB EXPERIENCE COBOL NAME: NUM-TECHNOLO-90CR-1YR TECHNOLOGIST - 90 HRS + TRAINING 3 1361 1363 N PROV1405 THE NUMBER OF TECHNOLOGISTS WHO HAVE COMPLETED THREE YEARS (90 SEMESTER HOURS) OF ACADEMIC STUDY AND COM- PLETED AT LEAST ONE YEAR TRAINING IN A SCHOOL OF MEDICAL TECHNOLOGY (CFR 493.1433(B)(2). COBOL NAME: NUM-TECHNOLO-3YR-1YR 010 HISTOCOMPATIBILITY 1 1364 1364 C PROV1865 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-010-HISTOCOMPAT VALUES: N NOT APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 15 MEDICARE LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME Y APPROVED 010A TRANSPLANT 1 1365 1365 C PROV1870 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN THIS SUBSPECIALTY COBOL NAME: SC-010A-TRANSPLANT VALUES: N NOT APPROVED Y APPROVED 010B NON-TRANSPLANT 1 1366 1366 C PROV1875 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN THIS SUBSPECIALTY COBOL NAME: SC-010B-NON-TRANSPLANT VALUES: N NOT APPROVED Y APPROVED 100 MICROBIOLOGY 1 1367 1367 C PROV1880 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-100-MICROBIO VALUES: N NOT APPROVED Y APPROVED 110 BACTERIOLOGY 1 1368 1368 C PROV1885 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-110-BACTERIOLOGY VALUES: N NOT APPROVED Y APPROVED 110C MYCOBACTERIOLOGY 1 1369 1369 C PROV1890 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN MYCOBACTERIOLOGY, WHICH IS WITHIN THE BACTERIOLOGY SUBSPECIALTY COBOL NAME: SC-110C-MYCOBACT VALUES: N NOT APPROVED Y APPROVED 120 MYCOLOGY 1 1370 1370 C PROV1895 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-120-MYCOLOGY VALUES: N NOT APPROVED Y APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 16 MEDICARE LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 130 PARASITOLOGY 1 1371 1371 C PROV1900 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-130-PARASITOLOGY VALUES: N NOT APPROVED Y APPROVED 140 VIROLOGY 1 1372 1372 C PROV1910 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-140-VIROLOGY VALUES: N NOT APPROVED Y APPROVED 150 OTHER MICROBIOLOGY 1 1373 1373 C PROV1915 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-150-OTHER-MICROBIO VALUES: N NOT APPROVED Y APPROVED 200 DIAGNOSTIC IMMUNOLOGY 1 1374 1374 C PROV1920 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-200-DIAG-IMMUNOL VALUES: N NOT APPROVED Y APPROVED 210 SYPHILIS 1 1375 1375 C PROV1925 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-210-SYPHILIS VALUES: N NOT APPROVED Y APPROVED 220 GEN IMMUNOLOGY 1 1376 1376 C PROV1930 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-220-GEN-IMMUNOL VALUES: N NOT APPROVED Y APPROVED 300 CHEMISTRY 1 1377 1377 C PROV1935 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-300-CHEMISTRY VALUES: N NOT APPROVED Y APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 17 MEDICARE LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 310 ROUTINE CHEMISTRY 1 1378 1378 C PROV1940 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-310-ROUTINE VALUES: N NOT APPROVED Y APPROVED 320 URINALYSIS 1 1379 1379 C PROV1945 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-320-URINALYSIS VALUES: N NOT APPROVED Y APPROVED 330 OTHER CHEMISTRY 1 1380 1380 C PROV1950 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-330-OTHER-CHEMISTRY VALUES: N NOT APPROVED Y APPROVED 330D ENDOCRINOLOGY 1 1381 1381 C PROV1955 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN ENDOCRINOLOGY, WHICH IS WITHIN THE OTHER CHEMISTRY SUBSPECIALTY COBOL NAME: SC-330D-ENDOCRINOLOGY VALUES: N NOT APPROVED Y APPROVED 330E TOXICOLOGY 1 1382 1382 C PROV1960 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN TOXICOLOGY, WHICH IS WITHIN THE OTHER CHEMISTRY SUBSPECIALTY COBOL NAME: SC-330E-TOXICOLOGY VALUES: N NOT APPROVED Y APPROVED 400 HEMATOLOGY 1 1383 1383 C PROV1965 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-400-HEMATOLOGY VALUES: N NOT APPROVED Y APPROVED 500 IMMUNOHEMATOLOGY 1 1384 1384 C PROV1970 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-500-IMMUNOHEM VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 18 MEDICARE LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME N NOT APPROVED Y APPROVED 510 ABO + RH GROUP 1 1385 1385 C PROV1975 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-510-ABO-RH-GROUP VALUES: N NOT APPROVED Y APPROVED 520 RH TITERS 1 1386 1386 C PROV1980 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-520-RH-TITERS VALUES: N NOT APPROVED Y APPROVED 530 COMPATIBILITY TEST 1 1387 1387 C PROV1985 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-530-CROSS-MATCH VALUES: N NOT APPROVED Y APPROVED 540 ANTIBODY DETECT + OTHER 1 1388 1388 C PROV1990 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-540-OTHER-IMMUNOHEM VALUES: N NOT APPROVED Y APPROVED 600 PATHOLOGY 1 1389 1389 C PROV1995 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-600-PATHOLOGY VALUES: N NOT APPROVED Y APPROVED 610 HISTOPATHOLOGY 1 1390 1390 C PROV2000 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-610-HISTOPATH VALUES: N NOT APPROVED Y APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 19 MEDICARE LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 620 ORAL PATHOLOGY 1 1391 1391 C PROV2005 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-620-ORAL VALUES: N NOT APPROVED Y APPROVED 630 CYTOLOGY 1 1392 1392 C PROV2010 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-630-CYTOLOGY VALUES: N NOT APPROVED Y APPROVED 800 RADIOBIOASSAY 1 1393 1393 C PROV2015 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-800-RADIOBIO VALUES: N NOT APPROVED Y APPROVED 900 CYTOGENETICS 1 1394 1394 C PROV2020 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY COBOL NAME: SC-900-CYTOGENETICS VALUES: N NOT APPROVED Y APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 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 6 62 67 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 68 68 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 38 69 106 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 5 107 111 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00510 BLUE SHIELD (ALABAMA) 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 BLUE SHIELD (INDIANA) 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 BLUE SHIELD (KENTUCKY) 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 BLUE SHIELD (EMPIRE) 00820 BLUE SHIELD (NORTH DAKOTA) 00825 BLUE SHIELD (NORTH DAKOTA/WYOMING) 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865 BLUE SHIELD (PENNSYLVANIA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 3 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00900 BLUE SHIELD (TEXAS) 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 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 PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 129 138 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RECORD TYPE 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 140 141 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 1 142 142 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 2 143 144 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (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) 2 145 146 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (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 STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 206 206 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF CONTROL 2 207 208 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 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE MEDICARE OR MEDICAID VENDOR NUMBER 12 359 370 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 OTHER PERSONNEL 7.2 379 385 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL DIRECTOR QUALIFICATIONS 1 1395 1395 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 4 BS/BA 5 OTHER TECHNOLOGISTS - ASSOC DEGREE 7.2 1396 1402 N PROV0735 THE NUMBER OF TECHNOLOGISTS WITH ASSOCIATE DEGREES IN RADIOLOGIC TECHNOLOGY. COBOL NAME: NUM-AS-RADIO-TECH * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 9 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TECHNOLOGISTS - BS/BA DEGREE 7.2 1403 1409 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 1410 1416 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: 10/04/94 1DATE: 01/02/95 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 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 6 62 67 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 68 68 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 38 69 106 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 5 107 111 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) 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 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 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 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 3 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 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 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00510 BLUE SHIELD (ALABAMA) 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 BLUE SHIELD (INDIANA) 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 BLUE SHIELD (KENTUCKY) 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 BLUE SHIELD (EMPIRE) 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) 00900 BLUE SHIELD (TEXAS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 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) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 21200 MASSACHUSETTS/MAINE 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) PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 129 138 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 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 140 141 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 1 142 142 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 2 143 144 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 145 146 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 9 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 206 206 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 2 207 208 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 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE FISCAL YEAR ENDING DATE 4 340 343 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT MEDICARE OR MEDICAID VENDOR NUMBER 12 359 370 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 10 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME OCCUPATIONAL THERAPISTS 7.2 372 378 N PROV1050 THE NUMBER OF FULL TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-OCCUP-THERAPISTS PHYSICAL THERAPISTS 7.2 387 393 N PROV1125 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS-THERAPY RELATED PROVIDER NUMBER 10 459 468 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 TYPE OF FACILITY (CLIA LAB TYPE) 2 523 524 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 PHYSICAL THERAPISTS 7.2 1182 1188 N PROV1120 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS-THERAPISTS SPEECH PATHOLOGISTS, AUDIOLOGISTS 7.2 1196 1202 N PROV1220 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS OR AUDIOLOGISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-SPEECH-PATH-AUDIO DOES FACIL. PROVIDES OPT OCCUP 1 1417 1417 C PROV1685 DOES FACILITY PROVIDE OCCUPATIONAL THERAPY SERVICES ?? COBOL NAME: PROVIDES-OCCUP-THERAPY VALUES: N NO Y YES PHYSICAL THERAPIST - ARRANGEMENT 7.2 1418 1424 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 11 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME SPEECH PATHOLOGISTS - ARRANGEMENT 7.2 1425 1431 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 1432 1438 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 SRV: PHYSICAL THERAPY/SPEECH PATH 1 1439 1439 C PROV2500 INDICATES IF PHYSICAL THERAPY AND/OR SPEECH PATHOLOGY SERVICES ARE PROVIDED BY A OUTPATIENT PHYSICAL THERAPY PROVIDER. COBOL NAME: SP-SPEECH-AND-PATH VALUES: 1 PHYSICAL THERAPY 2 SPEECH PATHOLOGY 3 BOTH 4 OCCUPATIONAL THERAPY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 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 6 62 67 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 68 68 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 38 69 106 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 5 107 111 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) 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 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 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 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 3 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 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 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 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) PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 129 138 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 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME P PENDING W WORK REGION CODE 2 140 141 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 1 142 142 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 2 143 144 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 2 145 146 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 52 WISCONSIN 53 WYOMING * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 206 206 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF CONTROL 2 207 208 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 FOR PROFIT - OTHER 05 NOT FOR PROFIT - INDIVIDUAL 06 NOT FOR PROFIT - PARTNERSHIP 07 NOT FOR PROFIT - CORPORATION 08 NOT FOR PROFIT - OTHER 09 GOVERNMENT - STATE 10 GOVERNMENT - COUNTY 11 GOVERNMENT - CITY 12 GOVERNMENT - CITY/COUNTY 13 GOV. - HOSP. DIST. OR AUTHORITY 14 GOVERNMENT - NON FEDERAL OTHER 15 GOV. - VETERANS ADMINISTRATION 16 GOVERNMENT - PHS HOSPITAL 17 GOVERNMENT - MILITARY 18 GOVERNMENT - FEDERAL OTHER ZIP CODE 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE FISCAL YEAR ENDING DATE 4 340 343 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT MEDICARE OR MEDICAID VENDOR NUMBER 12 359 370 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 9 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RELATED PROVIDER NUMBER 10 459 468 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 TYPE OF FACILITY (CLIA LAB TYPE) 2 523 524 C PROV2890 INDICATES THE CATEGORY WHICH REPRESENTS THE TYPE OF FACILITY. COBOL NAME: TYPE-FACILITY VALUES: 01 RENAL TRANSPLANT CENTER 02 RENAL DIALYSIS CENTER 03 RENAL DIALYSIS FACILITY (HOSPITAL-BASED) 04 RENAL DIALYSIS FACILITY(NON-HOSPITAL-BASED) 05 RENAL TRANSPLANT & DIALYSIS CENTER 06 RENAL TRANSPLANT CENTER & DIALYSIS FACILITY CAPD CERTIFICATION 1 1440 1440 C PROV0070 INDICATES THE ELIGIBILITY OF AN END STAGE RENAL DISEASE FACILITY TO PROVIDE CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD) SERVICES. COBOL NAME: CAPD-CD VALUES: A ELIGIBLE B ELIGIBILITY BASED ON ACCEPTABLE PLAN OF CORR C ELIGIBILITY DEPENDS ON APPROVAL OF DIRECTOR E NOT ELIGIBLE CCPD CERTIFICATION 1 1441 1441 C PROV0090 INDICATES THE ELIGIBILITY OF AN END STAGE RENAL DISEASE FACILITY TO PROVIDE CONTINUOUS CYCLE PERITONEAL DIALYSIS (CCPD) SERVICES. COBOL NAME: CCPD-CD VALUES: A ELIGIBLE B ELIGIBILITY BASED ON ACCEPTABLE PLAN OF CORR C ELIGIBILITY DEPENDS ON APPROVAL OF DIRECTOR E NOT ELIGIBLE COMPLIANCE: FURNISH DATA TO MIS 1 1442 1442 C PROV0235 INDICATES IF AN ESRD FACILITY IS IN COMPLIANCE WITH THE REQUIREMENT TO FURNISH DATA TO A NATIONAL ESRD MEDICAL INFORMATION SYSTEM. COBOL NAME: COMPL-FURNISH-DATA VALUES: 4 MET 5 NOT MET * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 10 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COMPLIANCE: MEMBERSHIP IN NETWORK 1 1443 1443 C PROV0250 INDICATES IF AN ESRD FACILITY PARTICIPATES IN NETWORK ACTIVITIES. COBOL NAME: COMPL-MEMBER-NETWORK VALUES: 4 MET 5 NOT MET COMPLIANCE: PROVIDER STATUS 1 1444 1444 C PROV0275 INDICATES IF PROVIDER IS PART OF AN APPROVED PROVIDER APPROVED IN THE MEDICARE PROGRAM. COBOL NAME: COMPL-PROV-STATUS VALUES: 4 MET 5 NOT MET ESRD NETWORK # 2 1445 1446 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 FACILITY ADMINISTRATION, LOCATION 1 1447 1447 C PROV0470 INDICATES HOW A FACILITY IS ADMINISTERED AND WHERE IT IS LOCATED. COBOL NAME: FACILITY-ADMIN-LOCTN VALUES: 1 HOSPITAL ADMINISTERED, HOSPITAL LOCATED 2 HOSPITAL ADMINISTERED, NON-HOSPITAL LOCATED 3 NON-HOSPITAL ADMINISTERED, HOSPITAL LOCATED 4 NON-HOSPITAL ADMINISTERED AND LOCATED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 11 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MUR: TRANSPLANTATION 1 1448 1448 C PROV0265 INDICATES HOW A RENAL DIALYSIS CENTER MEETS MINIMAL UTILIZATION RATES FOR TRANSPLANTATION. COBOL NAME: COMPL-MUR-TRANSP VALUES: 1 CONDITIONAL 2 UNCONDITIONAL 3 EXCEPTION 5 NOT MET PATIENT DIALYSIS TRAINING CERT 1 1449 1449 C PROV1600 INDICATES HOW AN END STAGE RENAL DIALYSIS FACILITY IS CERTIFIED TO PROVIDE PATIENT DIALYSIS TRAINING. COBOL NAME: PATIENT-DIAL-TRN-CERT VALUES: A ELIGIBLE TO SUPPLY B ELIGIBILITY IS BASED ON PLAN OF CORRECTION C ELIGIBILITY DEPENDS ON APPROVAL OF PHYSICIAN E NOT ELIGIBLE TO SUPPLY SERVICES PATIENT DIALYSIS TRAINING CODE 1 1450 1450 C PROV1590 INDICATES THE ELIGIBITY OF AN END STAGE RENAL DIALYSIS TO PROVIDE PATIENT DIALYSIS TRAINING. COBOL NAME: PATIENT-DIAL-TRAIN-CD VALUES: A ELIGIBLE TO PROVIDE PATIENT DIALYSIS TRAINING B NOT ELIGIBLE TO PROVIDE PATIENT DIALYSIS TRNG C VOLUNTARY WITHDRAWAL TO PROVIDE PATIENT TRNG D TERMINATION TO RPOVIDE PATIENT DIALYSIS TRNG PATIENT DIALYSIS TRAINING DATE 6 1451 1456 C PROV1595 THE DATE OF THE DETERMINATION OF ELIGIBILITY OF AN END STAGE RENAL DISEASE FACILITY TO PROVIDE PATIENT DIALYSIS TRAINING. COBOL NAME: PATIENT-DIAL-TRAIN-DT RENAL DIALYSIS CENTER CODE 1 1457 1457 C PROV1760 INDICATES THE ELIGIBILITY OF AN END STAGE DIALYSIS FACILITY TO PROVIDE RENAL DIALYSIS CENTER SERVICES. COBOL NAME: RENAL-DIAL-CENTER-CD VALUES: A ELIGIBLE B NOT ELIGIBLE C VOLUNTARY WITHDRAWAL D TERMINATION RENAL DIALYSIS CENTER DATE 6 1458 1463 C PROV1765 DATE OF THE DETERMINATION OF ELIGIBILITY OF AN END STAGE RENAL DIALYSIS FACILITY TO PROVIDE DIALYSIS CENTER SERVICES. COBOL NAME: RENAL-DIAL-CENTER-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 12 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RENAL DIALYSIS FACILITY CODE 1 1464 1464 C PROV1580 INDICATES THE ELIGIBILITY OF AN END STAGE RENAL DIALYSIS FACILITY TO PROVIDE RENAL DIALYSIS FACILITY SERVICES. COBOL NAME: PATIENT-DIAL-FACTY-CD VALUES: A ELIGIBLE B NOT ELIGIBLE C VOLUNTARY WITHDRAWAL D TERMINATION RENAL DIALYSIS FACILITY DATE 6 1465 1470 C PROV1585 DATE OF THE DETERMINATION OF ELIGIBILITY OF AN END STAGE RENAL DIALYSIS FACILITY TO PROVIDE DIALYSIS FACILITY SERVICES. COBOL NAME: PATIENT-DIAL-FACTY-DT RENAL TRANSPLANT CENTER CODE 1 1471 1471 C PROV1770 INDICATES THE ELIGIBILITY OF AN END STAGE RENAL DIALYSIS FACILITY TO PROVIDE TRANSPLANTATION SERVICES. COBOL NAME: RENAL-TRANSP-CENTER-CD VALUES: A ELIGIBLE B NOT ELIGIBLE C VOLUNTARY WITHDRAWAL D TERMINATION RENAL TRANSPLANT CENTER DATE 6 1472 1477 C PROV1775 DATE OF THE DETERMINATION OF ELIGIBILITY OF AN END STAGE RENAL DIALYSIS FACILITY TO PROVIDE TRANSPLANTATION SERVICES. COBOL NAME: RENAL-TRANSP-CENTER-DT SELF DIALYSIS CERTIFICATION 1 1478 1478 C PROV2030 THE STATE AGENCY'S CERTIFICATION OF ELIGIBILITY OF AN END STAGE RENAL DIALYSIS FACILITY TO PROVIDE SELF DIALYSIS SERVICES. COBOL NAME: SELF-DIAL-CERT VALUES: A ELIGIBLE B ELIGIBILITY IS BASED ON ACCEPTABLE POC C ELIGIBILITY DEPENDS ON APPROVAL OF PHYSICIAN E NOT ELIGIBLE SELF DIALYSIS CODE 1 1479 1479 C PROV2025 INDICATES THE ELIGIBILITY OF AN END STAGE RENAL DIALYSIS FACILITY TO PROVIDE SELF DIALYSIS SERVICES. COBOL NAME: SELF-DIAL-CD VALUES: A ELIGIBLE B NOT ELIGIBLE C VOLUNTARY WITHDRAWAL D TERMINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 13 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SELF DIALYSIS DATE 6 1480 1485 C PROV2035 DATE OF THE DETERMINATION OF ELIGIBILITY OF AN END STAGE RENAL DIALYSIS FACILITY TO PROVIDE SELF DIALYSIS SERVICES. COBOL NAME: SELF-DIAL-DT STAFF ASSISTED DIALYSIS CERT 1 1486 1486 C PROV2705 INDICATES HOW AN END STAGE RENAL DIALYSIS FACILITY IS CERTIFED TO PROVIDE STAFF ASSISTED RENAL DIALYSIS. COBOL NAME: STAFF-ASDIAL-CERT VALUES: A ELIGIBLE TO SUPPLY B ELIGIBILITY BASED ON ACCEPTABLE POC C ELIGIBILITY BASED ON APPROVAL OF MD DIRECTOR E NOT ELIGIBLE TO SUPPLY SERVICE STATIONS - HEMODIALYSIS 3 1487 1489 N PROV1230 THE TOTAL NUMBER OF HEMODIALYSIS STATIONS IN AN END STAGE RENAL DISEASE (ESRD) FACILITY. COBOL NAME: NUM-STATION-HEMO STATIONS - PERITONEAL 3 1490 1492 N PROV1235 THE TOTAL NUMBER OF PERITONEAL STATIONS IN AN END STAGE RENAL DISEASE (ESRD) FACILITY. COBOL NAME: NUM-STATION-PERT STATIONS - TOTAL 3 1493 1495 N PROV2855 THE TOTAL NUMBER OF APPROVED DIALYSIS STATIONS IN AN END STAGE RENAL DIALYSIS FACILITY. COBOL NAME: TOT-STATIONS TRANSPLANTATION CERTIFICATION 1 1496 1496 C PROV2870 INDICATES HOW AN END STAGE RENAL DIALYSIS FACILITY IS CERTIFIED TO PROVIDE TRANSPLANTATION SERVICES SERVICES. COBOL NAME: TRANSP-CERT VALUES: A ELIGIBLE TO SUPPLY B ELIGIBILITY IS BASED ON ACCEPTABLE POC C ELIGIBILITY DEPENDS ON APPROVAL OF PHYSICIAN D ELIGIBILITY DEPENDS ON HISTO LAB ARRANGEMENTS E NOT ELIGIBLE TO SUPPLY SERVICES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 2 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 6 62 67 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 68 68 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 38 69 106 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 5 107 111 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 01390 AETNA (WASHINGTON) PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 129 138 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 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 3 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME REGION CODE 2 140 141 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 1 142 142 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 2 143 144 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 2 145 146 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 65 GUAM 66 SAIPAN STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 206 206 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 2 207 208 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 ZIP CODE 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE BEDS - TOTAL 5 253 257 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 5 258 262 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS COMPLIANCE: LIFE SAFETY CODE 1 320 320 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 4 340 343 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT MEDICARE OR MEDICAID VENDOR NUMBER 12 359 370 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PROGRAM PARTICIPATION 1 407 407 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) 1 425 425 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) 1 426 426 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 RELATED PROVIDER NUMBER 10 459 468 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 ACTIVITY THERAPISTS - CONTRACT 7.2 526 532 N PROV0695 THE NUMBER OF FULL TIME EQUIVALENT ACTIVITIES THERAPISTS UNDER CONTRACT TO THE FACILITY COBOL NAME: NUM-ACT-THER-CONTRACT ACTIVITY THERAPISTS - FULL TIME 7.2 533 539 N PROV0700 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES THERAPISTS EMPLOYED FULL TIME BY THE FACILITY COBOL NAME: NUM-ACT-THER-FULL-TIME ACTIVITY THERAPISTS - PART TIME 7.2 540 546 N PROV0705 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES THERAPISTS EMPLOYED PART-TIME BY THE FACILITY. COBOL NAME: NUM-ACT-THER-PART-TIME ADMINISTRATOR - CONTRACT 7.2 547 553 N PROV0710 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-ADMN-CONTRACT ADMINISTRATOR - FULL TIME 7.2 554 560 N PROV0715 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS EMPLOYED ON A FULL TIME BASIS BY THE FACILITY. COBOL NAME: NUM-ADMN-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 9 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ADMINISTRATOR - PART TIME 7.2 561 567 N PROV0720 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS EMPLOYED ON A PART-TIME BASIS BY THE FACILITY. COBOL NAME: NUM-ADMN-PART-TIME ADMISSION SUSPENSION DATE 6 568 573 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 AIDES/ORDERLIES - CONTRACT 7.2 574 580 N PROV1000 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-NURSE-AID-CONTRACT AIDES/ORDERLIES - FULL TIME 7.2 581 587 N PROV1005 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES EMPLOYED BY THE FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-AID-FULL-TIME AIDES/ORDERLIES - PART TIME 7.2 588 594 N PROV1010 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES EMPLOYED BY THE FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-AID-PART-TIME BEDS - NURSING FACILITY 4 599 602 N PROV1455 NUMBER OF MEDICAID CERTIFIED SKILLED NURSING CARE BEDS IN A FACILITY. COBOL NAME: NUM-T19-SNF-BEDS COMPLIANCE: BEDS PER ROOM WAIVER 1 608 608 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 COMPLIANCE: PATIENT ROOM SIZE 1 609 609 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 1 610 610 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 7.2 611 617 N PROV0785 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DENTIST-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 10 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME DENTISTS - FULL TIME 7.2 618 624 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 7.2 625 631 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 7.2 632 638 N PROV0805 THE NUMBER OF FULL-TIME EQUIVALENT UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DIET-CONTRACT DIETITIANS - FULL TIME 7.2 639 645 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 7.2 646 652 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 1 653 653 C PROV0465 INDICATES IF A FACILITY USES RESIDENTS TO DEVELOP AND TEST CLINICAL TREATMENTS. COBOL NAME: EXPER-RESEARCH VALUES: N NO Y YES FOOD SERVICE - CONTRACT 7.2 654 660 N PROV0860 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-FOOD-SRV-CONTRACT FOOD SERVICE - FULL TIME 7.2 661 667 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 7.2 668 674 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 7.2 675 681 N PROV0925 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-HOUSE-CONTRACT HOUSEKEEPING - FULL TIME 7.2 682 688 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 11 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME HOUSEKEEPING - PART TIME 7.2 689 695 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 7.2 696 702 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 7.2 703 709 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 7.2 710 716 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 # 6 717 722 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 7.2 723 729 N PROV0960 NUMBER OF MEDICAL DIRECTORS UNDER CONTRACT. COBOL NAME: NUM-MED-CONTRACT MEDICAL DIRECTOR - FULL TIME 7.2 730 736 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 MEDICAL DIRECTOR - PART TIME 7.2 737 743 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 MENTAL HEALTH SERVICES - CONTRACT 7.2 744 750 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 7.2 751 757 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 7.2 758 764 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 12 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MULTI-FACILITY ORGANIZATION NAME 38 765 802 C PROV0680 THE NAME OF THE MULTI-FACILITY ORGANIZATION THAT OWNS THE FACILITY. COBOL NAME: NAME-MULT-FACL-ORG MULTI-FACILITY ORGANIZATION OWNED 1 803 803 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: N NO Y YES OCCUPATIONAL THERAPIST - CONTRACT 7.2 804 810 N PROV1035 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-THER-CONTRACT OCCUPATIONAL THERAPIST - FULL TIME 7.2 811 817 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 OCCUPATIONAL THERAPIST - PART TIME 7.2 818 824 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 OCCUPATIONAL THERAPY ASST-CONTRACT 7.2 825 831 N PROV1020 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-AID-CONTRACT OCCUPATIONAL THERAPY ASST-FULL 7.2 832 838 N PROV1025 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-AID-FULL-TIME OCCUPATIONAL THERAPY ASST-PART 7.2 839 845 N PROV1030 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-AID-PART-TIME ORGANIZED FAMILY GROUP 1 846 846 C PROV1535 INDICATES IF THE FACILITY HAS AN ORGANIZED GROUP OF FAMILY MEMBERS OF RESIDENTS. COBOL NAME: ORG-FAMILY-GRP VALUES: N NO Y YES ORGANIZED RESIDENT GROUP 1 847 847 C PROV1540 INDICATES IF THE FACILITY HAS AN ORGANIZED RESIDENTS GROUP. COBOL NAME: ORG-RESID-GRP VALUES: N NO Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 13 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OTHER - CONTRACT 7.2 848 854 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 7.2 855 861 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 7.2 862 868 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 PHYSICIAN - CONTRACT 7.2 869 875 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 7.2 876 882 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 7.2 883 889 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 PHARMACISTS - CONTRACT 7.2 890 896 N PROV1085 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-PHAR-CONTRACT PHARMACISTS - FULL TIME 7.2 897 903 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 7.2 904 910 N PROV1095 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-PHAR-PART-TIME PHYSICAL THERAPISTS - CONTRACT 7.2 911 917 N PROV1430 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-CONTRACT PHYSICAL THERAPISTS - FULL TIME 7.2 918 924 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 14 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PHYSICAL THERAPISTS - PART TIME 7.2 925 931 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 ASST - CONTRACT 7.2 932 938 N PROV1415 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-AID-CONTRACT PHYSICAL THERAPY ASST - FULL TIME 7.2 939 945 N PROV1420 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-AID-FULL-TIME PHYSICAL THERAPY ASST - PART TIME 7.2 946 952 N PROV1425 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-AID-PART-TIME PHYSICIAN EXTENDER - CONTRACT 7.2 953 959 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 7.2 960 966 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 7.2 967 973 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 7.2 974 980 N PROV1130 THE NUMBER OF FULL TIME EQUIVALENT PODIATRISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-POD-CONTRACT PODIATRISTS - FULL TIME 7.2 981 987 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 7.2 988 994 N PROV1140 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-POD-PART-TIME PRIOR ADMISSION SUSPENSION DATE 6 995 1000 C PROV1610 PREVIOUS DATE A SUSPENSION OF ADMISSIONS WAS INVOKED FOR A PROVIDER. COBOL NAME: PRIOR-ADMIN-SUSP-DT PRIOR RESCIND SUSPENSION DATE 6 1001 1006 C PROV1640 THE EFFECTIVE DATE OF A PREVIOUS SUSPENSION OF ADMISSIONS TO A LTC FACILITY. COBOL NAME: PRIOR-RESC-SUSP-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 15 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PROVIDER BASED FACILITY 1 1007 1007 C PROV1675 INDICATES IF A LONG TERM CARE FACILITY IS PROVIDER BASED. COBOL NAME: PROV-BASED-FACILITY VALUES: N NOT HOSPITAL BASED Y HOSPITAL BASED REGISTERED NURSE - CONTRACT 7.2 1008 1014 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 1015 1021 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 1022 1028 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 RESCIND SUSPENSION DATE 6 1029 1034 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 SOCIAL WORKER - CONTRACT 7.2 1035 1041 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 1042 1048 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 1049 1055 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 SPECIAL CARE BEDS-AIDS 3 1056 1058 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 1059 1061 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 1062 1064 N PROV0800 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS NEEDING DIALYSIS. COBOL NAME: NUM-DIAL-BEDS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 16 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPECIAL CARE BEDS-DISABLED CHILD 3 1065 1067 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 1068 1070 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 1071 1073 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 1074 1076 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 1077 1079 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 1080 1082 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 1083 1089 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 1090 1096 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 SPEECH PATHOLOGIST - PART TIME 7.2 1097 1103 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 1104 1104 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 17 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: ACTIVITIES-ONSITE-NON RES 1 1105 1105 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 1106 1106 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 1107 1107 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 1108 1108 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 1109 1109 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 SRV: CLINICAL LAB-OFFSITE-RESIDENT 1 1110 1110 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 1111 1111 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 18 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: CLINICAL LAB-ONSITE-RESIDENTS 1 1112 1112 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 1113 1113 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-RESIDENTS 1 1114 1114 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 1115 1115 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 SRV: DIETARY-ONSITE-NON RESIDENTS 1 1116 1116 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 1117 1117 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 1118 1118 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 19 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: HOUSEKEEPING-OFFSITE-RES 1 1119 1119 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 1120 1120 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 1121 1121 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 1122 1122 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 SRV: MENTAL HEALTH-ONSITE-RESID 1 1123 1123 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 1124 1124 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 1125 1125 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 20 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: NURSING-ONSITE-RESIDENTS 1 1126 1126 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 1127 1127 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 1128 1128 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 1129 1129 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 SRV: PHARMACY-OFFSITE-RESIDENTS 1 1130 1130 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 SRV: PHARMACY-ONSITE-NON RESIDENTS 1 1131 1131 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 1132 1132 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 21 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHYS EXTENDER-OFFSITE-RESID 1 1133 1133 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 1134 1134 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 1135 1135 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 1136 1136 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 1137 1137 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 SRV: PHYS THER-ONSITE-RESIDENTS 1 1138 1138 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 1139 1139 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 22 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHYSICIAN-ONSITE-NON RESIDENT 1 1140 1140 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 1141 1141 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 1142 1142 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 1143 1143 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 1144 1144 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 SRV: SOCIAL WORK-OFFSITE-RESIDENTS 1 1145 1145 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 1146 1146 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 23 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: SOCIAL WORK-ONSITE-RESIDENTS 1 1147 1147 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 1148 1148 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 1149 1149 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 1150 1150 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: VOCATIONAL-OFFSITE-RESIDENTS 1 1151 1151 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 1152 1152 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 1153 1153 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 24 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: XRAY-OFFSITE-RESIDENTS 1 1154 1154 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 1155 1155 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: 10/04/94 1DATE: 01/02/95 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 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 6 62 67 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 68 68 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 38 69 106 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 5 107 111 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 01390 AETNA (WASHINGTON) PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 129 138 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 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 3 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME REGION CODE 2 140 141 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 1 142 142 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 2 143 144 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 2 145 146 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 65 GUAM 66 SAIPAN STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 206 206 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 2 207 208 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 03 STATE 04 CITY/TOWN 05 COUNTY 06 CITY/COUNTY 07 OTHER ZIP CODE 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE BEDS - TOTAL 5 253 257 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 5 258 262 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS COMPLIANCE: LIFE SAFETY CODE 1 320 320 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 4 340 343 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT LICENSED PRACTICAL NURSES 7.2 351 357 N PROV0955 NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL OR VOCATIONAL NURSES EMPLOYED BY A FACILITY. COBOL NAME: NUM-LPN-LVN MEDICARE OR MEDICAID VENDOR NUMBER 12 359 370 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME PROGRAM PARTICIPATION 1 407 407 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) 1 425 425 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 7.2 428 434 N PROV1145 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PROFESSIONAL NURSES EMPLOYED BY A PROVIDER. COBOL NAME: NUM-REG-NURS RELATED PROVIDER NUMBER 10 459 468 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 6 568 573 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 COMPLIANCE: BEDS PER ROOM WAIVER 1 608 608 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 COMPLIANCE: PATIENT ROOM SIZE 1 609 609 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 LTC CROSS REFERENCE PROVIDER # 6 717 722 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 9 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR ADMISSION SUSPENSION DATE 6 995 1000 C PROV1610 PREVIOUS DATE A SUSPENSION OF ADMISSIONS WAS INVOKED FOR A PROVIDER. COBOL NAME: PRIOR-ADMIN-SUSP-DT PRIOR RESCIND SUSPENSION DATE 6 1001 1006 C PROV1640 THE EFFECTIVE DATE OF A PREVIOUS SUSPENSION OF ADMISSIONS TO A LTC FACILITY. COBOL NAME: PRIOR-RESC-SUSP-DT PROVIDER BASED FACILITY 1 1007 1007 C PROV1675 INDICATES IF A LONG TERM CARE FACILITY IS PROVIDER BASED. COBOL NAME: PROV-BASED-FACILITY VALUES: N NOT DISTINCT PART OF HOSP,SNF,ICF Y DISTINCT PART OF A HOSPITAL, SNF OR ICF RESCIND SUSPENSION DATE 6 1029 1034 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 BEDS - ICF/MR 4 1497 1500 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 1501 1507 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 6 1508 1513 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 6 1514 1519 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 6 1520 1525 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 LTC END DATE 6 1526 1531 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 6 1532 1537 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 10 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME TOTAL # OF EMPLOYEES 9.2 1538 1546 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: 10/04/94 1DATE: 01/02/95 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 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 6 62 67 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 68 68 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 38 69 106 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 5 107 111 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) 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 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 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 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 3 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 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 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 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) PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 129 138 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 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME P PENDING W WORK REGION CODE 2 140 141 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 1 142 142 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 2 143 144 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 2 145 146 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 52 WISCONSIN 53 WYOMING * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 206 206 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF CONTROL 2 207 208 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 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE MEDICARE OR MEDICAID VENDOR NUMBER 12 359 370 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 OTHER PERSONNEL 7.2 379 385 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL PHYSICIAN ASSISTANTS 7.2 394 400 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 1547 1547 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 VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 9 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME N NO Y YES NURSE PRACTITIONERS 7.2 1548 1554 N PROV1015 NUMBER OF FULL-TIME EQUIVALENT NURSE PRACTITIONERS IN A RURAL HEALTH CLINIC. COBOL NAME: NUM-NURSE-PRACT PARENT PROVIDER NUMBER 10 1555 1564 C PROV1560 THE IDENTIFICATION NUMBER OF THE PARENT PROVIDER WHEN A RURAL HEALTH CLINIC IS PART OF AN EXISTING MEDICARE PROVIDER. COBOL NAME: PARENT-PROV-NUM PHYSICIANS 7.2 1565 1571 N PROV1110 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIANS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS TITLE OF FEDERAL PROGRAM 26 1572 1597 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: 10/04/94 1DATE: 01/02/95 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 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 6 62 67 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 68 68 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 38 69 106 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 5 107 111 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00510 BLUE SHIELD (ALABAMA) 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 BLUE SHIELD (INDIANA) 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 BLUE SHIELD (KENTUCKY) 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 BLUE SHIELD (EMPIRE) 00820 BLUE SHIELD (NORTH DAKOTA) 00825 BLUE SHIELD (NORTH DAKOTA/WYOMING) 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865 BLUE SHIELD (PENNSYLVANIA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 3 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00900 BLUE SHIELD (TEXAS) 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 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 PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 129 138 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME RECORD TYPE 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 140 141 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 1 142 142 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 2 143 144 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 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) 2 145 146 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 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 STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 206 206 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF CONTROL 2 207 208 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL ZIP CODE 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE MEDICARE OR MEDICAID VENDOR NUMBER 12 359 370 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: 10/04/94 1DATE: 01/02/95 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 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 6 62 67 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 68 68 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 38 69 106 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 5 107 111 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) 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 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 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 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 3 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 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 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 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) PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 129 138 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 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME P PENDING W WORK REGION CODE 2 140 141 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 1 142 142 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 2 143 144 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 2 145 146 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 52 WISCONSIN 53 WYOMING * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 206 206 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF CONTROL 2 207 208 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 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE FISCAL YEAR ENDING DATE 4 340 343 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT MEDICARE OR MEDICAID VENDOR NUMBER 12 359 370 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 RELATED PROVIDER NUMBER 10 459 468 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: OCCUPATIONAL THERAPY 1 501 501 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 9 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHYSICAL THERAPY 1 511 511 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 SRV: SOCIAL 1 519 519 C PROV2485 INDICATES HOW SOCIAL SERVICES ARE PROVIDED. COBOL NAME: SP-SOCIAL VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: SPEECH PATHOLOGY 1 520 520 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 3 PROVIDED BY INDEPENDENT CONTRACTOR PARTICIPATION MEDICARE OPT/SP 1 1598 1598 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: OCCUPATIONAL THERAPY #2 1 1599 1599 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 1600 1600 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 10 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: ORTHOTIC/PROSTHETIC 1 1601 1601 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 1602 1602 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 SRV: ORTHOTIC/PROSTHETIC #3 1 1603 1603 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 1604 1604 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 1605 1605 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 1606 1606 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 11 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHYSICIAN #2 1 1607 1607 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 1608 1608 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 1609 1609 C PROV2420 INDICATES HOW PSYCHOLOGICAL SERVICES ARE PROVIDED. COBOL NAME: SP-PSYCHOLOGICAL VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: PSYCHOLOGICAL #2 1 1610 1610 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 1611 1611 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 1612 1612 C PROV2455 INDICATES HOW RESPIRATORY CARE SERVICES ARE PROVIDED. COBOL NAME: SP-RESP-CARE 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 12 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: RESPIRATORY CARE #2 1 1613 1613 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 1614 1614 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 1615 1615 C PROV2490 INDICATES HOW SOCIAL SERVICES ARE PROVIDED. COBOL NAME: SP-SOCIAL-2 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: SOCIAL #3 1 1616 1616 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 1617 1617 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 1618 1618 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: 10/04/94 1DATE: 01/02/95 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 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 6 62 67 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 68 68 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 38 69 106 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 5 107 111 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) 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 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 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 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 3 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 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 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00510 BLUE SHIELD (ALABAMA) 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 BLUE SHIELD (INDIANA) 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 BLUE SHIELD (KENTUCKY) 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 BLUE SHIELD (EMPIRE) 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) 00900 BLUE SHIELD (TEXAS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 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) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 21200 MASSACHUSETTS/MAINE 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) PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 129 138 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 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 140 141 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 1 142 142 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 2 143 144 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 145 146 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 9 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 206 206 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 2 207 208 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 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE COMPLIANCE: LIFE SAFETY CODE 1 320 320 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 4 340 343 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 10 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MEDICARE OR MEDICAID VENDOR NUMBER 12 359 370 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 RELATED PROVIDER NUMBER 10 459 468 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: PHARMACY 1 510 510 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 SRV: OTHER 1 1209 1209 C PROV2340 INDICATES HOW OTHER (NOT SPECIFIED) SERVICES ARE PROVIDED. COBOL NAME: SP-OTHER VALUES: N NOT OFFERED Y OFFERED DATE CENTER BEGAN PROVIDING SERV 6 1619 1624 C PROV0415 THE DATE AN AMBULATORY SURGICAL CENTER (ASC) BEGAN PROVIDING HEALTH CARE SERVICES. COBOL NAME: DT-SERVICE-BEGAN FREE STANDING INDICATOR (ASC) 1 1625 1625 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: 1 FREE STANDING HOSPITAL BASED INDICATOR 1 1626 1626 C PROV0565 INDICATES IF AN AMBULATORY SURGICAL CENTER IS HOSPITAL BASED. THIS INDICATOR IS USED BY SOME STANDARD REPORTS TO GET CERTAIN PROVIDER RANGES. COBOL NAME: HOSP-BASED-IND VALUES: 1 HOSPITAL BASED OPERATING ROOMS 2 1627 1628 N PROV1055 THE NUMBER OF OPERATING ROOMS IN AN AMBULATORY SURGICAL CENTER. COBOL NAME: NUM-OPERATING-ROOMS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 11 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPEC: CARDIOVASCULAR 1 1629 1629 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 1630 1630 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 1631 1631 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 1632 1632 C PROV2240 INDICATES IF NEUROLOGICAL SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-NEUROLOGICAL VALUES: N NOT OFFERED Y OFFERED SPEC: OBSTETRICS/GYNECOLOGY 1 1633 1633 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 1634 1634 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 1635 1635 C PROV2305 INDICATES IF ORAL SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-ORAL VALUES: N NOT OFFERED Y OFFERED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 12 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPEC: ORTHOPEDIC 1 1636 1636 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 1637 1637 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 1638 1638 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 1639 1639 C PROV2525 INDICATES IF THORACIC SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-THORACIC VALUES: N NOT OFFERED Y OFFERED SPEC: UROLOGY 1 1640 1640 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 1641 1641 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 1642 1642 C PROV2200 INDICATES HOW LABORATORY SERVICES ARE PROVIDED. COBOL NAME: SP-LABORATORY VALUES: 1 PROVIDED DIRECTLY BY THE FACILITY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 13 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 2 PROVIDED THROUGH AN OUTSIDE SOURCE 3 COMBINATION SRV: RADIOLOGY 1 1643 1643 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: 10/04/94 1DATE: 01/02/95 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 2 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 6 62 67 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 68 68 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 38 69 106 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 5 107 111 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) 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 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 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 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 3 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 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 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 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) PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 129 138 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 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME P PENDING W WORK REGION CODE 2 140 141 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 1 142 142 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 2 143 144 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 2 145 146 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 52 WISCONSIN 53 WYOMING * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 206 206 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF CONTROL 2 207 208 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 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE COMPLIANCE: LIFE SAFETY CODE 1 320 320 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 4 340 343 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT LICENSED PRACTICAL NURSES 7.2 351 357 N PROV0955 NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL OR VOCATIONAL NURSES EMPLOYED BY A FACILITY. COBOL NAME: NUM-LPN-LVN * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 9 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MEDICARE OR MEDICAID VENDOR NUMBER 12 359 370 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 OTHER PERSONNEL 7.2 379 385 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL REGISTERED NURSES 7.2 428 434 N PROV1145 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PROFESSIONAL NURSES EMPLOYED BY A PROVIDER. COBOL NAME: NUM-REG-NURS RELATED PROVIDER NUMBER 10 459 468 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: OCCUPATIONAL THERAPY 1 501 501 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 1 511 511 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 1 520 520 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 3 COMBINATION TYPE OF FACILITY (CLIA LAB TYPE) 2 523 524 C PROV2890 INDICATES THE CATEGORY WHICH REPRESENTS THE TYPE OF FACILITY. COBOL NAME: TYPE-FACILITY VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 10 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 01 HOSPITAL 02 SKILLED NURSING FACILITY 03 NURSING FACILITY 04 HOME HEALTH AGENCY 05 FREESTANDING HOSPICE HOME HEALTH AIDES 7.2 1162 1168 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 1206 1206 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 1207 1207 C PROV2250 INDICATES HOW NURSING SERVICES ARE PROVIDED. COBOL NAME: SP-NURSING VALUES: 1 PROVIDED BY STAFF SRV: OTHER 1 1209 1209 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 TOTAL # OF EMPLOYEES 9.2 1538 1546 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 1565 1571 N PROV1110 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIANS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS SRV: PHYSICIAN 1 1606 1606 C PROV2385 INDICATES HOW PHYSICIAN SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICIAN VALUES: 1 PROVIDED BY STAFF * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 11 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ACUTE/RESPITE CARE INDICATOR 1 1644 1644 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 1645 1651 N PROV1225 THE NUMBER OF FULL-TIME EQUIVALENT COUNSELORS EMPLOYED BY A HOSPICE. COBOL NAME: NUM-STAFF-COUNSL COUNSELORS - VOLUNTEER 7.2 1652 1658 N PROV1480 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER COUNSELORS IN A HOSPICE. COBOL NAME: NUM-VOL-COUNSL HOME HEALTH AIDES - VOLUNTEER 7.2 1659 1665 N PROV1485 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER HOME HEALTH AIDES IN A HOSPICE. COBOL NAME: NUM-VOL-HHA HOMEMAKERS - STAFF 7.2 1666 1672 N PROV0915 THE NUMBER OF FULL-TIME EQUIVALENT HOMEMAKERS EMPLOYED BY A HOSPICE. COBOL NAME: NUM-HOMEMAKERS HOMEMAKERS - VOLUNTEER 7.2 1673 1679 N PROV1490 THE NUMBER OF FULL-TIME EQUIVALENT HOMEMAKERS IN A HOSPICE. COBOL NAME: NUM-VOL-HOMEMKR LPNS/LVNS - VOLUNTEER 7.2 1680 1686 N PROV1495 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER LICENSED PRACTICAL/VOCATIONAL NURSES IN A HOSPICE. COBOL NAME: NUM-VOL-LPN-LVN MEDICAL SOCIAL WORKERS 7.2 1687 1693 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 1694 1700 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 1701 1707 N PROV1500 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER PHYSICIANS IN A HOSPICE. COBOL NAME: NUM-VOL-PHYS REGISTERED NURSES - VOLUNTEER 7.2 1708 1714 N PROV1505 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER REGISTERED NURSES IN A HOSPICE. COBOL NAME: NUM-VOL-REG-NURS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 12 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: COUNSELING 1 1715 1715 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 1716 1716 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 1717 1717 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 1718 1718 C PROV2225 INDICATES HOW MEDICAL SUPPLIES SERVICES ARE PROVIDED BY A HOSPICE. COBOL NAME: SP-MEDICAL-SUPPLIES VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: SHORT TERM INPATIENT CARE 1 1719 1719 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 13 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME VOLUNTEERS - OTHER 7.2 1720 1726 N PROV1080 THE NUMBER OF FULL-TIME EQUIVALENT OTHER VOLUNTEERS IN A HOSPICE. COBOL NAME: NUM-OTHER-VOLS VOLUNTEERS - TOTAL 9.2 1727 1735 N PROV2860 THE NUMBER OF FULL-TIME VOLUNTEERS IN A HOSPICE. COBOL NAME: TOT-VOLS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 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 6 62 67 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 68 68 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 38 69 106 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 5 107 111 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) 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 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 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 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 3 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 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 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 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) PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 129 138 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 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME P PENDING W WORK REGION CODE 2 140 141 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 1 142 142 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 2 143 144 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 2 145 146 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 52 WISCONSIN 53 WYOMING * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 206 206 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 3 TERMINATION TYPE OF CONTROL 2 207 208 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ZIP CODE 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE MEDICARE OR MEDICAID VENDOR NUMBER 12 359 370 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 1 CLIA67 LABORATORIES, CATEGORY = "18" (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 CLIA67 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: 18 CLIA67 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 2 CLIA67 LABORATORIES, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 6 62 67 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 68 68 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 38 69 106 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 5 107 111 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) 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 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 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 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 3 CLIA67 LABORATORIES, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 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 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00510 BLUE SHIELD (ALABAMA) 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 BLUE SHIELD (INDIANA) 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 BLUE SHIELD (KENTUCKY) 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 BLUE SHIELD (EMPIRE) 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) 00900 BLUE SHIELD (TEXAS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 CLIA67 LABORATORIES, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 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) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 21200 MASSACHUSETTS/MAINE 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) PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 CLIA67 LABORATORIES, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 129 138 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 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 140 141 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 1 142 142 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 2 143 144 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 CLIA67 LABORATORIES, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 CLIA67 LABORATORIES, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 145 146 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 CLIA67 LABORATORIES, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 9 CLIA67 LABORATORIES, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 206 206 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 2 207 208 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 - CITY 06 GOVERNMENT - COUNTY 07 GOVERNMENT - STATE 08 GOVERNMENT - FEDERAL 09 GOVERNMENT - OTHER 10 OTHER (SURVEYED PRIOR TO 040491) 11 UNKNOWN (PRIOR TO 040491 SURVEYS) ZIP CODE 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE MEDICARE OR MEDICAID VENDOR NUMBER 12 359 370 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 10 CLIA67 LABORATORIES, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CALENDAR YEAR TEST VOLUME 2 1216 1217 C PROV2615 THE NUMBER OF TESTS PERFORMED BY A LAB FOR THE PRE- VIOUS CALENDAR YEAR FOR ALL SPECIALTIES AND SUB- SPECIALTIES COBOL NAME: SPEC-CALENDAR-YEAR CLIA LAB PROGRAM STATUS 1 1218 1218 C PROV0615 THE TYPE OF LABORATORY, I.E. HOSPITAL OR INDEPEDENT, AND THE PROGRAM(S) (MEDICARE, CLIA) IN WHICH THE LAB PARTICIPATES COBOL NAME: LAB-PROGRAM-STATUS VALUES: 2 INDEPENDENT CLIA LAB 3 INDEPENDENT MEDICARE/CLIA LAB 4 HOSPITAL BASED CLIA ONLY LAB CYTOTECHNOLOGISTS-PROF EXAM 3 1219 1221 N PROV0775 NUMBER OF CYTOTECHNOLOGISTS QUALIFIED UNDER CFR 405.1437(B)(3) WHICH REQUIRES SATISFACTORY GRADES IN PROFICIENCY EXAMINATIONS. COBOL NAME: NUM-CYTOTECHS-3 CYTOTECHNOLOGISTS-2 YR COLL 3 1222 1224 N PROV0765 NUMBER OF CYTOTECHNOLOGISTS QUALIFIED UNDER CFR 493.1437(B)(1) WHICH REQUIRES TWO YEARS OF COLLEGE, TWELVE MONTHS OF CYTOTECHNOLOGY TRAINING AND SIX MONTHS OF FORMAL TRAINING. COBOL NAME: NUM-CYTOTECHS-1 CYTOTECHNOLOGISTS-6 MO TRAIN 3 1225 1227 N PROV0770 # OF CYTOTECHNOLOGISTS QUALIFIED UNDER CFR CFR 493.1437(B)(2) WHICH REQUIRES THAT PRIOR TO 1/1/69, THE CYTOTECH IS A HS GRAD WITH 6 MTHS TRNG IN CYTOTECH, AND 2 YRS FULLTIME SUPERVISORY EXPER IN CYTOTECHNOLOGY COBOL NAME: NUM-CYTOTECHS-2 GENERAL SUPERVISOR - CYTOTECH 3 1228 1230 N PROV0880 THE NUMBER OF LAB GENERAL SUPERVISORS, QUALIFIED UNDER CFR 493.1427(B)(5), WHO HAVE FOUR YEARS EXPERIENCE AS CYTOTECHNOLOGISTS. COBOL NAME: NUM-GN-SUP-CYTOTECH GENERAL SUPERVISOR - GRANDFATHERED 3 1231 1233 N PROV0885 THE NUMBER OF LAB GENERAL SUPERVISORS QUALIFIED PRIOR TO 7/1/71 WITH AT LEAST 15 YEARS FULL-TIME EXPERIENCE PRIOR TO 1/1/68. (SEE CFR 493.1427(B)(6). COBOL NAME: NUM-GN-SUP-GRFATHER GENERAL SUPERVISOR - MD/DOCTORATE 3 1234 1236 N PROV0895 THE NUMBER OF LAB GENERAL SUPERVISORS, QUALIFIED UNDER CFR 493.1427(B)(2) WHO ARE PHYSICIANS OR HAVE DOCTORAL DEGREES IN A CLINICAL, PHYSICAL OR BIOLOGICAL SCIENCE AND 2 YEARS EXPERIENCE IN A LABORATORY. COBOL NAME: NUM-GN-SUP-PHYS-DOCT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 11 CLIA67 LABORATORIES, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME GENERAL SUPERVISOR - QUALIFIED DIR 3 1237 1239 N PROV0900 THE NUMBER OF GENERAL SUPERVISORS QUALIFIED UNDER CFR 493.1427(B)(1) WHO MAY ALSO SERVE AS THE LABORATORY DIRECTOR COBOL NAME: NUM-GN-SUP-QUALIF GENERAL SUPERVISOR - 6 YRS EXP 3 1240 1242 N PROV0875 THE NUMBER OF LAB GENERAL SUPERVISORS, QUALIFIED UNDER CFR 493.1427(B)(4), WHO ARE LAB TECHNOLOGISTS WITH AT LEAST 6 YRS FULL-TIME LAB EXPERIENCE. COBOL NAME: NUM-GN-SUP-CLT-PLUS6 GENERAL SUPERVISOR-MASTERS DEGREE 3 1243 1245 N PROV0890 THE NUMBER OF LAB GENERAL SUPERVISORS QUALIFIED UNDER CFR 493.1427(B)32) WHO POSSESS MASTER'S DEGREES IN A CHEMICAL, PHYSICAL OR BIOLOGICAL SCIENCE AND HAVE AT LEAST 4 YEARS LAB EXPERIENCE. COBOL NAME: NUM-GN-SUP-MST-DEGREE IMMUNOHEMATOLOGY TEST FOR TRANSFUS 1 1246 1246 C PROV2085 INDICATES IF A LABORATORY PERFORMS IMMUNOHEMATOLOGY TESTS FOR TRANSFUSION PURPOSES COBOL NAME: SP-BLOOD-BANK-IMMUN VALUES: N NO Y YES LAB DIRECTORS - DOCTORATES 3 1247 1249 N PROV0830 THE NUMBER OF LAB DIRECTORS QUALIFIED UNDER CFR 493.1415(B)(4), WHICH REQUIRES DOCTORAL DEGREES AND BOARD CERTIFICATION OR 4 OR MORE YEARS EXPERIENCE IN AN APPROVED CLINICAL LABORATORY. COBOL NAME: NUM-DIR-DOCT-DEGREE LAB DIRECTORS - GRANDFATHERED 3 1250 1252 N PROV0835 THE NUMBER OF LAB DIRECTORS QUALIFIED UNDER CFR 493.1415(B)(5) WHO QUALIFIED PRIOR TO JULY 1, 1971, UNDER THE GRANDFATHER CLAUSE. COBOL NAME: NUM-DIR-GRFATHER LAB DIRECTORS - MD PATHOLOGISTS 3 1253 1255 N PROV0840 THE NUMBER OF LAB DIRECTORS QUALIFIED UNDER CFR 493.1415(B)(1) WHO ARE PHYSICIANS BOARD CERTIFIED IN ANATOMICAL AND/OR CLINICAL PATHOLOGY OR POSSESS EQUIVALENT QUALIFICATIONS. COBOL NAME: NUM-DIR-PATHOLOGIST LAB DIRECTORS - MD SPECIALTY 3 1256 1258 N PROV0845 THE NUMBER OF LAB DIRECTORS QUALIFIED UNDER CFR 493.1415(B)(2), WHO ARE PHYSICIANS BOARD CERTIFIED IN ONE OF THE LAB SPECIALTIES OR WHO HAVE 4 YEARS OF FT EXPERIENCE IN A LAB, INCLUDING 2 YEARS SPECIALIZED TRNG COBOL NAME: NUM-DIR-PHYS-BOARD * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 12 CLIA67 LABORATORIES, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME LAB DIRECTORS - ORAL PATHOLOGY 3 1259 1261 N PROV0825 NUMBER OF LABORATORY DIRECTORS WHO ARE BOARD CERTIFIED IN ORAL PATHOLOGY OR_WHO POSSESS EQUIVALENT QUALIFICATIONS._SEE CFR 493.1415(B)(3) COBOL NAME: NUM-DIR-DENTIST LAB DIRECTORS - STATE DEEMED 3 1262 1264 N PROV0850 NUMBER OF DIRECTORS THAT QUALIFY UNDER STATE LAW TO DIRECT THE LABORATORY (CFR 493.1415(B)(6)). COBOL NAME: NUM-DIR-STATE-DEEMED TECH SUPER - BA/BS CHEMISTRY 3 1265 1267 N PROV1275 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(S) TO PERFORM CHEMISTRY TESTS, WHO ARE DIRECTORS WITH A BS IN CHEMICAL SCIENCE AND 6 YEARS RELATED EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-CHEM TECH SUPER - BA/BS HEMATOLOGY 3 1268 1270 N PROV1285 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER_CFR 493.1421(O) TO PERFORM HEMATOLOGY TESTS, WHO ARE DIRECTORS WITH A BS IN BIOLOGY, IMMUNOLOGY OR MICRO- BIOLOGY, AND HAVE 6 YEARS EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-HEM TECH SUPER - BA/BS IMMUNOHEM 3 1271 1273 N PROV1290 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(R) TO PERFORM BLOOD GROUPING TESTS, WHO ARE DIRECTORS WITH A BS IN BIOLOGY, IMMUNOLOGY OR MICRO- BIOLOGY, AND 6 YEARS EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-IMHE TECH SUPER - BA/BS IMMUNOLOGY 3 1274 1276 N PROV1295 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(P) TO PERFORM DIAGNOSTIC IMMUNOLOGY TESTS, WHO ARE DIRECTORS WITH A BS IN BIOLOGY, CHEMISTRY, IMMU- NOLOGY OR MICROBIOLOGY, AND HAVE 6 YEARS EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-IMM TECH SUPER - BA/BS MICROBIO 3 1277 1279 N PROV1300 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(N) TO PERFORM MICROBIOLOGY TESTS WHO ARE DIRECTORS WITH A BS IN BIOLOGY AND 6 YEARS MICROBIOLOGY EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-MICR TECH SUPER - BA/BS RADIOBIO 3 1280 1282 N PROV1305 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(Q) TO PERFORM RADIOBIOASSAY TESTS WHO ARE DIRECTORS WITH A BS IN CHEMICAL, PHYSICAL OR BIOLOGICAL SCIENCE AND HAVE 6 YEARS EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-RADI * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 13 CLIA67 LABORATORIES, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TECH SUPER - BA/BS SPEC EXP 3 1283 1285 N PROV1280 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(T) TO PERFORM SPECIFIC LAB TESTS WHO ARE DIRECTORS WITH A BS IN MEDICAL TECHNOLOGY AND HAVE 6 YEARS SPECIALIZED EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-EXP TECH SUPER - CLINICAL CHEMISTRY 3 1286 1288 N PROV1310 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(D) TO PERFORM TESTS IN CHEM UNDER THE SUP OF A BOARD CERT MD OR HAVE EQUIV QUALIFS OR HAVE DOCT/MAST DEGREE IN CHEM AND 4 YRS EXP IN CLINICAL CHEMISTRY COBOL NAME: NUM-TECH-SUP-CHEMISTRY TECH SUPER - CYTOGENETICS 3 1289 1291 N PROV1315 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(K) TO PERFORM IN CLINICAL CYTOGENETICS WHO ARE DIRECTORS WITH A DOCTORAL DEGREE IN BIOLOGY OR PHYSICIANS AND HAVE 4 YEARS EXPERIENCE IN GENETICS COBOL NAME: NUM-TECH-SUP-CYTOGEN TECH SUPER - CYTOLOGY 3 1292 1294 N PROV1320 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(F) TO PERFORM CYTOLOGY TESTS UNDER THE SUPERVISION OF A BOARD CERTIFIED PHYSICIAN OR WHO POSSESS EQUIVALENT QUALIFICATIONS COBOL NAME: NUM-TECH-SUP-CYTOLOGY TECH SUPER - DIAGNOSTIC IMMUN 3 1295 1297 N PROV1345 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(C) TO PERFORM TESTS IN DIAGNOSTIC IMMUN- OLOGY UNDER THE SUP OF A BOARD CERT MD OR HAVE EQUIV QUALIFS OR HAVE DOCT/MAST DEGREE IN RELATED SCIENCES COBOL NAME: NUM-TECH-SUP-IMMUNOL TECH SUPER - HEMATOLOGY 3 1298 1300 N PROV1330 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(E) TO PERFORM HEMATOLOGY TESTS UNDER SUPERVISION OF A BOARD CERT MD OR WHO POSSESS BS OR MS DEGREES IN RELATED SCIENCES AND 4 YRS HEMATOLOGY EXPER. COBOL NAME: NUM-TECH-SUP-HEMATOLOGY TECH SUPER - HISTO PATHOLOGY 3 1301 1303 N PROV1325 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(G) TO PERFORM TESTS IN HISTOPATHOLOGY UNDER THE SUPERVISION OF A BOARD CERTIFIED MD OR WHO POSSESS EQUIVALENT QUALIFICATIONS COBOL NAME: NUM-TECH-SUP-DERMATOLGY TECH SUPER - HISTOCOMPATIBILITY 3 1304 1306 N PROV1335 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(J)TO PERFORM TESTS IN HISTO UNDER SUP OF MD OR WHO POSSESS DOCT DEGREES OR ARE MD'S WITH 4 YRS EXP IN IMMUNOLOGY INCLUDING 2 YRS OF HISTO TESTING COBOL NAME: NUM-TECH-SUP-HISTOCOM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 14 CLIA67 LABORATORIES, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TECH SUPER - IMMUNOHEMATOLOGY 3 1307 1309 N PROV1340 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(L) TO PERFORM TESTS IN IMMUNOHEMATOLOGY UNDER SUP OF A BOARD CERT MD OR HAVE EQUIV QUALIFS OR ARE PHYSICIANS WITH 2 YRS EXP IN IMMUNOHEMATOLOGY COBOL NAME: NUM-TECH-SUP-IMMUNOHEM TECH SUPER - MICROBIOLOGY 3 1310 1312 N PROV1350 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(B) TO PERFORM MICRO TESTS UNDER SUPERV OF A BOARD CERT MD, OR WHO HOLD DOCTORAL OR MASTER DEGREES IN MICRO AND HAVE 4 YRS EXP IN CLINICAL MICROBIOLOGY COBOL NAME: NUM-TECH-SUP-MICROBIO TECH SUPER - ORAL PATHOLOGY 3 1313 1315 N PROV1355 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(H) TO PERFORM TESTS IN ORAL PATHOLOGY UNDER SUPERVISION OF A BOARD CERT MD OR WHO HAVE EQUIVALENT QUALIFICATIONS COBOL NAME: NUM-TECH-SUP-ORAL-PATH TECH SUPER - PATHOLOGIST 3 1316 1318 N PROV1360 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(A) TO PERFORM ALL BUT HISTOCOMPATIBILITY AND CLINICAL CYTOGENETICS WHO ARE MD'S CERT IN BOTH ANATOMICAL AND CLINICAL PATH OR HAVE EQUIV QUALIFICATNS COBOL NAME: NUM-TECH-SUP-PATHOLOGY TECH SUPER - PHS EXAM 3 1319 1321 N PROV1365 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(M) WITH SATISFACTORY GRADES IN EXAMINATIONS CONDUCTED BY THE PUBLIC HEALTH SERVICE. COBOL NAME: NUM-TECH-SUP-PHS-EXAM TECH SUPER - RADIOBIOASSAY 3 1322 1324 N PROV1370 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(I) WHO ARE BOARD CERT MD'S OR WHO HAVE A DOCTORATE/MASTERS/BACH DEGREE IN RELATED SCIENCES OR ARE PHYSICIANS WITH 4 YEARS EXP IN RADIOBIOASSAY COBOL NAME: NUM-TECH-SUP-RADIOBIO TECHNICIAN TRAINEES 3 1325 1327 N PROV1375 THE NUMBER OF TECHNICIAN TRAINEES IN LABORATORIES WHO ARE HIGH SCHOOL GRADUATES AND WHO ARE RECEIVING THE REQUIRED 2 YEARS LAB EXPERIENCE AND ARE PARTICIPATING IN A STRUCTURED TRAINING PROGRAM.(CFR 493.1402) COBOL NAME: NUM-TECH-TRAINEES TECHNICIANS - GRANDFATHERED 3 1328 1330 N PROV1245 THE NUMBER OF TECHNICIANS QUALIFIED UNDER CFR 493.1441(B)(5) WHO WAS PERFORMING THE DUTIES OF A LAB TECHNICIAN BETWEEN 7/1/61 & 1/1/68 AND HAS AT LEAST 5 YEARS EXPERIENCE PRIOR TO 1/1/68. COBOL NAME: NUM-TECH-GRFATHER * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 15 CLIA67 LABORATORIES, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TECHNICIANS - MILITARY 3 1331 1333 N PROV1260 THE NUMBER OF TECHNICIANS QUALIFIED UNDER CFR 493.1441(B)(4) WHO COMPLETED AN OFFICIAL MILITARY MEDICAL LABORATORY PROCEDURES COURSE OF AT LEAST 50 WEEKS DURATION. COBOL NAME: NUM-TECH-MILITARY TECHNICIANS - PROFICIENCY EXAM 3 1334 1336 N PROV1265 THE NUMBER OF TECHNICIANS QUALIFIED UNDER CFR 493.1441(B)(6) WHO ACHIEVED A SATISFACTORY GRADE IN AN APPROVED PROFICIENCY EXAMINATION PRIOR TO 12/31/77. COBOL NAME: NUM-TECH-PES-EXAM TECHNICIANS-AA PLUS 60 CREDIT HRS 3 1337 1339 N PROV1380 THE NUMBER OF LABORATORY TECHNICIANS WHO HAVE COMPLETED EITHER 60 HOURS OF ACADEMIC CREDIT OR HAVE ASSOCIATE DEGREES IN A COURSE OF STUDY THAT INCLUDES MEDICAL LABORATORY TECHNIQUES (CFR 493.1441(B)(1). COBOL NAME: NUM-TECH-60-CREDITS TECHNICIANS-HIGH SCH + EXPERIENCE 3 1340 1342 N PROV1255 THE NUMBER OF TECHNICIANS QUALIFIED UNDER CFR 493.1441(B)(3) WHO ARE HIGH SCHOOL GRADUATES AND HAVE TWO YEARS OF PERTINENT LABORATORY EXPERIENCE. COBOL NAME: NUM-TECH-HS-AND-2YR TECHNICIANS-HIGH SCH + TRAINING 3 1343 1345 N PROV1250 THE NUMBER OF TECHNICIANS QUALIFIED UNDER CFR 493.1441(B)(2) WHO COMPLETED HIGH SCHOOL AND ONE YEAR IN A TECHNICIAN TRAINING PROGRAM. COBOL NAME: NUM-TECH-HS-AND-1YR TECHNOLOGIST - BACHELORS DEGREE 3 1346 1348 N PROV1385 THE NUMBER OF LAB TECHNOLOGISTS WHO HAVE EARNED BACHELOR'S DEGREES IN CHEMICAL, BIOLOGICAL, OR PHYSICAL SCIENCE AND HAVE ONE YEAR EXPERIENCE/TRAINING IN RELATED SPECIALTY (CFR 493.1433(B)(3)). COBOL NAME: NUM-TECHNOLO-BS-BA TECHNOLOGIST - BS MED TECH 3 1349 1351 N PROV1390 THE NUMBER OF TECHNOLOGISTS WHO HAVE EARNED BACHELOR'S DEGREES IN MEDICAL TECHNOLOGY (CFR 493.1433(B)(1)). COBOL NAME: NUM-TECHNOLO-BS-MT TECHNOLOGIST - GRANDFATHERED 3 1352 1354 N PROV1395 THE NUMBER OF TECHNOLOGISTS WHO QUALIFIED PRIOR TO JULY 1, 1971 & WHO WERE PERFORMING AS TECHNOLOGISTS BETWEEN 7/1/61 & 1/1/68 & HAVE AT LEAST TEN YEARS LAB EXPERIENCE PRIOR TO 1/1/68 (CFR 493.1433(B)(5)). COBOL NAME: NUM-TECHNOLO-GRFATHER TECHNOLOGIST - PROFICIENCY EXAM 3 1355 1357 N PROV1400 THE NUMBER OF TECHNOLOGISTS WHO HAVE ACHIEVED A SATISFACTORY GRADE IN A PROFICIENCY EXAM APPROVED BY THE SECRETARY (CFR 493.1433(B)(6)). COBOL NAME: NUM-TECHNOLO-PES-EXAM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 16 CLIA67 LABORATORIES, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TECHNOLOGIST - 90 HRS + EXP 3 1358 1360 N PROV1410 THE NUMBER OF TECHNOLOGISTS WHO HAVE COMPLETED THREE YEARS (90 SEMESTER HOURS) OF PERTINENT ACADEMIC STUDIES OUTLINED IN CFR 493.1433(B)(4) AND HAVE ONE YEAR OF LAB EXPERIENCE COBOL NAME: NUM-TECHNOLO-90CR-1YR TECHNOLOGIST - 90 HRS + TRAINING 3 1361 1363 N PROV1405 THE NUMBER OF TECHNOLOGISTS WHO HAVE COMPLETED THREE YEARS (90 SEMESTER HOURS) OF ACADEMIC STUDY AND COM- PLETED AT LEAST ONE YEAR TRAINING IN A SCHOOL OF MEDICAL TECHNOLOGY (CFR 493.1433(B)(2). COBOL NAME: NUM-TECHNOLO-3YR-1YR 010 HISTOCOMPATIBILITY 1 1364 1364 C PROV1865 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-010-HISTOCOMPAT VALUES: N NOT APPROVED Y APPROVED 010A TRANSPLANT 1 1365 1365 C PROV1870 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN THIS SUBSPECIALTY COBOL NAME: SC-010A-TRANSPLANT VALUES: N NOT APPROVED Y APPROVED 010B NON-TRANSPLANT 1 1366 1366 C PROV1875 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN THIS SUBSPECIALTY COBOL NAME: SC-010B-NON-TRANSPLANT VALUES: N NOT APPROVED Y APPROVED 100 MICROBIOLOGY 1 1367 1367 C PROV1880 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-100-MICROBIO VALUES: N NOT APPROVED Y APPROVED 110 BACTERIOLOGY 1 1368 1368 C PROV1885 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-110-BACTERIOLOGY VALUES: N NOT APPROVED Y APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 17 CLIA67 LABORATORIES, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 110C MYCOBACTERIOLOGY 1 1369 1369 C PROV1890 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN MYCOBACTERIOLOGY, WHICH IS WITHIN THE BACTERIOLOGY SUBSPECIALTY COBOL NAME: SC-110C-MYCOBACT VALUES: N NOT APPROVED Y APPROVED 120 MYCOLOGY 1 1370 1370 C PROV1895 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-120-MYCOLOGY VALUES: N NOT APPROVED Y APPROVED 130 PARASITOLOGY 1 1371 1371 C PROV1900 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-130-PARASITOLOGY VALUES: N NOT APPROVED Y APPROVED 140 VIROLOGY 1 1372 1372 C PROV1910 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-140-VIROLOGY VALUES: N NOT APPROVED Y APPROVED 150 OTHER MICROBIOLOGY 1 1373 1373 C PROV1915 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-150-OTHER-MICROBIO VALUES: N NOT APPROVED Y APPROVED 200 DIAGNOSTIC IMMUNOLOGY 1 1374 1374 C PROV1920 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-200-DIAG-IMMUNOL VALUES: N NOT APPROVED Y APPROVED 210 SYPHILIS 1 1375 1375 C PROV1925 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-210-SYPHILIS VALUES: N NOT APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 18 CLIA67 LABORATORIES, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME Y APPROVED 220 GEN IMMUNOLOGY 1 1376 1376 C PROV1930 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-220-GEN-IMMUNOL VALUES: N NOT APPROVED Y APPROVED 300 CHEMISTRY 1 1377 1377 C PROV1935 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-300-CHEMISTRY VALUES: N NOT APPROVED Y APPROVED 310 ROUTINE CHEMISTRY 1 1378 1378 C PROV1940 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-310-ROUTINE VALUES: N NOT APPROVED Y APPROVED 320 URINALYSIS 1 1379 1379 C PROV1945 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-320-URINALYSIS VALUES: N NOT APPROVED Y APPROVED 330 OTHER CHEMISTRY 1 1380 1380 C PROV1950 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-330-OTHER-CHEMISTRY VALUES: N NOT APPROVED Y APPROVED 330D ENDOCRINOLOGY 1 1381 1381 C PROV1955 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN ENDOCRINOLOGY, WHICH IS WITHIN THE OTHER CHEMISTRY SUBSPECIALTY COBOL NAME: SC-330D-ENDOCRINOLOGY VALUES: N NOT APPROVED Y APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 19 CLIA67 LABORATORIES, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 330E TOXICOLOGY 1 1382 1382 C PROV1960 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN TOXICOLOGY, WHICH IS WITHIN THE OTHER CHEMISTRY SUBSPECIALTY COBOL NAME: SC-330E-TOXICOLOGY VALUES: N NOT APPROVED Y APPROVED 400 HEMATOLOGY 1 1383 1383 C PROV1965 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-400-HEMATOLOGY VALUES: N NOT APPROVED Y APPROVED 500 IMMUNOHEMATOLOGY 1 1384 1384 C PROV1970 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-500-IMMUNOHEM VALUES: N NOT APPROVED Y APPROVED 510 ABO + RH GROUP 1 1385 1385 C PROV1975 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-510-ABO-RH-GROUP VALUES: N NOT APPROVED Y APPROVED 520 RH TITERS 1 1386 1386 C PROV1980 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-520-RH-TITERS VALUES: N NOT APPROVED Y APPROVED 530 COMPATIBILITY TEST 1 1387 1387 C PROV1985 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-530-CROSS-MATCH VALUES: N NOT APPROVED Y APPROVED 540 ANTIBODY DETECT + OTHER 1 1388 1388 C PROV1990 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-540-OTHER-IMMUNOHEM VALUES: N NOT APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 20 CLIA67 LABORATORIES, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME Y APPROVED 600 PATHOLOGY 1 1389 1389 C PROV1995 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-600-PATHOLOGY VALUES: N NOT APPROVED Y APPROVED 610 HISTOPATHOLOGY 1 1390 1390 C PROV2000 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-610-HISTOPATH VALUES: N NOT APPROVED Y APPROVED 620 ORAL PATHOLOGY 1 1391 1391 C PROV2005 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-620-ORAL VALUES: N NOT APPROVED Y APPROVED 630 CYTOLOGY 1 1392 1392 C PROV2010 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-630-CYTOLOGY VALUES: N NOT APPROVED Y APPROVED 800 RADIOBIOASSAY 1 1393 1393 C PROV2015 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-800-RADIOBIO VALUES: N NOT APPROVED Y APPROVED 900 CYTOGENETICS 1 1394 1394 C PROV2020 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY COBOL NAME: SC-900-CYTOGENETICS VALUES: N NOT APPROVED Y APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 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 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 CURRENT SURVEY DATE 6 62 67 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 2 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ELIGIBILITY CODE 1 68 68 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 38 69 106 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 5 107 111 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) 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 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 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 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 3 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 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 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 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) PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 129 138 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 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME REGION CODE 2 140 141 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 1 142 142 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 2 143 144 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 2 145 146 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 206 206 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 3 TERMINATION TYPE OF CONTROL 2 207 208 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ZIP CODE 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE MEDICARE OR MEDICAID VENDOR NUMBER 12 359 370 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 RELATED PROVIDER NUMBER 10 459 468 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: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 1 SCREENING MAMMOGRAPHY, CATEGORY = "20" (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 SCREENING MAMMOGRAPHY 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: 20 SCREENING MAMMOGRAPHY 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 2 SCREENING MAMMOGRAPHY, CATEGORY = "20" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 6 62 67 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 68 68 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 38 69 106 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 5 107 111 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) 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 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 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 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 3 SCREENING MAMMOGRAPHY, CATEGORY = "20" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 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 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00510 BLUE SHIELD (ALABAMA) 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 BLUE SHIELD (INDIANA) 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 BLUE SHIELD (KENTUCKY) 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 BLUE SHIELD (EMPIRE) 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) 00900 BLUE SHIELD (TEXAS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 SCREENING MAMMOGRAPHY, CATEGORY = "20" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 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) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 21200 MASSACHUSETTS/MAINE 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) PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 SCREENING MAMMOGRAPHY, CATEGORY = "20" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 129 138 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 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 140 141 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 1 142 142 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 2 143 144 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 SCREENING MAMMOGRAPHY, CATEGORY = "20" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 SCREENING MAMMOGRAPHY, CATEGORY = "20" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME WY WYOMING STATE CODE (SSA) 2 145 146 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 SCREENING MAMMOGRAPHY, CATEGORY = "20" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 9 SCREENING MAMMOGRAPHY, CATEGORY = "20" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF ACTION 1 206 206 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 2 207 208 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 OTHER ZIP CODE 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE ACCREDITATION INDICATOR 1 235 235 C PROV0010 INDICATES THE ORGANIZATION THAT IS RESPONSIBLE FOR THE ACCREDITATION OF THE PROVIDER. COBOL NAME: ACCRED-STAT VALUES: 1 AMERICAN COLLEGE OF RADIOLOGY RELATED PROVIDER NUMBER 10 459 468 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: 10/04/94 1DATE: 01/02/95 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 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 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 13 40 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 41 41 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 42 42 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 43 45 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 46 55 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 56 61 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 CURRENT SURVEY DATE 6 62 67 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 2 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ELIGIBILITY CODE 1 68 68 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 38 69 106 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 5 107 111 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) 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 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 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 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 3 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) 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 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 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) PARTICIPATION DATE 6 112 117 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 118 123 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 124 128 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 129 138 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 1 139 139 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 4 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME REGION CODE 2 140 141 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 1 142 142 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 2 143 144 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 5 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 2 145 146 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 6 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 7 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME STATES REGION CODE 3 147 149 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 150 187 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 188 197 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 198 199 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE 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 20 NOTIFICATION BANKRUPTCY TERMINATION DATE/EXPIRATION DATE 1 6 200 205 C PROV4500 DATE THE NON CLIA88 PROVIDER HAS BEEN TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 206 206 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 3 TERMINATION TYPE OF CONTROL 2 207 208 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. * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/04/94 1DATE: 01/02/95 POS RECORD LAYOUT PAGE: 8 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ZIP CODE 5 209 213 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 214 215 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 216 218 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 219 221 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 222 222 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE MEDICARE OR MEDICAID VENDOR NUMBER 12 359 370 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 RELATED PROVIDER NUMBER 10 459 468 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 1736 1736 C PROV3710 INDICATED WHETHER THIS FQHC IS FEDERALLY FUNDED. COBOL NAME: FED-FUNDED-FFHC VALUES: N NO Y YES FQHC APPROVED RHC PROVIDER # 6 1737 1742 C PROV3705 APPROVED FQHC'S RELATED RHC PROVIDER NUMBER. COBOL NAME: APPROVED-RHC-PROV-NUM FQHC APPROVED RURAL HEALTH CLINIC 1 1743 1743 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: 10/04/94