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 = 01/04/2005 * * * ********************************************* 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 1 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 SHORT TERM 02 LONG TERM 03 RELIGIOUS NONMEDICAL HEALTH CARE INSTITUTIONS 04 PSYCHIATRIC 05 REHABILITATION 06 CHILDRENS' 07 ALCOHOL/DRUG 08 PPS EXEMPT REHABILITATION UNIT 09 PPS EXEMPT PSYCHIATRIC UNIT 11 CRITICAL ACCESS HOSPITALS CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 01 HOSPITALS CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 2 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 BLUE CROSS (INDIANA) 00131 ADMINISTAR FEDERAL (CHICAGO) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 3 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 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) 00452 UNITED GOVT SERVICES 00454 USG CALIFORNIA 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 4 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 5 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 6 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 7 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATES REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 8 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP 5 VALIDATION (ACCRD) TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 VOLUNTARY NON-PROFIT - CHURCH 02 VOLUNTARY NON-PROFIT - PRIVATE 03 VOLUNTARY NON-PROFIT - OTHER 04 PROPRIETARY 05 GOVERNMENT - FEDERAL 06 GOVERNMENT - STATE 07 GOVERNMENT - LOCAL 08 GOV. - HOSP. DIST. OR AUTH. ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 9 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD ACCREDITATION EFFECTIVE DATE 8 274 281 C PROV0000 THE EFFECTIVE DATE OF THE CURRENT PERIOD OF ACCREDITATION BY THE JOINT COMMISSION ON ACCREDITATION OF HEALTH CARE ORGANIZATIONS (JCAHO) OR THE AMERICAN OSTEOPATHIC ASSOCIATION (AOA). COBOL NAME: ACCRED-EFF-DT ACCREDITATION EXPIRATION DATE 8 282 289 C PROV0005 THE EXPIRATION DATE OF THE CURRENT PERIOD OF ACCREDITATION BY THE JOINT COMMITTEE ON ACCREDITATION OF HEALTH CARE ORGANIZATIONS (JCAHO) OR THE AMERICAN OSTEOPATHIC ASSOCIATION (AOA). COBOL NAME: ACCRED-EXP-DT ACCREDITATION INDICATOR 1 290 290 C PROV0010 INDICATES THE ORGANIZATION THAT IS RESPONSIBLE FOR THE ACCREDITATION OF THE PROVIDER. COBOL NAME: ACCRED-STAT VALUES: 0 NONE 1 JCAHO 2 AOA 4 BOTH ALCOHOL/DRUG UNIT BEDS 3 291 293 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 8 294 301 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 1 302 302 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 1 303 303 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 10 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 8 304 311 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 4 312 315 N PROV0740 TOTAL NUMBER OF BEDS IN A FACILITY, INCLUDING THOSE IN NON-PARTICIPATING OR NON-LICENSED AREAS. COBOL NAME: NUM-BEDS BEDS - TOTAL CERTIFIED 4 316 319 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS CERTIFIED RN ANESTHETISTS 7.2 320 326 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 10 327 336 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 10 337 346 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 10 347 356 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 10 357 366 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 10 367 376 C PROV0150 NUMBER ASSIGNED TO A HOSPITAL LABORATORY LICENSED IN ACCORDANCE WITH THE CLINICAL LABORATORY IMPROVEMENT ACT (CLIA). COBOL NAME: CLIA-ID-NUM-E * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 11 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COMPLIANCE: LIFE SAFETY CODE 1 377 377 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 1 378 378 C PROV0280 INDICATES IF A WAIVER OF THE SCOPE OF SERVICES REQUIREMENT HAS BEEN RECOMMENDED FOR A HOSPITAL. COBOL NAME: COMPL-SCOPE-OF-SERV VALUES: 1 WAIVER RECOMMENDED COMPLIANCE: TECHNICAL PERSONNEL 1 379 379 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 1 380 380 C PROV0290 INDICATES IF A WAIVER OF THE 24 HOUR REGISTERED NURSE REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-24-HR-RN VALUES: 1 WAIVER RECOMMENDED CURRENT SURVEY EVER ACCREDITED 1 381 381 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 1 382 382 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 1 383 383 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 12 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME DATE OF VALIDATION SURVEY 8 384 391 C PROV0450 DATE A VALIDATION SURVEY IS PERFORMED BY THE STATE AGENCY IN A JCAH OR AOA ACCREDITED HOSPITAL. COBOL NAME: DT-VALID-SURVEY DIETICIANS 7.2 392 398 N PROV0820 NUMBER OF FULL-TIME EQUIVALENT DIETICIANS EMPLOYED BY A FACILITY. COBOL NAME: NUM-DIETICIANS FISCAL YEAR ENDING DATE 4 399 402 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT INHALATION THERAPISTS 7.2 403 409 N PROV0950 NUMBER OF FULLTIME EQUIVALENT INHALATION THERAPISTS EMPLOYED BY A HOSPITAL. COBOL NAME: NUM-INHAL-THERAPY LICENSED PRACT/VOCAT NURSES 7.2 410 416 N PROV0955 NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL OR VOCATIONAL NURSES EMPLOYED BY A FACILITY. COBOL NAME: NUM-LPN-LVN MEDICAL SCHOOL AFFILIATION 1 417 417 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 MEETS 1861 DEFINITION 1 418 418 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 7.2 419 425 N PROV1050 THE NUMBER OF FULL TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-OCCUP-THERAPISTS OTHER PERSONNEL 7.2 426 432 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL PARTICIPATING CODE (Y,N) 1 433 433 C PROV1575 THIS CODE INDICATES WHETHER A PROVIDER IS PARTICIPATING IN THE MEDICAID OR MEDICARE PROGRAM. COBOL NAME: PARTICIPATING-CD VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 13 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME N NON-PARTICIPATING PROVIDER Y PARTICIPATING PROVIDER PHYSICAL THERAPISTS 7.2 434 440 N PROV1125 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS-THERAPY PHYSICIAN ASSISTANTS 7.2 441 447 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 6 448 453 C PROV1520 A PROVIDER NUMBER PREVIOUSLY ASSIGNED TO A PPS EXEMPT PROVIDER OR UNIT. COBOL NAME: OLD-PROV-NUM PROGRAM PARTICIPATION 1 454 454 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 3 455 457 N PROV1690 THE NUMBER OF BEDS IN A PPS EXEMPT PSYCHIATRIC UNIT OF A HOSPITAL. COBOL NAME: PSY-UNIT-BED-SZ PSYCHIATRIC UNIT EFFECTIVE DATE 8 458 465 C PROV1695 THE DATE A PSYCHIATRIC UNIT BECAME EXEMPT FROM THE PROSPECTIVE PAYMENT SYSTEM (PPS). COBOL NAME: PSY-UNIT-EFF-DT PSYCHIATRIC UNIT INDICATOR 1 466 466 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 1 467 467 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 14 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PSYCHIATRIC UNIT TERMINATION DATE 8 468 475 C PROV1710 THE DATE A PSYCHIATRIC UNIT IS NO LONGER EXEMPT FROM THE PROSPECTIVE PAYMENT SYSTEM. COBOL NAME: PSY-UNIT-TERM-DT REGIONAL OVERRIDE #1 (NUMBER BEDS) 1 476 476 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) 1 477 477 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) 1 478 478 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 7.2 479 485 N PROV1145 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PROFESSIONAL NURSES EMPLOYED BY A PROVIDER. COBOL NAME: NUM-REG-NURS REGISTERED PHARMACISTS 7.2 486 492 N PROV1100 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PHARMACISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHARMACIST-REG REHABILITATION UNIT BEDS 3 493 495 N PROV1730 THE NUMBER OF BEDS IN A PPS EXEMPT REHABILITATION UNIT OF A HOSPITAL. COBOL NAME: REHAB-UNIT-BED-SZ REHABILITATION UNIT EFFECT DATE 8 496 503 C PROV1735 THE DATE A REHABILITATION UNIT BECAME EXEMPT FROM THE PROSPECTIVE PAYMENT SYSTEM. COBOL NAME: REHAB-UNIT-EFF-DT REHABILITATION UNIT INDICATOR 1 504 504 C PROV1740 INDICATES IF A HOSPITAL HAS A PPS EXEMPT REHABILITATION UNIT. COBOL NAME: REHAB-UNIT-IND VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 15 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME Y REHAB UNIT REHABILITATION UNIT TERMINAT CODE 1 505 505 C PROV1745 THIS ELEMENT INDICATES THE REASON FOR A HOSPITAL REHABILITATION UNIT'S TERMINATION OF ITS EXCLUSION STATUS UNDER PROSPECTIVE PAYMENT SYSTEM. COBOL NAME: REHAB-UNIT-TERM-CD VALUES: 0 ACTIVE 1 VOLUNTARY-MERGER OR CLOSURE 2 VOLUNTARY-DISSATISFIED WITH REIMBURSEMENT 3 RISK OF INVOLUNTARY TERMINATION 4 VOLUNTARY-OTHER 5 FAILURE TO MEET HEALTH/SAFETY 6 FAILURE TO MEET AGREEMENT 7 PROVIDER STATUS CHANGE REHABILITATION UNIT TERMINAT DATE 8 506 513 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 10 514 523 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 1 524 524 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 1 525 525 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 1 526 526 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: 10/06/2004 1DATE: 01/04/2005 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 1 527 527 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) 7.2 528 534 N PROV1165 THE NUMBER OF FULL-TIME EQUIVALENT RESIDENTS (PHYSICIANS) EMPLOYED BY A HOSPITAL. COBOL NAME: NUM-RESID-PHYS SEPARATE COST ENTITY INDICATOR 1 535 535 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 1 536 536 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 1 537 537 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 1 538 538 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 1 539 539 C PROV5675 INDICIATES HOW BLOOD BANK SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-BLOOD-BANK VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 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 1 540 540 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 1 541 541 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 1 542 542 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 1 543 543 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 1 544 544 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 18 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: EMERGENCY SERVICES(ORGANIZED) 1 545 545 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 1 546 546 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 1 547 547 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 1 548 548 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 1 549 549 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 19 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: LABORATORY (ANATOMICAL) 1 550 550 C PROV2205 INDICATES HOW ANATOMICAL LABORATORY SERVICES ARE PROVIDED IN A HOSPITAL. COBOL NAME: SP-LABORATORY-ANATOM VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: LABORATORY (CLINICAL) 1 551 551 C PROV2210 INDICATES HOW CLINICAL LABORATORY SERVICES ARE PROVIDED IN A HOSPITAL. COBOL NAME: SP-LABORATORY-CLINIC VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: LONG TERM CARE UNIT 1 552 552 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 1 553 553 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 1 554 554 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 20 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: OBSTETRICS 1 555 555 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 1 556 556 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 1 557 557 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 1 558 558 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 1 559 559 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 21 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: ORGAN BANK 1 560 560 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 1 561 561 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 1 562 562 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 1 563 563 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 1 564 564 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 22 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHARMACY 1 565 565 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 1 566 566 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 1 567 567 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 1 568 568 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) 1 569 569 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) 1 570 570 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: 10/06/2004 1DATE: 01/04/2005 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 1 571 571 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 1 572 572 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 1 573 573 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 1 574 574 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 1 575 575 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 24 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SWING BED INDICATOR 1 576 576 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 1 577 577 C PROV2800 INDICATES THE SIZE OF A HOSPITAL PROVIDING SWING BED SERVICES. COBOL NAME: SWINGBED-SIZE-CD VALUES: 1 49 OR FEWER BEDS 2 50 TO 99 BEDS TYPE OF FACILITY 2 578 579 C PROV2890 INDICATES THE CATEGORY WHICH REPRESENTS THE TYPE OF FACILITY. COBOL NAME: TYPE-FACILITY VALUES: 01 SHORT - TERM 02 LONG - TERM 03 RELIGIOUS NONMEDICAL HEALTH CARE INSTITUTION 04 PSYCHIATRIC 05 REHABILITATION 06 CHILDRENS 07 ALCOHOL AND/OR DRUG HOSPITAL 11 CRITICAL ACCESS HOSPITALS TYPE OF NON-PARTICIPATING PROVIDER 1 580 580 C PROV0690 INDICATES WHETHER A NON-PARTICIPATING HOSPITAL IS FEDERAL OR OTHER THAN FEDERAL. COBOL NAME: NON-PARTICIPATING-TYPE VALUES: E EMERGENCY HOSPITAL NON-FEDERAL F EMERGENCY HOSPITAL FEDERAL SPEECH PATHOLOGISTS, AUDIOLOGISTS 7.2 1429 1435 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 1616 1622 N PROV1110 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIANS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS SRV: RESPIRATORY CARE 1 1665 1665 C PROV2455 INDICATES HOW RESPIRATORY CARE SERVICES ARE PROVIDED. COBOL NAME: SP-RESP-CARE VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 25 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT MEDICAL SOCIAL WORKERS 7.2 1742 1748 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 1 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 03 TITLE 18/19 CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 02 SNF/NF (DUALLY CERTIFIED) CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 2 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 BLUE CROSS (INDIANA) 00131 ADMINISTAR FEDERAL (CHICAGO) 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 3 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 00452 UNITED GOVT SERVICES 00454 USG CALIFORNIA 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 4 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 5 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 6 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 7 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATES REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 8 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 FOR PROFIT - INDIVIDUAL 02 FOR PROFIT - PARTNERSHIP 03 FOR PROFIT - CORPORATION 04 NONPROFIT - CHURCH RELATED 05 NONPROFIT - CORPORATION 06 NONPROFIT - OTHER 07 GOVERNMENT - STATE 08 GOVERNMENT - COUNTY 09 GOVERNMENT - CITY 10 GOVERNMENT - CITY/COUNTY 11 GOVERNMENT - HOSPITAL DISTRICT 12 GOVERNMENT - FEDERAL ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 9 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD BEDS - TOTAL 4 312 315 N PROV0740 TOTAL NUMBER OF BEDS IN A FACILITY, INCLUDING THOSE IN NON-PARTICIPATING OR NON-LICENSED AREAS. COBOL NAME: NUM-BEDS BEDS - TOTAL CERTIFIED 4 316 319 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS COMPLIANCE: LIFE SAFETY CODE 1 377 377 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: 1 WAIVER RECOMMENDED COMPLIANCE: 24 HR REGISTERED NURSE 1 380 380 C PROV0290 INDICATES IF A WAIVER OF THE 24 HOUR REGISTERED NURSE REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-24-HR-RN VALUES: 1 WAIVER RECOMMENDED FISCAL YEAR ENDING DATE 4 399 402 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT PROGRAM PARTICIPATION 1 454 454 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) 1 476 476 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) 1 477 477 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 10 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME VALUES: Y RECORD HAS BEEN APPROVED RELATED PROVIDER NUMBER 10 514 523 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 PROFESSIONAL - CONTRACT 7.2 581 587 N PROV0695 THE NUMBER OF FULL TIME EQUIVALENT ACTIVITIES PROFESSIONALS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-ACT-THER-CONTRACT ACTIVITY PROFESSIONAL - FULL TIME 7.2 588 594 N PROV0700 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES PROFESSIONALS EMPLOYED FULL TIME BY A FACILITY. COBOL NAME: NUM-ACT-THER-FULL-TIME ACTIVITY PROFESSIONAL - PART TIME 7.2 595 601 N PROV0705 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES PROFESSIONALS EMPLOYED PART TIME BY A FACILITY. COBOL NAME: NUM-ACT-THER-PART-TIME ADMINISTRATION - CONTRACT 7.2 602 608 N PROV0710 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-ADMN-CONTRACT ADMINISTRATOR - FULL TIME 7.2 609 615 N PROV0715 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF EMPLOYED ON A FULL TIME BASIS BY A FACILITY. COBOL NAME: NUM-ADMN-FULL-TIME ADMINISTRATOR - PART TIME 7.2 616 622 N PROV0720 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF EMPLOYED ON A PART-TIME BASIS BY A FACILITY. COBOL NAME: NUM-ADMN-PART-TIME BEDS - MEDICARE SNF 4 623 626 N PROV1445 NUMBER OF MEDICARE CERTIFIED SNF BEDS IN A FACILITY. COBOL NAME: NUM-T18-SNF-BEDS BEDS - NURSING FACILITY 4 627 630 N PROV1455 NUMBER OF MEDICAID CERTIFIED SKILLED NURSING CARE BEDS IN A FACILITY. COBOL NAME: NUM-T19-SNF-BEDS BEDS - SNF/NF 4 631 634 N PROV1450 NUMBER OF BEDS CERTIFIED FOR BOTH MEDICARE AND MEDICAID SKILLED NURSING CARE IN A LONG TERM CARE FACILITY. COBOL NAME: NUM-T1819-SNF-BEDS CERT NURSE AIDES - CONTRACT 7.2 635 641 N PROV1000 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-NURSE-AID-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 11 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CERT NURSE AIDES - FULL TIME 7.2 642 648 N PROV1005 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-AID-FULL-TIME CERT NURSE AIDES - PART TIME 7.2 649 655 N PROV1010 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-AID-PART-TIME CHRISTIAN SCIENCE INDICATOR 1 656 656 C PROV0110 INDICATES IF A PROVIDER IS A CHRISTIAN SCIENCE FACILITY COBOL NAME: CHRISTIAN-SCIENCE-IND VALUES: Y CHRISTIAN SCIENCE COMPLIANCE: BEDS PER ROOM WAIVER 1 657 657 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 1 658 658 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 1 659 659 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 7.2 660 666 N PROV0785 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DENTIST-CONTRACT DENTISTS - FULL TIME 7.2 667 673 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 7.2 674 680 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 7.2 681 687 N PROV0805 THE NUMBER OF FULL-TIME EQUIVALENT UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DIET-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 12 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME DIETITIANS - FULL TIME 7.2 688 694 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 7.2 695 701 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 1 702 702 C PROV0465 INDICATES IF A FACILITY USES RESIDENTS TO DEVELOP AND TEST CLINICAL TREATMENTS. COBOL NAME: EXPER-RESEARCH VALUES: Y YES FOOD SERVICE - CONTRACT 7.2 703 709 N PROV0860 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-FOOD-SRV-CONTRACT FOOD SERVICE - FULL TIME 7.2 710 716 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 7.2 717 723 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 7.2 724 730 N PROV0925 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-HOUSE-CONTRACT HOUSEKEEPING - FULL TIME 7.2 731 737 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 7.2 738 744 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 7.2 745 751 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 7.2 752 758 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 13 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME LPN/LVN - PART TIME 7.2 759 765 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 # 6 766 771 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 7.2 772 778 N PROV0960 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS UNDER CONTRCAT TO A FACILITY. COBOL NAME: NUM-MED-CONTRACT MEDICAL DIRECTOR - FULL TIME 7.2 779 785 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 7.2 786 792 N PROV0970 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MED-PART-TIME MEDICATION AIDES/TECHS-CONTRACT 7.2 793 799 N PROV5180 THE NUMBER OF FULL-TIMR EQUIVALENT MEDICATION AIDES/ TECHNICIANS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-MED-AID-CONTRACT MEDICATION AIDES/TECHS-FULL TIME 7.2 800 806 N PROV5170 THE NUMBER OF FULL-TIME EQUIVALENT MEDICATION AIDES/ TECHNICIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MED-AID-FULL-TIME MEDICATION AIDES/TECHS-PART TIME 7.2 807 813 N PROV5175 THE NUMBER OF FULL-TIME EQUIVALENT MEDICATION AIDES/ TECHNICIANS EMPLOYED BYA FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MED-AID-PART-TIME MENTAL HEALTH SERVICES - CONTRACT 7.2 814 820 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 7.2 821 827 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 14 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MENTAL HEALTH SERVICES - PART TIME 7.2 828 834 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 38 835 872 C PROV0680 THE NAME OF THE MULTI-FACILITY ORGANIZATION THAT OWNS THE FACILITY. COBOL NAME: NAME-MULT-FACL-ORG MULTI-FACILITY ORGANIZATION OWNED 1 873 873 C PROV0675 INDICATES IF A FACILITY IS OWNED BY AN ORGANIZATION THAT OWNS (OR LEASES) TWO OR MORE NURSING FACILITIES. COBOL NAME: MULT-FACL-ORG VALUES: Y YES NURSE AIDES IN TRNG - CONTRACT 7.2 874 880 N PROV5165 NUMBER OF FULL TIME EQUIVALENT NURSE AIDES IN TRAINING UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-AID-TRNG-CONTRACT NURSE AIDES IN TRNG-FULL TIME 7.2 881 887 N PROV5155 THE NUMBER OF FULL-TIME EQUIVALENT NURSE AIDES IN TRAINING EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-AID-TRNG-FULL-TIME NURSE AIDES IN TRNG-PART TIME 7.2 888 894 N PROV5160 THE NUMBER OF FULL-TIME EQUIVALENT NURSE AIDES IN TRAINING EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-AID-TRNG-PART-TIME NURSES WITH ADMIN DUTIES-CONTRACT 7.2 895 901 N PROV5150 THE NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-NURSE-ADM-CONTRACT NURSES WITH ADMIN DUTIES-FULL TIME 7.2 902 908 N PROV5135 THE NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-ADM-FULL-TIME NURSES WITH ADMIN DUTIES-PART TIME 7.2 909 915 N PROV5145 NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-ADM-PART-TIME OCCUP THERAPY AIDE - CONTRACT 7.2 916 922 N PROV1020 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-AID-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 15 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OCCUP THERAPY AIDE - FULL TIME 7.2 923 929 N PROV1025 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-AID-FULL-TIME OCCUP THERAPY AIDE - PART TIME 7.2 930 936 N PROV1030 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-AID-PART-TIME OCCUP THERAPY ASST - CONTRACT 7.2 937 943 N PROV5195 THE NUMBER OF FULL TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS UNDER CONTRCAT TO A FACILITY. COBOL NAME: NUM-OCC-ASST-CONTRACT OCCUP THERAPY ASST - FULL TIME 7.2 944 950 N PROV5185 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-ASST-FULL-TIME OCCUP THERAPY ASST - PART TIME 7.2 951 957 N PROV5190 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-ASST-PART-TIME OCCUPATIONAL THERAPIST - CONTRACT 7.2 958 964 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 7.2 965 971 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 7.2 972 978 N PROV1045 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-THER-PART-TIME ORGANIZED FAMILY GROUP 1 979 979 C PROV1535 INDICATES IF THE FACILITY HAS AN ORGANIZED GROUP OF FAMILY MEMBERS OF RESIDENTS. COBOL NAME: ORG-FAMILY-GRP VALUES: Y YES ORGANIZED RESIDENT GROUP 1 980 980 C PROV1540 INDICATES IF THE FACILITY HAS AN ORGANIZED RESIDENTS GROUP. COBOL NAME: ORG-RESID-GRP VALUES: Y YES OTHER - CONTRACT 7.2 981 987 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 16 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OTHER - FULL TIME 7.2 988 994 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 7.2 995 1001 N PROV3255 THE NUMBER OF FULL-TIME EQUIVALENT PERSONS NOT INCLUDED IN ANY OTHER CATEGORIES EMPLOYED BY THE FACILITY ON A PART-TIME BASIS. COBOL NAME: NUM-OTH-PART-TIME OTHER ACTIVITIES STAFF-CONTRACT 7.2 1002 1008 N PROV5270 NUMBER OF CONTRACT STAFF HOURS FOR OTHER ACTIVITIES. COBOL NAME: NUM-OTH-ACT-CONTRACT OTHER ACTIVITIES STAFF-FULL TIME 7.2 1009 1015 N PROV5260 NUMBER OF FULL-TIME STAFF HOURS FOR OTHER ACTIVITIES. COBOL NAME: NUM-OTH-ACT-FULL-TIME OTHER ACTIVITIES STAFF-PART TIME 7.2 1016 1022 N PROV5305 NUMBER OF PART TIME STAFF HOURS PROVIDED BY OTHER ACTIV ITIES STAFF. COBOL NAME: NUM-OTH-ACT-PART-TIME OTHER PHYSICIAN - CONTRACT 7.2 1023 1029 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 1030 1036 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 1037 1043 N PROV1070 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OTH-PHY-PART-TIME OTHR SOCIAL SERV STAFF-CONTRACT 7.2 1044 1050 N PROV5300 NUMBER OF CONTRACT STAFF HOURS PROVIDED BY OTHER SOCIAL SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-CONTRACT OTHR SOCIAL SERV STAFF-FULL TIME 7.2 1051 1057 N PROV5290 NUMBER OF FULL-TIME STAFF HOURS PROVIDED BY OTHER SOCIA L SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-FULL-TIME OTHR SOCIAL SERV STAFF-PART TIME 7.2 1058 1064 N PROV5295 NUMBER OF PART-TIME STAFF HOURS PROVIDED BY OTHER SOCIA L SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-PART-TIME PHARMACISTS - CONTRACT 7.2 1065 1071 N PROV1085 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-PHAR-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 17 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PHARMACISTS - FULL TIME 7.2 1072 1078 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 1079 1085 N PROV1095 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-PHAR-PART-TIME PHYS THER ASST - CONTRACT 7.2 1086 1092 N PROV5210 NUMBER OF CONTRACT STAFF HOURS FOR PHYSICAL THERAPY ASS ISTANTS. COBOL NAME: NUM-THER-ASST-CONTRACT PHYS THER ASST - FULL TIME 7.2 1093 1099 N PROV5200 NUMBER OF FULL-TIME STAFF HOURS FOR PHYSICAL THERAPY AS SISTANTS. COBOL NAME: NUM-THER-ASST-FULL-TIME PHYS THER ASST - PART TIME 7.2 1100 1106 N PROV5205 NUMBER OF PART-TIME STAFF HOURS FOR PHYSICAL THERAPY AS SISTANTS. COBOL NAME: NUM-THER-ASST-PART-TIME PHYSICAL THERAPISTS - CONTRACT 7.2 1107 1113 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 1114 1120 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 1121 1127 N PROV1440 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-PART-TIME PHYSICAL THERAPY AIDE - CONTRACT 7.2 1128 1134 N PROV1415 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-AID-CONTRACT PHYSICAL THERAPY AIDE - FULL TIME 7.2 1135 1141 N PROV1420 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-AID-FULL-TIME PHYSICAL THERAPY AIDE - PART TIME 7.2 1142 1148 N PROV1425 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-AID-PART-TIME PHYSICIAN EXTENDER - CONTRACT 7.2 1149 1155 N PROV3270 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIAN EXTENDERS UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-PHYS-EXT-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 18 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PHYSICIAN EXTENDER - FULL TIME 7.2 1156 1162 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 1163 1169 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 1170 1176 N PROV1130 THE NUMBER OF FULL TIME EQUIVALENT PODIATRISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-POD-CONTRACT PODIATRISTS - FULL TIME 7.2 1177 1183 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 1184 1190 N PROV1140 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-POD-PART-TIME PROVIDER BASED FACILITY 1 1191 1191 C PROV1675 INDICATES IF A LONG TERM CARE FACILITY IS PROVIDER BASED. COBOL NAME: PROV-BASED-FACILITY VALUES: Y HOSPITAL BASED REGISTERED NURSE - CONTRACT 7.2 1192 1198 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 1199 1205 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 1206 1212 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 8 1213 1220 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 RN DIRECTOR OF NURSING - CONTRACT 7.2 1221 1227 N PROV5130 THE NUMBER OF FULL TIME EQUIVALENT RN DIRECTOR OF NURSI NG UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-RN-DON-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 19 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RN DIRECTOR OF NURSING - FULL TIME 7.2 1228 1234 N PROV5120 THE NUMBER OF FULL-TIME EQUIVALENT RN DIRECTOR OF NURSING EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-RN-DON-FULL-TIME RN DIRECTOR OF NURSING - PART TIME 7.2 1235 1241 N PROV5140 THE NUMBER OF FULL-TIME EQUIVALENT RN DIRECTOR OF NURSING EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-RN-DON-PART-TIME SOCIAL WORKER - CONTRACT 7.2 1242 1248 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 1249 1255 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 1256 1262 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 1263 1265 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 1266 1268 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 1269 1271 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 1272 1274 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 1275 1277 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 1278 1280 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 1281 1283 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 20 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPECIAL CARE BEDS-SPEC REHAB 3 1284 1286 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 1287 1289 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 1290 1296 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 1297 1303 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 1304 1310 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 1311 1311 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 1312 1312 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 1313 1313 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 1314 1314 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 21 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME Y SERVICE IS PROVIDED SRV: BLOOD ADMIN-ONSITE-NONRES 1 1315 1315 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 1316 1316 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 1317 1317 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 1318 1318 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 1319 1319 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 1320 1320 C PROV3435 INDICATES IF DENTAL SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-DENTAL-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DENTAL-ONSITE-NON RESIDENTS 1 1321 1321 C PROV3430 INDICATES IF DENTAL SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-DENTAL-ON-NON-RES VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 22 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DENTAL-ONSITE-RESIDENTS 1 1322 1322 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 1323 1323 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 1324 1324 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 1325 1325 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 1326 1326 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 1327 1327 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 23 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: HOUSEKEEPING-ONSITE-RESIDENTS 1 1328 1328 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 1329 1329 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 1330 1330 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 1331 1331 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 1332 1332 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 1333 1333 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 1334 1334 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 24 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: OCCUP THER-OFFSITE-RESIDENTS 1 1335 1335 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 1336 1336 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 1337 1337 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: OTH ACTIVITIES-OFFSITE TO RES 1 1338 1338 C PROV5255 FIELD 3 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF OFFSITE TO RESIDENTS. COBOL NAME: SP-OTH-ACT-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH ACTIVITIES-ONSITE NONRES 1 1339 1339 C PROV5250 FIELD 2 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF ONSITE TO NONRESIDENTS. COBOL NAME: SP-OTH-ACT-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH ACTIVITIES-ONSITE RES 1 1340 1340 C PROV5245 FIELD 1 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF ONSITE TO RESIDENTS. COBOL NAME: SP-OTH-ACT-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-OFFSITE TO RES 1 1341 1341 C PROV5285 FIELD 3 - INDICATES SERVICES PROVIDED BY OTHER SOCIAL S ERVICES STAFF OFFSITE TO RESIDENTS. COBOL NAME: SP-OTH-SOC-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 25 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: OTH SOC SRV-ONSITE TO NONRES 1 1342 1342 C PROV5280 INDICATES IF OTHER SOCIAL SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-OTH-SOC-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-ONSITE TO RES 1 1343 1343 C PROV5275 FIELD 1 - INDICATES SERVICES PROVIDED BY SOCIAL SERVICE S STAFF ONSITE TO RESIDENTS. COBOL NAME: SP-OTH-SOC-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHARMACY-OFFSITE-RESIDENTS 1 1344 1344 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 1345 1345 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 1346 1346 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 1347 1347 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 1348 1348 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 26 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHYS EXTENDER-ONSITE-RESIDENT 1 1349 1349 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 1350 1350 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 1351 1351 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 1352 1352 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 1353 1353 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 1354 1354 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 1355 1355 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 27 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PODIATRY-OFFSITE-RESIDENTS 1 1356 1356 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 1357 1357 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 1358 1358 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 1359 1359 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 1360 1360 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 1361 1361 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 1362 1362 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 28 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: SPEECH PATH-ONSITE-NON RESID 1 1363 1363 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 1364 1364 C PROV3410 INDICATES IF SPEECH/LANGUAGE PATHOLOGY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-SPEECH-PH-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: THER REC SPEC-OFFSITE TO RES 1 1365 1365 C PROV5225 INDICATES IF THERAPEUTIC RECRECATION SPECIALIST SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-THER-REC-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: THER REC SPEC-ONSITE-NONRES 1 1366 1366 C PROV5220 INDICATES IF THERAPEUTIC RECREATION SPECIALIST SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-THER-REC-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: THER REC SPEC-ONSITE-RESIDENT 1 1367 1367 C PROV5215 INDICATES IF THERAPEUTIC RECREATION SPECIALIST SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-THER-REC-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: VOCATIONAL-OFFSITE-RESIDENTS 1 1368 1368 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 1369 1369 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 29 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: VOCATIONAL-ONSITE-RESIDENTS 1 1370 1370 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 1371 1371 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 1372 1372 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 SRV: XRAY-ONSITE-RESIDENTS 1 1373 1373 C PROV3500 INDICATES IF DIAGNOSTIC XRAY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-DIAG-XRAY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED THER REC SPEC - CONTRACT 7.2 1374 1380 N PROV5240 NUMBER OF CONTRACT STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-CONTRACT THER REC SPEC - FULL TIME 7.2 1381 1387 N PROV5230 NUMBER OF FULL-TIME STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-FULL-TIME THER REC SPEC - PART TIME 7.2 1388 1394 N PROV5235 NUMBER OF PART-TIME STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 1 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 03 TITLE 18/19 CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 03 SNF/NF (DISTINCT PART) CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 2 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 BLUE CROSS (INDIANA) 00131 ADMINISTAR FEDERAL (CHICAGO) 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 3 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 00452 UNITED GOVT SERVICES 00454 USG CALIFORNIA 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 4 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 5 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 6 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 7 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATES REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 8 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 FOR PROFIT - INDIVIDUAL 02 FOR PROFIT - PARTNERSHIP 03 FOR PROFIT - CORPORATION 04 NONPROFIT - CHURCH RELATED 05 NONPROFIT - CORPORATION 06 NONPROFIT - OTHER 07 GOVERNMENT - STATE 08 GOVERNMENT - COUNTY 09 GOVERNMENT - CITY 10 GOVERNMENT - CITY/COUNTY 11 GOVERNMENT - HOSPITAL DISTRICT 12 GOVERNMENT - FEDERAL ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 9 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD BEDS - TOTAL 4 312 315 N PROV0740 TOTAL NUMBER OF BEDS IN A FACILITY, INCLUDING THOSE IN NON-PARTICIPATING OR NON-LICENSED AREAS. COBOL NAME: NUM-BEDS BEDS - TOTAL CERTIFIED 4 316 319 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS COMPLIANCE: LIFE SAFETY CODE 1 377 377 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: 1 WAIVER RECOMMENDED COMPLIANCE: 24 HR REGISTERED NURSE 1 380 380 C PROV0290 INDICATES IF A WAIVER OF THE 24 HOUR REGISTERED NURSE REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-24-HR-RN VALUES: 1 WAIVER RECOMMENDED FISCAL YEAR ENDING DATE 4 399 402 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT PROGRAM PARTICIPATION 1 454 454 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) 1 476 476 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) 1 477 477 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 10 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME VALUES: Y RECORD HAS BEEN APPROVED RELATED PROVIDER NUMBER 10 514 523 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 PROFESSIONAL - CONTRACT 7.2 581 587 N PROV0695 THE NUMBER OF FULL TIME EQUIVALENT ACTIVITIES PROFESSIONALS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-ACT-THER-CONTRACT ACTIVITY PROFESSIONAL - FULL TIME 7.2 588 594 N PROV0700 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES PROFESSIONALS EMPLOYED FULL TIME BY A FACILITY. COBOL NAME: NUM-ACT-THER-FULL-TIME ACTIVITY PROFESSIONAL - PART TIME 7.2 595 601 N PROV0705 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES PROFESSIONALS EMPLOYED PART TIME BY A FACILITY. COBOL NAME: NUM-ACT-THER-PART-TIME ADMINISTRATION - CONTRACT 7.2 602 608 N PROV0710 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-ADMN-CONTRACT ADMINISTRATOR - FULL TIME 7.2 609 615 N PROV0715 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF EMPLOYED ON A FULL TIME BASIS BY A FACILITY. COBOL NAME: NUM-ADMN-FULL-TIME ADMINISTRATOR - PART TIME 7.2 616 622 N PROV0720 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF EMPLOYED ON A PART-TIME BASIS BY A FACILITY. COBOL NAME: NUM-ADMN-PART-TIME BEDS - MEDICARE SNF 4 623 626 N PROV1445 NUMBER OF MEDICARE CERTIFIED SNF BEDS IN A FACILITY. COBOL NAME: NUM-T18-SNF-BEDS BEDS - NURSING FACILITY 4 627 630 N PROV1455 NUMBER OF MEDICAID CERTIFIED SKILLED NURSING CARE BEDS IN A FACILITY. COBOL NAME: NUM-T19-SNF-BEDS BEDS - SNF/NF 4 631 634 N PROV1450 NUMBER OF BEDS CERTIFIED FOR BOTH MEDICARE AND MEDICAID SKILLED NURSING CARE IN A LONG TERM CARE FACILITY. COBOL NAME: NUM-T1819-SNF-BEDS CERT NURSE AIDES - CONTRACT 7.2 635 641 N PROV1000 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-NURSE-AID-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 11 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CERT NURSE AIDES - FULL TIME 7.2 642 648 N PROV1005 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-AID-FULL-TIME CERT NURSE AIDES - PART TIME 7.2 649 655 N PROV1010 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-AID-PART-TIME CHRISTIAN SCIENCE INDICATOR 1 656 656 C PROV0110 INDICATES IF A PROVIDER IS A CHRISTIAN SCIENCE FACILITY COBOL NAME: CHRISTIAN-SCIENCE-IND VALUES: Y CHRISTIAN SCIENCE COMPLIANCE: BEDS PER ROOM WAIVER 1 657 657 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 1 658 658 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 1 659 659 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 7.2 660 666 N PROV0785 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DENTIST-CONTRACT DENTISTS - FULL TIME 7.2 667 673 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 7.2 674 680 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 7.2 681 687 N PROV0805 THE NUMBER OF FULL-TIME EQUIVALENT UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DIET-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 12 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME DIETITIANS - FULL TIME 7.2 688 694 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 7.2 695 701 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 1 702 702 C PROV0465 INDICATES IF A FACILITY USES RESIDENTS TO DEVELOP AND TEST CLINICAL TREATMENTS. COBOL NAME: EXPER-RESEARCH VALUES: Y YES FOOD SERVICE - CONTRACT 7.2 703 709 N PROV0860 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-FOOD-SRV-CONTRACT FOOD SERVICE - FULL TIME 7.2 710 716 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 7.2 717 723 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 7.2 724 730 N PROV0925 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-HOUSE-CONTRACT HOUSEKEEPING - FULL TIME 7.2 731 737 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 7.2 738 744 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 7.2 745 751 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 7.2 752 758 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 13 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME LPN/LVN - PART TIME 7.2 759 765 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 # 6 766 771 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 7.2 772 778 N PROV0960 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS UNDER CONTRCAT TO A FACILITY. COBOL NAME: NUM-MED-CONTRACT MEDICAL DIRECTOR - FULL TIME 7.2 779 785 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 7.2 786 792 N PROV0970 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MED-PART-TIME MEDICATION AIDES/TECHS-CONTRACT 7.2 793 799 N PROV5180 THE NUMBER OF FULL-TIMR EQUIVALENT MEDICATION AIDES/ TECHNICIANS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-MED-AID-CONTRACT MEDICATION AIDES/TECHS-FULL TIME 7.2 800 806 N PROV5170 THE NUMBER OF FULL-TIME EQUIVALENT MEDICATION AIDES/ TECHNICIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MED-AID-FULL-TIME MEDICATION AIDES/TECHS-PART TIME 7.2 807 813 N PROV5175 THE NUMBER OF FULL-TIME EQUIVALENT MEDICATION AIDES/ TECHNICIANS EMPLOYED BYA FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MED-AID-PART-TIME MENTAL HEALTH SERVICES - CONTRACT 7.2 814 820 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 7.2 821 827 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 14 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MENTAL HEALTH SERVICES - PART TIME 7.2 828 834 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 38 835 872 C PROV0680 THE NAME OF THE MULTI-FACILITY ORGANIZATION THAT OWNS THE FACILITY. COBOL NAME: NAME-MULT-FACL-ORG MULTI-FACILITY ORGANIZATION OWNED 1 873 873 C PROV0675 INDICATES IF A FACILITY IS OWNED BY AN ORGANIZATION THAT OWNS (OR LEASES) TWO OR MORE NURSING FACILITIES. COBOL NAME: MULT-FACL-ORG VALUES: Y YES NURSE AIDES IN TRNG - CONTRACT 7.2 874 880 N PROV5165 NUMBER OF FULL TIME EQUIVALENT NURSE AIDES IN TRAINING UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-AID-TRNG-CONTRACT NURSE AIDES IN TRNG-FULL TIME 7.2 881 887 N PROV5155 THE NUMBER OF FULL-TIME EQUIVALENT NURSE AIDES IN TRAINING EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-AID-TRNG-FULL-TIME NURSE AIDES IN TRNG-PART TIME 7.2 888 894 N PROV5160 THE NUMBER OF FULL-TIME EQUIVALENT NURSE AIDES IN TRAINING EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-AID-TRNG-PART-TIME NURSES WITH ADMIN DUTIES-CONTRACT 7.2 895 901 N PROV5150 THE NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-NURSE-ADM-CONTRACT NURSES WITH ADMIN DUTIES-FULL TIME 7.2 902 908 N PROV5135 THE NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-ADM-FULL-TIME NURSES WITH ADMIN DUTIES-PART TIME 7.2 909 915 N PROV5145 NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-ADM-PART-TIME OCCUP THERAPY AIDE - CONTRACT 7.2 916 922 N PROV1020 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-AID-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 15 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OCCUP THERAPY AIDE - FULL TIME 7.2 923 929 N PROV1025 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-AID-FULL-TIME OCCUP THERAPY AIDE - PART TIME 7.2 930 936 N PROV1030 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-AID-PART-TIME OCCUP THERAPY ASST - CONTRACT 7.2 937 943 N PROV5195 THE NUMBER OF FULL TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS UNDER CONTRCAT TO A FACILITY. COBOL NAME: NUM-OCC-ASST-CONTRACT OCCUP THERAPY ASST - FULL TIME 7.2 944 950 N PROV5185 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-ASST-FULL-TIME OCCUP THERAPY ASST - PART TIME 7.2 951 957 N PROV5190 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-ASST-PART-TIME OCCUPATIONAL THERAPIST - CONTRACT 7.2 958 964 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 7.2 965 971 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 7.2 972 978 N PROV1045 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-THER-PART-TIME ORGANIZED FAMILY GROUP 1 979 979 C PROV1535 INDICATES IF THE FACILITY HAS AN ORGANIZED GROUP OF FAMILY MEMBERS OF RESIDENTS. COBOL NAME: ORG-FAMILY-GRP VALUES: Y YES ORGANIZED RESIDENT GROUP 1 980 980 C PROV1540 INDICATES IF THE FACILITY HAS AN ORGANIZED RESIDENTS GROUP. COBOL NAME: ORG-RESID-GRP VALUES: Y YES OTHER - CONTRACT 7.2 981 987 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 16 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OTHER - FULL TIME 7.2 988 994 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 7.2 995 1001 N PROV3255 THE NUMBER OF FULL-TIME EQUIVALENT PERSONS NOT INCLUDED IN ANY OTHER CATEGORIES EMPLOYED BY THE FACILITY ON A PART-TIME BASIS. COBOL NAME: NUM-OTH-PART-TIME OTHER ACTIVITIES STAFF-CONTRACT 7.2 1002 1008 N PROV5270 NUMBER OF CONTRACT STAFF HOURS FOR OTHER ACTIVITIES. COBOL NAME: NUM-OTH-ACT-CONTRACT OTHER ACTIVITIES STAFF-FULL TIME 7.2 1009 1015 N PROV5260 NUMBER OF FULL-TIME STAFF HOURS FOR OTHER ACTIVITIES. COBOL NAME: NUM-OTH-ACT-FULL-TIME OTHER ACTIVITIES STAFF-PART TIME 7.2 1016 1022 N PROV5305 NUMBER OF PART TIME STAFF HOURS PROVIDED BY OTHER ACTIV ITIES STAFF. COBOL NAME: NUM-OTH-ACT-PART-TIME OTHER PHYSICIAN - CONTRACT 7.2 1023 1029 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 1030 1036 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 1037 1043 N PROV1070 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OTH-PHY-PART-TIME OTHR SOCIAL SERV STAFF-CONTRACT 7.2 1044 1050 N PROV5300 NUMBER OF CONTRACT STAFF HOURS PROVIDED BY OTHER SOCIAL SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-CONTRACT OTHR SOCIAL SERV STAFF-FULL TIME 7.2 1051 1057 N PROV5290 NUMBER OF FULL-TIME STAFF HOURS PROVIDED BY OTHER SOCIA L SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-FULL-TIME OTHR SOCIAL SERV STAFF-PART TIME 7.2 1058 1064 N PROV5295 NUMBER OF PART-TIME STAFF HOURS PROVIDED BY OTHER SOCIA L SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-PART-TIME PHARMACISTS - CONTRACT 7.2 1065 1071 N PROV1085 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-PHAR-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 17 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PHARMACISTS - FULL TIME 7.2 1072 1078 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 1079 1085 N PROV1095 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-PHAR-PART-TIME PHYS THER ASST - CONTRACT 7.2 1086 1092 N PROV5210 NUMBER OF CONTRACT STAFF HOURS FOR PHYSICAL THERAPY ASS ISTANTS. COBOL NAME: NUM-THER-ASST-CONTRACT PHYS THER ASST - FULL TIME 7.2 1093 1099 N PROV5200 NUMBER OF FULL-TIME STAFF HOURS FOR PHYSICAL THERAPY AS SISTANTS. COBOL NAME: NUM-THER-ASST-FULL-TIME PHYS THER ASST - PART TIME 7.2 1100 1106 N PROV5205 NUMBER OF PART-TIME STAFF HOURS FOR PHYSICAL THERAPY AS SISTANTS. COBOL NAME: NUM-THER-ASST-PART-TIME PHYSICAL THERAPISTS - CONTRACT 7.2 1107 1113 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 1114 1120 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 1121 1127 N PROV1440 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-PART-TIME PHYSICAL THERAPY AIDE - CONTRACT 7.2 1128 1134 N PROV1415 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-AID-CONTRACT PHYSICAL THERAPY AIDE - FULL TIME 7.2 1135 1141 N PROV1420 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-AID-FULL-TIME PHYSICAL THERAPY AIDE - PART TIME 7.2 1142 1148 N PROV1425 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-AID-PART-TIME PHYSICIAN EXTENDER - CONTRACT 7.2 1149 1155 N PROV3270 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIAN EXTENDERS UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-PHYS-EXT-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 18 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PHYSICIAN EXTENDER - FULL TIME 7.2 1156 1162 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 1163 1169 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 1170 1176 N PROV1130 THE NUMBER OF FULL TIME EQUIVALENT PODIATRISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-POD-CONTRACT PODIATRISTS - FULL TIME 7.2 1177 1183 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 1184 1190 N PROV1140 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-POD-PART-TIME PROVIDER BASED FACILITY 1 1191 1191 C PROV1675 INDICATES IF A LONG TERM CARE FACILITY IS PROVIDER BASED. COBOL NAME: PROV-BASED-FACILITY VALUES: Y HOSPITAL BASED REGISTERED NURSE - CONTRACT 7.2 1192 1198 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 1199 1205 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 1206 1212 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 8 1213 1220 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 RN DIRECTOR OF NURSING - CONTRACT 7.2 1221 1227 N PROV5130 THE NUMBER OF FULL TIME EQUIVALENT RN DIRECTOR OF NURSI NG UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-RN-DON-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 19 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RN DIRECTOR OF NURSING - FULL TIME 7.2 1228 1234 N PROV5120 THE NUMBER OF FULL-TIME EQUIVALENT RN DIRECTOR OF NURSING EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-RN-DON-FULL-TIME RN DIRECTOR OF NURSING - PART TIME 7.2 1235 1241 N PROV5140 THE NUMBER OF FULL-TIME EQUIVALENT RN DIRECTOR OF NURSING EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-RN-DON-PART-TIME SOCIAL WORKER - CONTRACT 7.2 1242 1248 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 1249 1255 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 1256 1262 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 1263 1265 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 1266 1268 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 1269 1271 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 1272 1274 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 1275 1277 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 1278 1280 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 1281 1283 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 20 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPECIAL CARE BEDS-SPEC REHAB 3 1284 1286 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 1287 1289 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 1290 1296 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 1297 1303 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 1304 1310 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 1311 1311 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 1312 1312 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 1313 1313 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 1314 1314 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 21 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME Y SERVICE IS PROVIDED SRV: BLOOD ADMIN-ONSITE-NONRES 1 1315 1315 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 1316 1316 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 1317 1317 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 1318 1318 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 1319 1319 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 1320 1320 C PROV3435 INDICATES IF DENTAL SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-DENTAL-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DENTAL-ONSITE-NON RESIDENTS 1 1321 1321 C PROV3430 INDICATES IF DENTAL SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-DENTAL-ON-NON-RES VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 22 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DENTAL-ONSITE-RESIDENTS 1 1322 1322 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 1323 1323 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 1324 1324 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 1325 1325 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 1326 1326 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 1327 1327 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 23 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: HOUSEKEEPING-ONSITE-RESIDENTS 1 1328 1328 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 1329 1329 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 1330 1330 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 1331 1331 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 1332 1332 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 1333 1333 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 1334 1334 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 24 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: OCCUP THER-OFFSITE-RESIDENTS 1 1335 1335 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 1336 1336 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 1337 1337 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: OTH ACTIVITIES-OFFSITE TO RES 1 1338 1338 C PROV5255 FIELD 3 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF OFFSITE TO RESIDENTS. COBOL NAME: SP-OTH-ACT-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH ACTIVITIES-ONSITE NONRES 1 1339 1339 C PROV5250 FIELD 2 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF ONSITE TO NONRESIDENTS. COBOL NAME: SP-OTH-ACT-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH ACTIVITIES-ONSITE RES 1 1340 1340 C PROV5245 FIELD 1 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF ONSITE TO RESIDENTS. COBOL NAME: SP-OTH-ACT-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-OFFSITE TO RES 1 1341 1341 C PROV5285 FIELD 3 - INDICATES SERVICES PROVIDED BY OTHER SOCIAL S ERVICES STAFF OFFSITE TO RESIDENTS. COBOL NAME: SP-OTH-SOC-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 25 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: OTH SOC SRV-ONSITE TO NONRES 1 1342 1342 C PROV5280 INDICATES IF OTHER SOCIAL SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-OTH-SOC-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-ONSITE TO RES 1 1343 1343 C PROV5275 FIELD 1 - INDICATES SERVICES PROVIDED BY SOCIAL SERVICE S STAFF ONSITE TO RESIDENTS. COBOL NAME: SP-OTH-SOC-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHARMACY-OFFSITE-RESIDENTS 1 1344 1344 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 1345 1345 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 1346 1346 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 1347 1347 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 1348 1348 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 26 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHYS EXTENDER-ONSITE-RESIDENT 1 1349 1349 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 1350 1350 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 1351 1351 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 1352 1352 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 1353 1353 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 1354 1354 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 1355 1355 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 27 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PODIATRY-OFFSITE-RESIDENTS 1 1356 1356 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 1357 1357 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 1358 1358 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 1359 1359 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 1360 1360 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 1361 1361 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 1362 1362 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 28 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: SPEECH PATH-ONSITE-NON RESID 1 1363 1363 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 1364 1364 C PROV3410 INDICATES IF SPEECH/LANGUAGE PATHOLOGY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-SPEECH-PH-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: THER REC SPEC-OFFSITE TO RES 1 1365 1365 C PROV5225 INDICATES IF THERAPEUTIC RECRECATION SPECIALIST SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-THER-REC-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: THER REC SPEC-ONSITE-NONRES 1 1366 1366 C PROV5220 INDICATES IF THERAPEUTIC RECREATION SPECIALIST SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-THER-REC-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: THER REC SPEC-ONSITE-RESIDENT 1 1367 1367 C PROV5215 INDICATES IF THERAPEUTIC RECREATION SPECIALIST SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-THER-REC-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: VOCATIONAL-OFFSITE-RESIDENTS 1 1368 1368 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 1369 1369 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 29 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: VOCATIONAL-ONSITE-RESIDENTS 1 1370 1370 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 1371 1371 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 1372 1372 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 SRV: XRAY-ONSITE-RESIDENTS 1 1373 1373 C PROV3500 INDICATES IF DIAGNOSTIC XRAY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-DIAG-XRAY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED THER REC SPEC - CONTRACT 7.2 1374 1380 N PROV5240 NUMBER OF CONTRACT STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-CONTRACT THER REC SPEC - FULL TIME 7.2 1381 1387 N PROV5230 NUMBER OF FULL-TIME STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-FULL-TIME THER REC SPEC - PART TIME 7.2 1388 1394 N PROV5235 NUMBER OF PART-TIME STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 1 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 TITLE 18 ONLY CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 04 SKILLED NURSING FACILITIES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 2 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 BLUE CROSS (INDIANA) 00131 ADMINISTAR FEDERAL (CHICAGO) 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 3 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 00452 UNITED GOVT SERVICES 00454 USG CALIFORNIA 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 4 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 5 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 6 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 7 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATES REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 8 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 FOR PROFIT - INDIVIDUAL 02 FOR PROFIT - PARTNERSHIP 03 FOR PROFIT - CORPORATION 04 NONPROFIT - CHURCH RELATED 05 NONPROFIT - CORPORATION 06 NONPROFIT - OTHER 07 GOVERNMENT - STATE 08 GOVERNMENT - COUNTY 09 GOVERNMENT - CITY 10 GOVERNMENT - CITY/COUNTY 11 GOVERNMENT - HOSPITAL DISTRICT 12 GOVERNMENT - FEDERAL ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 9 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD BEDS - TOTAL 4 312 315 N PROV0740 TOTAL NUMBER OF BEDS IN A FACILITY, INCLUDING THOSE IN NON-PARTICIPATING OR NON-LICENSED AREAS. COBOL NAME: NUM-BEDS BEDS - TOTAL CERTIFIED 4 316 319 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS COMPLIANCE: LIFE SAFETY CODE 1 377 377 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: 1 WAIVER RECOMMENDED COMPLIANCE: 24 HR REGISTERED NURSE 1 380 380 C PROV0290 INDICATES IF A WAIVER OF THE 24 HOUR REGISTERED NURSE REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-24-HR-RN VALUES: 1 WAIVER RECOMMENDED FISCAL YEAR ENDING DATE 4 399 402 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT PROGRAM PARTICIPATION 1 454 454 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) 1 476 476 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) 1 477 477 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 10 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME VALUES: Y RECORD HAS BEEN APPROVED RELATED PROVIDER NUMBER 10 514 523 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 PROFESSIONAL - CONTRACT 7.2 581 587 N PROV0695 THE NUMBER OF FULL TIME EQUIVALENT ACTIVITIES PROFESSIONALS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-ACT-THER-CONTRACT ACTIVITY PROFESSIONAL - FULL TIME 7.2 588 594 N PROV0700 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES PROFESSIONALS EMPLOYED FULL TIME BY A FACILITY. COBOL NAME: NUM-ACT-THER-FULL-TIME ACTIVITY PROFESSIONAL - PART TIME 7.2 595 601 N PROV0705 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES PROFESSIONALS EMPLOYED PART TIME BY A FACILITY. COBOL NAME: NUM-ACT-THER-PART-TIME ADMINISTRATION - CONTRACT 7.2 602 608 N PROV0710 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-ADMN-CONTRACT ADMINISTRATOR - FULL TIME 7.2 609 615 N PROV0715 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF EMPLOYED ON A FULL TIME BASIS BY A FACILITY. COBOL NAME: NUM-ADMN-FULL-TIME ADMINISTRATOR - PART TIME 7.2 616 622 N PROV0720 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF EMPLOYED ON A PART-TIME BASIS BY A FACILITY. COBOL NAME: NUM-ADMN-PART-TIME BEDS - MEDICARE SNF 4 623 626 N PROV1445 NUMBER OF MEDICARE CERTIFIED SNF BEDS IN A FACILITY. COBOL NAME: NUM-T18-SNF-BEDS BEDS - NURSING FACILITY 4 627 630 N PROV1455 NUMBER OF MEDICAID CERTIFIED SKILLED NURSING CARE BEDS IN A FACILITY. COBOL NAME: NUM-T19-SNF-BEDS BEDS - SNF/NF 4 631 634 N PROV1450 NUMBER OF BEDS CERTIFIED FOR BOTH MEDICARE AND MEDICAID SKILLED NURSING CARE IN A LONG TERM CARE FACILITY. COBOL NAME: NUM-T1819-SNF-BEDS CERT NURSE AIDES - CONTRACT 7.2 635 641 N PROV1000 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-NURSE-AID-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 11 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CERT NURSE AIDES - FULL TIME 7.2 642 648 N PROV1005 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-AID-FULL-TIME CERT NURSE AIDES - PART TIME 7.2 649 655 N PROV1010 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-AID-PART-TIME CHRISTIAN SCIENCE INDICATOR 1 656 656 C PROV0110 INDICATES IF A PROVIDER IS A CHRISTIAN SCIENCE FACILITY COBOL NAME: CHRISTIAN-SCIENCE-IND VALUES: Y CHRISTIAN SCIENCE COMPLIANCE: BEDS PER ROOM WAIVER 1 657 657 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 1 658 658 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 1 659 659 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 7.2 660 666 N PROV0785 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DENTIST-CONTRACT DENTISTS - FULL TIME 7.2 667 673 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 7.2 674 680 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 7.2 681 687 N PROV0805 THE NUMBER OF FULL-TIME EQUIVALENT UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DIET-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 12 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME DIETITIANS - FULL TIME 7.2 688 694 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 7.2 695 701 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 1 702 702 C PROV0465 INDICATES IF A FACILITY USES RESIDENTS TO DEVELOP AND TEST CLINICAL TREATMENTS. COBOL NAME: EXPER-RESEARCH VALUES: Y YES FOOD SERVICE - CONTRACT 7.2 703 709 N PROV0860 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-FOOD-SRV-CONTRACT FOOD SERVICE - FULL TIME 7.2 710 716 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 7.2 717 723 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 7.2 724 730 N PROV0925 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-HOUSE-CONTRACT HOUSEKEEPING - FULL TIME 7.2 731 737 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 7.2 738 744 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 7.2 745 751 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 7.2 752 758 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 13 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME LPN/LVN - PART TIME 7.2 759 765 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 # 6 766 771 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 7.2 772 778 N PROV0960 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS UNDER CONTRCAT TO A FACILITY. COBOL NAME: NUM-MED-CONTRACT MEDICAL DIRECTOR - FULL TIME 7.2 779 785 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 7.2 786 792 N PROV0970 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MED-PART-TIME MEDICATION AIDES/TECHS-CONTRACT 7.2 793 799 N PROV5180 THE NUMBER OF FULL-TIMR EQUIVALENT MEDICATION AIDES/ TECHNICIANS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-MED-AID-CONTRACT MEDICATION AIDES/TECHS-FULL TIME 7.2 800 806 N PROV5170 THE NUMBER OF FULL-TIME EQUIVALENT MEDICATION AIDES/ TECHNICIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MED-AID-FULL-TIME MEDICATION AIDES/TECHS-PART TIME 7.2 807 813 N PROV5175 THE NUMBER OF FULL-TIME EQUIVALENT MEDICATION AIDES/ TECHNICIANS EMPLOYED BYA FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MED-AID-PART-TIME MENTAL HEALTH SERVICES - CONTRACT 7.2 814 820 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 7.2 821 827 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 14 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MENTAL HEALTH SERVICES - PART TIME 7.2 828 834 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 38 835 872 C PROV0680 THE NAME OF THE MULTI-FACILITY ORGANIZATION THAT OWNS THE FACILITY. COBOL NAME: NAME-MULT-FACL-ORG MULTI-FACILITY ORGANIZATION OWNED 1 873 873 C PROV0675 INDICATES IF A FACILITY IS OWNED BY AN ORGANIZATION THAT OWNS (OR LEASES) TWO OR MORE NURSING FACILITIES. COBOL NAME: MULT-FACL-ORG VALUES: Y YES NURSE AIDES IN TRNG - CONTRACT 7.2 874 880 N PROV5165 NUMBER OF FULL TIME EQUIVALENT NURSE AIDES IN TRAINING UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-AID-TRNG-CONTRACT NURSE AIDES IN TRNG-FULL TIME 7.2 881 887 N PROV5155 THE NUMBER OF FULL-TIME EQUIVALENT NURSE AIDES IN TRAINING EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-AID-TRNG-FULL-TIME NURSE AIDES IN TRNG-PART TIME 7.2 888 894 N PROV5160 THE NUMBER OF FULL-TIME EQUIVALENT NURSE AIDES IN TRAINING EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-AID-TRNG-PART-TIME NURSES WITH ADMIN DUTIES-CONTRACT 7.2 895 901 N PROV5150 THE NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-NURSE-ADM-CONTRACT NURSES WITH ADMIN DUTIES-FULL TIME 7.2 902 908 N PROV5135 THE NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-ADM-FULL-TIME NURSES WITH ADMIN DUTIES-PART TIME 7.2 909 915 N PROV5145 NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-ADM-PART-TIME OCCUP THERAPY AIDE - CONTRACT 7.2 916 922 N PROV1020 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-AID-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 15 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OCCUP THERAPY AIDE - FULL TIME 7.2 923 929 N PROV1025 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-AID-FULL-TIME OCCUP THERAPY AIDE - PART TIME 7.2 930 936 N PROV1030 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-AID-PART-TIME OCCUP THERAPY ASST - CONTRACT 7.2 937 943 N PROV5195 THE NUMBER OF FULL TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS UNDER CONTRCAT TO A FACILITY. COBOL NAME: NUM-OCC-ASST-CONTRACT OCCUP THERAPY ASST - FULL TIME 7.2 944 950 N PROV5185 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-ASST-FULL-TIME OCCUP THERAPY ASST - PART TIME 7.2 951 957 N PROV5190 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-ASST-PART-TIME OCCUPATIONAL THERAPIST - CONTRACT 7.2 958 964 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 7.2 965 971 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 7.2 972 978 N PROV1045 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-THER-PART-TIME ORGANIZED FAMILY GROUP 1 979 979 C PROV1535 INDICATES IF THE FACILITY HAS AN ORGANIZED GROUP OF FAMILY MEMBERS OF RESIDENTS. COBOL NAME: ORG-FAMILY-GRP VALUES: Y YES ORGANIZED RESIDENT GROUP 1 980 980 C PROV1540 INDICATES IF THE FACILITY HAS AN ORGANIZED RESIDENTS GROUP. COBOL NAME: ORG-RESID-GRP VALUES: Y YES OTHER - CONTRACT 7.2 981 987 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 16 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OTHER - FULL TIME 7.2 988 994 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 7.2 995 1001 N PROV3255 THE NUMBER OF FULL-TIME EQUIVALENT PERSONS NOT INCLUDED IN ANY OTHER CATEGORIES EMPLOYED BY THE FACILITY ON A PART-TIME BASIS. COBOL NAME: NUM-OTH-PART-TIME OTHER ACTIVITIES STAFF-CONTRACT 7.2 1002 1008 N PROV5270 NUMBER OF CONTRACT STAFF HOURS FOR OTHER ACTIVITIES. COBOL NAME: NUM-OTH-ACT-CONTRACT OTHER ACTIVITIES STAFF-FULL TIME 7.2 1009 1015 N PROV5260 NUMBER OF FULL-TIME STAFF HOURS FOR OTHER ACTIVITIES. COBOL NAME: NUM-OTH-ACT-FULL-TIME OTHER ACTIVITIES STAFF-PART TIME 7.2 1016 1022 N PROV5305 NUMBER OF PART TIME STAFF HOURS PROVIDED BY OTHER ACTIV ITIES STAFF. COBOL NAME: NUM-OTH-ACT-PART-TIME OTHER PHYSICIAN - CONTRACT 7.2 1023 1029 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 1030 1036 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 1037 1043 N PROV1070 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OTH-PHY-PART-TIME OTHR SOCIAL SERV STAFF-CONTRACT 7.2 1044 1050 N PROV5300 NUMBER OF CONTRACT STAFF HOURS PROVIDED BY OTHER SOCIAL SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-CONTRACT OTHR SOCIAL SERV STAFF-FULL TIME 7.2 1051 1057 N PROV5290 NUMBER OF FULL-TIME STAFF HOURS PROVIDED BY OTHER SOCIA L SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-FULL-TIME OTHR SOCIAL SERV STAFF-PART TIME 7.2 1058 1064 N PROV5295 NUMBER OF PART-TIME STAFF HOURS PROVIDED BY OTHER SOCIA L SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-PART-TIME PHARMACISTS - CONTRACT 7.2 1065 1071 N PROV1085 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-PHAR-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 17 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PHARMACISTS - FULL TIME 7.2 1072 1078 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 1079 1085 N PROV1095 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-PHAR-PART-TIME PHYS THER ASST - CONTRACT 7.2 1086 1092 N PROV5210 NUMBER OF CONTRACT STAFF HOURS FOR PHYSICAL THERAPY ASS ISTANTS. COBOL NAME: NUM-THER-ASST-CONTRACT PHYS THER ASST - FULL TIME 7.2 1093 1099 N PROV5200 NUMBER OF FULL-TIME STAFF HOURS FOR PHYSICAL THERAPY AS SISTANTS. COBOL NAME: NUM-THER-ASST-FULL-TIME PHYS THER ASST - PART TIME 7.2 1100 1106 N PROV5205 NUMBER OF PART-TIME STAFF HOURS FOR PHYSICAL THERAPY AS SISTANTS. COBOL NAME: NUM-THER-ASST-PART-TIME PHYSICAL THERAPISTS - CONTRACT 7.2 1107 1113 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 1114 1120 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 1121 1127 N PROV1440 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-PART-TIME PHYSICAL THERAPY AIDE - CONTRACT 7.2 1128 1134 N PROV1415 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-AID-CONTRACT PHYSICAL THERAPY AIDE - FULL TIME 7.2 1135 1141 N PROV1420 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-AID-FULL-TIME PHYSICAL THERAPY AIDE - PART TIME 7.2 1142 1148 N PROV1425 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-AID-PART-TIME PHYSICIAN EXTENDER - CONTRACT 7.2 1149 1155 N PROV3270 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIAN EXTENDERS UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-PHYS-EXT-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 18 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PHYSICIAN EXTENDER - FULL TIME 7.2 1156 1162 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 1163 1169 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 1170 1176 N PROV1130 THE NUMBER OF FULL TIME EQUIVALENT PODIATRISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-POD-CONTRACT PODIATRISTS - FULL TIME 7.2 1177 1183 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 1184 1190 N PROV1140 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-POD-PART-TIME PROVIDER BASED FACILITY 1 1191 1191 C PROV1675 INDICATES IF A LONG TERM CARE FACILITY IS PROVIDER BASED. COBOL NAME: PROV-BASED-FACILITY VALUES: Y HOSPITAL BASED REGISTERED NURSE - CONTRACT 7.2 1192 1198 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 1199 1205 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 1206 1212 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 8 1213 1220 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 RN DIRECTOR OF NURSING - CONTRACT 7.2 1221 1227 N PROV5130 THE NUMBER OF FULL TIME EQUIVALENT RN DIRECTOR OF NURSI NG UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-RN-DON-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 19 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RN DIRECTOR OF NURSING - FULL TIME 7.2 1228 1234 N PROV5120 THE NUMBER OF FULL-TIME EQUIVALENT RN DIRECTOR OF NURSING EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-RN-DON-FULL-TIME RN DIRECTOR OF NURSING - PART TIME 7.2 1235 1241 N PROV5140 THE NUMBER OF FULL-TIME EQUIVALENT RN DIRECTOR OF NURSING EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-RN-DON-PART-TIME SOCIAL WORKER - CONTRACT 7.2 1242 1248 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 1249 1255 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 1256 1262 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 1263 1265 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 1266 1268 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 1269 1271 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 1272 1274 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 1275 1277 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 1278 1280 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 1281 1283 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 20 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPECIAL CARE BEDS-SPEC REHAB 3 1284 1286 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 1287 1289 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 1290 1296 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 1297 1303 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 1304 1310 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 1311 1311 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 1312 1312 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 1313 1313 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 1314 1314 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 21 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME Y SERVICE IS PROVIDED SRV: BLOOD ADMIN-ONSITE-NONRES 1 1315 1315 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 1316 1316 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 1317 1317 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 1318 1318 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 1319 1319 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 1320 1320 C PROV3435 INDICATES IF DENTAL SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-DENTAL-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DENTAL-ONSITE-NON RESIDENTS 1 1321 1321 C PROV3430 INDICATES IF DENTAL SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-DENTAL-ON-NON-RES VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 22 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DENTAL-ONSITE-RESIDENTS 1 1322 1322 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 1323 1323 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 1324 1324 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 1325 1325 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 1326 1326 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 1327 1327 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 23 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: HOUSEKEEPING-ONSITE-RESIDENTS 1 1328 1328 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 1329 1329 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 1330 1330 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 1331 1331 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 1332 1332 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 1333 1333 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 1334 1334 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 24 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: OCCUP THER-OFFSITE-RESIDENTS 1 1335 1335 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 1336 1336 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 1337 1337 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: OTH ACTIVITIES-OFFSITE TO RES 1 1338 1338 C PROV5255 FIELD 3 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF OFFSITE TO RESIDENTS. COBOL NAME: SP-OTH-ACT-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH ACTIVITIES-ONSITE NONRES 1 1339 1339 C PROV5250 FIELD 2 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF ONSITE TO NONRESIDENTS. COBOL NAME: SP-OTH-ACT-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH ACTIVITIES-ONSITE RES 1 1340 1340 C PROV5245 FIELD 1 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF ONSITE TO RESIDENTS. COBOL NAME: SP-OTH-ACT-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-OFFSITE TO RES 1 1341 1341 C PROV5285 FIELD 3 - INDICATES SERVICES PROVIDED BY OTHER SOCIAL S ERVICES STAFF OFFSITE TO RESIDENTS. COBOL NAME: SP-OTH-SOC-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 25 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: OTH SOC SRV-ONSITE TO NONRES 1 1342 1342 C PROV5280 INDICATES IF OTHER SOCIAL SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-OTH-SOC-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-ONSITE TO RES 1 1343 1343 C PROV5275 FIELD 1 - INDICATES SERVICES PROVIDED BY SOCIAL SERVICE S STAFF ONSITE TO RESIDENTS. COBOL NAME: SP-OTH-SOC-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHARMACY-OFFSITE-RESIDENTS 1 1344 1344 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 1345 1345 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 1346 1346 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 1347 1347 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 1348 1348 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 26 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHYS EXTENDER-ONSITE-RESIDENT 1 1349 1349 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 1350 1350 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 1351 1351 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 1352 1352 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 1353 1353 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 1354 1354 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 1355 1355 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 27 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PODIATRY-OFFSITE-RESIDENTS 1 1356 1356 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 1357 1357 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 1358 1358 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 1359 1359 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 1360 1360 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 1361 1361 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 1362 1362 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 28 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: SPEECH PATH-ONSITE-NON RESID 1 1363 1363 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 1364 1364 C PROV3410 INDICATES IF SPEECH/LANGUAGE PATHOLOGY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-SPEECH-PH-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: THER REC SPEC-OFFSITE TO RES 1 1365 1365 C PROV5225 INDICATES IF THERAPEUTIC RECRECATION SPECIALIST SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-THER-REC-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: THER REC SPEC-ONSITE-NONRES 1 1366 1366 C PROV5220 INDICATES IF THERAPEUTIC RECREATION SPECIALIST SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-THER-REC-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: THER REC SPEC-ONSITE-RESIDENT 1 1367 1367 C PROV5215 INDICATES IF THERAPEUTIC RECREATION SPECIALIST SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-THER-REC-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: VOCATIONAL-OFFSITE-RESIDENTS 1 1368 1368 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 1369 1369 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 29 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: VOCATIONAL-ONSITE-RESIDENTS 1 1370 1370 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 1371 1371 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 1372 1372 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 SRV: XRAY-ONSITE-RESIDENTS 1 1373 1373 C PROV3500 INDICATES IF DIAGNOSTIC XRAY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-DIAG-XRAY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED THER REC SPEC - CONTRACT 7.2 1374 1380 N PROV5240 NUMBER OF CONTRACT STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-CONTRACT THER REC SPEC - FULL TIME 7.2 1381 1387 N PROV5230 NUMBER OF FULL-TIME STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-FULL-TIME THER REC SPEC - PART TIME 7.2 1388 1394 N PROV5235 NUMBER OF PART-TIME STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 1 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 HOME HEALTH AGENCY CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 05 HOME HEALTH AGENCIES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 2 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00000 DUMMY FOR MEDICAID HHA 00011 CAHABA 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00131 ADMINISTAR FEDERAL (CHICAGO) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00180 BLUE CROSS (MAINE) 00230 BLUE CROSS (MISSISSIPPI) 00290 BLUE CROSS (NEW MEXICO) 00332 COMMUNITY MUTUAL INSURANCE CO 00362 BLUE CROSS (INDEPENDENCE) 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00450 BLUE CROSS (WISCONSIN) 00452 UNITED GOVT SERVICES 00454 USG CALIFORNIA 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 3 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 51051 AETNA (PETALUMA) 51100 AETNA (CLEARWATER) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 4 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 5 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 6 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 STATES REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 7 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP 5 VALIDATION (ACCRD) TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 VOL. NON-PROF. - RELIGIOUS AFF. 02 VOLUNTARY NON-PROFIT - PRIVATE 03 VOLUNTARY NON-PROFIT - OTHER 04 PROPRIETARY 05 GOVERNMENT - STATE/COUNTY 06 GOVERNMENT - COMB. GOVT & VOL. * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 8 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 07 GOVERNMENT - LOCAL ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD ACCREDITATION INDICATOR 1 290 290 C PROV0010 INDICATES THE ORGANIZATION THAT IS RESPONSIBLE FOR THE ACCREDITATION OF THE PROVIDER. COBOL NAME: ACCRED-STAT VALUES: 0 NONE 1 JCAHO 2 CHAP DIETICIANS 7.2 392 398 N PROV0820 NUMBER OF FULL-TIME EQUIVALENT DIETICIANS EMPLOYED BY A FACILITY. COBOL NAME: NUM-DIETICIANS FISCAL YEAR ENDING DATE 4 399 402 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT LICENSED PRACT/VOCAT NURSES 7.2 410 416 N PROV0955 NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL OR VOCATIONAL NURSES EMPLOYED BY A FACILITY. COBOL NAME: NUM-LPN-LVN OCCUPATIONAL THERAPISTS 7.2 419 425 N PROV1050 THE NUMBER OF FULL TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-OCCUP-THERAPISTS OTHER PERSONNEL 7.2 426 432 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 9 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PROGRAM PARTICIPATION 1 454 454 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) 1 477 477 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 7.2 479 485 N PROV1145 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PROFESSIONAL NURSES EMPLOYED BY A PROVIDER. COBOL NAME: NUM-REG-NURS REGISTERED PHARMACISTS 7.2 486 492 N PROV1100 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PHARMACISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHARMACIST-REG RELATED PROVIDER NUMBER 10 514 523 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 1 556 556 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 1 565 565 C PROV2365 INDICATES HOW PHARMACY SERVICES ARE PROVIDED. COBOL NAME: SP-PHARMACY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 10 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHYSICAL THERAPY 1 566 566 C PROV2370 INDICATES HOW PHYSICAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICAL-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION TYPE OF FACILITY 2 578 579 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 1395 1395 C PROV0555 INDICATES HOW THE AGENCY PROVIDES HOME HEALTH AIDE TRAINING AND COMPETENCY EVALUATION PROGRAMS. COBOL NAME: HHA-PROVIDES-DIRECT VALUES: 1 AIDE TRAINING 2 COMPETENCY EVALUATION PROG. 3 AIDE TRAINING AND COMPETENCY PROG. 4 NEITHER BRANCH OPERATION INDICATOR 1 1396 1396 C PROV1525 INDICATES IF THE AGENCY OPERATES ANY BRANCHES. COBOL NAME: OPERS-BRANCHES VALUES: N NO Y YES BRANCHES 3 1397 1399 N PROV0745 THE NUMBER OF BRANCHES OPERATED BY THE AGENCY. COBOL NAME: NUM-BRANCHES CHANGE OF OWNERSHIP INDICATOR 1 1400 1400 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 11 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME HHA QUALIFIED FOR OPT 1 1401 1401 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 1402 1408 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 1409 1409 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 1410 1415 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 1416 1421 C PROV0650 IF THE AGENCY IS BASED IN ANOTHER MEDICARE OR MEDICAID FACILITY, THE PROVIDER NUMBER OF THAT FACILITY. COBOL NAME: MEDICAID-CARE-VEND-NUM SOCIAL WORKERS 7.2 1422 1428 N PROV1185 THE NUMBER OF FULL TIME EQUIVALENT SOCIAL WORKERS EMPLOYED BY THE AGENCY. COBOL NAME: NUM-SOCIAL-WRKS SPEECH PATHOLOGISTS, AUDIOLOGISTS 7.2 1429 1435 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 1436 1436 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 1437 1437 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 12 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 1 PROVIDED BY AGENCY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: INTERNS AND RESIDENTS 1 1438 1438 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 1439 1439 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 1440 1440 C PROV2250 INDICATES HOW NURSING SERVICES ARE PROVIDED. COBOL NAME: SP-NURSING VALUES: 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: NUTRITIONAL GUIDANCE 1 1441 1441 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 1442 1442 C PROV2340 INDICATES HOW OTHER (NOT SPECIFIED) SERVICES ARE PROVIDED. COBOL NAME: SP-OTHER VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 13 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: SPEECH THERAPY 1 1443 1443 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 1444 1444 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 1445 1445 C PROV2725 INDICATES IF THE AGENCY IS A SUBUNIT OF ANOTHER AGENCY. COBOL NAME: SUBUNIT-IND VALUES: N NO Y YES SUBUNIT OPERATION INDICATOR 1 1446 1446 C PROV1530 INDICATES IF THE AGENCY OPERATES ANY SUBUNITS. COBOL NAME: OPERS-SUBUNITS VALUES: N NO Y YES SUBUNITS 3 1447 1449 N PROV1240 THE NUMBER OF SUBUNITS OPERATED BY THE AGENCY. COBOL NAME: NUM-SUBUNITS SURETY BOND INDICATOR 1 1450 1450 C PROV5680 SURETY BOND INDICATOR, VALID VALUES ARE "N" OR "Y" OR "W" COBOL NAME: SURETY-BOND-IND VALUES: N NO W WAIVER Y YES PHYSICAL THERAPISTS ON STAFF 7.2 1481 1487 N PROV1120 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY AN OUTPATIENT PHYSICAL THERAPY PROVIDER OR A HOME HEALTH AGENCY PROVIDER. COBOL NAME: NUM-PHYS-THERAPISTS SRV: LABORATORY 1 1697 1697 C PROV2200 INDICATES HOW LABORATORY SERVICES ARE PROVIDED. COBOL NAME: SP-LABORATORY VALUES: 0 NOT PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 14 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 1 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 X-RAY CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 07 PORTABLE X-RAY SUPPLIERS CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 2 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00011 CAHABA 00122 HCSC - MICHIGAN 00131 ADMINISTAR FEDERAL (CHICAGO) 00452 UNITED GOVT SERVICES 00454 USG CALIFORNIA 00510 BLUE SHIELD (ALABAMA) 00511 CAHABA 00520 BLUE SHIELD (ARKANSAS) 00528 BLUE SHIELD (ARKANSAS/LOUISIANA) 00542 BLUE SHIELD (CALIFORNIA) 00550 BLUE SHIELD (COLORADO) 00570 BLUE SHIELD (DELAWARE) 00580 BLUE SHIELD (DISTRICT OF COLUMBIA) 00590 BLUE SHIELD (FLORIDA) 00621 BLUE SHIELD (ILLINOIS) 00630 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) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 3 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00801 BLUE SHIELD (BUFFALO) 00803 BLUE SHIELD (EMPIRE) 00805 BLUE SHIELD OF NEW YORK 00820 BLUE SHIELD (NORTH DAKOTA) 00825 BLUE SHIELD (NORTH DAKOTA/WYOMING) 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865 BLUE SHIELD (PENNSYLVANIA) 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00883 PALMETTO 00900 BLUE SHIELD (TEXAS) 00901 TRAILBLAZERS HEALTH ENTERPRISES 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 00973 BLUE SHIELD (PUERTO RICO) 00974 BLUE SHIELD (VIRGIN ISLANDS) 01010 AETNA (PEORIA) 01020 AETNA (ALASKA) 01030 AETNA (ARIZONA) 01040 AETNA (GEORGIA) 01120 AETNA (HAWAII) 01290 AETNA (NEVADA) 01360 AETNA (NEW MEXICO) 01370 AETNA (OKLAHOMA) 01380 AETNA (OREGON) 01390 AETNA (WASHINGTON) 02050 OCCIDENTAL (CALIFORNIA) 05130 EQICOR (IDAHO) 05440 EQICOR (TENNESSEE) 05535 EQICOR (NORTH CAROLINA) 10071 TRAVELERS (RRB) 10230 TRAVELERS (CONNECTICUT) 10240 TRAVELERS (MINNESOTA) 10250 TRAVELERS (MISSISSIPPI) 10490 TRAVELERS (VIRGINIA) 10492 TRAVELERS - VIRGINIA SPECIAL PROJECT 11260 GENERAL AMERICAN 14330 GROUP HEALTH INC (NEW YORK) 16360 NATIONWIDE (OHIO) 16510 NATIONWIDE (WEST VIRGINIA) 21200 MASSACHUSETTS/MAINE 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 4 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 31144 NATIONAL HERITAGE INSURANCE CO MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 5 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 6 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 7 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATES REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 8 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 INDIVIDUAL 02 PARTNERSHIP 03 CORPORATION 04 OTHER THAN PRIVATE ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 9 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD FISCAL YEAR ENDING DATE 4 399 402 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT OTHER PERSONNEL 7.2 426 432 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL DIRECTOR QUALIFICATIONS 1 1451 1451 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 1452 1458 N PROV0735 THE NUMBER OF TECHNOLOGISTS WITH ASSOCIATE DEGREES IN RADIOLOGIC TECHNOLOGY. COBOL NAME: NUM-AS-RADIO-TECH TECHNOLOGISTS - BS/BA DEGREE 7.2 1459 1465 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 1466 1472 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 1 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 OPT OR SPECH PATHOLOGY CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 08 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 2 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 BLUE CROSS (INDIANA) 00131 ADMINISTAR FEDERAL (CHICAGO) 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 3 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 00452 UNITED GOVT SERVICES 00454 USG CALIFORNIA 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00510 BLUE SHIELD (ALABAMA) 00511 CAHABA 00520 BLUE SHIELD (ARKANSAS) 00528 BLUE SHIELD (ARKANSAS/LOUISIANA) 00542 BLUE SHIELD (CALIFORNIA) 00550 BLUE SHIELD (COLORADO) 00570 BLUE SHIELD (DELAWARE) 00580 BLUE SHIELD (DISTRICT OF COLUMBIA) 00590 BLUE SHIELD (FLORIDA) 00621 BLUE SHIELD (ILLINOIS) 00630 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) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 4 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 00805 BLUE SHIELD OF NEW YORK 00820 BLUE SHIELD (NORTH DAKOTA) 00825 BLUE SHIELD (NORTH DAKOTA/WYOMING) 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865 BLUE SHIELD (PENNSYLVANIA) 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00883 PALMETTO 00900 BLUE SHIELD (TEXAS) 00901 TRAILBLAZERS HEALTH ENTERPRISES 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 00973 BLUE SHIELD (PUERTO RICO) 00974 BLUE SHIELD (VIRGIN ISLANDS) 01010 AETNA (PEORIA) 01020 AETNA (ALASKA) 01030 AETNA (ARIZONA) 01040 AETNA (GEORGIA) 01120 AETNA (HAWAII) 01290 AETNA (NEVADA) 01360 AETNA (NEW MEXICO) 01370 AETNA (OKLAHOMA) 01380 AETNA (OREGON) 01390 AETNA (WASHINGTON) 02050 OCCIDENTAL (CALIFORNIA) 05130 EQICOR (IDAHO) 05440 EQICOR (TENNESSEE) 05535 EQICOR (NORTH CAROLINA) 10071 TRAVELERS (RRB) 10230 TRAVELERS (CONNECTICUT) 10240 TRAVELERS (MINNESOTA) 10250 TRAVELERS (MISSISSIPPI) 10490 TRAVELERS (VIRGINIA) 10492 TRAVELERS - VIRGINIA SPECIAL PROJECT 11260 GENERAL AMERICAN 14330 GROUP HEALTH INC (NEW YORK) 16360 NATIONWIDE (OHIO) 16510 NATIONWIDE (WEST VIRGINIA) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 21200 MASSACHUSETTS/MAINE 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 5 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 6 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 7 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 8 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 STATES REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 9 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 VOL. NON-PROF. NOT CHURCH 02 VOLUNTARY NON PROFIT CHURCH 03 STATE GOVERNMENT 04 LOCAL GOVERNMENT 05 COMBINATION GOVERNMENT & VOL. 06 PROPRIETARY ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 10 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD FISCAL YEAR ENDING DATE 4 399 402 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT OCCUPATIONAL THERAPISTS 7.2 419 425 N PROV1050 THE NUMBER OF FULL TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-OCCUP-THERAPISTS PHYSICAL THERAPISTS 7.2 434 440 N PROV1125 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS-THERAPY RELATED PROVIDER NUMBER 10 514 523 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 2 578 579 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 SPEECH PATHOLOGISTS, AUDIOLOGISTS 7.2 1429 1435 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 1473 1473 C PROV1685 DOES FACILITY PROVIDE OCCUPATIONAL THERAPY SERVICES ?? COBOL NAME: PROVIDES-OCCUP-THERAPY VALUES: N NO Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 11 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME PHYSICAL THERAPIST - ARRANGEMENT 7.2 1474 1480 N PROV1105 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY ARRANGEMENT IN AN OUTPATIENT PHYSICAL THERAPY FACILITY. COBOL NAME: NUM-PHY-THER-ARGNM PHYSICAL THERAPISTS ON STAFF 7.2 1481 1487 N PROV1120 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY AN OUTPATIENT PHYSICAL THERAPY PROVIDER OR A HOME HEALTH AGENCY PROVIDER. COBOL NAME: NUM-PHYS-THERAPISTS SPEECH PATHOLOGISTS - ARRANGEMENT 7.2 1488 1494 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 1495 1501 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 1502 1502 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 1 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 END STAGE RENAL DISEASE CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 09 END STAGE RENAL DISEASE FACILITIES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 2 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 BLUE CROSS (INDIANA) 00131 ADMINISTAR FEDERAL (CHICAGO) 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 3 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 00452 UNITED GOVT SERVICES 00454 USG CALIFORNIA 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00901 TRAILBLAZERS HEALTH ENTERPRISES 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 4 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 5 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 6 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 7 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATES REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 8 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 FOR PROFIT 02 NOT FOR PROFIT 03 PUBLIC ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 9 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME DIETICIANS 7.2 392 398 N PROV0820 NUMBER OF FULL-TIME EQUIVALENT DIETICIANS EMPLOYED BY A FACILITY. COBOL NAME: NUM-DIETICIANS FISCAL YEAR ENDING DATE 4 399 402 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT OTHER PERSONNEL 7.2 426 432 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL REGISTERED NURSES 7.2 479 485 N PROV1145 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PROFESSIONAL NURSES EMPLOYED BY A PROVIDER. COBOL NAME: NUM-REG-NURS RELATED PROVIDER NUMBER 10 514 523 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 MULTI-FACILITY ORGANIZATION NAME 38 835 872 C PROV0680 THE NAME OF THE MULTI-FACILITY ORGANIZATION THAT OWNS THE FACILITY. COBOL NAME: NAME-MULT-FACL-ORG MULTI-FACILITY ORGANIZATION OWNED 1 873 873 C PROV0675 INDICATES IF A FACILITY IS OWNED BY AN ORGANIZATION THAT OWNS (OR LEASES) TWO OR MORE NURSING FACILITIES. COBOL NAME: MULT-FACL-ORG VALUES: Y YES SOCIAL WORKERS 7.2 1422 1428 N PROV1185 THE NUMBER OF FULL TIME EQUIVALENT SOCIAL WORKERS EMPLOYED BY THE AGENCY. COBOL NAME: NUM-SOCIAL-WRKS ESRD NETWORK # 2 1503 1504 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 10 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 09 INDIANA, KENTUCKY AND OHIO 10 ILLINOIS 11 MICH-MINN-NORTH DAKOTA-SOUTH DAKOTA-WISCONSIN 12 IOWA, KANSAS, MISSOURI AND NEBRASKA 13 ARKANSAS, LOUISIANA AND OKLAHOMA 14 TEXAS 15 ARIZONA-COLO-NEVADA-NEW MEXI-UTAH AND WYOMING 16 ALASKA, IDAHO, MONTANA, OREGON AND WASHINGTON 17 COUNTIES IN NORTHERN CALIF, HAWAII, AS, GUAM 18 COUNTIES IN SOUTHERN CALIFORNIA NUMBER OF PATIENTS TUE. 4TH SHIFT 3 1505 1507 N PROV5540 NUMBER OF PATIENTS TUE. 4TH SHIFT COBOL NAME: NUM-PATIENT-TUE-SHIFT-4 STATIONS - HEMODIALYSIS 3 1508 1510 N PROV1230 THE TOTAL NUMBER OF HEMODIALYSIS STATIONS IN AN END STAGE RENAL DISEASE (ESRD) FACILITY. COBOL NAME: NUM-STATIONS-HEMO STATIONS - TOTAL 3 1511 1513 N PROV2855 THE TOTAL NUMBER OF APPROVED DIALYSIS STATIONS IN AN END STAGE RENAL DIALYSIS FACILITY. COBOL NAME: TOT-STATIONS HOSPITAL BASED INDICATOR 1 1681 1681 C PROV0565 HOSPITAL BASED INDICATOR COBOL NAME: HOSP-BASED-IND VALUES: Y HOSPITAL BASED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 1 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 02 TITLE 19 ONLY CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 10 NURSING FACILITIES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 2 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00452 UNITED GOVT SERVICES 00454 USG CALIFORNIA 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 3 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 4 NURSING FACILITIES, CATEGORY = "10" (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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 5 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 6 NURSING FACILITIES, CATEGORY = "10" (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 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 7 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 FOR PROFIT - 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 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD BEDS - TOTAL 4 312 315 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 8 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME BEDS - TOTAL CERTIFIED 4 316 319 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS COMPLIANCE: LIFE SAFETY CODE 1 377 377 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: 1 WAIVER RECOMMENDED COMPLIANCE: 24 HR REGISTERED NURSE 1 380 380 C PROV0290 INDICATES IF A WAIVER OF THE 24 HOUR REGISTERED NURSE REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-24-HR-RN VALUES: 1 WAIVER RECOMMENDED FISCAL YEAR ENDING DATE 4 399 402 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT PROGRAM PARTICIPATION 1 454 454 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) 1 476 476 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) 1 477 477 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 10 514 523 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 9 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ACTIVITY PROFESSIONAL - CONTRACT 7.2 581 587 N PROV0695 THE NUMBER OF FULL TIME EQUIVALENT ACTIVITIES PROFESSIONALS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-ACT-THER-CONTRACT ACTIVITY PROFESSIONAL - FULL TIME 7.2 588 594 N PROV0700 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES PROFESSIONALS EMPLOYED FULL TIME BY A FACILITY. COBOL NAME: NUM-ACT-THER-FULL-TIME ACTIVITY PROFESSIONAL - PART TIME 7.2 595 601 N PROV0705 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES PROFESSIONALS EMPLOYED PART TIME BY A FACILITY. COBOL NAME: NUM-ACT-THER-PART-TIME ADMINISTRATION - CONTRACT 7.2 602 608 N PROV0710 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-ADMN-CONTRACT ADMINISTRATOR - FULL TIME 7.2 609 615 N PROV0715 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF EMPLOYED ON A FULL TIME BASIS BY A FACILITY. COBOL NAME: NUM-ADMN-FULL-TIME ADMINISTRATOR - PART TIME 7.2 616 622 N PROV0720 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATIVE STAFF EMPLOYED ON A PART-TIME BASIS BY A FACILITY. COBOL NAME: NUM-ADMN-PART-TIME BEDS - NURSING FACILITY 4 627 630 N PROV1455 NUMBER OF MEDICAID CERTIFIED SKILLED NURSING CARE BEDS IN A FACILITY. COBOL NAME: NUM-T19-SNF-BEDS CERT NURSE AIDES - CONTRACT 7.2 635 641 N PROV1000 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-NURSE-AID-CONTRACT CERT NURSE AIDES - FULL TIME 7.2 642 648 N PROV1005 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-AID-FULL-TIME CERT NURSE AIDES - PART TIME 7.2 649 655 N PROV1010 THE NUMBER OF FULL-TIME EQUIVALENT CERTIFIED NURSE AIDES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-AID-PART-TIME COMPLIANCE: BEDS PER ROOM WAIVER 1 657 657 C PROV0225 INDICATES IF A WAIVER OF THE BEDS PER ROOM REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-BEDS-PER-ROOM VALUES: 1 WAIVER RECOMMENDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 10 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COMPLIANCE: PATIENT ROOM SIZE 1 658 658 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 1 659 659 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 7.2 660 666 N PROV0785 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DENTIST-CONTRACT DENTISTS - FULL TIME 7.2 667 673 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 7.2 674 680 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 7.2 681 687 N PROV0805 THE NUMBER OF FULL-TIME EQUIVALENT UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DIET-CONTRACT DIETITIANS - FULL TIME 7.2 688 694 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 7.2 695 701 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 1 702 702 C PROV0465 INDICATES IF A FACILITY USES RESIDENTS TO DEVELOP AND TEST CLINICAL TREATMENTS. COBOL NAME: EXPER-RESEARCH VALUES: Y YES FOOD SERVICE - CONTRACT 7.2 703 709 N PROV0860 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-FOOD-SRV-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 11 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FOOD SERVICE - FULL TIME 7.2 710 716 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 7.2 717 723 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 7.2 724 730 N PROV0925 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-HOUSE-CONTRACT HOUSEKEEPING - FULL TIME 7.2 731 737 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 7.2 738 744 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 7.2 745 751 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 7.2 752 758 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 7.2 759 765 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 # 6 766 771 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 7.2 772 778 N PROV0960 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS UNDER CONTRCAT TO A FACILITY. COBOL NAME: NUM-MED-CONTRACT MEDICAL DIRECTOR - FULL TIME 7.2 779 785 N PROV0965 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MED-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 12 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MEDICAL DIRECTOR - PART TIME 7.2 786 792 N PROV0970 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MED-PART-TIME MEDICATION AIDES/TECHS-CONTRACT 7.2 793 799 N PROV5180 THE NUMBER OF FULL-TIMR EQUIVALENT MEDICATION AIDES/ TECHNICIANS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-MED-AID-CONTRACT MEDICATION AIDES/TECHS-FULL TIME 7.2 800 806 N PROV5170 THE NUMBER OF FULL-TIME EQUIVALENT MEDICATION AIDES/ TECHNICIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MED-AID-FULL-TIME MEDICATION AIDES/TECHS-PART TIME 7.2 807 813 N PROV5175 THE NUMBER OF FULL-TIME EQUIVALENT MEDICATION AIDES/ TECHNICIANS EMPLOYED BYA FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MED-AID-PART-TIME MENTAL HEALTH SERVICES - CONTRACT 7.2 814 820 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 7.2 821 827 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 7.2 828 834 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 38 835 872 C PROV0680 THE NAME OF THE MULTI-FACILITY ORGANIZATION THAT OWNS THE FACILITY. COBOL NAME: NAME-MULT-FACL-ORG MULTI-FACILITY ORGANIZATION OWNED 1 873 873 C PROV0675 INDICATES IF A FACILITY IS OWNED BY AN ORGANIZATION THAT OWNS (OR LEASES) TWO OR MORE NURSING FACILITIES. COBOL NAME: MULT-FACL-ORG VALUES: Y YES NURSE AIDES IN TRNG - CONTRACT 7.2 874 880 N PROV5165 NUMBER OF FULL TIME EQUIVALENT NURSE AIDES IN TRAINING UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-AID-TRNG-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 13 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME NURSE AIDES IN TRNG-FULL TIME 7.2 881 887 N PROV5155 THE NUMBER OF FULL-TIME EQUIVALENT NURSE AIDES IN TRAINING EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-AID-TRNG-FULL-TIME NURSE AIDES IN TRNG-PART TIME 7.2 888 894 N PROV5160 THE NUMBER OF FULL-TIME EQUIVALENT NURSE AIDES IN TRAINING EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-AID-TRNG-PART-TIME NURSES WITH ADMIN DUTIES-CONTRACT 7.2 895 901 N PROV5150 THE NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-NURSE-ADM-CONTRACT NURSES WITH ADMIN DUTIES-FULL TIME 7.2 902 908 N PROV5135 THE NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-ADM-FULL-TIME NURSES WITH ADMIN DUTIES-PART TIME 7.2 909 915 N PROV5145 NUMBER OF FULL-TIME EQUIVALENT NURSES WITH ADMINISTRATIVE DUTIES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-ADM-PART-TIME OCCUP THERAPY AIDE - CONTRACT 7.2 916 922 N PROV1020 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-AID-CONTRACT OCCUP THERAPY AIDE - FULL TIME 7.2 923 929 N PROV1025 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-AID-FULL-TIME OCCUP THERAPY AIDE - PART TIME 7.2 930 936 N PROV1030 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY AIDES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-AID-PART-TIME OCCUP THERAPY ASST - CONTRACT 7.2 937 943 N PROV5195 THE NUMBER OF FULL TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS UNDER CONTRCAT TO A FACILITY. COBOL NAME: NUM-OCC-ASST-CONTRACT OCCUP THERAPY ASST - FULL TIME 7.2 944 950 N PROV5185 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-ASST-FULL-TIME OCCUP THERAPY ASST - PART TIME 7.2 951 957 N PROV5190 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-ASST-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 14 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OCCUPATIONAL THERAPIST - CONTRACT 7.2 958 964 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 7.2 965 971 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 7.2 972 978 N PROV1045 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-THER-PART-TIME ORGANIZED FAMILY GROUP 1 979 979 C PROV1535 INDICATES IF THE FACILITY HAS AN ORGANIZED GROUP OF FAMILY MEMBERS OF RESIDENTS. COBOL NAME: ORG-FAMILY-GRP VALUES: Y YES ORGANIZED RESIDENT GROUP 1 980 980 C PROV1540 INDICATES IF THE FACILITY HAS AN ORGANIZED RESIDENTS GROUP. COBOL NAME: ORG-RESID-GRP VALUES: Y YES OTHER - CONTRACT 7.2 981 987 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 7.2 988 994 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 7.2 995 1001 N PROV3255 THE NUMBER OF FULL-TIME EQUIVALENT PERSONS NOT INCLUDED IN ANY OTHER CATEGORIES EMPLOYED BY THE FACILITY ON A PART-TIME BASIS. COBOL NAME: NUM-OTH-PART-TIME OTHER ACTIVITIES STAFF-CONTRACT 7.2 1002 1008 N PROV5270 NUMBER OF CONTRACT STAFF HOURS FOR OTHER ACTIVITIES. COBOL NAME: NUM-OTH-ACT-CONTRACT OTHER ACTIVITIES STAFF-FULL TIME 7.2 1009 1015 N PROV5260 NUMBER OF FULL-TIME STAFF HOURS FOR OTHER ACTIVITIES. COBOL NAME: NUM-OTH-ACT-FULL-TIME OTHER ACTIVITIES STAFF-PART TIME 7.2 1016 1022 N PROV5305 NUMBER OF PART TIME STAFF HOURS PROVIDED BY OTHER ACTIV ITIES STAFF. COBOL NAME: NUM-OTH-ACT-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 15 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OTHER PHYSICIAN - CONTRACT 7.2 1023 1029 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 1030 1036 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 1037 1043 N PROV1070 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OTH-PHY-PART-TIME OTHR SOCIAL SERV STAFF-CONTRACT 7.2 1044 1050 N PROV5300 NUMBER OF CONTRACT STAFF HOURS PROVIDED BY OTHER SOCIAL SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-CONTRACT OTHR SOCIAL SERV STAFF-FULL TIME 7.2 1051 1057 N PROV5290 NUMBER OF FULL-TIME STAFF HOURS PROVIDED BY OTHER SOCIA L SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-FULL-TIME OTHR SOCIAL SERV STAFF-PART TIME 7.2 1058 1064 N PROV5295 NUMBER OF PART-TIME STAFF HOURS PROVIDED BY OTHER SOCIA L SERVICES STAFF. COBOL NAME: NUM-OTH-SOC-PART-TIME PHARMACISTS - CONTRACT 7.2 1065 1071 N PROV1085 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-PHAR-CONTRACT PHARMACISTS - FULL TIME 7.2 1072 1078 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 1079 1085 N PROV1095 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-PHAR-PART-TIME PHYS THER ASST - CONTRACT 7.2 1086 1092 N PROV5210 NUMBER OF CONTRACT STAFF HOURS FOR PHYSICAL THERAPY ASS ISTANTS. COBOL NAME: NUM-THER-ASST-CONTRACT PHYS THER ASST - FULL TIME 7.2 1093 1099 N PROV5200 NUMBER OF FULL-TIME STAFF HOURS FOR PHYSICAL THERAPY AS SISTANTS. COBOL NAME: NUM-THER-ASST-FULL-TIME PHYS THER ASST - PART TIME 7.2 1100 1106 N PROV5205 NUMBER OF PART-TIME STAFF HOURS FOR PHYSICAL THERAPY AS SISTANTS. COBOL NAME: NUM-THER-ASST-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 16 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PHYSICAL THERAPISTS - CONTRACT 7.2 1107 1113 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 1114 1120 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 1121 1127 N PROV1440 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-PART-TIME PHYSICAL THERAPY AIDE - CONTRACT 7.2 1128 1134 N PROV1415 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-AID-CONTRACT PHYSICAL THERAPY AIDE - FULL TIME 7.2 1135 1141 N PROV1420 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-AID-FULL-TIME PHYSICAL THERAPY AIDE - PART TIME 7.2 1142 1148 N PROV1425 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY AIDE EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-AID-PART-TIME PHYSICIAN EXTENDER - CONTRACT 7.2 1149 1155 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 1156 1162 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 1163 1169 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 1170 1176 N PROV1130 THE NUMBER OF FULL TIME EQUIVALENT PODIATRISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-POD-CONTRACT PODIATRISTS - FULL TIME 7.2 1177 1183 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 1184 1190 N PROV1140 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-POD-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 17 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PROVIDER BASED FACILITY 1 1191 1191 C PROV1675 INDICATES IF A LONG TERM CARE FACILITY IS PROVIDER BASED. COBOL NAME: PROV-BASED-FACILITY VALUES: Y HOSPITAL BASED REGISTERED NURSE - CONTRACT 7.2 1192 1198 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 1199 1205 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 1206 1212 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 8 1213 1220 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 RN DIRECTOR OF NURSING - CONTRACT 7.2 1221 1227 N PROV5130 THE NUMBER OF FULL TIME EQUIVALENT RN DIRECTOR OF NURSI NG UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-RN-DON-CONTRACT RN DIRECTOR OF NURSING - FULL TIME 7.2 1228 1234 N PROV5120 THE NUMBER OF FULL-TIME EQUIVALENT RN DIRECTOR OF NURSING EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-RN-DON-FULL-TIME RN DIRECTOR OF NURSING - PART TIME 7.2 1235 1241 N PROV5140 THE NUMBER OF FULL-TIME EQUIVALENT RN DIRECTOR OF NURSING EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-RN-DON-PART-TIME SOCIAL WORKER - CONTRACT 7.2 1242 1248 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 1249 1255 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 1256 1262 N PROV1180 THE NUMBER OF FULL-TIME EQUIVALENT SOCIAL WORKERS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-SOCIAL-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 18 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPECIAL CARE BEDS-AIDS 3 1263 1265 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 1266 1268 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 1269 1271 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 1272 1274 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 1275 1277 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 1278 1280 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 1281 1283 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 1284 1286 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 1287 1289 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 1290 1296 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 1297 1303 N PROV1195 THE NUMBER OF FULL-TIME EQUIVALENT SPPECH PATHOLOGISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-SPCH-PATH-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 19 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPEECH PATHOLOGIST - PART TIME 7.2 1304 1310 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 1311 1311 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 1312 1312 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 1313 1313 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 1314 1314 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 1315 1315 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 1316 1316 C PROV3515 INDICATES IF ADMINISTRATION AND STORAGE OF BLOOD SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-ADM-BLOOD-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 20 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: CLINICAL LAB-OFFSITE-RESIDENT 1 1317 1317 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 1318 1318 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 1319 1319 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 1320 1320 C PROV3435 INDICATES IF DENTAL SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-DENTAL-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DENTAL-ONSITE-NON RESIDENTS 1 1321 1321 C PROV3430 INDICATES IF DENTAL SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-DENTAL-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: DENTAL-ONSITE-RESIDENTS 1 1322 1322 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 1323 1323 C PROV3345 INDICATES IF DIETARY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-DIETARY-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 21 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: DIETARY-ONSITE-NON RESIDENTS 1 1324 1324 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 1325 1325 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 1326 1326 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 1327 1327 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 1328 1328 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 1329 1329 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 1330 1330 C PROV3460 INDICATES IF MENTAL HEALTH SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-MEN-HLTH-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 22 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: MENTAL HEALTH-ONSITE-RESID 1 1331 1331 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 1332 1332 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 1333 1333 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 1334 1334 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 1335 1335 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 1336 1336 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 1337 1337 C PROV3350 INDICATES IF OCCUPATIONAL THERAPY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-OCC-THER-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 23 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: OTH ACTIVITIES-OFFSITE TO RES 1 1338 1338 C PROV5255 FIELD 3 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF OFFSITE TO RESIDENTS. COBOL NAME: SP-OTH-ACT-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH ACTIVITIES-ONSITE NONRES 1 1339 1339 C PROV5250 FIELD 2 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF ONSITE TO NONRESIDENTS. COBOL NAME: SP-OTH-ACT-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH ACTIVITIES-ONSITE RES 1 1340 1340 C PROV5245 FIELD 1 - INDICATES OTHER ACTIVITY SERVICES PROVIDED BY STAFF ONSITE TO RESIDENTS. COBOL NAME: SP-OTH-ACT-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-OFFSITE TO RES 1 1341 1341 C PROV5285 FIELD 3 - INDICATES SERVICES PROVIDED BY OTHER SOCIAL S ERVICES STAFF OFFSITE TO RESIDENTS. COBOL NAME: SP-OTH-SOC-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-ONSITE TO NONRES 1 1342 1342 C PROV5280 INDICATES IF OTHER SOCIAL SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-OTH-SOC-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: OTH SOC SRV-ONSITE TO RES 1 1343 1343 C PROV5275 FIELD 1 - INDICATES SERVICES PROVIDED BY SOCIAL SERVICE S STAFF ONSITE TO RESIDENTS. COBOL NAME: SP-OTH-SOC-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: PHARMACY-OFFSITE-RESIDENTS 1 1344 1344 C PROV3330 INDICATES IF PHARMACY SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-PHARMACY-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 24 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHARMACY-ONSITE-NON RESIDENTS 1 1345 1345 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 1346 1346 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 1347 1347 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 1348 1348 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 1349 1349 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 1350 1350 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 1351 1351 C PROV3370 INDICATES IF PHYSICAL THERAPY SERVICES ARE PROVIDED ONSITE TO NON RESIDENTS. COBOL NAME: SP-PHYS-THER-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 25 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHYS THER-ONSITE-RESIDENTS 1 1352 1352 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 1353 1353 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 1354 1354 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 1355 1355 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 1356 1356 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 1357 1357 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 1358 1358 C PROV3440 INDICATES IF PODIATRY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-PODIATRY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 26 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: SOCIAL WORK-OFFSITE-RESIDENTS 1 1359 1359 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 1360 1360 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 1361 1361 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 1362 1362 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 1363 1363 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 1364 1364 C PROV3410 INDICATES IF SPEECH/LANGUAGE PATHOLOGY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-SPEECH-PH-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: THER REC SPEC-OFFSITE TO RES 1 1365 1365 C PROV5225 INDICATES IF THERAPEUTIC RECRECATION SPECIALIST SERVICES ARE PROVIDED OFFSITE TO RESIDENTS. COBOL NAME: SP-THER-REC-OFF-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 27 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: THER REC SPEC-ONSITE-NONRES 1 1366 1366 C PROV5220 INDICATES IF THERAPEUTIC RECREATION SPECIALIST SERVICES ARE PROVIDED ONSITE TO NONRESIDENTS. COBOL NAME: SP-THER-REC-ON-NON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: THER REC SPEC-ONSITE-RESIDENT 1 1367 1367 C PROV5215 INDICATES IF THERAPEUTIC RECREATION SPECIALIST SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-THER-REC-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED SRV: VOCATIONAL-OFFSITE-RESIDENTS 1 1368 1368 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 1369 1369 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 1370 1370 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 1371 1371 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 1372 1372 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 28 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: XRAY-ONSITE-RESIDENTS 1 1373 1373 C PROV3500 INDICATES IF DIAGNOSTIC XRAY SERVICES ARE PROVIDED ONSITE TO RESIDENTS. COBOL NAME: SP-DIAG-XRAY-ON-RES VALUES: N SERVICE IS NOT PROVIDED Y SERVICE IS PROVIDED THER REC SPEC - CONTRACT 7.2 1374 1380 N PROV5240 NUMBER OF CONTRACT STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-CONTRACT THER REC SPEC - FULL TIME 7.2 1381 1387 N PROV5230 NUMBER OF FULL-TIME STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-FULL-TIME THER REC SPEC - PART TIME 7.2 1388 1394 N PROV5235 NUMBER OF PART-TIME STAFF HOURS PROVIDED BY THERAPEUTIC RECREATION SPECIALIST. COBOL NAME: NUM-THER-REC-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 1 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 02 TITLE 19 ONLY CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 11 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 2 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00452 UNITED GOVT SERVICES 00454 USG CALIFORNIA 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 3 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 4 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 5 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 6 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- 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 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 7 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 PRIVATE NON PROFIT 02 PRIVATE PROPRIETARY 03 STATE 04 CITY/TOWN 05 COUNTY 06 CITY/COUNTY 07 OTHER ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD BEDS - TOTAL 4 312 315 N PROV0740 TOTAL NUMBER OF BEDS IN A FACILITY, INCLUDING THOSE IN NON-PARTICIPATING OR NON-LICENSED AREAS. COBOL NAME: NUM-BEDS BEDS - TOTAL CERTIFIED 4 316 319 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS COMPLIANCE: LIFE SAFETY CODE 1 377 377 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 8 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 1 WAIVER RECOMMENDED FISCAL YEAR ENDING DATE 4 399 402 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT LICENSED PRACT/VOCAT NURSES 7.2 410 416 N PROV0955 NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL OR VOCATIONAL NURSES EMPLOYED BY A FACILITY. COBOL NAME: NUM-LPN-LVN PROGRAM PARTICIPATION 1 454 454 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) 1 476 476 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 7.2 479 485 N PROV1145 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PROFESSIONAL NURSES EMPLOYED BY A PROVIDER. COBOL NAME: NUM-REG-NURS RELATED PROVIDER NUMBER 10 514 523 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 COMPLIANCE: BEDS PER ROOM WAIVER 1 657 657 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 1 658 658 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 9 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME PROVIDER BASED FACILITY 1 1191 1191 C PROV1675 INDICATES IF A LONG TERM CARE FACILITY IS PROVIDER BASED. COBOL NAME: PROV-BASED-FACILITY VALUES: Y DISTINCT PART OF A HOSPITAL, SNF OR ICF RESCIND SUSPENSION DATE 8 1213 1220 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 ADMISSION SUSPENSION DATE 8 1514 1521 C PROV0030 THE DATE THAT PAYMENTS FOR NEW ADMISSIONS IN A LONG TERM CARE FACILITY WILL BE DENIED IF AN INTERMEDIATE SANCTION IS TAKEN AGAINST THE FACILITY. COBOL NAME: ADMIN-SUSP-DT BEDS - ICF/MR 4 1522 1525 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 1526 1532 N PROV0780 NUMBER OF FULL-TIME EQUIVALENT DIRECT CARE PERSONNEL EMPLOYED BY AN INTERMEDIATE CARE FACILITY FOR THE MENTALLY RETARDED. COBOL NAME: NUM-DCARE-PERSNL LTC AGREEMENT BEGINNING DATE 8 1533 1540 C PROV0620 THE BEGINNING DATE OF A CERTIFIED LONG TERM CARE FACILI TY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-BEGIN-DT LTC AGREEMENT ENDING DATE 8 1541 1548 C PROV0625 THE ENDING DATE OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-END-DT LTC AGREEMENT EXTENSION DATE 8 1549 1556 C PROV0630 THE LAST DATE OF AN EXTENSION OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-EXT-DT PRIOR ADMISSION SUSPENSION DATE 8 1557 1564 C PROV1610 PREVIOUS DATE A SUSPENSION OF ADMISSIONS WAS INVOKED FOR A PROVIDER. COBOL NAME: PRIOR-ADMIN-SUSP-DT PRIOR LTC END DATE 8 1565 1572 C PROV1630 THE LAST DATE OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT FOR A PRIOR SURVEY. COBOL NAME: PRIOR-LTC-END-DT PRIOR LTC EXTENSION DATE 8 1573 1580 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 10 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR RESCIND SUSPENSION DATE 8 1581 1588 C PROV1640 THE EFFECTIVE DATE OF A PREVIOUS SUSPENSION OF ADMISSIONS TO A LTC FACILITY. COBOL NAME: PRIOR-RESC-SUSP-DT TOTAL # OF EMPLOYEES 9.2 1589 1597 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 1 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 RURAL HEALTH CLINICS CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 12 RURAL HEALTH CLINICS CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 2 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 BLUE CROSS (INDIANA) 00131 ADMINISTAR FEDERAL (CHICAGO) 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 3 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 00452 UNITED GOVT SERVICES 00454 USG CALIFORNIA 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 4 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 5 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 6 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 7 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATES REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 8 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 03 STATE GOVERNMENT 04 LOCAL GOVERNMENT 05 FEDERAL GOVERNMENT 1A FOR PROFIT INDIVIDUAL 1B FOR PROFIT CORPORATION 1C FOR PROFIT PARTNERSHIP 2A NON PROFIT INDIVIDUAL 2B NON PROFIT CORPORATION 2C NON PROFIT PARTNERSHIP ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 9 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COBOL NAME: WS-SSA-MSA-SIZE-CD FISCAL YEAR ENDING DATE 4 399 402 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT OTHER PERSONNEL 7.2 426 432 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL PHYSICIAN ASSISTANTS 7.2 441 447 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 1598 1598 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: N NO Y YES NURSE PRACTITIONERS 7.2 1599 1605 N PROV1015 NUMBER OF FULL-TIME EQUIVALENT NURSE PRACTITIONERS IN A RURAL HEALTH CLINIC. COBOL NAME: NUM-NURSE-PRACT PARENT PROVIDER NUMBER 10 1606 1615 C PROV1560 THE IDENTIFICATION NUMBER OF THE PARENT PROVIDER WHEN A PROVIDER IS PART OF AN EXISTING MEDICARE PROVIDER. COBOL NAME: PARENT-PROV-NUM PHYSICIANS 7.2 1616 1622 N PROV1110 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIANS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS TITLE OF FEDERAL PROGRAM 26 1623 1648 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 1 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 13 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 2 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00011 CAHABA 00122 HCSC - MICHIGAN 00452 UNITED GOVT SERVICES 00454 USG CALIFORNIA 00510 BLUE SHIELD (ALABAMA) 00511 CAHABA 00520 BLUE SHIELD (ARKANSAS) 00528 BLUE SHIELD (ARKANSAS/LOUISIANA) 00542 BLUE SHIELD (CALIFORNIA) 00550 BLUE SHIELD (COLORADO) 00570 BLUE SHIELD (DELAWARE) 00580 BLUE SHIELD (DISTRICT OF COLUMBIA) 00590 BLUE SHIELD (FLORIDA) 00621 BLUE SHIELD (ILLINOIS) 00630 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) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 3 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME 00803 BLUE SHIELD (EMPIRE) 00805 BLUE SHIELD OF NEW YORK 00820 BLUE SHIELD (NORTH DAKOTA) 00825 BLUE SHIELD (NORTH DAKOTA/WYOMING) 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865 BLUE SHIELD (PENNSYLVANIA) 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00883 PALMETTO 00900 BLUE SHIELD (TEXAS) 00901 TRAILBLAZERS HEALTH ENTERPRISES 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 00973 BLUE SHIELD (PUERTO RICO) 00974 BLUE SHIELD (VIRGIN ISLANDS) 01010 AETNA (PEORIA) 01020 AETNA (ALASKA) 01030 AETNA (ARIZONA) 01040 AETNA (GEORGIA) 01120 AETNA (HAWAII) 01290 AETNA (NEVADA) 01360 AETNA (NEW MEXICO) 01370 AETNA (OKLAHOMA) 01380 AETNA (OREGON) 01390 AETNA (WASHINGTON) 02050 OCCIDENTAL (CALIFORNIA) 05130 EQICOR (IDAHO) 05440 EQICOR (TENNESSEE) 05535 EQICOR (NORTH CAROLINA) 10071 TRAVELERS (RRB) 10230 TRAVELERS (CONNECTICUT) 10240 TRAVELERS (MINNESOTA) 10250 TRAVELERS (MISSISSIPPI) 10490 TRAVELERS (VIRGINIA) 10492 TRAVELERS - VIRGINIA SPECIAL PROJECT 11260 GENERAL AMERICAN 14330 GROUP HEALTH INC (NEW YORK) 16360 NATIONWIDE (OHIO) 16510 NATIONWIDE (WEST VIRGINIA) 21200 MASSACHUSETTS/MAINE 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 4 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 5 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 6 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 7 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 STATES REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 8 PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE, CATEGORY = "13" (SEE POSITIONS 3-4 SHORT DESCRIPTION LEN START END TYPE SAS NAME 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 1 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 COMPREHENSIVE OUTPATIENT CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 14 COMPREHENSIVE OUTPATIENT REHAB FACILITIES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 2 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 BLUE CROSS (INDIANA) 00131 ADMINISTAR FEDERAL (CHICAGO) 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 3 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 00452 UNITED GOVT SERVICES 00454 USG CALIFORNIA 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 4 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 5 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 6 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 7 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATES REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 8 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 PROPRIETARY 02 NON PROFIT CHURCH 03 NON PROFIT OTHER 04 GOVERNMENT ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 9 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FISCAL YEAR ENDING DATE 4 399 402 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT RELATED PROVIDER NUMBER 10 514 523 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 1 556 556 C PROV2270 INDICATES HOW OCCUPATIONAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-OCCUP-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: PHYSICAL THERAPY 1 566 566 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 1 574 574 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 1 575 575 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 SRV: NURSING 1 1440 1440 C PROV2250 INDICATES HOW NURSING SERVICES ARE PROVIDED. COBOL NAME: SP-NURSING VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 10 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 3 COMBINATION PARENT PROVIDER NUMBER 10 1606 1615 C PROV1560 THE IDENTIFICATION NUMBER OF THE PARENT PROVIDER WHEN A PROVIDER IS PART OF AN EXISTING MEDICARE PROVIDER. COBOL NAME: PARENT-PROV-NUM PARTICIPATION MEDICARE OPT/SP 1 1649 1649 C PROV1570 INDICATES IF A COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY ALSO PARTICIPATES IN MEDICARE AS A PROVIDER OF OUTPATIENT PHYSICAL THERAPY AND/OR SPEECH PATHOLOGY. COBOL NAME: PARTIC-OPT-SP VALUES: N NO Y YES SRV: NURSING #2 1 1650 1650 C PROV6140 INDICATES HOW NURSING SERVICES ARE PROVIDED COBOL NAME: SP-NURSING-2 VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: NURSING #3 1 1651 1651 C PROV6145 INDICATES HOW NURSING SERVICES ARE PROVIDED COBOL NAME: SP-NURSING-3 VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: OCCUPATIONAL THERAPY #2 1 1652 1652 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 1653 1653 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 11 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: ORTHOTIC/PROSTHETIC 1 1654 1654 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 1655 1655 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 1656 1656 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 1657 1657 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 1658 1658 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 1659 1659 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 12 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHYSICIAN #2 1 1660 1660 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 1661 1661 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 1662 1662 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 1663 1663 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 1664 1664 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 1665 1665 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 13 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: RESPIRATORY CARE #2 1 1666 1666 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 1667 1667 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 1668 1668 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 1669 1669 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 1670 1670 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 1671 1671 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 1 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 AMBULATORY SURGICAL CENTER CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 15 AMBULATORY SURGICAL CENTERS CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 2 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 BLUE CROSS (INDIANA) 00131 ADMINISTAR FEDERAL (CHICAGO) 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 3 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 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) 00452 UNITED GOVT SERVICES 00454 USG CALIFORNIA 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00510 BLUE SHIELD (ALABAMA) 00511 CAHABA 00520 BLUE SHIELD (ARKANSAS) 00528 BLUE SHIELD (ARKANSAS/LOUISIANA) 00542 BLUE SHIELD (CALIFORNIA) 00550 BLUE SHIELD (COLORADO) 00570 BLUE SHIELD (DELAWARE) 00580 BLUE SHIELD (DISTRICT OF COLUMBIA) 00590 BLUE SHIELD (FLORIDA) 00621 BLUE SHIELD (ILLINOIS) 00630 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) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 4 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00805 BLUE SHIELD OF NEW YORK 00820 BLUE SHIELD (NORTH DAKOTA) 00825 BLUE SHIELD (NORTH DAKOTA/WYOMING) 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865 BLUE SHIELD (PENNSYLVANIA) 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00883 PALMETTO 00900 BLUE SHIELD (TEXAS) 00901 TRAILBLAZERS HEALTH ENTERPRISES 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 00973 BLUE SHIELD (PUERTO RICO) 00974 BLUE SHIELD (VIRGIN ISLANDS) 01010 AETNA (PEORIA) 01020 AETNA (ALASKA) 01030 AETNA (ARIZONA) 01040 AETNA (GEORGIA) 01120 AETNA (HAWAII) 01290 AETNA (NEVADA) 01360 AETNA (NEW MEXICO) 01370 AETNA (OKLAHOMA) 01380 AETNA (OREGON) 01390 AETNA (WASHINGTON) 02050 OCCIDENTAL (CALIFORNIA) 05130 EQICOR (IDAHO) 05440 EQICOR (TENNESSEE) 05535 EQICOR (NORTH CAROLINA) 10071 TRAVELERS (RRB) 10230 TRAVELERS (CONNECTICUT) 10240 TRAVELERS (MINNESOTA) 10250 TRAVELERS (MISSISSIPPI) 10490 TRAVELERS (VIRGINIA) 10492 TRAVELERS - VIRGINIA SPECIAL PROJECT 11260 GENERAL AMERICAN 14330 GROUP HEALTH INC (NEW YORK) 16360 NATIONWIDE (OHIO) 16510 NATIONWIDE (WEST VIRGINIA) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 21200 MASSACHUSETTS/MAINE 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 5 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 6 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 7 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 8 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 STATES REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 9 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP 5 VALIDATION (ACCRD) TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 PROPRIETARY 02 NON PROFIT 03 GOVERNMENT ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 10 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD ACCREDITATION INDICATOR 1 290 290 C PROV0010 INDICATES THE ORGANIZATION THAT IS RESPONSIBLE FOR THE ACCREDITATION OF THE PROVIDER. COBOL NAME: ACCRED-STAT VALUES: 0 NONE 1 JCAHO 2 AAAHC 3 AAAASF 4 AOA COMPLIANCE: LIFE SAFETY CODE 1 377 377 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 4 399 402 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT RELATED PROVIDER NUMBER 10 514 523 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 1 565 565 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 1442 1442 C PROV2340 INDICATES HOW OTHER (NOT SPECIFIED) SERVICES ARE PROVIDED. COBOL NAME: SP-OTHER VALUES: N NOT OFFERED Y OFFERED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 11 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME DATE CENTER BEGAN PROVIDING SERV 8 1672 1679 C PROV0415 THE DATE AN AMBULATORY SURGICAL CENTER (ASC) BEGAN PROVIDING HEALTH CARE SERVICES. COBOL NAME: DT-SERVICE-BEGAN FREE STANDING INDICATOR (ASC) 1 1680 1680 C PROV0550 INDICATES IF THE AMBULATORY SURGICAL CENTER IS FREE STANDING. THIS INDICATOR IS USED BY SOME STANDARD REPORTS TO GET CERTAIN PROVIDER RANGES. COBOL NAME: FREE-STAND-IND VALUES: Y YES FREE STANDING HOSPITAL BASED INDICATOR 1 1681 1681 C PROV0565 HOSPITAL BASED INDICATOR COBOL NAME: HOSP-BASED-IND VALUES: 1 HOSPITAL BASED OPERATING ROOMS 2 1682 1683 N PROV1055 THE NUMBER OF OPERATING ROOMS IN AN AMBULATORY SURGICAL CENTER. COBOL NAME: NUM-OPERATING-ROOMS SPEC: CARDIOVASCULAR 1 1684 1684 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 1685 1685 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 1686 1686 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 1687 1687 C PROV2240 INDICATES IF NEUROLOGICAL SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-NEUROLOGICAL VALUES: N NOT OFFERED Y OFFERED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 12 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPEC: OBSTETRICS/GYNECOLOGY 1 1688 1688 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 1689 1689 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 1690 1690 C PROV2305 INDICATES IF ORAL SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-ORAL VALUES: N NOT OFFERED Y OFFERED SPEC: ORTHOPEDIC 1 1691 1691 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 1692 1692 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 1693 1693 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 1694 1694 C PROV2525 INDICATES IF THORACIC SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-THORACIC VALUES: N NOT OFFERED Y OFFERED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 13 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPEC: UROLOGY 1 1695 1695 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 1696 1696 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 1697 1697 C PROV2200 INDICATES HOW LABORATORY SERVICES ARE PROVIDED. COBOL NAME: SP-LABORATORY VALUES: 1 PROVIDED DIRECTLY BY THE FACILITY 2 PROVIDED THROUGH AN OUTSIDE SOURCE 3 COMBINATION SRV: RADIOLOGY 1 1698 1698 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 1 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 HOSPICE CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 16 HOSPICES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 2 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 BLUE CROSS (INDIANA) 00131 ADMINISTAR FEDERAL (CHICAGO) 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 3 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 00452 UNITED GOVT SERVICES 00454 USG CALIFORNIA 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 4 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 5 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 6 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 7 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATES REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 8 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP 5 VALIDATION (ACCRD) TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 VOLUNTARY NON-PROFIT - CHURCH 02 VOLUNTARY NON-PROFIT - PRIVATE 03 VOLUNTARY NON-PROFIT - OTHER 04 PROPRIETARY - INDIVIDUAL 05 PROPRIETARY - PARTNERSHIP 06 PROPRIETARY - CORPORATION 07 PROPRIETARY - OTHER 08 GOVERNMENT - STATE 09 GOVERNMENT - COUNTY 10 GOVERNMENT - CITY 11 GOVERNMENT - CITY-COUNTY 12 COMBINATION GOV. & NONPROFIT 13 OTHER ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 9 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD ACCREDITATION INDICATOR 1 290 290 C PROV0010 INDICATES THE ORGANIZATION THAT IS RESPONSIBLE FOR THE ACCREDITATION OF THE PROVIDER. COBOL NAME: ACCRED-STAT VALUES: 0 NONE 1 JCAHO 2 CHAP COMPLIANCE: LIFE SAFETY CODE 1 377 377 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 4 399 402 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT LICENSED PRACT/VOCAT NURSES 7.2 410 416 N PROV0955 NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL OR VOCATIONAL NURSES EMPLOYED BY A FACILITY. COBOL NAME: NUM-LPN-LVN OTHER PERSONNEL 7.2 426 432 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL REGISTERED NURSES 7.2 479 485 N PROV1145 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PROFESSIONAL NURSES EMPLOYED BY A PROVIDER. COBOL NAME: NUM-REG-NURS RELATED PROVIDER NUMBER 10 514 523 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 1 556 556 C PROV2270 INDICATES HOW OCCUPATIONAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-OCCUP-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 10 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: PHYSICAL THERAPY 1 566 566 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 1 575 575 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 2 578 579 C PROV2890 INDICATES THE CATEGORY WHICH REPRESENTS THE TYPE OF FACILITY. COBOL NAME: TYPE-FACILITY VALUES: 01 HOSPITAL 02 SKILLED NURSING FACILITY 03 NURSING FACILITY 04 HOME HEALTH AGENCY 05 FREESTANDING HOSPICE HOME HEALTH AIDES 7.2 1402 1408 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 1439 1439 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 1440 1440 C PROV2250 INDICATES HOW NURSING SERVICES ARE PROVIDED. COBOL NAME: SP-NURSING VALUES: 1 PROVIDED BY STAFF 3 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 11 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: OTHER 1 1442 1442 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 1589 1597 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 1616 1622 N PROV1110 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIANS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS SRV: PHYSICIAN 1 1659 1659 C PROV2385 INDICATES HOW PHYSICIAN SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICIAN VALUES: 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION ACUTE/RESPITE CARE INDICATOR 1 1699 1699 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 1700 1706 N PROV1225 THE NUMBER OF FULL-TIME EQUIVALENT COUNSELORS EMPLOYED BY A HOSPICE. COBOL NAME: NUM-STAFF-COUNSL COUNSELORS - VOLUNTEER 7.2 1707 1713 N PROV1480 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER COUNSELORS IN A HOSPICE. COBOL NAME: NUM-VOL-COUNSL HOME HEALTH AIDES - VOLUNTEER 7.2 1714 1720 N PROV1485 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER HOME HEALTH AIDES IN A HOSPICE. COBOL NAME: NUM-VOL-HHA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 12 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME HOMEMAKERS - STAFF 7.2 1721 1727 N PROV0915 THE NUMBER OF FULL-TIME EQUIVALENT HOMEMAKERS EMPLOYED BY A HOSPICE. COBOL NAME: NUM-HOMEMAKERS HOMEMAKERS - VOLUNTEER 7.2 1728 1734 N PROV1490 THE NUMBER OF FULL-TIME EQUIVALENT HOMEMAKERS IN A HOSPICE. COBOL NAME: NUM-VOL-HOMEMKR LPNS/LVNS - VOLUNTEER 7.2 1735 1741 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 1742 1748 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 1749 1755 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 1756 1762 N PROV1500 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER PHYSICIANS IN A HOSPICE. COBOL NAME: NUM-VOL-PHYS REGISTERED NURSES - VOLUNTEER 7.2 1763 1769 N PROV1505 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER REGISTERED NURSES IN A HOSPICE. COBOL NAME: NUM-VOL-REG-NURS SRV: COUNSELING 1 1770 1770 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 1771 1771 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 13 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: HOMEMAKER 1 1772 1772 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 1773 1773 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 1774 1774 C PROV2480 INDICATES HOW SHORT TERM INPATIENT CARE SERVICES ARE PROVIDED BY A HOSPICE. COBOL NAME: SP-SHORT-TERM-INCARE VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION VOLUNTEERS - OTHER 7.2 1775 1781 N PROV1080 THE NUMBER OF FULL-TIME EQUIVALENT OTHER VOLUNTEERS IN A HOSPICE. COBOL NAME: NUM-OTHER-VOLS VOLUNTEERS - TOTAL 9.2 1782 1790 N PROV2860 THE NUMBER OF FULL-TIME VOLUNTEERS IN A HOSPICE. COBOL NAME: TOT-VOLS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 1 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 ORGAN PROCUREMENT CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 17 ORGAN PROCUREMENT ORGANIZATIONS CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 2 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 BLUE CROSS (INDIANA) 00131 ADMINISTAR FEDERAL (CHICAGO) 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 3 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 00452 UNITED GOVT SERVICES 00454 USG CALIFORNIA 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 4 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 5 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 6 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 7 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 56 CANADA 59 MEXICO 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN STATES REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 8 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 3 TERMINATION TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 1 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 COMMUNITY MENTAL HEALTH CENTERS CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 19 COMMUNITY MENTAL HEALTH CENTERS CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 2 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 BLUE CROSS (INDIANA) 00131 ADMINISTAR FEDERAL (CHICAGO) 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 3 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 00452 UNITED GOVT SERVICES 00454 USG CALIFORNIA 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 4 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 5 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 6 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 7 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 STATES REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 8 COMMUNITY MENTAL HEALTH CENTERS, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 3 TERMINATION TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 PROPRIETARY 02 CHURCH RELATED 03 NONPROFIT CORPORATION 04 OTHER NONPROFIT 05 STATE 06 LOCAL 07 FEDERAL ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD RELATED PROVIDER NUMBER 10 514 523 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 1 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 FEDERALLY QUALIFIED HEALTH CENTERS CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 21 FEDERALLY QUALIFIED HEALTH CENTERS CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 2 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 BLUE CROSS (INDIANA) 00131 ADMINISTAR FEDERAL (CHICAGO) 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 3 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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) 00452 UNITED GOVT SERVICES 00454 USG CALIFORNIA 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00511 CAHABA 00883 PALMETTO 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 01390 AETNA (WASHINGTON) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 4 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED P PENDING W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 5 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CN CANADA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA MX MEXICO NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 6 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 7 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 STATES REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 8 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 07 OTH-STATUS CHG TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 3 TERMINATION TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 RELIGIOUS AFFILIATION 02 PRIVATE 03 OTHER 04 PROPRIETARY 05 GOVERNMENT - STATE/COUNTY 06 GOVERNMENT - COMB. GOVT & VOL. ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD RELATED PROVIDER NUMBER 10 514 523 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 9 FEDERALLY QUALIFIED HEALTH CENTERS, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FEDERALLY FUNDED HEALTH CENTER 1 1791 1791 C PROV3710 INDICATED WHETHER THIS FQHC IS FEDERALLY FUNDED. COBOL NAME: FED-FUNDED-FFHC VALUES: N NO Y YES FQHC APPROVED RHC PROVIDER # 6 1792 1797 C PROV3705 APPROVED FQHC'S RELATED RHC PROVIDER NUMBER. COBOL NAME: APPROVED-RHC-PROV-NUM FQHC APPROVED RURAL HEALTH CLINIC 1 1798 1798 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: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 1 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 CLIA88 LABORATORY CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 22 CLIA88 LABORATORIES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 8 7 14 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY 28 15 42 C PROV3225 CITY IN WHICH THE PROVIDER IS PHYSICALLY LOCATED. COBOL NAME: CITY COMPLIANCE: PLAN OF CORRECTION 1 43 43 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 44 44 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 45 47 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 48 57 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 8 58 65 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 2 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 8 66 73 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 74 74 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 50 75 124 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME INTERMEDIARY NUMBER 5 125 129 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00011 CAHABA 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00122 HCSC - MICHIGAN 00123 HCSC OF MICHIGAN 00130 BLUE CROSS (INDIANA) 00131 ADMINISTAR FEDERAL (CHICAGO) 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 3 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 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) 00452 UNITED GOVT SERVICES 00454 USG CALIFORNIA 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00510 BLUE SHIELD (ALABAMA) 00511 CAHABA 00520 BLUE SHIELD (ARKANSAS) 00528 BLUE SHIELD (ARKANSAS/LOUISIANA) 00542 BLUE SHIELD (CALIFORNIA) 00550 BLUE SHIELD (COLORADO) 00570 BLUE SHIELD (DELAWARE) 00580 BLUE SHIELD (DISTRICT OF COLUMBIA) 00590 BLUE SHIELD (FLORIDA) 00621 BLUE SHIELD (ILLINOIS) 00630 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) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 4 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00805 BLUE SHIELD OF NEW YORK 00820 BLUE SHIELD (NORTH DAKOTA) 00825 BLUE SHIELD (NORTH DAKOTA/WYOMING) 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865 BLUE SHIELD (PENNSYLVANIA) 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00883 PALMETTO 00900 BLUE SHIELD (TEXAS) 00901 TRAILBLAZERS HEALTH ENTERPRISES 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 00952 WPS - ILLINOIS 00953 WPS - MICHIGAN 00954 WI PHYSICIAN SERVICES - MN 00973 BLUE SHIELD (PUERTO RICO) 00974 BLUE SHIELD (VIRGIN ISLANDS) 01010 AETNA (PEORIA) 01020 AETNA (ALASKA) 01030 AETNA (ARIZONA) 01040 AETNA (GEORGIA) 01120 AETNA (HAWAII) 01290 AETNA (NEVADA) 01360 AETNA (NEW MEXICO) 01370 AETNA (OKLAHOMA) 01380 AETNA (OREGON) 01390 AETNA (WASHINGTON) 02050 OCCIDENTAL (CALIFORNIA) 05130 EQICOR (IDAHO) 05440 EQICOR (TENNESSEE) 05535 EQICOR (NORTH CAROLINA) 10071 TRAVELERS (RRB) 10230 TRAVELERS (CONNECTICUT) 10240 TRAVELERS (MINNESOTA) 10250 TRAVELERS (MISSISSIPPI) 10490 TRAVELERS (VIRGINIA) 10492 TRAVELERS - VIRGINIA SPECIAL PROJECT 11260 GENERAL AMERICAN 14330 GROUP HEALTH INC (NEW YORK) 16360 NATIONWIDE (OHIO) 16510 NATIONWIDE (WEST VIRGINIA) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 21200 MASSACHUSETTS/MAINE 31140 NATIONAL HERITAGE (CA) 31142 NATIONAL HERITAGE INSURANCE CO (MAINE) 31143 NATIONAL HERITAGE INSURANCE CO 31144 NATIONAL HERITAGE INSURANCE CO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 5 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICARE OR MEDICAID VENDOR NUMBER 15 130 144 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 8 145 152 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 8 153 160 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 161 165 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 166 175 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE 1 176 176 C PROV1720 THIS INDICATOR SPECIFIES THE CURRENT STATUS OF RECORD. COBOL NAME: RECORD-TYPE VALUES: A ACCEPTED D DELETED N NOT-A-LAB P PENDING T TEMPORARY (CLIA ONLY) W WORK REGION CODE 2 177 178 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 6 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 179 179 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE ABBREVIATION 2 180 181 C PROV3230 STATE ABBREVIATION COBOL NAME: STATE-ABBREV VALUES: AK ALASKA AL ALABAMA AR ARKANSAS AS AMERICAN SAMOA AZ ARIZONA CA CALIFORNIA CO COLORADO CT CONNECTICUT DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA FN FOREIGN GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MP SAIPAN MS MISSISSIPPI MT MONTANA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 7 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESSEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING STATE CODE (SSA) 2 182 183 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 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 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 8 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 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 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN 99 FOREIGN STATES REGION CODE 3 184 186 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 9 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME STREET ADDRESS 50 187 236 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 237 246 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE # 1 2 247 248 C PROV4770 TERMINATION CODE #1, THE REASON A FACILITY HAS BEEN TERMINATED FROM THE CLIA, MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: TERM-CD-1 VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG 08 NONPAYMENT OF FEES 09 REV/UNSUCCESSFUL PARTICIPATION IN PT 10 REV/OTHER REASON 11 INCOMPLETE CLIA APPLICATION INFORMATION 12 NO LONGER PERFORMING TESTS 13 MULTIPLE TO SINGLE SITE CERTIFICATE 14 SHARED LABORATORY 15 FAILURE TO RENEW WAIVER PPMP CERTIFICATE 16 DUPLICATE CLIA NUMBER 17 UNDELIVERABLE 20 NOTIFICATION BANKRUPTCY 33 LAB NOT AFFILIATED WITH ACCRED ORGANIZATION 99 OIG ACTION - DO NOT ACTIVATE TERMINATION DATE/EXPIRATION DATE 1 8 249 256 C PROV4500 THE DATE THE LABORATORY'S CERTIFICATE TERMINATED OR THE EXPIRATION DATE OF THE CURRENT CLIA CERTIFICATE. FOR OTHER NON-CLIA PROVIDERS, IT IS THE DATE THE FACILITY WAS TERMINATED. COBOL NAME: EXP-DT-1 TYPE OF ACTION 1 257 257 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 10 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 4 CHANGE OF OWNERSHIP 5 CLIA VALIDATION 6 ONSITE SURVEY DUE TO FLEXIBLE SURVEY TYPE OF CONTROL 2 258 259 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 RELIGIOUS AFFILIATION 02 PRIVATE 03 OTHER 04 PROPRIETARY 05 GOVERNMENT - CITY 06 GOVERNMENT - COUNTY 07 GOVERNMENT - STATE 08 GOVERNMENT - FEDERAL 09 GOVERNMENT - OTHER 10 UNKNOWN ZIP CODE 5 260 264 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 265 266 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 267 269 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 270 272 C SSAMSACD SSA MSA CODE COBOL NAME: WS-SSA-MSA-CD SSA MSA SIZE CODE 1 273 273 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE-CD FISCAL YEAR ENDING DATE 4 399 402 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT TYPE OF FACILITY 2 578 579 C PROV2890 INDICATES THE CATEGORY WHICH REPRESENTS THE TYPE OF FACILITY. COBOL NAME: TYPE-FACILITY VALUES: 01 AMBULATORY SURGERY CENTER 02 COMMUNITY CLINIC 03 COMPREHENSIVE OUTPATIENT REHAB 04 ANCILLARY TEST SITE 05 END STAGE RENAL DISEASE DIALYSIS 06 HEALTH FAIR * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 11 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 07 HEALTH MAINTENANCE ORGANIZATION 08 HOME HEALTH AGENCY 09 HOSPICE 10 HOSPITAL 11 INDEPENDENT 12 INDUSTRIAL 13 INSURANCE 14 INTERM. CARE FACIL. MENTALLY RETARDED 15 MOBILE UNIT 16 PHARMACY 17 SCHOOL/STUDENT HEALTH SERVICE 18 SKILLED NURSING/NURSING FACILITY 19 PHYSICIAN OFFICE 20 OTHER PRACTITIONER 21 TISSUE BANK/REPOSITORIES 22 BLOOD BANKS 23 RURAL HEALTH CLINIC 24 FEDERALLY QUALIFIED HEALTH CENTER 25 AMBULANCE 26 PUBLIC HEALTH LABORATORY 27 OTHER ACCREDITED BY AABB 1 1799 1799 C PROV4205 INDICATES IF THE LAB IS ACCREDITED THE AMERICAN ASSOCIATION OF BLOOD BANKS. THIS INFORMATION IS FROM THE LABORATORY'S HCFA-116. COBOL NAME: ACCRED-AABB-IND VALUES: X YES ACCREDITED BY AOA 1 1800 1800 C PROV4200 INDICATES IF THE LAB IS ACCREDITED BY THE AMERICAN OSTEOPATHIC ASSOCIATION. THIS INFORMATION IS FROM THE LABORATORY'S HCFA-116. COBOL NAME: ACCRED-AOA-IND VALUES: X YES ACCREDITED BY ASHI 1 1801 1801 C PROV4225 INDICATES IF THE LAB IS ACCREDITED BY THE AMERICAN SOCIETY FOR HISTOCOMPATIBILITY AND IMMUNOGENETICS. THIS INFORMATION IS FROM THE LABORATORY'S HCFA-116. COBOL NAME: ACCRED-ASHI-IND VALUES: X YES ACCREDITED BY CAP 1 1802 1802 C PROV4210 INDICATES IF THE LAB IS ACCREDITED BY THE COLLEGE OF AMERICAN PATHOLOGISTS. THIS INFORMATION IS FROM THE LABORATORY'S HCFA-116. COBOL NAME: ACCRED-CAP-IND VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 12 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME X YES ACCREDITED BY COLA 1 1803 1803 C PROV4215 INDICATES IF THE LAB IS ACCREDITED BY THE COMMISSION ON OFFICE LABORATORY ACCREDITATION. THIS INFORMATION IS FROM THE LABORATORY'S HCFA-116. COBOL NAME: ACCRED-COLA-IND VALUES: X YES ACCREDITED BY JCAHO 1 1804 1804 C PROV4195 INDICATES IF THE LAB IS ACCREDITED BY THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATION. THIS INFORMATION IS FROM THE LABORATORY'S HCFA-116. COBOL NAME: ACCRED-JCAHO-IND VALUES: X YES ACCREDITED Y MATCH DATE AABB 8 1805 1812 C PROV5040 THE DATE THE AMERICAN ASSOCIATION OF BLOOD BANKS NOTIFIES HCFA THAT LAB IS ACCREDITED WITH AABB. THE EARLIEST Y MATCH DATE INITIATES THE BILLING OF THE CERTIFICATE OF ACCREDITATION FEES. COBOL NAME: ACCRED-AABB-DT ACCREDITED Y MATCH DATE AOA 8 1813 1820 C PROV5045 THE DATE THE LAB WAS ACCREDITED BY THE AMERICAN OSTEOPATHIC ASSOCIATION. THIS INFORMATION IS SUPPLIED BY THE ACCREDITING ORGANIZATION. COBOL NAME: ACCRED-AOA-DT ACCREDITED Y MATCH DATE ASHI 8 1821 1828 C PROV5055 THE DATE THE LAB WAS ACCREDITED BY THE AMERICAN SOCIETY FOR HISTOCOMPATIBILITY AND IMMUNOGENETICS. THIS INFORMATION IS SUPPLIED BY THE ACCREDITING ORGANIZATION COBOL NAME: ACCRED-ASHI-DT ACCREDITED Y MATCH DATE CAP 8 1829 1836 C PROV5060 THE DATE THE COLLEGE OF AMERICAN PATHOLOGIST NOTIFIES HCFA THAT LAB IS ACCREDITED BY CAP. THE EARLIEST Y MATCH DATE INITIATES THE BILLING FOR THE CERTIFICATE OF ACCREDITATION FEES. COBOL NAME: ACCRED-CAP-DT ACCREDITED Y MATCH DATE COLA 8 1837 1844 C PROV5065 THE DATE THE COMMISSION ON OFFICE LABORATORY ACCREDITATION NOTIFIES HCFA THAT LAB IS ACCREDITED WITH COLA. THE EARLIEST Y MATCH DATE INITIATES THE BILLING OF THE CERTIFICATE OF ACCREDITATION FEES COBOL NAME: ACCRED-COLA-DT ACCREDITED Y MATCH DATE JCAHO 8 1845 1852 C PROV5070 THE DATE THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS NOTIFIES HCFA THAT LAB IS ACCREDITED. THE EARLIEST Y MATCH DATE INITIATES THE BILLING OF THE CERTIFICATE OF ACCREDITATION FEES COBOL NAME: ACCRED-JCAHO-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 13 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ACCREDITED Y MATCH IND AABB 1 1853 1853 C PROV4970 INDICATES IF THE LAB IS ACCREDITED BY THE AMERICAN ASSOCIATION OF BLOOD BANKS. THIS INFORMATION IS SUPPLIED BY THE ACCREDITING ORGANIZATION. COBOL NAME: ACCRED-AABB-MATCH-IND VALUES: Y YES ACCREDITED Y MATCH IND AOA 1 1854 1854 C PROV4975 INDICATES IF THE LAB IS ACCREDITED BY THE AMERICAN OSTEOPATHIC ASSOCIATION. THIS INFORMATION IS SUPPLIED BY THE ACCREDITING ORGANIZATION. COBOL NAME: ACCRED-AOA-MATCH-IND VALUES: Y YES ACCREDITED Y MATCH IND ASHI 1 1855 1855 C PROV4985 INDICATES IF THE LAB IS ACCREDITED BY THE AMERICAN SOCIETY FOR HISTOCOMPATIBILITY AND IMMUNOGENETICS. THIS INFORMATION IS SUPPLIED BY THE ACCREDITING ORGANIZATION. COBOL NAME: ACCRED-ASHI-MATCH-IND VALUES: Y YES ACCREDITED Y MATCH IND CAP 1 1856 1856 C PROV4990 INDICATES IF THE LAB IS ACCREDITED BY COLLEGE OF AMERICAN PATHOLOGISTS. THIS INFORMATION IS SUPPLIED BY THE ACCREDITING ORGANIZATION. COBOL NAME: ACCRED-CAP-MATCH-IND VALUES: Y YES ACCREDITED Y MATCH IND COLA 1 1857 1857 C PROV4960 INDICATES IF THE LAB IS ACCREDITED BY THE COMMISSION ON OFFICE LABORATORY ACCREDITATION. THIS INFORMATION IS SUPPLIED BY THE ACCREDITING ORGANIZATION. COBOL NAME: ACCRED-COLA-MATCH-IND VALUES: Y YES ACCREDITED Y MATCH IND JCAHO 1 1858 1858 C PROV4995 INDICATES IF LAB IS ACCREDITED BY THE JOINT COMMISSION ON ACCREDITAION OF HEALTHCARE ORGANIZATIONS. THIS INFORMATION IS SUPPLIED BY THE ACCREDITING ORGANIZATION. COBOL NAME: ACCRED-JCAHO-MATCH-IND VALUES: Y YES AFFILIATED CLIA NUMBER 1 10 1859 1868 C PROV4240 AFFILIATED CLIA NUMBER 1 COBOL NAME: AFFIL-PROV-NUM-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 14 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME AFFILIATED CLIA NUMBER 2 10 1869 1878 C PROV4245 AFFILIATED CLIA NUMBER 2 COBOL NAME: AFFIL-PROV-NUM-2 AFFILIATED CLIA NUMBER 3 10 1879 1888 C PROV4250 AFFILIATED CLIA NUMBER 3 COBOL NAME: AFFIL-PROV-NUM-3 AFFILIATED CLIA NUMBER 4 10 1889 1898 C PROV4255 AFFILIATED CLIA NUMBER 4 COBOL NAME: AFFIL-PROV-NUM-4 AFFILIATED CLIA NUMBER 5 10 1899 1908 C PROV4260 AFFILIATED CLIA NUMBER 5 COBOL NAME: AFFIL-PROV-NUM-5 AFFILIATED CLIA NUMBER 6 10 1909 1918 C PROV4265 AFFILIATED CLIA NUMBER 6 COBOL NAME: AFFIL-PROV-NUM-6 AFFILIATED CLIA NUMBER 7 10 1919 1928 C PROV4270 AFFILIATED CLIA NUMBER 7 COBOL NAME: AFFIL-PROV-NUM-7 AFFILIATED CLIA NUMBER 8 10 1929 1938 C PROV4275 AFFILIATED CLIA NUMBER 8 COBOL NAME: AFFIL-PROV-NUM-8 APPLICATION ACCRED ANNUAL TEST VOL 9 1939 1947 N PROV4390 ACCREDITED ANNUAL TEST VOLUME. THIS FIELD IS CALCULATED USING THE CLIA APPLICATION DATA. COBOL NAME: APPL-ACCR-ANN-TEST-VOL APPLICATION ACCRED SCHEDULE CODE 1 1948 1948 C PROV4365 ACCREDITATION SCHEDULE CODE. THIS SCHEDULE IS FIGURED USING THE CLIA APPLICATION DATA. COBOL NAME: APPL-ACCRED-SCHED-CD VALUES: A SPEC COUNT < 4 (2,001 TO 10,000 TOT. VOL.) B SPEC COUNT > 3 (2,001 T0 10,000 TOT. VOL.) C SPEC COUNT < 4 (10,001 TO 25,000 TOT. VOL.) D SPEC COUNT > 3 (10,001 TO 25,000 TOT. VOL.) E SPEC COUNT > 0 (25,001 TO 50,000 TOT. VOL.) F SPEC COUNT > 0 (50,001 TO 75,000 TOT. VOL.) G SPEC COUNT > 0 (75,001 TO 100,000 TOT. VOL.) H SPEC COUNT > 0 (100,001 TO 500,000 TOT. VOL.) I SPEC COUNT > 0 (500,001 TO 1,000,000 TOT VOL) J SPEC COUNT > 0 (1,000,001 OR MORE TOT. VOL.) V TOTAL VOLUME: 1 TO 2,000 APPLICATION RECEIVED DATE 8 1949 1956 C PROV4340 APPLICATION RECEIVED DATE. THE DATE THE APPLICATION WAS ADDED OR THE 109 DATA WAS UPDATED WITH APPLICATION DATA COBOL NAME: APPL-RECEIVED-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 15 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME APPLICATION TOTAL ANNUAL TEST VOL 11 1957 1967 N PROV4325 APPLICATION TOTAL ANNUAL TEST VOLUME. THIS FIELD IS CALCULATED USING CLIA APPLICATION DATA. COBOL NAME: APPL-TOT-ANN-TEST-VOL APPLICATION TYPE 1 1968 1968 C PROV4695 THE TYPE OF CLIA CERTIFICATE APPLIED FOR BY A LAB COBOL NAME: TYPE-APPLICATION VALUES: 1 COMP 2 WAIV 3 ACCR 4 PPMP CERT TYPE CODE # 1 1 1969 1969 C PROV3810 A CODE THAT IDENTIFIES THE TYPE OF LABORATORY CERTIFICATE CURRENTLY IN EFFECT COBOL NAME: CERT-TYPE-CD-1 VALUES: 1 COMPLIANCE 2 WAIVER 3 ACCREDITATION 4 MICROSCOPY 5 PARTIAL ACC 9 REGISTRATION CERTIFICATE MAILED DATE 1 8 1970 1977 C PROV4700 CERTIFICATE MAILED DATE 1 COBOL NAME: CERT-MAILED-DT-1 CLIA CERT. EFFECTIVE DATE # 1 8 1978 1985 C PROV3860 DATE THE CURRENT LABORATORY CERTIFICATE IS EFFECTIVE, DETERMINED BY THE APPROVAL DATE OF THE CERTIFICATE APPLICATION UNLESS OVERRIDDEN. COBOL NAME: EFF-DT-1 CLIA MEDICARE NUMBER 12 1986 1997 C PROV4885 CLIA MEDICARE NUMBER COBOL NAME: CLIA-MEDICARE-NUM FAX PHONE NUMBER 10 1998 2007 C PROV5800 THE 10 DIGIT FAX PHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF THE LABORATORY COBOL NAME: FAX-NUM LABORATORY CLASSIFICATION 2 2008 2009 C PROV5935 CLIA LABORATORY CLASSIFICATION DETERMINES IF LAB IS CLIA EXEMPT, VA LABORATORY OR STANDARD LABORATORY COBOL NAME: CLIA-LAB-CLASS-CD VALUES: 00 CLIA LABORATORY 05 CLIA EXEMPT 10 VA LABORATORY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 16 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MULTIPLE SITE CERTIFICATE IND 1 2010 2010 C PROV4175 INDICATES IF A LAB HAS APPLIED FOR ONE CERTIFICATE FOR MULTIPLE SITES. COBOL NAME: MULTI-SITE-IND VALUES: N NO Y YES NON-PROFIT CODE 1 2011 2011 C PROV4190 NON-PROFIT CODE INDICATOR COBOL NAME: NON-PROFIT-IND VALUES: N NO Y YES NUMBER NON-WAIVED INDIVIDUALS 9 2012 2020 N PROV4330 TOTAL NUMBER NON-WAIVED INDIVIDUALS LISTED ON PAGE 4 OF THE HCFA-116. COBOL NAME: TOT-NUM-NON-WAIVED-IND NUMBER OF CLINICAL CONSULTANTS 4 2021 2024 N PROV4295 NUMBER OF CLINICAL CONSULTANTS AS REPORTED ON THE LABORATORY APPLICATION FORM HCFA-116 COBOL NAME: NUM-CLIN-CONSULT NUMBER OF DIRECTORS 4 2025 2028 N PROV4290 NUMBER OF DIRECTORS COBOL NAME: NUM-DIRECTORS NUMBER OF GENERAL SUPERVISORS 4 2029 2032 N PROV4310 NUMBER OF GENERAL SUPERVISORS AS REPORTED ON THE LABORATORY APPLICATION FORM HCFA-116 COBOL NAME: NUM-GEN-SUPER NUMBER OF LAB SITES 4 2033 2036 N PROV4180 THE TOTAL NUMBER OF LAB SITES FOR WHICH A LAB HAS APPLIED FOR A SINGLE CERTIFICATE. COBOL NAME: TOT-NUM-SITES NUMBER OF LABS DIRECTLY AFFILIATED 1 2037 2037 N PROV4235 NUMBER OF LABORATORIES DIRECTLY AFFILIATED COBOL NAME: NUM-AFFIL-LABS NUMBER OF TECHNICAL CONSULTANTS 4 2038 2041 N PROV4300 NUMBER OF TECHNICAL CONSULTANTS AS REPORTED ON THE LABORATORY APPLICATION FORM HCFA-116 COBOL NAME: NUM-TECH-CONSULT NUMBER OF TECHNICAL SUPERVISORS 4 2042 2045 N PROV4305 NUMBER OF TECHNICAL SUPERVISORS AS REPORTED ON THE LABORATORY APPLICATION FORM HCFA-116 COBOL NAME: NUM-TECH-SUPER NUMBER OF TESTING PERSONNEL 4 2046 2049 N PROV4315 NUMBER OF TEST PERSONNEL AS REPORTED ON THE LABORATORY APPLICAITON FORM HCFA-116 COBOL NAME: NUM-TEST-PERSONNEL * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 17 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME NUMBER WAIVED INDIVIDUALS 6 2050 2055 N PROV4285 TOTAL NUMBER OF INDIVIDUALS INVOLVED IN WAIVED LABORATORY TESTING AS REPORTED ON THE LABORATORY APPLICATION FORM HCFA 116 COBOL NAME: TOT-NUM-WAIVED-IND PREVIOUSLY REGULATED INDICATOR 1 2056 2056 C PROV3610 INDICATES IF THE LABORATORY WAS LICENSED UNDER CLIA 67 OR PARTICPATED IN THE MEDICARE/MEDICAID PROGRAMS. COBOL NAME: CLIA67-IND VALUES: N NO Y YES SHARED LAB CROSS REFERENCE # 10 2057 2066 C PROV4890 SHARED LAB CROSS REFERENCE # COBOL NAME: SHARED-LAB-XREF-NUM SHARED LAB INDICATOR 1 2067 2067 C PROV4880 SHARED LAB INDICATOR COBOL NAME: SHARED-LAB-IND VALUES: Y YES SURVEY CERTIFICATE SCHEDULE CODE 1 2068 2068 C PROV4470 1557 CERTIFICATE SCHEDULE CODE. THIS CODE IS SYSTEM GENERATED AND IS BASED ON THE TEST VOLUME AND SPECIAL TIES ENTERED INTO ODIE FOLLOWING THE SURVEY. CLIA FEES ARE BASED ON THE SCHEDULE CODES. COBOL NAME: SURV-CERT-SCHED-CD VALUES: A SPEC COUNT < 4 (2,001 TO 10,000 TOT. VOL.) B SPEC COUNT > 3 (2,001 T0 10,000 TOT. VOL.) C SPEC COUNT < 4 (10,001 TO 25,000 TOT. VOL.) D SPEC COUNT > 3 (10,001 TO 25,000 TOT. VOL.) E SPEC COUNT > 0 (25,001 TO 50,000 TOT. VOL.) F SPEC COUNT > 0 (50,001 TO 75,000 TOT. VOL.) G SPEC COUNT > 0 (75,001 TO 100,000 TOT. VOL.) H SPEC COUNT > 0 (100,001 TO 500,000 TOT. VOL.) I SPEC COUNT > 0 (500,001 TO 1,000,000 TOT VOL) J SPEC COUNT > 0 (1,000,001 OR MORE TOT. VOL.) V TOTAL VOLUME: 1 TO 2,000 SURVEY COMPLIANCE SCHEDULE CODE 1 2069 2069 C PROV4475 1557 COMPLIANCE SCHEDULE CODE THIS CODE IS SYSTEM GENERATED AND IS BASED ON THE NUMBER OF TESTS AND SPECIALTIES ENTERED INTO ODIE FOLLOWING THE SURVEY. CLIA FEES ARE BASED ON THE SCHEDULE CODES. COBOL NAME: SURV-COMPL-SCHED-CD VALUES: A SPEC COUNT < 4 (2,001 TO 10,000 TOT. VOL.) B SPEC COUNT > 3 (2,001 T0 10,000 TOT. VOL.) C SPEC COUNT < 4 (10,001 TO 25,000 TOT. VOL.) D SPEC COUNT > 3 (10,001 TO 25,000 TOT. VOL.) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004 1DATE: 01/04/2005 POS RECORD LAYOUT PAGE: 18 CLIA88 LABORATORIES, CATEGORY = "22" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME E SPEC COUNT > 0 (25,001 TO 50,000 TOT. VOL.) F SPEC COUNT > 0 (50,001 TO 75,000 TOT. VOL.) G SPEC COUNT > 0 (75,001 TO 100,000 TOT. VOL.) H SPEC COUNT > 0 (100,001 TO 500,000 TOT. VOL.) I SPEC COUNT > 0 (500,001 TO 1,000,000 TOT VOL) J SPEC COUNT > 0 (1,000,001 OR MORE TOT. VOL.) V TOTAL VOLUME: 1 TO 2,000 SURVEY TEST VOLUME TOTAL 9 2070 2078 N PROV4460 SURVEY TEST VOLUME TOTAL. THE NUMBER OF TESTS PERFORMED ANNUALLY IN A LABORATORY. THIS INFORMATION IS COLLECTED AT THE TIME OF THE STATE SURVEY AGENCY INSPECTION. COBOL NAME: SURV-TOT-ANN-TEST-VOL TERMINATION CODE 2 2079 2080 C PROV5805 THE REASON A LABORATORY'S CLIA CERTIFICATE HAS ENDED COBOL NAME: TERM-CD VALUES: 00 ACTIVE 01 VOL-MERG,CLOSE 02 VOL-REIMBURSE 03 VOL-RISK INVOL 04 VOL-OTHER 05 INVOL-FAIL REQ 06 INVOL-AGREEMNT 07 OTH-STATUS CHG 08 NONPAYMENT OF FEES 09 REV/UNSUCCESSFUL PARTICIPATION IN PT 10 REV/OTHER REASON 11 INCOMPLETE CLIA APPLICATION INFORMATION 12 NO LONGER PERFORMING TESTS 13 MULTIPLE TO SINGLE SITE CERTIFICATE 14 SHARED LABORATORY 15 FAILURE TO RENEW WAIVER PPMP CERTIFICATE 16 DUPLICATE CLIA NUMBER 17 UNDELIVERABLE 20 NOTIFICATION BANKRUPTCY 33 LAB NOT AFFILIATED WITH ACCRED ORGANIZATION 99 OIG ACTION - DO NOT ACTIVATE TOTAL WAIVED TEST VOL 9 2081 2089 N PROV4280 TOTAL WAIVED TEST VOLUMES COBOL NAME: TOT-ANN-TEST-VOL-WAIVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/06/2004