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Facets Extended Enterprise ® Provider Batch Import Subsystem Guide

Release 4.41 February 2007 Revised April 2007

Facets Extended Enterprise ® Provider Batch Import Subsystem Guide Release 4.41 February 2007 Revised April 2007

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Provider Batch Import Subsystem Guide

Contents

Contents

Chapter 1. Introduction

1

Chapter 2. User Reference

3

Overview

3

Highlights of the Provider Import Subsystem

3

Keyword Format

4

Record Type Keywords

5

Special Provider Processing

11

Creating Keyword Input Data

19

XPFH Header Record

20

Date Sensitive Record Types

22

Address Sharing

24

Date-sensitive Addresses

24

Tables Keyed with Sequence Number

25

PCP/Capitation Relationship Data

29

Terminating Providers

33

Attachments

37

Run File User-Defined Run Parameters

42

Provider Batch Load (ErCcsRunXpf0) Run File Sample

45

Generation of XLOW Columns

49

Run Controls

49

Appendix A. Sample Input

51

Practitioner

51

Facility

53

Group (IPA is similar)

55

Appendix B. XP/F Provider Data Model Navigation Tool

57

Appendix C. Update Code Defaults by Record Type

61

Contents

Provider Batch Import Subsystem Guide

Appendix D. Table Level Edits

65

Overview

65

Field, Record and Relational Edits

65

Appendix E. Attachment Table Level Edits

Overview

117

117

Appendix F. Error Messages

123

Index

Index-1

Provider Batch Import Subsystem Guide

Document Revision History

Document Revision History

The original 4.40 Facets Provider Batch Import Subsystem Guide was issued in October 2006. The following table shows subsequent changes that have been made to this document.

Date

Chapter

Description

April 10, 2007

Appendix D Table Level Edits

Added missing keywords for PRSQ (STARS 47291)

April 10, 2007

Appendix D Table Level Edits

Added a new run book option (NPIchkdigValidate) to the job to give users the ability to perform the Luhn Check Digit edit optionally. (STARS 46298)

January 9, 2007

Appendix D Table Level Edits

Corrected the Entity and Type values for

Relational Edit @pNWPR_MCTR_RSTR. STARS 46588.

Document Revision History

Provider Batch Import Subsystem Guide

Provider Batch Import Subsystem Guide

Introduction

Chapter 1

Introduction

Health plans implementing Facets need a way to load their provider information to the Facets database and to maintain that information on an ongoing basis. The Facets Provider Import subsystem (XP/F) is a batch load process that facilitates the initial loading and subsequent maintenance of practitioners, facilities, groups, Independent Practice Associations (addresses, certification information, network affiliations, tax information, etc.).

The strength of XP/F is the integration of incoming provider data with the data that already exists on the Facets database. XP/F interrogates the Facets database and uses it to edit the incoming data, thereby reducing the possibility of creating erroneous rows on the Facets database. This feature allows you to update Facets online and load data via batch without negative impact.

Two special features have been developed expressly for XP/F.

The Provider Reference Lookup table (CMC_PRXP_XREF) and appropriate indices that support retention and look-up capability to synchronize the Provider key of the data source with the Facets Provider key. This capability is especially valuable in supporting initial and periodic network affiliation updates.

The Find Provider capability assures non-duplication of rows on the Common Provider Indicative Information table (CMC_PRCP_COMM_PRAC) and potentially the Base Provider Table for Practitioner, Facility, Group and IPA table (CMC_PRPR_PROV) that exist prior to any import.

Whether provider data is to be loaded to Facets just once or at regular intervals, and regardless of where provider information is maintained, XP/F enables batch updates and/or additions while preserving database integrity.

Changes in 4.31

The Provider Batch Import Subsystem Guide for release 4.31 reflects the current data and functionality of the XP/F subsystem. Compared with earlier versions of this document, however, the Guide no longer contains the Keywords by Record Type appendix. The decision was made to remove that appendix because the information is contained in appendix D, Table Level Edits appendix.

Introduction

Provider Batch Import Subsystem Guide

Provider Batch Import Subsystem Guide

User Reference

Chapter 2

User Reference

Overview

The Facets Provider Import Subsystem is a batch load process that facilitates the initial loading and subsequent maintenance of providers and their associated information (addresses, network affiliations, credentialing, etc.). Consider the diagram below:

, credentialing, etc.). Consider the diagram below: Keyword Data ClaimFacts or External Source Facets Database

Keyword

Data

ClaimFacts

or

External Source

Facets

Database

Keyword Data ClaimFacts or External Source Facets Database XP/F Provider data stored on an external system

XP/F

Provider data stored on an external system must be mapped to the XP/F input format. The XP/F input data is per provider and in comma-delimited keyword format.

Highlights of the Provider Import Subsystem

These are the highlights of XP/F:

Update codes are available to apply any customer-directed instructions to direct the manner in which each input record will affect the Facets database.

In the absence of any customer-directed instructions regarding update codes, the import can query the Facets database to determine the presence or absence of rows and/or data to decide if an update or an insert is to occur.

When a new date sensitive row (for example, NWPR) is created, the conversion can conditionally update the term date of a prior existing row.

Three levels of edits ensure data integrity: Field level, Record level, and Relational. Following are examples of each:

Field Edit

On NWPR, the effective date is required and must be a valid date.

Record Edit

Also on NWPR, and on other date-sensitive rows, actual termination dates require a termination reason code.

User Reference

Provider Batch Import Subsystem Guide

Relational Edit

When creating a new credentialing row (PRCR), the provider ID must be valid. In other words, either a row must exist on the Facility Indicative Information Data table (CMC_PRFA_FACILITY) or Common Provider Indicative Information table (CMC_PRCP_COMM_PRAC), either in the input data stream or on the database.

Data Synchronization: A table and appropriate indices support retention and lookup capability synchronizing the Provider key of the data source with the Facets Provider key.

Find Provider capability is included, to assure non-duplication of rows on the Common Provider Indicative Information table (CMC_PRCP_COMM_PRAC) and potentially the Base Provider Table for Practitioner, Facility, Group and IPA (CMC_PRPR_PROV) that exist prior to any import.

Each of the four valid Provider Entity Types (Practitioners, Facilities, Groups and IPAs) is processed in accordance with the special rules for each type.

Keyword Format

Each field in the input stream is independent of its position because it is governed by a format defined as keyword. The keyword format is made up of two parts:

The first is the actual keyword that is identified by the program to process that data correctly.

The second part that is the actual data.

The two parts are connected by the literal =.

An example of a keyword is: @pPRCP_LAST_NAME=”Smith”

Provider Batch Import Subsystem Guide

User Reference

Record Type Keywords

A keyword of @pRECTYPE (Record Type) indicates the Facets table in which the data will eventually reside. Other specialized keywords may be used to indicate control parameters, such as a function of insert, update, or apply. After being edited, XP/F output is written directly to the Facets database.

The following record types can be input to XP/F; they are shown by Provider Entity. Details on each record type are included in the tables that follow.

Practitioner

Facility

IPA

Groups

Practitioner

Practitioner Record Types

Description

Facets Table Name

XPFH

     

XP/F Header Record

Used only in XP/F

PRCP

     

Common Practitioner

CMC_PRCP_COMM_PRAC

 

PRPR

   

Provider

CMC_PRPR_PROV

   

MCTN

 

Tax Name

CMC_MCTN_TAX_NAME

   

MCTI

 

Tax Information

CMC_MCTI_TAX_INFO

   

PRER

 

Entity Relation

CMC_PRER_RELATION

   

NWPR

 

Network Provider Relation

CMC_NWPR_RELATION

   

NWPX

 

Provider Common

CMC_NWPX_RELATION

Relationships

   

NWGX

 

Provider Global Common Relationships

CMC_NWGX_RELATION

   

PRDS

 

Date

CMC_PRDS_DATE

   

NWPE

 

PCP/Capitation

CMC_NWPE_RELATION

Relationship Data

   

NWCR

 

Global Capitation

CMC_NWCR_RELATION

Relationship Data

   

NPPR

 

Non-Participating Provider

CMC_NPPR_AGGR

   

PRCV

 

Covering Provider

CMC_PRCV_COV_PRAC

   

PRCH

 

Provider Level Claims Payment Hold

CMC_PRCH_CLM_HOLD

   

PRRF

 

Referral Provider

CMC_PRRF_REF_PROF

Exceptions Table

User Reference

Provider Batch Import Subsystem Guide

Practitioner Record Types

Description

Facets Table Name

   

PRAD

 

Address

CMC_PRAD_ADDRESS

     

PRSR

Location Services

CMC_PRSR_LOC_SVCS

     

PROF

Office Hours

CMC_PROF_OFF_HRS

     

PRSQ

Site Quality Assurance

CMC_PRSQ_SITE_QA

 

PRCR

   

Credentialing data

CMC_PRCR_CREDEN

   

PRHI

 

Professional History

CMC_PRHI_HIST

   

PRMO

 

Monitor

CMC_PRMO_MONITOR

   

PRPM

 

Malpractice Provider

CMC_PRPM_RELATION

   

PRRE

 

Related Entity

CMC_PRRE_RELATION

   

PRAF

 

Facility Affiliation

CMC_PRAF_FAC_AFFIL

   

PRCF

 

Certification

CMC_PRCF_CERT

   

PRLA

 

Languages

CMC_PRLA_LANG

   

PRRG

 

Registration

CMC_PRRG_REG

   

PRSN

 

Sanction

CMC_PRSN_SANCTION

   

PRQA

 

Quality Assurance

CMC_PRQA_QA

LEOF

       

Identifies the end of the data stream.

Facility

 

Facility Record Types

Description

Facets Table Name

XPFH

   

XP/F Header Record

(Used only in XP/F.)

PRPR

   

Provider

CMC_PRPR_PROV

PRFA

   

Facility

CMC_PRFA_FACILITY

 

MCTN

 

Tax Name

CMC_MCTN_TAX_NAME

 

MCTI

 

Tax Information

CMC_MCTI_TAX_INFO

 

PRER

 

Entity Relation

CMC_PRER_RELATION

 

NWPR

 

Network Provider Relation

CMC_NWPR_RELATION

 

NWPX

 

Provider Common

CMC_NWPX_RELATION

Relationships

 

NWGX

 

Provider Global Common Relationships

CMC_NWGX_RELATION

 

PRDS

 

Date

CMC_PRDS_DATE

 

NWPE

 

PCP/Capitation

CMC_NWPE_RELATION

Relationship Data

Provider Batch Import Subsystem Guide

User Reference

 

Facility Record Types

Description

Facets Table Name

 

NWCR

 

Global Capitation

CMC_NWCR_RELATION

Relationship Data

 

NPPR

 

Non-Participating Provider

CMC_NPPR_AGGR

 

PRCH

 

Provider Level Claims Payment Hold

CMC_PRCH_CLM_HOLD

 

PRRF

 

Referral Provider

CMC_PRRF_REF_PROF

Exceptions Table

 

PRAD

 

Address

CMC_PRAD_ADDRESS

   

PRSR

Location Services

CMC_PRSR_LOC_SVCS

   

PROF

Office Hours

CMC_PROF_OFF_HRS

   

PRSQ

Site Quality Assurance

CMC_PRSQ_SITE_QA

 

PRCR

 

Credentialing data

CMC_PRCR_CREDEN

   

PRPM

Malpractice Provider

CMC_PRPM_RELATION

   

PRRG

Registration

CMC_PRRG_REG

   

PRSN

Sanction

CMC_PRSN_SANCTION

   

PRST

Facility Staff

CMC_PRST_FAC_STAFF

   

PRFB

Facility Beds

CMC_PRFB_FAC_BED

   

PRFC

Facility Accreditation

CMC_PRFC_ACCRED

LEOF

     

Identifies the end of the data stream.

Groups

 

Groups Record Types

Description

Facets Table Name

XPFH

   

XP/F Header Record

(Used only in XP/F.)

PRPR

   

Provider

CMC_PRPR_PROV

 

MCTN

 

Tax Name

CMC_MCTN_TAX_NAME

 

MCTI

 

Tax Information

CMC_MCTI_TAX_INFO

 

PRAD

 

Address

CMC_PRAD_ADDRESS

   

PRSR

Location Services

CMC_PRSR_LOC_SVCS

   

PROF

Office Hours

CMC_PROF_OFF_HRS

   

PRSQ

Site Quality Assurance

CMC_PRSQ_SITE_QA

 

PRER

 

Entity Relation

CMC_PRER_RELATION

 

PRAF

 

Facility Affiliation

CMC_PRAF_FAC_AFFIL

User Reference

Provider Batch Import Subsystem Guide

 

Groups Record Types

Description

Facets Table Name

 

PRCH

 

Provider Level Claims Payment Hold

CMC_PRCH_CLM_HOLD

 

PRRF

 

Referral Provider Exceptions Table

CMC_PRRF_REF_PROF

 

PRCV

 

Covering Provider

CMC_PRCV_COV_PRAC

 

PRDS

 

Date

CMC_PRDS_DATE

 

PRCR

 

Credentialing data

CMC_PRCR_CREDEN

   

PRPM

Malpractice Provider

CMC_PRPM_RELATION

   

PRRG

Registration

CMC_PRRG_REG

 

NWPR

 

Network Provider Relation

CMC_NWPR_RELATION

 

NWPE

 

PCP/Capitation Relationship Data

CMC_NWPE_RELATION

 

NWCR

 

Global Capitation

CMC_NWCR_RELATION

Relationship Data

 

NPPR

 

Non-Participating Provider

CMC_NPPR_AGGR

 

NWPX

 

Provider Common

CMC_NWPX_RELATION

Relationships

 

NWGX

 

Provider Global Common Relationships

CMC_NWGX_RELATION

LEOF

     

Identifies the end of the data stream.

IPA

 

IPA Record Types

Description

Facets Table Name

XPFH

   

XP/F Header Record

(Used only in XP/F.)

PRPR

   

Provider

CMC_PRPR_PROV

 

MCTN

 

Tax Name

CMC_MCTN_TAX_NAME

 

MCTI

 

Tax Information

CMC_MCTI_TAX_INFO

 

PRAD

 

Address

CMC_PRAD_ADDRESS

   

PRSR

Location Services

CMC_PRSR_LOC_SVCS

   

PROF

Office Hours

CMC_PROF_OFF_HRS

   

PRSQ

Site Quality Assurance

CMC_PRSQ_SITE_QA

 

PRAF

 

Facility Affiliation

CMC_PRAF_FAC_AFFIL

 

PRCH

 

Provider Level Claims Payment Hold

CMC_PRCH_CLM_HOLD

Provider Batch Import Subsystem Guide

User Reference

 

IPA Record Types

Description

Facets Table Name

 

PRRF

 

Referral Provider Exceptions Table

CMC_PRRF_REF_PROF

 

PRCV

 

Covering Provider

CMC_PRCV_COV_PRAC

 

PRCR

 

Credentialing data

CMC_PRCR_CREDEN

   

PRPM

Malpractice Provider

CMC_PRPM_RELATION

   

PRRG

Registration

CMC_PRRG_REG

 

NWPR

 

Network Provider Relation

CMC_NWPR_RELATION

 

NWPE

 

PCP/Capitation Relationship Data

CMC_NWPE_RELATION

 

NWCR

 

Global Capitation

CMC_NWCR_RELATION

Relationship Data

 

NPPR

 

Non-Participating Provider

CMC_NPPR_AGGR

 

NWPX

 

Provider Common

CMC_NWPX_RELATION

Relationships

 

NWGX

 

Provider Global Common Relationships

CMC_NWGX_RELATION

LEOF

     

Identifies the end of the data stream.

Record Hierarchy

There is a hierarchy for the records passed through XP/F, as indicated by the indentations in the tables above and in appendix B. For example, if office services information for a location must be passed, it is necessary to pass the minimum identifying keywords for record type PRPR, the minimum identifying keywords for PRAD, and the PROF keywords. (Sample input is shown in appendix A.)

A special record type, XPFH, is also required. Unique to the provider import process, XPFH represents the XP/Facets provider-level header data, and triggers the beginning of the data stream for each individual provider.

Additionally, the Provider Reference Lookup table (CMC_PRXP_XREF) in the Provider data model is used to facilitate updates via a look-up of the Facets Provider key using the input source provider key (vendor data).

Update Codes

The input data stream is processed one provider at a time. That is, the first input @pRECTYPE = XPFH begins an input data stream for one provider and ends with the last row immediately preceding the next input @pRECTYPE = XPFH. The XPFH record type contains a keyword of @pXPFH _UPDATE_CD

User Reference

Provider Batch Import Subsystem Guide

(provider-level update code), which is the function that pertains to the entire provider data stream. The IN and UP update codes are described below.

If the @pXPFH _UPDATE_CD is submitted as an AP (Apply), it is translated to IN if the provider does not already exist on the Facets database, or to UP if the provider does exist on the Facets database.

Each of the other record types utilizes a record level update code that pertains to that record type only and overrides the XPFH update code for that individual record alone.

For example, the record level @pPRAD_UPDATE_CD pertains only to the PRAD record on which it is indicated. If the update code of AP is indicated, or if the update keyword is absent at the record level, the system uses the XPFH update code. If the XPFH Update code is AP (Apply), the system inserts a new row or updates an existing row, as determined by the absence or presence of the row either in input or on the database. Each record type has an appropriate default update code, as detailed in appendix C.

IN

Insert

If the row is already there: Error

 

If the row is not there: Insert

UP

Update

If the row is already there: Update

 

If the row is not there: Error

AP

Apply

If the row is already there: Update

If the row is not there: Insert

NOTE: The update code AP is not valid for the following record types: PRHI, PROF, PRPM, PRRG, and PRSN.

Provider Batch Import Subsystem Guide

User Reference

Special Provider Processing

Whenever the Facets Provider key is known and its keyword is passed, the input Facets Provider key is used for the XP/F provider update. However, if the Facets Provider key is not known by the data source, XP/F provides the following two special functions to determine further processing.

1. Facets Provider key determination.

Generally, the data source (for example, vendor or credentialing agency) can be expected to use its own established provider key structure, which is likely different from the Facets Provider key structure. Therefore, a mechanism is created to retain and cross-index the data source key within the Facets provider data model.

XP/F includes a mechanism to accommodate the input data source’s provider key and indexed for future look-ups whenever an update of that source data is run. Indexing off the vendor key field yields the Facets Provider key to permit an efficient update.

The Provider Vendor Cross Reference table (CMC_PRXP_XREF) is used for this purpose. This table accommodates all columns necessary to identify a provider within its affiliation with the data source. Refer to the section Provider Cross-Referencing below for more details.

2. Finds Provider processing.

In order to maintain data integrity, it is critical to avoid duplicating provider data wherever possible. This is particularly true of practitioners, where the Facets data model calls for a one-to-many relationship between common practitioner and provider rows. Therefore, XP/F includes a Find Provider routine that incorporates a data-element-level match process.

Selection of match criteria is user-defined and variable for each potential data source. The XP/F Find Provider routine requires run file settings whereby users can set parameters for matching criteria for each individual run that are appropriate to the input data available from each specific vendor. Depending on the matching criteria set for the run, XP/F attempts to find a matched pre- existing PRPR row or a matched pre-existing PRCP row to avoid redundancy of data. (See the Run File section, starting on page 42, for a comprehensive description of the run file.)

Find provider processing determines the Facets Provider key when processing a set of input rows for a provider and is executed if the PRPR_ID (or PRCP_ID) is not provided in the XPFH header row, or the CMC_PRXP_XREF alternate key index is unmatched.

There is a search hierarchy:

a. When the keyword for the National Provider Identifier (NPI) is present on the XPFH record type, XPF attempts to match a pre-existing PRPR row or

User Reference

Provider Batch Import Subsystem Guide

pre-existing PRCP row with this NPI. The search begins at this point, and if no rows are found, the search fails.

If not, then:

b. When the MatchPrcpSsn is Y, and the Entity is a P, Facets searches on PrcpSSN.

If not, then:

c. The Tax ID is searched for if MCTN_ID is populated; otherwise XP/F will error for lack of search parameters.

If the search fails, it is possible that a subsequent “not found” condition may determine that the provider data be inserted, and a Facets key can be generated automatically by the XP/F subsystem.

Determining the Correct Facets Provider Key

The Facets Provider key can be established in one of three ways:

1. The Facets Provider key may be known to the vendor (or other source of the input), and may be passed accordingly via the XPFH header row PRPR_ID (or PRCP_ID, as appropriate to the update type).

2. When the vendor does not know the Facets Provider key, the vendor’s input key can be used for a lookup via the Provider Reference Lookup table (CMC_PRXP_XREF), matching the MCRE_ID and PRPR_MCPR_INPUT_ID to the XPFH header row MCRE_ID and XPFH_MCPR_INPUT_ID. This process is described below under Provider Cross-Referencing.

3. When the vendor does not know the Facets Provider key and no matching CMC_PRXP_XREF row is found, the Find Provider subroutine is executed. If the provider is found, the system writes an appropriate CMC_PRXP_XREF row to facilitate future update activity.

Upon failure of all the above to link the input to an existing Facets provider, the input may be deemed an Insert, and an appropriate Facets key is generated (see Automatic Generation of Provider ID, page 16).

Provider Cross-Referencing

External vendors have their own established identifiers to identify a provider within their system. The Provider Reference Lookup table (CMC_PRXP_XREF) provides a cross-reference between an external vendor’s provider identifier (which could be several data elements concatenated together) and the provider identifier in Facets.

CMC_PRXP_XREF serves as a mechanism to synchronize the provider key used by the data source (vendor) with the appropriate Facets Provider key. The Facets Provider key is the PRPR_ID.

Provider Batch Import Subsystem Guide

User Reference

CMC_PRXP_XREF consists of the following columns:

PRPR_MCPR_INPUT_ID (key) Vendor Provider ID

MCRE_ID (key) Vendor ID

PRPR_ID Facets Provider ID

PRCP_ID Facets Common Practitioner ID

If the PRPR_ID is not provided in the XPFH, the provider cross-referencing process must then be performed to determine whether the Provider data being input belongs to an existing Facets Provider.

Use the input MCRE_ID and XPFH_MCPR_INPUT_ID from the XPFH header record to match to the MCRE_ID and PRPR_MCPR_INPUT_ID on the CMC_PRXP_XREF table, respectively.

a. If unmatched, exit this process and perform the Find Provider routine.

b. If matched, use the corresponding PRPR_ID on the CMC_PRXP_XREF table to update the appropriate Facets Provider.

TriZetto strongly recommends that customers use the Provider Cross-Reference feature because it can significantly increase the efficiency of XP/F in handling ongoing updates.

Find Provider Processing

This section describes the Find Provider subroutine, a data-element-level match subroutine that is one attempt of XP/F to establish a Facets Provider key. When the XPFH record does not supply a PRPR_ID or the XREF was not used, all providers go through the Find Provider subroutine.

For a new provider, the first step in assigning the Facets key occurs if the PRPR_ID is provided in the input data stream on the XPFH record. This mechanism is appropriate for an insert, if the PRPR_ID is to be directly controlled. Similarly, a PRCP_ID should be assigned via the XPFH, to be used for inserts, or input via XPFH. An NPI may be passed on XPFH to be used for a database search.

In the second step, the system attempts to find the PRPR_ID (or PRCP_ID) using the data source proprietary key based on a lookup to the PRXP table. (See Provider Cross-Referencing, page 12). Note, however, that this look-up does not successfully match upon the initial load of data from a specific source, because that source proprietary key will not yet have been introduced into the database.

When actual record keys are not available, XP/F employs a data-element-level search process. XP/F determines whether a specific provider may already exist on Facets, having been previously loaded, and avoids duplication of potentially shared data (especially, PRCP).

User Reference

Provider Batch Import Subsystem Guide

Setting the Match Criteria

Processing parameters are passed via run file settings, which contain a set of match criteria switches that can be updated for each separate data source.

Refer to the ORM for complete details on the run file settings. Below is a list of values that may be used as match criteria.

If a match criteria is omitted or commented out, the value defaults to N.

Match Criteria Value

Table Matched to

Column Matched to

MatchPrcpLastName=Y

CMC_PRCP_COMM_PRAC

PRCP_LAST_NAME

MatchPrcpFirstName=Y

CMC_PRCP_COMM_PRAC

PRCP_FIRST_NAME

MatchPrcpMidInit=Y

CMC_PRCP_COMM_PRAC

PRCP_MID_INIT

MatchPrcpTitle=Y

CMC_PRCP_COMM_PRAC

PRCP_TITLE

MatchPrcpBirthDt=Y

CMC_PRCP_COMM_PRAC

PRCP_BIRTH_DT

MatchPrcpSex=Y

CMC_PRCP_COMM_PRAC

PRCP_SEX

MatchPrcpSsn=Y

CMC_PRCP_COMM_PRAC

PRCP_SSN

MatchPrprName=Y

CMC_PRPR_PROV

PRPR_NAME

MatchPrprMctnId=Y

CMC_PRPR_PROV

MCTN_ID

MatchPradAddr1=Y

CMC_PRAD_ADDRESS

PRAD_ADDR1

MatchPradCity=Y

CMC_PRAD_ADDRESS

PRAD_CITY

MatchPradState=Y

CMC_PRAD_ADDRESS

PRAD_STATE

MatchPradZip5Char=Y

CMC_PRAD_ADDRESS

PRAD_ZIP positions 1-5

MatchPradZip9Char=Y

CMC_PRAD_ADDRESS

PRAD_ZIP positions 1-9

MatchPrrgTypeId=Y

CMC_PRRG_REQ

PRRG_MCTR_TYPE

Provider Batch Import Subsystem Guide

User Reference

XPFH Header Data

The XPFH header record fulfills two distinct functions within XP/F.

1.

It signifies the beginning of the input data stream for each provider.

2.

It delivers the keys and data used as matching criteria for the Find Provider subroutines.

When the NPI keyword @pNPI is passed on XPFH, XPF automatically attempts to locate a provider with this NPI.

It

is important to remember that all data element level matching occurs against

the variables entered on the XPFH, not on the input PRPR or PRCP.

For example, if the run file identifies the following criteria, XP/F attempts to locate a provider where the PRCP_LAST_NAME, PRCP_FIRST_NAME, PRCP_BIRTH_DT, MCTN_ID, PRAD_CITY and PRAD_STATE all match the corresponding data passed in the XPFH header record.

MatchPrcpLastName=”Y”

MatchPrcpFirstName=”Y”

MatchPrcpBirthDt=”Y”

MatchPrprMctnId=”Y”

MatchPradCity=”Y”

MatchPradState=”Y”

When creating XPFH data, consider the intended run file switches. Run file

settings are used to validate the presence of XPFH data, and an error will occur if

a data element identified as a match criterion is missing.

Processing Flow

A Find Provider match routine requires either the Provider Tax ID (MCTN_ID)

or the Provider Social Security Number (PRCP_SSN) or the National Provider

Identifier (PRPR_NPI or PRCP_NPI) to facilitate the initial search.

When an NPI keyword @pNPI is passed on XPFH, XP/F attempts to locate a provider with the NPI.

Second, the Facets database is searched using the PRCP_SSN, if provided, plus all other matching criteria specified in the run file. Because Facets requires that Social Security numbers be unique, a successful match identifies the appropriate practitioner-type provider. Any additional match criteria specified in the XPFH header record are used to further validate the match.

Following is a list of the Find Provider match criteria:

Tax ID (from PRPR/MCTN)

Social Security Number (from PRCP - common practitioners only)

User Reference

Provider Batch Import Subsystem Guide

Name (from PRPR - Facilities, Groups or IPAs only)

Last Name (from PRCP - common practitioners only)

First Name (from PRCP - common practitioners only)

Middle Initial (from PRCP - common practitioners only)

Title (from PRCP - common practitioners only)

Sex (from PRCP - common practitioners only)

Birth Date (from PRCP - common practitioners only)

City (from PRAD)

State (from PRAD)

ZIP (from PRAD)

ID Number and Type (from PRRG)

If a matching provider is not returned, XP/F uses the MCTN_ID and interrogates all returned provider data. Depending upon the match criteria set in the run file switches, the Find Provider subroutine can potentially match data from the PRPR, PRCP, PRAD and PRRG tables, as long as data matching the search ID exists on the database.

If one exact match meets all criteria set in the run file switches (or multiple matches all contain the same PRCP_ID), the PRCP_ID is used for continued processing.

If one exact match is not obtained, XP/F makes a final attempt to find a provider, matching on Last Name, First Name, Sex and Birth Date.

If a match occurs, one of the following occurs:

neither the input nor the matched existing provider has a Social Security Number. This condition is acceptable, and processing can continue.

either the input or the matched existing provider has a Social Security Number. This condition is acceptable, and processing can continue.

both the input and the matched existing provider have Social Security Numbers. (If so, at this point in processing the numbers would be different.) This condition is not acceptable, and an error is generated.

Automatic Generation of Provider ID (PRPR_ID)

If both the Provider Cross-Referencing routine and the Find Provider routine fail to find a matched Provider on file, and the Provider data is to be Inserted, it is necessary to generate a complete 12-byte Facets PRPR_ID.

Provider Batch Import Subsystem Guide

User Reference

Bytes 1-9 consist of a root value, (the Provider’s Tax ID, Social Security number or NPI) as reported on the XPFH as @pMCTN_ID or @pPRCP_SSN or @pNPI. Use the appropriate PrprId setting in the run file to activate the desired approach. (See the Run File section, starting on page 42, for a comprehensive description of the run file settings.)

When the root is defined as MCTN_ID or PRCP_SSN, bytes 10 through 12 are user-defined via appropriate entries in the run file, where sort sequence is defined. The PRPR_ID Generation subroutine searches the run file settings and completes the Facets PRPR_ID, assigning values to bytes 10 through 12 corresponding to the run file entries.

When the root ID defined as NPI, only bytes 11 and 12 are user-defined.

Valid values for the Sort Sequence are:

A

= Alpha only; e.g., AAA, AAB, AAC… ZZZ

N

= Numeric only; e.g., 000, 001, 002…999

AN = Alphanumeric; e.g., AAA, AAB, AAC… AA0, AA1, AA2, …999

NA = Numeric/alpha; e.g., 000, 001, 002…009, 00A, 00B, 00C…ZZZ

When the root is defined as MCTN_ID or PRCP_SSN, an additional overriding valid value can be assigned to position 10 only:

x = Special character (where x is any specific character).

When the root is defined as NPI, identifying position 10 as a special character is not an option.

This is a sample run file entry:

## Use the following overrides to PRPR ID generation options

## Valid values for Root are "PRCP_ID" or "MCTN_ID"

export Root="MCTN_ID"

## Valid values for Sort Sequence are "A", "N" or "AN"

export SortSeq="AN"

## Any character may be specified for the Position 10 Value. If omitted,

## position 10 will be incremented similarly to positions 11 and 12.

#export Pos10Value="-"

User Reference

Provider Batch Import Subsystem Guide

Minimum Table Requirements

In order for any individual provider (Practitioner, Facility, IPA, or Group) to be meaningful from a Facets standpoint, the data for that provider must meet certain minimum requirements. These are the minimum hierarchical table requirements for each provider, by entity type:

Entity Type

Hierarchical Table Requirements

IPA or Group

PRPR, PRAD

Facility

PRPR, PRFA, PRAD

Practitioner

PRCP, either alone, or with:

PRCR, PRRE for credentialing input only;

PRPR, PRAD for affiliation and/or indicative input only;

PRPR, PRAD, PRCR, PRRE for both input categories

NOTE: Although a complete data stream for each individual provider may be met with minimal data, for purposes of this conversion, any individual table that fails the load edits causes all data in the provider data stream to be backed out.

Tax Reporting Data

XP/F supports a batch load of W-9 data in support of IRS tax reporting requirements. In the Facets Managed Care Data Model, the Tax Name table (CMC_MCTN_TAX_NAME) and Tax Information for Providers/Commission Entities table (CMC_MCTI_TAX_INFO) retain the pertinent data. These tables may also be loaded with the normal provider-specific input to XP/F.

Provider Batch Import Subsystem Guide

User Reference

Creating Keyword Input Data

When creating keyword delimited data, be sure to follow these rules:

1. Make sure the input data stream for each provider begins with an XPFH row. This row assures that the XPFH data conforms to your intended match criteria.

Please note that the XPFH row is at the PRPR level, and supports no more than one PRPR record type (@pRECTYPE) in its data stream. Refer to Appendix B for record type sequencing rules.

2. Use quotation marks for any input variables that are character formatted, for example, @pPRCP_LAST_NAME="Smith"

3. Do not use quotation marks when the input variable is numeric, for example, @pPRFB_NO=300; @pPRPM_PER_OCCUR_AMT=1000000.

4. Format dates with quotes, slashes and four-position year, as in "MM/DD/CCYY" for example, @pNWPR_TERM_DT="6/30/1998"

5. Do not format telephone numbers with extraneous characters like dashes; for example, @pPHONE="7184341234"

6. Do not use dollar signs for money fields, for example,

@pPRPM_PER_OCCUR_AMT=1000000.

7. Sequence the input record types in hierarchical order. (For more information, refer to the Record Types section, page 5.)

8. Make sure the input data set ends with a single LEOF record type, ending with one carriage return, which alerts XP/F that the last provider has been passed and processing may terminate.

9. Note that any unrecognized or misspelled keywords are ignored.

10. Note that keywords must be comma-separated with records delimited by a carriage return/line feed combination (DOS/Windows) or a line feed (UNIX).

User Reference

Provider Batch Import Subsystem Guide

XPFH Header Record

The XP/F subsystem is extremely sensitive to its input. Much of the control over processing is exerted via the XPFH record, in conjunction with run file settings. As mentioned earlier, the XPFH Header Record fulfills two distinct functions within XP/F.

1. It signifies the beginning of the input data stream for each provider.

2. It delivers the keys and data used as matching criteria for the Find Provider subroutines.

It is important to remember that all data-element-level matching occurs against the variables entered on the XPFH keyword record, not on the input PRPR or PRCP keyword record. This means that when inserting a provider, if the Facets PRPR_ID is to be based on the tax ID, the XPFH header record must contain the MCTN_ID.

Use the following guidelines when creating XPFH data.

Keyword

Guideline for Creating XPFH Data

@pRECTYPE

Must always be XPFH

@pXPFH_UPDATE_CD

If ADDING a new provider, use IN (insert).

If CHANGING an existing provider, use UP (update).

If the run is intended to respond to either the presence or absence of providers on the database, use AP (apply), which will handle either situation.

@pXPFH_ENTITY_TYPE

Must enter the appropriate entity type because XP/F edits accordingly.

Valid values: P (Practitioners); F (Facilities); G (Groups); I (IPAs).

@pMCRE_ID

If converting data from an outside vendor, or where the data source maintains its own key structure, it is highly desirable to use the XP/F exclusive lookup feature.

Before running XP/F, set up MCRE data to identify the data source. The MCRE_ID used in the XPFH is edited accordingly.

@pXPFH_MCPR_INPUT_ID

Use provider key from the data source as the XPFH_MCPR_INPUT_ID. XP/F builds a corresponding row in the new Facets PRXP Cross- Reference table, and future updates of this data are loaded more efficiently.

@pNPI

When the NPI is passed on X/PF, Find Provider attempts to locate a provider with this NPI.

Provider Batch Import Subsystem Guide

User Reference

Keyword

Guideline for Creating XPFH Data

@pMCTN_ID

Whenever Tax ID information is being used in Facets, use the XPFH MCTN_ID to deliver the Provider’s Tax ID.

It is highly recommended that this field be used, as it is used for the Find Provider subroutine.

@pPRCP_SSN

For Practitioners only, it is desirable to capture the Social Security Number, if it is known. Facets maintains exclusivity of Social Security Numbers, so their use helps in eliminating potential duplication of Common Practitioner rows.

It is highly recommended that this field be used, as it is used for the Find Provider subroutine.

@pPRPR_NAME

This field is used only for Facilities, Groups.

It is highly recommended that this field be used, as it is used for the Find Provider subroutine.

@pPRCP_LAST_NAME

These fields are used only for Practitioners, and should be populated.

@pPRCP_FIRST_NAME

It is highly recommended that these fields be used, as they are used for the Find Provider subroutine.

@pPRCP_MID_INIT

These fields are used only for Practitioners and are optional.

@pPRCP_TITLE

@pPRCP_BIRTH_DT

These fields are used only for Practitioners and should be populated whenever known.

@pPRCP_SEX

@pPRRG_MCTR_TYPE

Any known ancillary ID number can be used to further support the Find Provider process.

@pPRRG_ID

@pPRAD_ADDR1

Any known address elements lend further support to the Find Provider process, especially in identifying any PRPR_IDs that may exist for the input provider.

@pPRAD_CITY

@pPRAD_STATE

 

@pPRAD_ZIP

@pPRAD_ZIP_5CHAR

@pPRAD_ZIP_9CHAR

@pPRCP_ID

For Practitioners only, enter the PRCP_ID whenever it is known. If a practitioner is being inserted, always assign a PRCP_ID via XPFH.

@pPRPR_ID

Enter the PRPR_ID to bypass the system determination of PRPR_ID and proceed with processing.

User Reference

Provider Batch Import Subsystem Guide

Date Sensitive Record Types

When working with one of the date sensitive record types, the required keywords may vary depending on what it is you’re trying to do.

When a new date sensitive row is added, XP/F automatically changes the termination date of the previous row so that the rows are in sync. Consider the following examples.

I. To add a new row (NWPR) and update the termination date on the previous row (if one exists) requires the following keywords:

@pRECTYPE=NWPR @pNWPR_UPDATE_CD="IN" @pNWPR_EFF_DT and other pertinent keywords, which are optional

II. To change data other than the effective date on an existing date sensitive row (NWPR) requires the following keywords.

@pRECTYPE=NWPR @pNWPR_UPDATE_CD="UP" @pNWPR_EFF_DT @pNWPR_ACC_PAT_IND (This will change the existing NWPR_ACC_PAT_IND)

III. To change the effective date (which is part of the key) of an existing date sensitive row (NWPR) requires the following keywords. (Note: This also changes the termination date on a existing row to one day prior to the new effective date.)

@pRECTYPE=NWPR @pNWPR_UPDATE_CD="UP" @pNWPR_EFF_DT (this defines the unique NWPR row to be changed) @pNWPR_NEW_EFF_DT (this will establish the new key for this row) and other pertinent keywords, which are optional.

IV. To create a generation gap between an existing rows termination date (NWPR) and the new rows effective date requires the following keywords.

@pRECTYPE=NWPR @pNWPR_UPDATE_CD="IN" @pNWPR_EFF_DT @pNWPR_CREATE_GEN_GAP="Y" and other pertinent keywords, which are optional.

NOTES:

The presence of the keyword @pNWPR_CREATE_GEN_GAP="Y" indicates the intent to create a gap between the preceding row termination date and the new rows effective date.

Provider Batch Import Subsystem Guide

User Reference

Whenever XP/F automates the termination of a preceding row; it must automatically generate a valid XXXX_MCTR_TRSN. Because the row being terminated by the system is not present in input, you do not have the opportunity to specify a termination code. In these situations XP/F passes a default value of TRSN. Therefore, prior to running XP/F, it is important that you add the code TRSN to the list of valid user-defined MCTR codes in Facets.

User Reference

Provider Batch Import Subsystem Guide

Address Sharing

A Practitioner, Group or IPA provider may share one or more address rows with a single other provider. XP/F supports address sharing under the following guidelines:

Address sharing is valid only for Entity Types P, I, or G. Facilities may not share addresses with any other provider.

An address is shared when one provider PRPR row contains a valid PRAD_ID that matches another provider PRPR_ID. That other provider is considered the owner of the address data.

If an input PRPR row contains an entry for PRAD_ID, the PRAD_ID is validated against PRAD rows either in the input (for a previously processed provider’s data stream) or already on the database. If no PRAD_ID is passed on the PRPR row, XP/F applies the value in the PRPR_ID to the PRAD_ID and address sharing will not occur. Note that the keyword for PRAD_ID is valid only when address sharing occurs, and PRAD Rectypes are not permitted.

Updates to PRAD or subordinate (PRSR, PROF, PRSQ) rows are valid only within the data stream of the owner provider; i.e., the provider whose PRPR_ID matches the PRAD_ID in question.

PRAD_TYPE and PRAD_EFF_DT are required on PRAD rows, and are propagated to subordinate (PRSR, PROF, PRSQ) rows by XP/F.

PRAD_TYPE_CHECK is a required field on the PRPR row.

For any valid PRAD_TYPE_MAIL the PRACTICE_IND must be Y. Also, if the PRACTICE_IND is Y the PRAD_TYPE_MAIL must indicate a valid, existing PRAD row.

For any valid PRAD_TYPE the PRIM PRACTICE_IND must be Y. Also, if the PRACTICE_IND is Y the PRAD_TYPE_ PRIM must indicate a valid, existing PRAD row.

Date-sensitive Addresses

The Facets address structure is date sensitive and extends to the Provider Address Information by Address Type table (CMC_PRAD_ADDRESS), Provider Site Visit Evaluation Information table (CMC_PRSR_LOC_SVCS), Provider Office Hour Availability table (CMC_PROF_OFF_HRS), and User Defined Site Visit Descriptions table (CMC_PRSQ_SITE_QA). This permits entry of a new address without losing the old address, the ability to track the termination reason for each address location, and to reinstate a terminated address.

XP/F has keywords for the CMC_PRAD_ADDRESS table. When the effective date is passed within the PRAD RECTYPE, the date is propagated automatically

Provider Batch Import Subsystem Guide

User Reference

by the system to any subordinate RECTYPEs (for example, CMC_PRSR_LOC_SVC, CMC_PROF_OFF_HRS, and CMC_PRSQ_SITE_QA tables).

Tables Keyed with Sequence Number

The following five tables in the Provider Data Model contain a key data element called sequence number:

Provider Office Hour Availability (CMC_PROF_OFF_HRS)

Provider Registration Indicative Information (CMC_PRRG_REG)

Provider Specific Professional History (CMC_PRHI_HIST)

Provider Malpractice Information (CMC_PRPM_RELATION)

Provider Level Sanction Information table (CMC_PRSN_SANCTION)

Sequence numbering permits Facets to retain multiple rows of similar types. For example, there may be multiple PRRG Registration rows for the same registration type, differentiated by Sequence Number, or more than one PROF Office Hours row for Monday hours.

Because each of the five tables has unique requirements, XP/F handles each differently. In all cases, XP/F is programmed to expect highly deliberate data to be passed for these rows, to affect the database in a most exacting way. For this reason, update code AP (Apply) is not available for these record types.

The charts below outline the guidelines for passing data to PROF, PRRG, PRHI, PRPM, or PRSN.

NOTE: The corresponding XXXX_UPDATE_CODE is pivotal.

CMC_PROF_OFF_HRS (Provider Office Hour Availability)

PROF Keyword

Guidelines for passing data to PROF

If PROF_UPDATE_CD = IN

PROF_SEQ_NO is not required and will be ignored if passed. PROF_SEQ_NO will be generated by XP/F.

NOTES:

Additional rows may not be passed when PROF_UPDATE_CD=UP and no PROF_SEQ_NO for the same day.

PROF_DELETE_DAY may not be passed in this situation.

User Reference

Provider Batch Import Subsystem Guide

PROF Keyword

Guidelines for passing data to PROF

If PROF_UPDATE_CD = UP and PROF_SEQ_NO is passed

XP/F updates matched rows, and unmatched rows cause an error.

PROF_FROM_HR1 and PROF_TO_HR1 are required only if being updated.

If PROF_UPDATE_CD = UP and PROF_SEQ_NO is not passed

XP/F replaces all existing rows for the same PROF_DAYS.

For example, if five Monday rows exist on the database and two update Monday rows are input, the two input Monday rows replace the five existing Monday rows.

NOTE: Additional rows may not be passed when PROF_UPDATE_CD=IN for the same day under this XPFH.

If PROF_UPDATE_CD = UP and the keyword PROF_DELETE_DAY=Y

(PROF_SEQ_NO may or may not be passed)

XP/F deletes all the rows for the designated day.

NOTE: Keyword PROF_DELETE_DAY=Y should be used only when the user wants to delete all rows for a specified day without replacing hours for that day, for example, Monday office hours suspended.

If PROF_UPDATE_CD = UP

All PROF rows for the incoming PRAD_TYPE may be replaced by setting the run file ProfReplace switch to Y.

If PROF_UPDATE_CD = AP

Error. AP is not a valid update code for PROF.

CMC_PRHI_HIST (Provider Specific Professional History)

PRHI Keyword

Guidelines for passing data to PRHI

If PRHI_UPDATE_CD = IN

PRHI_SEQ_NO is not required. If it is passed it will be ignored, and the sequence number will be generated by XP/F.

If PRHI_UPDATE_CD = UP and PRHI_SEQ_NO is passed

XP/F will update the existing PRHI row with the same PRHI_FROM_DT and PRHI_SEQ_NO specified on the input.

If PRHI_UPDATE_CD = UP and PRHI_SEQ_NO is not passed

XP/F attempts to find exactly one row with a matching PRHI_FROM_DT and PRHI_MCTR_TYPE.

If exactly one row matches, that row is updated.

If no matching row is found, error with Row not found.

If multiple matching rows are found, error with Multiple matches found.

If PRHI_UPDATE_CD = AP

Error. AP is not a valid update code for PRHI.

Provider Batch Import Subsystem Guide

User Reference

CMC_PRSN_SANCTION (Provider Level Sanction Information table)

PRSN Keyword

Guidelines for passing data to PRSN

If PRSN_UPDATE_CD = IN

PRSN_SEQ_NO is not required and will be ignored

if

passed.

PRSN_SEQ_NO will be generated by XP/F.

If PRSN_UPDATE_CD = UP and PRSN_SEQ_NO is passed

XP/F updates matched rows, and unmatched rows cause an error.

If PRSN_UPDATE_CD = UP and PRSN_SEQ_NO is not passed.

XP/F attempts to match the logical key (PRCR_ID, PRSN_REF_ID, PRSN_TYPE and PRSN_EFF_DT).

A

match on the logical key updates the existing.

there is no match, or multiple matches, an error occurs.

If

If PRSN_UPDATE_CD = AP

Error. AP is not a valid update code for PRSN.

CMC_PRRG_REG (Provider Registration Indicative Information)

PRRG Keyword

Guidelines for passing data to PRRG

If PRRG_UPDATE_CD = IN

PRRG_SEQ_NO is not required and is ignored if passed. PRRG_SEQ_NO will be generated by XP/F.

If PRRG_UPDATE_CD = UP and PRRG_SEQ_NO is passed

XP/F updates matched rows, and unmatched rows cause an error.

If PRRG_UPDATE_CD = UP and PRRG_SEQ_NO is not passed.

XP/F attempts to match the logical key (PRCR_ID, PRRG_MCTR_TYPE, PRRG_ID and PRRG_STATE).

A

match on the logical key updates the existing. If

there is no match, or multiple matches, an error occurs.

If PRRG_UPDATE_CD = AP

Error. AP is not a valid update code for PRRG.

CMC_PRPM_RELATION (Provider Malpractice Information)

PRPM Keyword

Guides lines for passing data to PRPM

If PRPM_UPDATE_CD = IN

PRPM_SEQ_NO is not required and is ignored if passed. PRPM_SEQ_NO is generated by XP/F.

If PRPM_UPDATE_CD = UP and PRPM_SEQ_NO is passed

XP/F updates matched rows, and unmatched rows cause an error.

User Reference

Provider Batch Import Subsystem Guide

PRPM Keyword

Guides lines for passing data to PRPM

If PRPM_UPDATE_CD = UP and PRPM_SEQ_NO is not passed.

XP/F attempts to match the logical key (PRCR_ID, MCRE_MALP_ID, PRPM_POLICY_NO and PRPM_STATE).

A

match on the logical key updates the existing.

there is no match, or multiple matches, an error occurs.

If

If PRPM_UPDATE_CD = AP

Error. AP is not a valid update code for PRPM.

Provider Batch Import Subsystem Guide

User Reference

PCP/Capitation Relationship Data

Special rules are used by XP/F for processing NWPE, PCP/Capitation Relationship Data rows. Because the Provider ID (NWPE_CR_PR_ID) can reflect either the provider identified in the data stream or another provider (or Group or IPA) that already exists on the database, XP/F needs exact information to effect an appropriate update.

For this reason, two control keywords are used to specify edit rules for NWPE input:

@pNWPE_REC_TYPE denotes the type of provider addressed by this input NWPE record. Valid values are P (input provider is the PCP) or S (capitated relationship to a secondary provider).

@pNWPE_REL_TYPE denotes the type of Capitated Relationship addressed by this input NWPE record. Valid values are P (Primary), S (Secondary) or A (Agreement Only).

The following tables clarify the potential business relationship scenarios:

If incoming provider is the PCP (RecType=P):

REL_TYPE

Definition of PRPR_ID

Definition of

Capitated Relationship

NWPE_CR_PR_ID

Primary

Input NWPE PRPR_ID = input provider’s (PCP’s) PRPR_ID.

Input NWPE_CR_PR_ID = input provider’s PRPR_ID.

PCP is paid as capitated provider for lab services.

Secondary

Input NWPE PRPR_ID = input provider’s (PCP’s) PRPR_ID.

Input NWPE_CR_PR_ID = another provider’s PRPR_ID.

Lab is paid as capitated provider for lab services.

Agreement

Input NWPE PRPR_ID = input provider’s (PCP’s) PRPR_ID.

Input NWPE_CR_PR_ID = another provider’s PRPR_ID.

Lab is paid on a fee for service basis.

Only

If incoming provider is the Lab (RecType=S):

REL_TYPE

Definition of PRPR_ID

Definition of

Capitated Relationship

NWPE_CR_PR_ID

Primary

Invalid REL_TYPE when REC_TYPE = S

Not Applicable.

Not Applicable.

Secondary

Input NWPE PRPR_ID = another provider’s PRPR_ID.

Input NWPE_CR_PR_ID = input provider’s PRPR_ID.

Lab is paid as capitated provider for lab services.

User Reference

Provider Batch Import Subsystem Guide

REL_TYPE

Definition of PRPR_ID

Definition of

Capitated Relationship

NWPE_CR_PR_ID

Agreement

Input NWPE PRPR_ID = another provider’s PRPR_ID.

Input NWPE_CR_PR_ID = another provider’s PRPR_ID.

Lab is paid on a fee for service basis.

Only

Special Relational Edits for NWPE

The complex business scenarios handled by NWPE call for special editing rules, that are outlined below.

If @pNWPE_REC_TYPE="P" and @pNWPE_REL_TYPE="P"

NWPE/PRPR_ID, if passed, must equal incoming provider’s PRPR_ID

NWNW_ID is required and must be validated against CMC_NWNW_NETWORK.

NWPE_PFX is required and must be validated against CMC_PDPX_DESC.

NWPE_CR_PR_ID is required and must equal incoming provider’s PRPR_ID.

NWPE_EFF_DT is required and must be a valid date.

CRFS_SCHD_ID is required and must be validated against CMC_CRFS_SCHD_DESC.

CRPL_POOL_ID is required and must be validated against CMC_CRPL_POOL_DESC.

AGAG_ID may NOT be passed.

If @pNWPE_REC_TYPE="P" and @pNWPE_REL_TYPE="S"

NWPE/PRPR_ID, if passed, must equal incoming provider’s PRPR_ID

NWNW_ID is required and must be validated against CMC_NWNW_NETWORK.

NWPE_PFX is required and must be validated against CMC_PDPX_DESC.

NWPE_CR_PR_ID is required and must be validated. It may NOT equal the incoming provider’s PRPR_ID.

NWPE_EFF_DT is required and must be a valid date.

CRFS_SCHD_ID is required and must be validated against CMC_CRFS_SCHD_DESC.

Provider Batch Import Subsystem Guide

User Reference

CRPL_POOL_ID is required and must be validated against CMC_CRPL_POOL_DESC.

AGAG_ID is required and must be validated against CMC_AGAG_AGREEMENT.

If @pNWPE_REC_TYPE="P" and @pNWPE_REL_TYPE="S"

NWPE/PRPR_ID, if passed, must equal incoming provider’s PRPR_ID

NWNW_ID is required and must be validated against CMC_NWNW_NETWORK.

NWPE_PFX is required and must be validated against CMC_PDPX_DESC.

NWPE_CR_PR_ID is required and must be validated. It may NOT equal the incoming provider’s PRPR_ID.

NWPE_ADJ_PER is NOT allowed.

NWPE_EFF_DT is required and must be a valid date.

CRFS_SCHD_ID may NOT be passed.

CRPL_POOL_ID may NOT be passed.

AGAG_ID is required and must be validated against CMC_AGAG_AGREEMENT.

If @pNWPE_REC_TYPE="S" @pNWPE_REL_TYPE may NOT equal P

If @pNWPE_REC_TYPE="S" and @pNWPE_REL_TYPE="S"

NWPE/PRPR_ID is required and must be validated. It may NOT equal the incoming provider’s PRPR_ID.

NWNW_ID is required and must be validated against CMC_NWNW_NETWORK.

NWPE_PFX is required and must be validated against CMC_PDPX_DESC.

NWPE_CR_PR_ID is required and must equal incoming provider’s PRPR_ID.

NWPE_EFF_DT is required and must be a valid date.

CRFS_SCHD_ID is required and must be validated against CMC_CRFS_SCHD_DESC.

CRPL_POOL_ID is required and must be validated against CMC_CRPL_POOL_DESC.

User Reference

Provider Batch Import Subsystem Guide

AGAG_ID is required and must be validated against CMC_AGAG_AGREEMENT.

If @pNWPE_REC_TYPE="S" and @pNWPE_REL_TYPE="A"

NWPE/PRPR_ID is required and must be validated. It may NOT equal the incoming provider’s PRPR_ID.

NWNW_ID is required and must be validated against CMC_NWNW_NETWORK.

NWPE_PFX is required and must be validated against CMC_PDPX_DESC.

NWPE_CR_PR_ID is required and must equal incoming provider’s PRPR_ID.

NWPE_ADJ_PER may NOT be passed.

NWPE_EFF_DT is required and must be a valid date.

CRFS_SCHD_ID may NOT be passed.

CRPL_POOL_ID may NOT be passed.

AGAG_ID is required and must be validated against CMC_AGAG_AGREEMENT.

Provider Batch Import Subsystem Guide

User Reference

Terminating Providers

Provider termination capability has been incorporated into XP/F. Three types of terminations comprise this capability:

Global Relationship Termination: This functionality allows customers to terminate all relationship rows for NWPR, NWPE, NWCR, NPPR, PRER, or PRCV tables. This capability is intended to reduce provider maintenance.

Provider Termination: This functionality allows customers to definitively terminate a Practitioner, Provider Group, IPA or Facility ID, rendering the provider ID as inactive to Facets.

Common Practitioner Termination: This functionality allows customers to definitively terminate a Common Practitioner ID, which in turn, triggers a Provider Termination of all provider IDs associated with the common practitioner ID. This functionality renders the common practitioner ID inactive in Facets.

Note, there is no capability in online Facets to reverse a termination date once it is written to the database. Please review the Facets documentation for further information.

General Rules for Terminations

1. Terminations are permitted on Update only. If UPDATE_CODE is Insert, or if the system projects an Insert from UPDATE_CODE Apply, an error is generated and the provider is rolled back.

2. Updates to previously terminated providers are not permitted, and results in an error and roll back.

3. Terminations require a special input data stream, consisting of only XPFH and PRPR rows for PRPR-level terminations, or XPFH and PRCP rows for PRCP-level terminations. Global Relationship Terminations require XPFH and NWPR, NWPE, NWCR, NPPR, PRER, or PRCV rows.

4. The special data stream for termination must consist only of the appropriate triggering keywords.

5. Because XP/F does not process more than one PRPR per XPFH, it is important to pass data correctly when attempting terminations at the PRCP- level. This type of termination requires only RECTYPEs XPFH and PRCP.

Common Practitioner Terminations

Keywords in the Common Provider Indicative Information table (CMC_PRCP_COMM_PRAC) permit batch input of termination date and termination reason, @pPRCP_TERM_DATE and @pPRCP_MCTR_TRSN,

User Reference

Provider Batch Import Subsystem Guide

respectively. When a termination date is passed to the database, the practitioner is effectively inactive in the database, and no further updates can be done.

Terminating at the Common Practitioner level results in the termination of all Practitioner (PRPR) rows that are associated with the terminated Common Practitioner.

For Common Practitioner-level terminations, the keyword data should consist only of RECTYPEs XPFH and PRCP. Pass only the following triggering keywords in the input PRCP RECTYPE:

@pRECTYPE=”PRCP”

@pPRCP_TERM_DT=”MM/DD/CCYY”

@pPRCP_MCTR_TRSN=”XXXX” (where XXXX is a valid provider termination reason.)

Provider Terminations

Keywords in the Base Provider Table for Practitioner, Facility, Group and IPA (CMC_PRPR_PROV) permit batch input of termination date and termination reason, @pPRPR_TERM_DATE and @pPRPR_MCTR_TRSN, respectively. When a termination date is passed to the database, the provider is inactive in the database, and no further updates may be done.

For Provider-level terminations, the keyword data should consist only of RECTYPEs XPFH and PRPR. Pass only the following triggering keywords in the input PRPR RECTYPE:

@pRECTYPE=”PRPR”

@pPRPR_TERM_DT=”MM/DD/CCYY”

@pPRPR_MCTR_TRSN=”XXXX”

(where XXXX is a valid provider termination reason.)

Global Terminations

Global Terminations are handled by XP/F as they are handled on-line. Global Terminations apply to any of the following tables:

CMC_NWPR_RELATION (Participating Provider Link to Network ID)

CMC_NWPE_RELATION (PCP/Capitation Relationship Data)

CMC_NWCR_RELATION (Network Capitation Relationship table)

CMC_NPPR_AGGR (Participating Provider Agreement)

CMC_PRER_RELATION (Provider Entity Relationship Information Data)

Provider Batch Import Subsystem Guide

User Reference

CMC_PRCV_COV_PRAC (Provider Covering Provider Relationship Information)

The system recognizes any of the valid Global Relationship Termination types based on the presence of the triggering keywords:

@pRECTYPE=”NWPR”,@pNWPR_TERM_DT=”MM/DD/CCYY”,@pNWPR_MC

TR_TRSN=”XXXX”

@pRECTYPE=”NWPE”,@pNWPE_TERM_DT=”MM/DD/CCYY”,@pNWPE_MC

TR_TRSN=”XXXX”

@pRECTYPE=”NWCR”,@pNWCR_TERM_DT=”MM/DD/CCYY”,@pNWCR_MC

TR_TRSN=”XXXX”

@pRECTYPE=”NPPR”,@pNPPR_TERM_DT=”MM/DD/CCYY”,@pNPPR_MC

TR_TRSN=”XXXX”

@pRECTYPE=”PRER”,@pPRER _TERM_DT=”MM/DD/CCYY”,@pPRER _MCTR_TRSN=”XXXX”

@pRECTYPE=”PRCV”,@pPRCV _TERM_DT=”MM/DD/CCYY”,@pPRCV _MCTR_TRSN=”XXXX”

NOTE: Global Relationship terminations are permitted after any higher- level termination has been applied, because XP/F does not update a terminated provider.

When one or more triggering keyword is encountered, the system terminates all rows for the specified table as detailed below.

Networks (NWPR_RELATION) Terminate all rows from the NWPR_RELATION table where the current PRPR_ID equals the NWPR PRPR_ID.

Capitated Relationships (NWPE_RELATION) Primary Capitation:

Terminate all rows from the NWPE_RELATION table where the current PRPR_ID equals the NWPE PRPR_ID and NWPE_CRPR_ID.

Capitated Relationships (NWPE_RELATION) Secondary Capitation:

Terminate all rows from the NWPE_RELATION table where the current PRPR_ID equals the NWPE PRPR_ID but does not equal the NWPE_CRPR_ID.

NOTE: Neither online Facets nor XP/F terminates rows from the NWPE_RELATION table where the current PRPR_ID does not equal the NWPE PRPR_ID AND current PRPR_ID equals NWPE_CRPR_ID.

Global Capitation (NWCR_RELATION) Terminate all rows from the NWCR_RELATION table where the current PRPR_ID equals the NWCR_CR_PR_ID.

Out-of-Network (NPPR_RELATION) Terminate all rows from the NPPR_RELATION table where the current PRPR_ID equals the NPPR PRPR_ID.

User Reference

Provider Batch Import Subsystem Guide

Related Entities (PRER_RELATION) Terminate all rows from the PRER_RELATION table where the current PRPR_ID equals the PRER PRPR_ID or PRER_PRPR_ID.

NOTE: Because of the potential for impact on shared addresses, XP/F generates a warning following certain PRER-level terminations. Customers should take great care with PRER-level terminations.

Covering Provider-Covered by Terminate all rows from the PRCV_RELATION table where the current PRPR_ID equals the PRCV PRPR_ID.

Covering Provider-Covering For:

Terminate all rows from the PRCV_RELATION table where the current PRPR_ID equals the PRCV PRCV_PRPR_ID.

Provider Batch Import Subsystem Guide

User Reference

Attachments

Attachments fall within the scope of XP/F, and the following types of attachments are available for import within the Provider Data Model:

Addresses/Alternate Payees

Contacts

Memos

Notes

User Fields

XP/F can import memos, user fields, addresses/alternate payees, contact information and notes as attachments appropriate to the Base Provider Table for Practitioner, Facility, Group and IPA table (CMC_PRPR_PROV), Common Provider Indicative Information table (CMC_PRCP_COMM_PRAC), or Provider Address Information by Address Type table (CMC_PRAD_ADDRESS), depending upon the Entity Type:

When a memo is passed for a Provider, XP/F takes the incoming data and generates a CER_ATXR_ATTACH_U row with a style ID (ATSY_ID) of ATMM, and a CER_ATMM_MEMO_D row.

When a user field is passed for a Provider, XP/F takes the incoming data and generates a CER_ATXR_ATTACH_U row with a style ID (ATSY_ID) of CFUF, and a CER_ATUF_USERFLD_D row.

When an address or alternate payee is passed for a Provider, XP/F takes the incoming data and generates a CER_ATXR_ATTACH_U row with a style ID (ATSY_ID) of CFAP, and a CER_ATAD_ADDRESS_D row.

When contact information is passed for a Provider, XP/F takes the incoming data and generates a CER_ATXR_ATTACH_U row with a style ID (ATSY_ID) of ATCT, and a CER_ATCT_CONTACT_D row.

Notes work slightly differently because notes can consist of many lines of text. To indicate to XP/F the beginning and end of notes being passed, use a header record type of ATT0, and a trailer record type of ATTT. The lines of text are sent in 100-byte chunks with a record type of ATTD.

XP/F takes the incoming note and generates a CER_ATXR_ATTACH_U row with a style ID (ATSY_ID) of ATN0, a CER_ATNT_NOTE_D row, and one or many CER_ATND_NOTE_C rows. It is important to note that XP/F takes the incoming notes and overwrites any existing notes with the same user ID (ATXR_CREATE_USUS) as the incoming notes.

User Reference

Provider Batch Import Subsystem Guide

Destination Tables

When working with attachments it is important to know that there are destination tables:

CER_ATAD_ADDRESS_D

Addresses/Alternate Payees

CER_ATCT_CONTACT_D

Contacts

CER_ATMM_MEMO_D

Memos

CER_ATNT_NOTE_D

Notes

CER_ATND_NOTE_C

CER_ATUF_USERFLD_D

User Fields

Source Tables

There are also source tables. The source tables in the Provider data model applicable to XP/F are:

CMC_PRAD_ADDRESS (Provider Address Information by Address Type)

CMC_PRCP_COMM_PRAC (Common Provider Indicative Information)

CMC_PRPR_PROV (Base Provider Table for Practitioner, Facility, Group and IPA)

The following tables are a guide to appropriate attachments for each Provider Entity Type.

Practitioner: PRPR_ENTITY = P

Source Table

Type of

Destination Tables

ATSY_ID

ATTB_ID

Attachment

CMC_PRAD_ADDRESS

Contacts

CER_ATXR_ATTACH_U

ATCT

PRAD

CER_ATCT_CONTACT_D

(Contacts)

CMC_PRAD_ADDRESS

Notes

CER_ATXR_ATTACH_U

ATN0 [zero]

PRAD

CER_ATNT_NOTE_D

(Notes)

CER_ATND_NOTE_C

CMC_PRCP_COMM_PRAC

Memo

CER_ATXR_ATTACH_U

ATMM

PRCP

CER_ATMM_MEMO_D

(Memo)

Provider Batch Import Subsystem Guide

User Reference

Source Table

Type of

Destination Tables

ATSY_ID

ATTB_ID

Attachment

CMC_PRCP_COMM_PRAC

Notes

CER_ATXR_ATTACH_U

ATN0

PRCP

CER_ATNT_NOTE_D

(Notes)

CER_ATND_NOTE_C

CMC_PRCP_COMM_PRAC

User Fields

CER_ATXR_ATTACH_U

CFUF

PRCP

CER_ATUF_USERFLD_D

(User Fields)

CMC_PRPR_PROV

Addresses/

CER_ATXR_ATTACH_U

CFAP

PRPN

Alternate

CER_ATAD_ADDRESS_D

(Alternate

Payee

Payee)

CMC_PRPR_PROV

Memo

CER_ATXR_ATTACH_U

ATMM

PRPN

CER_ATMM_MEMO_D

(Memo)

CMC_PRPR_PROV

Notes

CER_ATXR_ATTACH_U

ATN0

PRPN

CER_ATNT_NOTE_D

(Notes)

CER_ATND_NOTE_C

Facility: PRPR_ENTITY = F

Source Table

Type of

Destination Tables

ATSY_ID

ATTB_ID

Attachment

CMC_PRAD_ADDRESS

Contacts

CER_ATXR_ATTACH_U

ATCT

PRAD

CER_ATCT_CONTACT_D

(Contacts)

CMC_PRAD_ADDRESS

Notes

CER_ATXR_ATTACH_U

ATN0 [zero]

PRAD

CER_ATNT_NOTE_D

(Notes)

CER_ATND_NOTE_C

CMC_PRPR_PROV

Addresses/

CER_ATXR_ATTACH_U

CFAP

PRFA

Alternate

CER_ATAD_ADDRESS_D

(Alternate

Payee

Payee)

CMC_PRPR_PROV

Memo