CAQH ProView™

Extract Guidelines

for

Participating Organizations

Please note this is a draft document. Changes may be made to these extract specifications since the CAQH ProView system is still in development. CAQH will distribute the final version of this document as soon as it is available.

© 2014 CAQH, All Rights Reserved.

Contents1Introduction31.1Overview31.2Purpose31.3Target Audience32Extract Submission32.1Using Participating Organization User Interface32.2Using Extract Services33Extract Retrieval44Extract Types44.1Standard Extract44.2Custom Extract45Extract Content45.1Extract Qualifying Criteria45.2Affiliated / Non-Affiliated Providers55.3Delegated Providers55.4XML Extract Package Contents55.4.1XML Extract File Layout65.4.2XML Extract Data Summary Layout65.5ASCII Extract Package Contents65.5.1ASCII Extract Section names75.5.2ASCII Extract Data File Layout85.5.3ASCII Extract Data Summary Layout85.6Replica/PDF Extract Package Contents85.6.1Replica/PDF Extract Data Summary Layout96Sanctions Extract96.1Sanctions Standard Extract96.2Sanctions Custom Extract106.3Sanctions Extract Format106.4Sanctions Extract Data File Layout106.5Sanctions Extract Package Contents107Backward Compatibility with Current UPD extract108Appendix A – Extract fields for Non-Affiliated and Delegated Providers11

1 Introduction

1.1 Overview

The Extract Guideline document is a compliation of instructions and documentation for Participating Organizations to set up and retrieve extracts from the CAQH ProView system (formerly Universal Provider Datasource, UPD). This document will explain multiple types of extract options including standard, custom and sanctions.

An extract is a file that contains the latest attested data for every provider associated with a Participating Organization. The data can be requested in various formats (e.g: ASCII, XML and Application Replica PDF). The delivery of the data is based on the schedule set up by the Participating Organization in the system.

In addition to provider’s latest self-attested information, CAQH ProView also can provide sanctions data associated with a provider to the Participating Organizations’ through the Sanctions Extract. This option is available for an additional fee.

1.2 Purpose

This document is intended to serve as a reference for data layout, field definitions, naming standards and all other information pertinent to the dissemination of provider information through various CAQH ProView extracts.

1.3 Target Audience

This document is intended for developers, data stewards, operational and technical staff or any other user involved in the exchange of data between CAQH ProView and its Participating Organizations.

2 Extract Submission

Extract requests can be established in CAQH ProView through the Participating Organization portal or by using the extract web service.

2.1 Using Participating Organization User Interface

The Participating Organization user interface in CAQH ProView will have a screen to schedule extracts. The extract submission screen will let the users define the extract contents, frequency and format.

2.2 Using Extract Services

The Participating Organization can also trigger custom extracts through the Custom Extract Generator Service. Please refer to the CAQH ProView Webservices Specifications document for more details.

3 Extract Retrieval

Both standard and custom extracts can be retrieved from the Participating Organization’s “Outgoing” FTP folder. The naming standards for each type of extract are outlined in the following sections.

4 Extract Types

4.1 Standard Extract

Standard Extracts contain the latest attested data for providers who have attested since the last extract run. It also includes a file that highlights the changes since the last attestation and a list of data elements that changed value along with their previous and current values.

Participating Organizations can create a standard extract by selecting the format of extract, extract frequency, and the sections required in each extract. They can also choose to include supporting documentation with their extracts. Supporting documentation will be a separate zip file that contains all the supporting documentation associated with all providers in the extract. The naming convention for these files will allow the Participating Organization to distinguish the supporting documents for each provider. Standard extracts can be scheduled to run immediately, at a later time, or on a recurring schedule.

4.2 Custom Extract

Custom extracts include the latest attested data for a provider, but allow Participating Organizations to customize the sections required in each extract. Custom extracts also let users filter data by Plan Provider IDs or CAQH Provider IDs. In CAQH ProView, custom extracts can also be scheduled to run immediately, at a later time, or on a recurring schedule.

5 Extract Content

5.1 Extract Qualifying Criteria

The following criteria must be satisfied for a provider to be included in the extract:

· Provider has attested and completed their profile/application (including supporting documentation) or re-attested with no changes.

· Provider in active status in the Participating Organizations roster.

· Provider has authorized the Participating Organization to access their data.

5.2 Affiliated / Non-Affiliated Providers

Based on a provider’s “Affiliation Flag” in the roster file, a Participating Organization can receive both affiliated and non-affiliated providers in their extracts. However, only certain fields will be populated for non-affiliated providers. The list of fields populated for non-affiliated providers are listed in Appendix A.

5.3 Delegated Providers

Based on a provider’s “Delegation Flag” in the roster file, a Participating Organization can receive delegated providers in their extracts as well. The list of fields populated for delegated providers are listed in Appendix A.

5.4 XML Extract Package Contents

The contents of the XML extract is as follows:

FileName: __XML.zip (POID is an identifier assigned by UPD for all its Participating Organizations)

XML Extract Zip file will contain the following:

· Separate XML files for each provider in the extract (Filename: _.xml)

· One Extract Index File (Filename: ExtractIndex.xml)

· One Data Summary File (Filename: DataSummary.txt)

· One Provider Attachment Index file (Filename:ProviderAttachment.txt)

· One ZIP file per provider with supporting documents (if requested) (Filename: _Attachments.zip)

· All provider supporting documents (if requested) (Filename: _.pdf)

Note: For large volume extracts that includes supporting documents, the supporting documents will be delivered as a separate file

Filename: __XML_Attachments.zip

The separate file will contain the following:

· One Provider Attachment Index file (Filename:ProviderAttachment.txt)

· All provider supporting documents (if requested) (Filename: _.pdf)

5.4.1 XML Extract File Layout

5.4.2 XML Extract Data Summary Layout

5.5 ASCII Extract Package Contents

The contents of the ASCII extract is as follows:

FileName: __ASCII.zip (POID is an identifier assigned by UPD for all its Participating Organizations)

ASCII Extract Zip file will contain the following:

· One file for each provider section (Filename: Provider.text) See layout for sections.

· One Data Summary File (Filename: DataSummary.txt)

· One Provider Attachment Index file (Filename:ProviderAttachment.txt)

· One ZIP file per provider with supporting documents (if requested) (Filename: _Attachments.zip)

· All provider supporting documents (if requested) (Filename: _.pdf)

Note: For large volume extracts that includes supporting documents, the supporting documents will delivered as a separate file

Filename: __ASCII_Attachments.zip

The separate file will contain the following:

· One Provider Attachment Index file (Filename:ProviderAttachment.txt)

· All provider supporting documents (if requested) (Filename: _.pdf)

5.5.1 ASCII Extract Section names

ProviderPersonalInformation

ProviderOtherName

ProviderOtherQuestions

ProviderReference

ProviderSpecialty

ProviderSubstanceAbuse

ProviderTimeGap

ProviderWorkHistory

ProviderMedicaid

ProviderMedicalAssociation

ProviderMedicalCondition

ProviderMedicalConditionProvider

ProviderMedicalLicense

ProviderMedicare

ProviderMilitary

ProviderNon-PracticeAddress

ProviderOtherBusinessInterest

ProviderOtherInterest

ProviderInsuranceCoverage

ProviderLanguage

ProviderLiabilityAction

ProviderMalpracticeCaseStatus

ProviderMalpracticeHistory

ProviderDisclosure

ProviderEducation

ProviderHospitalAssociate

ProviderHospitalPrivilege

ProviderCDS

ProviderCertification

ProviderCriminalAction

ProviderDEA

ProviderDegree

PracticeService

PracticeSpecialty

PracticeTaxID

ProviderAdverseAction

PracticeOtherQuestions

PracticeOtherTaxID

PracticePatientType

PracticePhoneCoverage

PracticeHours

PracticeInformation

PracticeLanguage

PracticeLimitation

PracticeOtherAddress

PracticeAccessibility

PracticeAssociate

PracticeAssociateOtherQuestions

PracticeAssociateSpecialty

PracticeBusinessArrangement

PracticeCertification

OwnershipDisclosure (new)

EntityOwnershipDetail (new)

MedicareMedicaidOwnershipDetail (new)

5.5.2 ASCII Extract Data File Layout

The extract layout for each data file in an ASCII Extract are as follows:

5.5.3 ASCII Extract Data Summary Layout

5.6 Replica/PDF Extract Package Contents

The contents of the ASCII extract is as follows:

FileName: __Replica.zip (POID is an identifier assigned by UPD for all its Participating Organizations)

Replica Extract Zip file will contain the following:

· One Data Summary File (Filename: DataSummary.txt)

· One document for each replica file (Filename: ReplicaApp__.pdf)

· One ZIP file per provider with supporting documents (if requested) (Filename: _Attachments.zip)

· All provider supporting documents (if requested) (Filename: _.pdf)

Note: For large volume extracts that includes supporting documents, the supporting documents will delivered as a separate file

Filename: __Replica_Attachments.zip

The separate file will contain the following:

· One Provider Attachment Index file (Filename:ProviderAttachment.txt)

· All provider supporting documents (if requested) (Filename: _.pdf)

5.6.1 Replica/PDF Extract Data Summary Layout

6 Sanctions Extract

CAQH SanctionsTrak is a centralized data collection process of querying national and state boards for sanctions data and loading this data to CAQH ProView. Sanctions are matched to unique providers within CAQH ProView. Participating Organizations can request this sanctions data through the CAQH ProView portal.

6.1 Sanctions Standard Extract

Sanctions Standard Extract can be scheduled to run on a recurring basis by the POs. The standard extract will contain additions and updates to sanctions since the last standard extract. When new sanctions are added or updates are made to existing sanctions for a provider, they will be reported on the next scheduled standard extract run for a Participating Organization (if the Participating Organization has purchased the sanctions module of CAQH ProView)

6.2 Sanctions Custom Extract

Sanctions Custom Extracts are ad hoc reports based on the most current Sanction data CAQH ProView has for a provider.The sanctions custom extract will be generated based on the criteria provided by a Participating Organization (if the Participating Organization has purchased the sanctions module of CAQH ProView).

6.3 Sanctions Extract Format

The sanctions extract will be delivered in a pipe-delimited text file. In addition, a PDF attachment will be available for each sanction if supplied by the sanction vendor. The PDF file can be linked to the provider in the pipe-delimited text file using the naming convention detailed below. In addition, the provider record in the ASCII file will contain the name of the PDF file that corresponds to the provider’s sanction image.

6.4 Sanctions Extract Data File Layout

6.5 Sanctions Extract Package Contents

FileName: _Sanctions_.zip

Sanctions ASCII extract zip file will contain the following:

· One text file that contains all the providers in the extract (Filename: SanctionExtract.txt)

· Sanction Image File for providers who have a sanctions image identified by the “SanctionImageName” field in the ASCII file (Filename: __.pdf)

7 Backward Compatibility with Current UPD Extract

CAQH will support existing UPD extract formats for a limited time. This will provide additional time for Participating Organizations to transition into the new layout. The existing UPD extract files and layout for ASCII and XML will be honored.

8 Appendix A – Extract fields for Non-Affiliated and Delegated Providers

File Name: CAQH ProView PO Extract Guidelines - DRAFT

Last Saved 11/14/2014

4

© 2014 CAQH, All Rights Reserved.

ProviderXSD_ProVie

w.txt

Copyright 2002, 2010 Council for Affordable Quality Healthcare (CAQH). All rights reserved. For use only in conjunction with CAQH's Universal Provider Data Source.

DataSummary

layout.txt

CAQH PIN|PlanProviderID|LicenseNumber|LastName|FirstName|MiddleName|PrimaryPracticeState|Status|XPath|Table|Element|Old Data|New Data|AnniversaryDate

ProView ASCII

Extract Layout_PO.xlsx

Sheet11ProviderPersonalInformationProviderAttestIDProviderIDLastNameFirstNameMiddleNameSuffixPrimaryPracticeStateOtherNameFlagBirthDateUSEligibleFlagSSNNIDDEAFlagCDSFlagUPINUPINFlagNPIFlagNPIMedicareProviderFlagMedicaidProviderFlagOtherGraduateEducationFlagFellowshipTrainingFlagTeachingAppointmentFlagSecondarySpecialtyFlagOtherSpecialtyFlagHospitalPrivilegeFlagHospitalAdmittingArrangementsWorkHistoryGapFlagActiveMilitaryFlagCitizenshipStatusVisaNumberFederalEmployeeIDNoMalpracticeClaimsFlagApplicationTypeECFMGFlagECFMGNumberECFMGIssueDateHospitalBasedFlagEmailAddressVisaTypeVisaStatusBirthCityBirthStateTaxIDSpouseLastNameSpouseFirstNameOtherCorrespondenceAddressEmergencyContactLastNameEmergencyContactFirstNameEmergencyContactMiddleNameEmergencyContactPhonePagerBeeperNumberAnsweringServicePhoneNumberCellPhoneNumberPagerBeeperDigitalFlagVisaExpirationDateEthnicityDescriptionVisaIssueDateECFMGExpirationDateWorkPermitStatusSpouseMiddleNameStateResidenceDateCitizenshipCountry_CountryNameMaritalStatus_MaritalStatusDescriptionGender_GenderDescriptionBirthCountry_CountryNameCorrespondenceAddressType_CorrespondenceAddressTypeDescriptionProviderType_ProviderTypeAbbreviationGraduateType_GraduateTypeDescriptionNIDCountry_CountryNameAttestDatePlanProviderIDLastRecredentialDateNextRecredentialDateCitizenshipCountryAffiliatedFlagDelegatedFlagProviderOtherPracticeStates2ProviderOtherNameProviderAttestIDProviderOtherNameIDLastNameFirstNameMiddleNameSuffixStartDateEndDateOtherNameExplanation3ProviderOtherQuestionsProviderAttestIDProviderOtherIDProviderAnswerFlagProviderAnswerTextProviderAnswerDateOtherQuestion_OtherQuestionSummary4ProviderReferenceProviderAttestIDProviderReferenceIDFirstNameLastNameAddressAddress2CityStateProvincePostalCodePhoneNumberStartDateEndDateTitleFaxNumberRelationshipYearsKnownMiddleNameEmployerNameEmailAddressCellPhoneNumberPhoneExtensionPhoneNumber2PhoneNumber2ExtensionDepartmentCountry_CountryNameSpecialty_SpecialtyNameReferenceType_ProviderTypeAbbreviationDegree_DegreeAbbreviation5ProviderSpecialtyProviderAttestIDProviderSpecialtyIDBoardCertifiedFlagCertificationDateRecertificationDateExpirationDateFutureBoardExamDateHMOFlagPPOFlagPOSFlagBoardCertificationExpiresFlagRecertifiedFlagStatusExpirationDateResultsPendingFlagListInDirectoryFlagSpecialtyBoardNameFailedBoardExamFlagFailedBoardExamBoardNameFailedBoardExamDateApplyCertificationFlagIntendApplyCertificationFlagIntendApplyCertificationDateExamAcceptedFlagNoCertificationExplanationAdmissibilityExpirationDatePartialExamFlagExamNameIntendingBoardFlagNotIntendingBoardFlagExamTakenDateCurrentCertificationFlagInitialCertificationDateFailedBoardExamExplanationFutureBoardExamDateOralFutureBoardExamDateWrittenCertificationNumberSpecialtyPercentStatusDateABMSFlagResultsPendingSpecialtyBoardNameFailedBoardExamAttemptsNotEligibleBoardFlagApplyCertificationDateSpecialtyBoardAddressSpecialtyBoardAddress2SpecialtyBoardCitySpecialtyBoardStateSpecialtyBoardPostalCodeNonCertifiedStatus_NonCertifiedStatusDescriptionSpecialtyClassification_SpecialtyClassificationDescriptionSpecialtyStatus_SpecialtyStatusDescriptionSubSpecialty_SpecialtyNameSpecialty_SpecialtyNameSpecialtyType_SpecialtyTypeDescription6ProviderSubstanceAbuseProviderAttestIDProviderSubstanceAbuseIDSubstanceDescriptionCurrentAbilityMonitorEntityNameAddressCityStatePostalCodeCurrentStatusAbstinentDateProviderNameProviderAddressProviderCityProviderPostalCodeProviderTelephoneProviderStateMonitorTypeDisclosureQuestion_DisclosureSummary7ProviderTimeGapProviderAttestIDProviderTimeGapIDStartDateEndDateGapExplanationGapDescription8ProviderWorkHistoryProviderAttestIDProviderWorkHistoryIDEmployerNameStartDateEndDateAddressAddress2CityStateProvincePostalCodeContactLastNameContactFirstNamePhoneNumberExitExplanationFaxNumberTitleAffiliationDescriptionOperatingStatusDescriptionPhoneExtensionDepartmentEmailAddressStatusDescriptionProfLiabilityCarrierCurrentEmployerFlagWorkHistoryType_WorkHistoryTypeDescriptionCountry_CountryName9ProviderMedicaidProviderAttestIDProviderMedicaidIDMedicaidNumberState10ProviderMedicalAssociationProviderAttestIDProviderMedicalAssociationIDAssociationNameAddressAddress2CityCountyStatePostalCodeExtZipPhoneNumberFaxNumberAnsweringServicePhoneNumberAssociationTypeStartDateEndDateExplanationGeographicRange_GeographicRangeDescription11ProviderMedicalConditionProviderAttestIDProviderMedicalConditionIDMedicalConditionPracticeAbilityCurrentStatusDisclosureQuestion_DisclosureSummary12ProviderMedicalConditionProviderProviderAttestIDProviderMedicalConditionProviderIDProviderMedicalConditionIDLastNameFirstNameMiddleNameDegreePhoneNumber13ProviderMedicalLicenseProviderAttestIDProviderLicenseIDLicenseNumberStateCurrentlyPracticingFlagExpirationDateLicenseTypeIssueDateLicenseUnlimitedFlagLicenseLimitationExplanationSponsorNameRelinquishDateRelinquishExplanationLicenseStatus_LicenseStatusDescription14ProviderMedicareProviderAttestIDProviderMedicareIDMedicareNumberStateVoluntarilyOptedOutMedicareFlag15ProviderMilitaryProviderAttestIDProviderMilitaryIDLastLocationDischargeRankBranchStartDateEndDateHonorableDischargeFlagDischargeExplanationReserveGuardFlagCourtMartialFlagCourtMartialExplanationActiveDutyCurrentPrimaryBaseNameCurrentDivisionCurrentAddressCurrentAddress2CurrentCityCurrentStateCurrentZipCurrentCountryCurrentPhoneNumberCurrentFaxNumberCurrentAppointmentDateCurrentMilitaryStatusPrevPrimaryBaseNamePrevDivisionPrevAddressPrevAddress2PrevCityPrevStatePrevZipPrevCountryPrevPhoneNumberPrevFaxNumberPrevAppointmentDatePrevMilitaryStatus16ProviderNon-PracticeAddressProviderAttestIDProviderAddressIDAddressAddress2CityStatePostalCodeYearsAtThisAddressProvincePhoneNumberFaxNumberEmailAddressCountyUnlistedFlagAddressType_AddressTypeDescriptionCountry_CountryName17ProviderOtherBusinessInterestProviderAttestIDProviderOtherBusinessIDOrganizationNameOrganizationTypeAddressAddress2CityStateZipExtZipPhoneNumberTaxIDPercentOwnedInvestmentType18ProviderOtherInterestProviderAttestIDProviderOtherInterestIDOtherInterestDescription19ProviderInsuranceCoverageProviderAttestIDProviderInsuranceIDInsuranceCarrierNameOriginalStartDateStartDateEndDateSelfInsuredFlagAddressAddress2CityStateProvincePostalCodePhoneNumberPolicyNumberIndividualCoverageFlagCoverageAmountOccurrenceCoverageAmountAggregateAgentLastNameAgentFirstNamePolicyHolderNoMalpracticeClaimsFlagRetroactiveDateTailNoseCoverageFlagTailNoseCoverageExplanationTimeWithCarrierCoverageLimitExceededFlagUnlimitedCoverageFlagFaxNumberWebsiteRenewalDateAgentAddressAgentAddress2AgentCityAgentStateAgentPostalCodeAgentProvinceSurchargeExplanationExcessCoverageAmountPhoneExtensionUnderwriterNameAffiliatedOrganizationNameAgentCountry_CountryNameCountry_CountryNameInsuranceType_InsuranceTypeDescriptionInsuranceCoverageType_InsuranceCoverageTypeDescription20ProviderLanguageProviderAttestIDProviderLanguageIDLanguageTypeLanguage_LanguageNamePrimaryLanguageFlag21ProviderLiabilityActionProviderAttestIDProviderLiabilityActionIDInsuranceHistoryCarrierNamePolicyNumberAddressCityStatePostalCodePhoneNumberStartDateEndDateCircumstancesDescriptionDisclosureQuestion_DisclosureSummary22ProviderMalpracticeCaseStatusProviderAttestIDProviderMalpracticeClaimStatusIDProviderMalpracticeIDClaimStatusSettlementAmountSettlementAmountPaidDefenseAttorneyStatusDateSoughtAmountTotalAmountDefenseAttorneyPhoneNumberDefenseAttorneyAddressDefenseAttorneyAddress2DefenseAttorneyCityDefenseAttorneyStateDefenseAttorneyPostalCodeDefenseAttorneyProvinceDefenseAttorneyCountyDefenseAttorneyCountry_CountryName23ProviderMalpracticeHistoryProviderAttestIDProviderMalpracticeIDInsuranceCarrierNameOccurrenceDateClaimDateAddressAddress2CityStateZipPhoneNumberPolicyNumberAllegationDescriptionPrimaryDefendantFlagNumberOtherCodefendantCaseInvolvementPatientInjuryDescriptionNPDBCaseFlagCourtSuitFiledFlagCourtDateCaseNumberCaseStateCaseCountyDistrictFederalCaseNumberDefendantNamePlaintiffNamePlaintiffAgeOtherDefendantNamesPatientOutcomeStillPendingFlagStillPendingDateTrialDateSetFlagProvinceProviderStatusProviderRoleCaseClosedDatePatientNamePatientAgeCaseCityIncidentLocationCarrierFlagContactNameClaimNumberOtherCaseDescriptionCourtCourtAddressLegalCounselFlagPatientDiedFlagCourtAddress2CourtCityLicenseNumberCourtStateCourtProvinceCourtZipCountry_CountryNameDisclosureQuestion_DisclosureSummaryPatientGender_GenderDescriptionCourtCountry_CountryNameMalpracticeResolution_MalpracticeResolutionMethod24ProviderDisclosureProviderAttestIDProviderDisclosureIDDisclosureAnswerFlagDisclosureDateDisclosureExplanationDisclosureQuestion_DisclosureSummary25ProviderEducationProviderAttestIDProviderEducationIDInstitutionNameAddressAddress2CityProvinceStatePostalCodeStartDateEndDateAffiliatedUniversityNameHospitalDepartmentNameTrainingAreaEmailAddressCertificateIssuedByProgramTitleAPAApprovedFlagProgramCompletedFlagProgramDirectorCompletionDateCertificateAwardedTeachingPositionCurrentProgramDirectorIncompleteExplanationPhoneNumberFaxNumberDisciplinaryActionFlagDisciplinaryActionExplanationProgramDirectorDegreeProgramTypeAdditionalTrainingDescriptionEducationTypeNameHoursCountry_CountryNameDegree_DegreeAbbreviationSpecialty_SpecialtyNameInstitutionType_InstitutionTypeDescription26ProviderHospitalAssociateProviderAttestIDProviderHospitalAssociateIDProviderHospitalIDAssociateFirstNameAssociateLastNameAssociateMiddleInitialAddressAddress2CityStateZipCountyPhoneNumberFaxNumberEmailAddressAssociateType_AssociateTypeDescription27ProviderHospitalPrivilegeProviderAttestIDProviderHospitalIDHospitalNameAddressAddress2CityStateZipCodePhoneNumberUnrestrictedPrivilegesFlagPrivilegeDescriptionTemporaryPrivilegesFlagAdmissionPercentStartDateEndDateStaffCategoryPrivilegeRestrictionExplanationApplicationDateNoPrivilegesExplanationFaxNumberEmailAddressExitExplanationAdmitInpatientFlagContactNameProvinceDepartmentTelephoneNumberMedicalStaffFaxNumberDepartmentNameSpecialtyLimitationExplanationWebsiteCoverageArrangementExplanationAdmitsPerMonthHospitalAffiliationType_HospitalAffiliationTypeDescriptionCountry_CountryName28ProviderCDSProviderAttestIDProviderCDSIDCDSNumberStateExpirationDateIssueDateCurrentlyPracticingFlagCDSLimitationExplanationCDSStatus29ProviderCertificationProviderAttestIDProviderCertificationIDCertificationFlagExpirationDateClassificationDescriptionCertificationTypeCertificationStatusCertificationNumberStateObtainedDateRelinquishedDateRelinquishedExplanationOtherCertificationExplanationCertificationDescriptionCountry_CountryName30ProviderCriminalActionProviderAttestIDProviderCriminalActionIDIncidentDateComplaintDateResolutionDateResolutionTypeAllegationsIncidentDetailsActionsTakenCurrentStatusPrivilegesAffectedSentenceFlagSentenceLengthLocationDisclosureQuestion_DisclosureSummary31ProviderDEAProviderAttestIDProviderDEAIDDEANumberStateExpirationDateIssueDateDEALicenseLimitationFlagDEALicenseLimitationExplanationNoDEAExplanationApplicationDate32ProviderDegreeProviderAttestIDProviderDegreeIDDegree_DegreeAbbreviation33PracticeServiceProviderAttestIDProviderPracticeServiceIDProviderPracticeIDServiceProvidedFlagAnesthesiaCategoryAnesthesiaFirstNameAnesthesiaLastNameOtherServiceDescriptionXrayCertificationTypeLaboratoryCertificationProgramNewPatientWaitTimeExistingPatientWaitTimeCallResponseTimeLaboratoryServicesDescriptionCLIAWaiverFlagCLIAWaiverExpirationDateCLIACertificationFlagCLIANumberCLIAWaiverNumberCLIAExpirationDateTaxIDBillingNameOmittedServiceDescriptionLaboratoryNameService_ServiceName34PracticeSpecialtyProviderAttestIDProviderPracticeSpecialtyIDProviderPracticeIDSpecialtyPercentPrimaryCareFlagSpecialtyCareFlagMultiCareFlagSpecialty_SpecialtyNameSubSpecialty_SpecialtyNameSpecialtyType_SpecialtyTypeDescription35PracticeTaxIDProviderAttestIDProviderPracticeTaxIDProviderPracticeIDGroupNameTaxIDPrimaryFlagGroupNumberTaxType_TaxTypeDescription36ProviderAdverseActionProviderAttestIDProviderAdverseActionIDOccurrenceDateOccurrenceExplanationActionDateActionExplanationCurrentStatusContactNameDepartmentNameAddressCityStatePhoneNumberPostalCodeLocationOrganizationNameEndDateDisclosureQuestion_DisclosureSummary37PracticeOtherQuestionsProviderAttestIDProviderPracticeOtherIDProviderPracticeIDParaProfessionalFlagParaProfessionalSupervisionFlagParaProfessionalBillingFlagProviderPracticeAnswerFlagProviderPracticeAnswerTextProviderPracticeAnswerDateOtherQuestion_OtherQuestionSummary38PracticeOtherTaxIDProviderAttestIDProviderPracticeOtherTaxIDProviderPracticeOtherIDProviderPracticeIDTaxID39PracticePatientTypeProviderAttestIDProviderPracticePatientIDProviderPracticeIDPatientFlagPatientExplanationPatientType_PatientTypeDescription40PracticePhoneCoverageProviderAttestIDProviderPracticePhoneCoverageIDProviderPracticeIDPhoneCoverageFlagPhoneCoverageTypeDescription41PracticeHoursProviderAttestIDProviderPracticeHoursIDProviderPracticeIDNoOfficeHoursFlagMorningHoursAfternoonHoursEveningHoursOfficeHoursEveningWeekendHoursEveningHoursFlagWeekendHoursFlagStartHours_HoursHoursType_HoursTypeDescriptionEndHours_HoursDayOfWeek_DayOfWeekName42PracticeInformationProviderAttestIDProviderPracticeIDPracticeNameAddressAddress2CityStateZipExtZipCountyPhoneNumberAfterHoursPhoneNumberFaxNumberEmailAddressCorrespondenceFlagPartnersFlagOtherAssociatesFlagCurrentlyPracticingFlagStartDateCoverage24x7FlagPracticeLimitationFlagADAApprovedFlagMinorityBusinessFlagInterpreterAvailableFlagMedicareNumberMedicaidNumberEPSDTCertifiedFlagEPSDTNumberPracticeOrganizationTypePhoneNumber2PatientAppointmentPhoneNumberAnsweringServicePhoneNumberPagerBeeperNumberListInDirectoryFlagW9PracticeNameInPracticeFlagPracticeIntentionExplanationEmergencyPhoneNumberPracticeDescriptionPatientsEnrolledPatientVisitsAppointmentsPerHourAverageWaitingTimeCallResponseTimeElectronicBillingFlagBWCNumberWorkersCompensationRiskNumberOwnershipDescriptionEmergencyProcedureNPIPracticeTypeDescriptionServiceTypeDescriptionDepartmentNameCellPhoneNumberPagerBeeperNumber2EndDatePhoneExtensionPatientAppointmentPhoneExtensionAnsweringServicePhoneExtensionCorrespondenceMethodAddressType_AddressTypeDescriptionPracticeWebsiteEHRAdoptionFlag43PracticeLanguageProviderAttestIDProviderPracticeLanguageIDProviderPracticeIDLanguageTypeLinguistNameLanguage_LanguageNameEmployeeType_EmployeeTypeDescription

44PracticeLimitationProviderAttestIDProviderPracticeLimitationIDProviderPracticeIDAgeLimitationFlagAgeLimitationMinimumAgeLimitationMaximumOtherLimitationDescriptionSpecialtyLimitationFlagSpecialtyLimitationDescriptionGenderLimitation_GenderLimitationDescription45PracticeOtherAddressProviderAttestIDProviderPracticeAddressIDProviderPracticeIDAddressAddress2CityCountyStatePostalCodeProvincePhoneNumberFaxNumberEmergencyPhoneNumberAnsweringServicePhoneNumberEmailAddressCheckPayableToCompanyNameAttentionAddressType_AddressTypeDescriptionCountry_CountryName46PracticeAccessibilityProviderAttestIDProviderPracticeAccessibilityIDProviderPracticeIDAccessibilityFlagOtherAccessibilityDescriptionAccessibility_AccessibilityDescription47PracticeAssociateProviderAttestIDProviderPracticeAssociateIDProviderPracticeIDAssociateFirstNameAssociateLastNameAssociateMiddleInitialAddressAddress2CityStateZipCountyPhoneNumberFaxNumberEmailAddressLicenseNumberLicenseStateHospitalDepartmentNameCheckPayableToElectronicBillingFlagCoverageFlagBillingCompanyCoverageArrangementExplanationTaxIDOtherSkillsEmergencyPhoneNumberAnsweringServicePhoneNumberTitleTaxIDNamePhoneExtensionDegree_DegreeAbbreviationProviderType_ProviderTypeAbbreviationAssociateType_AssociateTypeDescription48PracticeAssociateOtherQuestionsProviderAttestIDProviderPracticeAssociateOtherIDProviderPracticeAssociateIDProviderPracticeIDCoverageAvailability49PracticeAssociateSpecialtyProviderAttestIDProviderPracticeAssociateSpecialtyIDProviderPracticeAssociateIDProviderPracticeIDSpecialty_SpecialtyName50PracticeBusinessArrangementProviderAttestIDProviderPracticeBusinessArrangementIDProviderPracticeIDBusinessArrangementNameBusinessArrangementTypeTaxIDAddressAddress2CityStatePostalCodePhoneNumberProvinceCountry_CountryName51PracticeCertificationProviderAttestIDProviderPracticeCertificationIDProviderPracticeIDCertificationFlagExpirationDateOtherCertificationExplanationStaffCertifiedFlagProviderCertifiedFlagCertificationDescriptionCertificationDate52OwnershipDisclosureProviderAttestIDOwnershipDisclosureIDEntityTypeEntityNameDoingBusinessAsProviderNumberVendorNumberChainAffiliateNumberAddressAddress2CityCountyStateZipTelephoneOwnershipConvictionFlagEmployeeConvictionFlagFiscalIntermediaryEmploymentFlagMedicareMedicaidFacilityOwnerFlagOwnershipChangeWithinYearFlagOwnershipChangeDateAnticipateOwnershipChangeFlagOwnershipChangeAnticipateDateAnticipateBankruptcyFlagAnticipatedBankruptcyFilingDateManagementCompanyOperatedLeasedFlagFacilityOperationChangeDateAdminDirectorChangeFlagChainAffiliatedFlagAffiliatedNameAffiliatedEINAffiliatedAddressAffiliatedAddress2AffiliatedCityAffiliatedStateAffiliatedZipPriorChainAffiliatedFlagPriorAffiliatedNamePriorAffiliatedEINPriorAffiliatedAddressPriorAffiliatedAddress2PriorAffiliatedCityPriorAffiliatedStatePriorAffiliatedZipBedCapacityIncreaseFlag BedCapacityChangeYearCurrentBedsPriorBedsSignatureDateAuthRepNameTitleRemarks53EntityOwnershipDetailProviderAttestIDOwnershipDisclosureIDEntityOwnershipDetailIDEntityOwnershipNameEntityOwnershipEINEntityOwnershipAddressEntityOwnershipAddress2EntityOwnershipCityEntityOwnershipStateEntityOwnershipZip54MedicareMedicaidOwnershipDetailProviderAttestIDOwnershipDisclosureIDMedicareMedicailOwnershipDetailIDMedicareMedicaidOwnershipNameMedicareMedicaidOwnershipProviderNumberMedicareMedicaidOwnershipAddressMedicareMedicaidOwnershipAddress2MedicareMedicaidOwnershipCityMedicareMedicaidOwnershipStateMedicareMedicaidOwnershipZip

Sheet2

Sheet3

CAQH PIN|PlanProviderID|LicenseNumber|LastName|FirstName|MiddleName|PrimaryPracticeState|Status|XPath|Table|Element|Old Data|New Data|AnniversaryDate

CAQH PIN|PlanProviderID|LicenseNumber|LastName|FirstName|MiddleName|PrimaryPracticeState|Status|XPath|Table|Element|Old Data|New Data|AnniversaryDate

ProView Sanctions

ASCII Extract Layout.xlsx

Sheet1FieldField NameField DescriptionLengthFormat1CAQHProviderIDCAQH Provider ID8-10 numeric99999999992FirstNameFirst Name1-30 characters3MiddleNameMiddle Name1-25 characters4LastNameLast Name1-50 characters5SuffixSuffix1-10 characters6GenderGender1 characterM or F7AddressPrimary Credentialing Corresp. Address or Address from Sanction Issuer1-100 characters8Address2Primary Credentialing Corresp. Address2 or Address2 from Sanction Issuer1-100 characters9CityPrimary Credentialing Corresp. City or City from Sanction Issuer1-50 characters10StatePrimary Credentialing Corresp. State or State from Sanction Issuer2 charactersStandard State Abbreviations11ZipPrimary Credentialing Corresp. Zip Code or Zip Code from Sanction Issuer5 numeric9999912ExtZipPractice/Credentialing Corresp. Extended Zip Code Or Zip Code included from Sanction Issuer4 numeric999913SSN4Last four digits of Social Security Number4 numeric999914BirthdateBirth Date10 charactersmm/dd/yyyy15StatusCurrent System Status1-30 characters16StatusDateLast Status change Date10 charactersmm/dd/yyyy17PlanProviderIDOrganization’s Provider ID if provider on roster (null if run by parent plan)50 characters18PlanIDParticipating organization’s identification number or parent PlanID if run by the parent plan3 numeric99919SanctionLicenseNumberState License Number on the Sanction1-17 characters 20SanctionProviderTypeProviderType on the sanction4 Characters21SanctionBoardNameName of Sanctioning Board200 characters22SanctionReportingStateState of the Reporting Board2 charactersAZ23SanctionPublishDateDate Sanction published by the issuing board10 charactersmm/dd/yyyy24SanctionImageNameFile Name of the PDF image.  Format: {Provider ID}_{sanction date with/ without an A}_{sequential number}.pdf. Example: 10300008_20120121_19.pdf or 10300008_20120121A_19.pdf100 charactersalpha-numeric25SanctionCodeA code indicating the type of Sanction 5 digits9999926RosterFlagIndicator if provider is on your roster or one of your region rosters1 characterY or N27SanctionEffectiveDateSanction Effective Date10 charactersmm/dd/yyyy28SanctionPostedDateDate posted to the Universal Provider Datasource10 charactersmm/dd/yyyy

Sheet2

Sheet3

DelegatedandAffiliat

edExtract fields.xlsx

Fields V.1Field #Column1FieldSchema NameColumn2DescriptionSectionSub-SectionCommentsField Name (Legacy)DataTypeFieldLengthCAQHCAQH DisplayRequired FieldColorado Colorado DisplayGeorgia Georgia DisplayIllinois Illinois DisplayMassachusetts Massachusetts DisplayMinnesota Minnesota DisplayMississippi Mississippi DisplayNorth Carolina North Carolina DisplayNevada Nevada DisplayOklahoma Oklahoma DisplayOregon Oregon DisplayTexas Texas DisplayWashington Washington DisplayWest Virgina West Virgina Display1Provider Attest IDWhole NumberID Number (assigned by system) in the Provider data table for each provider’s attestationPersonal InformationGeneralProviderAttestIDint7XXXXXXXXXXXXXX2ProviderProvider IDWhole NumberUnique number assigned to a providerPersonal InformationGeneralProviderIDint8XXXXXXXXXXXXXX3Last NameLast name of providerPersonal InformationNameLastNamevarchar70XLast Name XXLast Name XLast Name XLast Name XLast Name XLast Name XLast Name XLast Name XLast Name XLast Name XLast Name XLast Name XLast Name XLast Name (as shown on state license) 4First NameFirst name of providerPersonal InformationNameFirstNamevarchar30XFirst Name XXFirst Name XFirst XFirst Name XFirst Name XFirst Name XFirst XFirst Name XFirst Name XFirst Name XFirst XFirst Name XFirst Name XFirst Name 5Middle NameMiddle name of providerPersonal InformationNameMiddleNamevarchar25XMiddle Name XXMiddle Name XMiddle XMiddle Name XMiddle Name XMiddle Name XMiddle XMiddle Name XMiddle Name XMiddle Name XMiddle XMiddle Name XMiddle Name XMiddle Name 6SuffixGenerational suffix of providerPersonal InformationNameSuffixvarchar10XSuffix XSuffix  XSuffix XSuffix X XSuffix  Suffix XSuffix XSuffix XSuffix XSuffix 7Primary StateThe state of the provider’s primary practice. Used to drive which Application a provider should input in the OASPersonal InformationPreparePrimaryPracticeStatechar2XPrimary Practice State - Label XXPrimary Practice State - Label XPrimary Practice State - Label XPrimary Practice State - Label XPrimary Practice State - Label XPrimary Practice State - Label  Primary Practice State - Label XPrimary Practice State - Label XPrimary Practice State - Label XPrimary Practice State - Label XPrimary Practice State - Label XPrimary Practice State - Label XPrimary Practice State - Label XPrimary Practice State - Label 8Other Names?Flag indicating that provider has previously used other namesPersonal InformationNameOtherNameFlagchar1XHave you ever used another names? XXHave you used other names? XIs there any other name under which you have been known or have used (e.g. maiden name)?  XIs there any other name under which you have been known (AKA/Maiden Name)?  XIs there any other name under which you have been known or have used since starting professional training?  9Birth DateDate of birth of provider (format YYYY-MM-DD HH:MM:SS)Personal InformationGeneralBirthDatedatetime8XBirth Date XXBirth Date XDate of Birth XBirth Date XDate of Birth XDate of Birth XBirthday Date XDate of Birth XBirth Date XDate of Birth XBirth Date XBirth Date XBirth Date XBirth Date 10US Practice Eligible?Flag indicating whether or not provider is eligible to practice medicine in the United StatesPersonal InformationVisaUSEligibleFlagchar1XAre you eligible to work in the United States? XIf no, do you have a legal right to reside permanently and work in the U.S.?  XAre you eligible to work in the United States?  11SSNSocial security numberPersonal InformationGeneralSSNvarchar9XSocial Security Number XXSocial Security Number XSocial Security Number XSocial Security Number XSocial Security # XSocial Security Number XSocial Security # XSocial Security Number XSocial Security Number XSocial Security Number XSocial Security Number XSocial Security Number XSocial Security Number XSocial Security # 12NIDSingle Line of TextForeign National identification numberProfessional IDsNIDNIDvarchar30XForeign National Identification Number (Do not enter National Provider Identification Number (NPI) here.)  XNational Identification Number (Do not enter National Provider Identification Number (NPI) here.)  13DEAFlagTwo OptionsFlag indicating whether or not provider has a DEA numberProfessional IDsDEADEAFlagchar1XDo you have a DEA Registration Certificate? X X XNot Applicable 14CDSFlagTwo OptionsFlag indicating whether or not provider has a CDS numberProfessional IDsCDSCDSFlagchar1XDo you have a State Controlled Substances Registration Certificate? X XThis certifies that I will prescribe/dispense Schedule VI controlled substances only (requires state certificate).  XNot Applicable 15UPINSingle Line of TextUnique Provider Identification NumberProfessional IDsUPINUPINvarchar6XIf Yes, UPIN XXUPIN XUPIN XMedicare Unique Provider ID# (UPIN) XUPIN # XUPIN XMedicare UPIN XUPIN Number XUPIN XXUPIN XUPIN XMedicare UPIN XUPIN 16UPINFlagTwo OptionsFlag indicating whether or not provider has a UPINProfessional IDsUPINUPINFlagchar1XDo you have a Unique Physicians Identification Number (UPIN)? X 17NPIFlagTwo OptionsFlag indicating whether or not provider has an NPIProfessional IDsNPINPIFlagchar1 18NPISingle Line of TextNPI NumberProfessional IDsNPINPIvarchar10XNational Provider Identification (NPI) Number XXNPI XNational Provider Identifier (NPI) XNational Provider Identification Number (NPI) XNational Practitioner Identification Number (NPI) XNPI XNational Physician Identifier (NPI) XNational Provider Identifier (NPI) XNPI (National Provider Identifier) XNPIDXNPIXNational Provider Identifier XNPI XNational Provider ID # (if available) 19Medicare FlagTwo OptionsFlag indicating whether or not provider is a Medicare provider Professional IDsMedicareMedicareProviderFlagchar1XAre you a participating Medicare provider? XXAre you a Participating Medicare Provider?  XAre you a participating Medicare provider?  20Medicaid FlagTwo OptionsFlag indicating whether or not provider is a Medicaid providerProfessional IDsMedicaidMedicaidProviderFlagchar1XAre you a participating Medicaid provider? XXAre you a Participating Medicaid Provider?  XAre you a participating Medicaid provider?  21Other FlagTwo OptionsFlag indicating whether or not provider has any Other Graduate EducationEducationEducationOtherGraduateEducationFlagchar1XDo you have other relevant education for which a degree was obtained? XDoes Not Apply  22Fellowship FlagTwo OptionsFlag indicating whether or not provider has any fellowshipTrainingFellowshipFellowshipTrainingFlagchar1XDo you have Fellowship training? XXDoes Not Apply  23Teaching Appointment FlagTwo OptionsFlag indicating whether or not provider has any teaching appointmentsTrainingTeachingTeachingAppointmentFlagchar1XDoes Not Apply  24Secondary Specialty FlagTwo OptionsFlag indicating whether or not provider has a secondary specialtySpecialtiesSpecialtySecondarySpecialtyFlagchar1XDo you have a Secondary Specialty? XXDo you have a secondary specialty?  25Other Specialty FlagTwo OptionsFlag indicating whether or not provider has more than two specialtiesSpecialtiesSpecialtyOtherSpecialtyFlagchar1XDo you have any Additional Specialties? XXDo you have any additional specialties?  26Hospital Privilege FlagFlag indicating whether or not provider has any hospital privilegesAffiliationsAdmitHospitalPrivilegeFlagchar1XDo you have hospital privileges? XX XI have hospital admitting privileges  X XDo you admit your own patients to hospitals? XIf you do not have hospital admitting privileges, check here XDo you have hospital privileges?  XDo you admit patients to the hospital under your own service? 27Hospital Admitting ArrangementsType of admitting arrangements if the provider does not admit patientsAffiliationsAdmitHospitalAdmittingArrangementsvarchar100XAdmitting Arrangements X XIf you do NOT have admitting privileges, what are your arrangements for hospital admission and inpatient coverage of your patients? XIf no hospital privileges, describe method/coverage for continuity of care XIf you do not have privileges, please provide plan for continuity of care  XAlternate Care of Hospitalized Patients: If you do not apply for admitting privileges, list the name/names of physicians or groups with whom you have established a current hospital admission coverage agreement: XIf no, please explain how your patients will be admitted, which hospital and who will provide patient care XPlease explain your plan for continuity of care for your patients who require admitting XAdmitting Arrangements  XNA 28Work History Gap FlagFlag indicating whether or not provider has any gaps in his or her work historyWork HistoryTime GapWorkHistoryGapFlagchar1XDo you have any work history gaps greater than 3 months? X XDo you have any work history gaps greater than 30 days?  29Active Military FlagFlag indicating whether or not provider is active in the militaryWork HistoryMilitaryActiveMilitaryFlagchar1XAre you currently on active military duty or on military reserve? XXAre you currently on Active Military Duty or Military Reserve?  XAre you currently on active or reserve military duty?  30Citizenship StatusIndicates status of citizenshipPersonal InformationVisaCitizenshipStatusvarchar50XAre you a citizen of the United States?  XU.S. Citizen  XU.S. Citizen XCitizenship  XCitizenship XAre you a US Citizen?XCitizenship  XAre you a US Citizen? 31Visa NumberVisa number reported by providerPersonal InformationVisaVisaNumbervarchar25 XResident Visa Number  XVisa Number  XVisa Number XVisa NumberXVisa Number  32Federal Employee IDID reported by providerPersonal InformationGeneralFederalEmployeeIDvarchar25 33No Malpractice Claims FlagFlag indicating if Provider has no Malpractice claims historyMalpracticeClaimsNoMalpracticeClaimsFlagchar1XNot Applicable  34Application TypeIndicates type of applicationPersonal InformationPrepareApplicationTypevarchar25 XInitial or Re-credentialing application?  XApplication Type  35ECFMG FlagTwo OptionsFlag indicating if provider has an ECFMG numberProfessional IDsECFMGECFMGFlagvarchar1 XIf you are a graduate of a foreign medical school, are you certified by the Educational Commission for Foreign Medical Graduates (ECFMG)?  XAre you ECFMG certified?  36ECFMG NumberSingle Line of TextECFMG NumberProfessional IDsECFMGECFMGNumbervarchar8XECFMG Number XECFMG Number XEducational Commission for Foreign Medical Graduates (ECFMG) Number XDate Issued XECFMG Certificate Number XECFMG Number XECFMG Number (applicable to foreign medical graduates)  XECFMG Number XUSMLE/ECFMG Number XEducational Commission for Foreign Medical Graduates (ECFMG) Number (if applicable) XECFMG Number XECFMG Number (applicable to foreign medical graduates) XECFMG # (if applicable) 37ECFMG Issue DateDate OnlyIndicates date ECFMG Number was issued (format YYYY-MM-DD HH:MM:SS)Professional IDsECFMGECFMGIssueDatedatetime8XECFMG Issue Date XXECFMG Issue Date XDate Issued XSerial Number for ECFMG XECFMG Date Passed XDate Issued XDate Issued  XDate of Certification XECFMG Certification Date XDate ECFMG Issued XECFMG Issue Date XDate Issued XECFMG Certificate Date 38Hospital FlagFlag indicating whther or not provider is hospital-basedPersonal InformationPrepareHospitalBasedFlagchar1XAre you a hospital-based provider? XXAre you a hospital-based provider? XAre you a hospital-based provider? XAre you a hospital-based provider? XAre you a hospital-based provider?  Are you a hospital-based provider? XAre you a hospital-based provider?  Are you a hospital-based provider? XAre you a hospital-based provider? XAre you a hospital-based provider? XAre you a hospital-based provider? XAre you a hospital-based provider?  Are you a hospital-based provider? XAre you a hospital-based provider? 39Email AddressEmail addressPersonal InformationContactEmailAddressvarchar100XE-Mail Address XE-Mail Address  XE-mail Address XE-mail Address XE-Mail Address  XE-Mail Address  XE-Mail Address  40Visa TypeType of VisaPersonal InformationVisaVisaTypevarchar20XIf citizenship is not USA, visa type  XVisa Type  XVisa Type XVisa Type XType of Visa 41Visa StatusStatus of VisaPersonal InformationVisaVisaStatusvarchar50XIf citizenship is not USA, visa status  Visa Status  XStatusXVisa Status  XIf no, what is status of your Visa? 42Birth CityCity in which provider was bornPersonal InformationGeneralBirthCityvarchar50XBirth City XCity of Birth XBirth City XBirth City XBirth City XBirth City XBirth City XBirth City XBirth City XBirth City XBirth City XBirth City XBirth City 43Birth StateState in which provider was bornPersonal InformationGeneralBirthStatechar2XBirth State XState of Birth XBirth State XBirth State XBirth State XBirth State XBirth State XBirth State XBirth State XBirth State XBirth State XBirth State XBirth State 44Tax IDProvider's TaxIDPersonal InformationGeneralTaxIDvarchar9XPersonal Tax ID Number  45Spouse Last NameProvider's spouse's last namePersonal InformationSpouse NameSpouseLastNamevarchar70XSpouse Last Name  Spouse Last Name (optional)  XLast Name  46Spouse First NameProvider's spouse's first namePersonal InformationSpouse NameSpouseFirstNamevarchar30XSpouse First Name  Spouse First Name (optional)  XFirst Name  47Other AddressAddress for Other CorrespondencePersonal InformationAddressOtherCorrespondenceAddressvarchar100XIf Other, please specify  48Emergency Contact Last NameLast name of emergency contact personPersonal InformationEmergency NameEmergencyContactLastNamevarchar70 XEmergency Contact Last Name  49Emergency Contact First NameFirst name of emergency contact personPersonal InformationEmergency NameEmergencyContactFirstNamevarchar30 XEmergency Contact First Name  50Emergency Contact Middle NameMiddle name of emergency contact personPersonal InformationEmergency NameEmergencyContactMiddleNamevarchar25 XEmergency Contact MI  51Emergency Contact PhonePhone Number of emergency contact personPersonal InformationContactEmergencyContactPhonevarchar10 XEmergency Contact Telephone Number  52Pager NumberProvider's pager or beeper numberPersonal InformationContactPagerBeeperNumbervarchar10 XPager Number XPager Number  XPractitioner's Beeper/Cell Number  XPager Number  53Answering Service Phone NumberProvider's answering service numberPersonal InformationContactAnsweringServicePhoneNumbervarchar10 54Cell Phone NumberProvider's cell phone numberPersonal InformationContactCellPhoneNumbervarchar10XCell Phone  XMobile / Alternate Number 55Pager Beeper Digital?Is the Provider's pager or beeper digital?Personal InformationContactPagerBeeperDigitalFlagchar1 56Visa Expiration DateVisa Expiration DatePersonal InformationVisaVisaExpirationDatedatetime8 XExpiration Date  XValid Through  XVisa Expiration Date XVisa Expiration Date XVisa Expiration Date XExpiration of Visa 57Ethnicity DescriptionIndicates the ethnic origin of providerPersonal InformationGeneralEthnicityDescriptionvarchar40 XRace/Ethnicity (voluntary)  58Visa Issue DateDate Visa was issuedPersonal InformationVisaVisaIssueDatedatetime8 XDate Issued  59ECFMG Expiration DateDate OnlyDate ECFMG expiresProfessional IDsECFMGECFMGExpirationDatedatetime8 XValid Through XValid Through  60Work Permit StatusIndicates whether the provider holds a permanent work permitPersonal InformationVisaWorkPermitStatusvarchar50 XIf no, do you hold a permanent work permit? 61Spouse Middle NameProvider's spouse's middle namePersonal InformationSpouse NameSpouseMiddleNamevarchar30 XMiddle Name  62State DateDate OnlyDate gained state recidencyTrainingTrainingStateResidenceDatedatetime8 XDate of Relocation to NV, if applicable  63Citizenship CountryName of countryPersonal InformationGeneralCitizenshipCountry_CountryNamevarchar50X XCitizenship (Country)  XCitizenship Country  XVisa Country XCitizenship XIf no, what is your citizenship? 64Marital StatusProvider's marital statusPersonal InformationGeneralMaritalStatus_MaritalStatusDescriptionvarchar15XMarital Status (optional)  XMarital Status (optional)  65Gender Indicates genderPersonal InformationGeneralGender_GenderDescriptionvarchar6XGender XXGender XGender XSex XGender XGender XGender XSex XGender XGender XGender XGender XGender XGender 66Birth CountryCountry in which provider was bornPersonal InformationGeneralBirthCountry_CountryNamevarchar50XBirth Country XXCitizenship XBirth Country XBirth Country XBirth Country XBirth Country XBirth Country XBirth Country XBirth Country XBirth Country XXBirth Country XBirth Country 67Correspondence DescriptionLocation where provider would like correspondence sent (primary office, secondary office, billing address, home)Personal InformationAddressCorrespondenceAddressType_CorrespondenceAddressTypeDescriptionvarchar50XTo what address would you like all correspondence forwarded?  XPreferred Mailing Address  68Graduate DescriptionOption SetType of EducationEducationEducationGraduateType_GraduateTypeDescriptionvarchar25XGraduate Type X XGraduate Type  69Provider TypeAbbreviation of the provider typePersonal InformationPrepareProviderType_ProviderTypeAbbreviationvarchar5XWhat type of provider are you? XXWhat type of provider are you? XWhat type of provider are you? XWhat type of provider are you? XWhat type of provider are you? XWhat type of provider are you? XWhat type of provider are you? XWhat type of provider are you? XWhat type of provider are you? XWhat type of provider are you? XWhat type of provider are you? XWhat type of provider are you? XWhat type of provider are you? X
Sharas Reddy: Sharas Reddy:Professional DesignationWhat type of provider are you? 70NID Country NameName of countryPersonal InformationGeneralNIDCountry_CountryNamevarchar50X XNID Country of Issue  71Attest DateThe last date the provider attested to his application data (format YYYY-MM-DD HH:MM:SS)Personal InformationPrepareAttestDatedatetime8XXXXXXXXXXXXXX72Plan IDUnique ID assigned to physician by planPersonal InformationPreparePlanProviderIDvarchar20XXXXXXXXXXXXXX73Last Credential DateThe last date the provider recredentialied with your health plan (format YYYY-MM-DD HH:MM:SS)Personal InformationPrepareLastRecredentialDatedatetime19XXXXXXXXXXXXXX74Next Credential DateThe next date the provider needs to be recredentialed with your health plan (format YYYY-MM-DD HH:MM:SS)Personal InformationPrepareNextRecredentialDatedatetime19XXXXXXXXXXXXXX75Provider IDWhole NumberID Number (assigned by system) in the Provider data table for each provider’s attestationPersonal InformationAddressProviderAttestIDintXXXXXXXXXXXXXX76AddressProvider IDWhole NumberID Number (assigned by system) for each provider addressPersonal InformationAddressProviderAddressIDsmallintXXXXXXX X XXXX77AddressStreet addressPersonal InformationAddressAddressvarchar100XAddress XAddress XStreet Address XStreet Address XStreet Address XAddress XHome Mailing Address  XAddress  XHome Street Address XStreet Address XAddress XAddress 78Address2Additional home street address informationPersonal InformationAddressAddress2varchar100XXXSuite, Deptartment, etc. XXXApt, Bldg, etc.  X XApt, Bldg, etc. XSuite, Deptartment, etc. XXApt, Bldg, etc. 79CityName of cityPersonal InformationAddressCityvarchar50XCity XCity XCity XCity XCity XCity XCity  XCity  XCity XCity XCity XCity 80StateName of statePersonal InformationAddressStatechar2XState XState XState XState XState XState XState  XState  XState XState XState XState 81Postal CodeZIP codePersonal InformationAddressPostalCodevarchar11XZip Code XZip Code XZip XZip XZip Code XZip Code XZIP  XZip Code  XZip XPostal Code XZip Code XZip Code 82Years at this AddressNumber of years at this addressPersonal InformationAddressYearsAtThisAddresssmallint 83ProvinceName of provincePersonal InformationAddressProvincevarchar50 XProvince  XProvince  XProvince  84Phone NumberPhone numberPersonal InformationContactPhoneNumbervarchar18XPhone Number XPhone Number XHome Telephone Number XDaytime Phone XPhone Number XHome Phone Number XHome Telephone Number  XPhone Number  XHome Telephone Number XPhone Number XHome Telephone Number XHome Telephone 85Fax NumberFax numberPersonal InformationContactFaxNumbervarchar10 XFax Number XFax Number  XHome Fax Number  XFax Number  XHome Fax 86Email AddressEmail addressPersonal InformationContactEmailAddressvarchar100 XE-Mail Address  XE-Mail Address  XEmail Address  87CountyName of county.Personal InformationAddressCountyvarchar50 88Phone Unlisted?Indicates whether the phone number is unlisted.Personal InformationContactUnlistedFlagchar1 XIs this # unlisted? 89Address TypeIndicates Current Home, Previous Home, Primary Practice MailingPersonal InformationAddressAddressType_AddressTypeDescriptionvarchar25XXXTo what address would you like all correspondence forwarded? XXXX X XXXX90Country NameName of countryPersonal InformationAddressCountry_CountryNamevarchar50 XCountry  XCountry  XCountry  91Provider IDWhole NumberID Number (assigned by system) in the Provider data table for each provider’s attestationPractice InformationAddressProviderAttestIDint4XXXXXXXXXXXXX92Practice AddressProvider IDWhole NumberID Number (assigned by system) for each provider addressPractice InformationAddressProviderPracticeAddressIDsmallint2 XX X X 93Provider IDSingle Line of TextID Number (assigned by system) for the provider’s practice locationPractice InformationAddressProviderPracticeIDvarchar100 XX X X 94AddressStreet addressPractice InformationAddressAddressvarchar100X XX XStreet Address X X 95Address 2Additional home street address informationPractice InformationAddressAddress2varchar100 XX X X 96CityName of cityPractice InformationAddressCityvarchar50X XX XCity X X 97CountyName of countyPractice InformationAddressCountyvarchar50 XX 98StateName of statePractice InformationAddressStatechar2X XX XState X X 99Postal CodeZIP codePractice InformationAddressPostalCodevarchar11X XX XZip Code X X 100ProvinceName of provincePractice InformationAddressProvincevarchar50 XProvince  101Phone NumberPhone numberPractice InformationAddressPhoneNumbervarchar10 X XPhone Number  102Fax NumberFax numberPractice InformationAddressFaxNumbervarchar10 X XFax Number  103Emergency NumberPhone Number of emergency contactPractice InformationAddressEmergencyPhoneNumbervarchar10 XEmergency or Pager Number  104Answering NumberPhone Numver for after hours contactPractice InformationAddressAnsweringServicePhoneNumbervarchar10 XAnswering Service Number  105Email AddressEmail addressPractice InformationAddressEmailAddressvarchar100 XE-Mail Address  106Check ToIf associate type is billing, name check payable toPractice InformationAddressCheckPayableTovarchar100 XMake Checks Payable To  107Company NameCompany Name associated with this addressPractice InformationPracticeCompanyNamevarchar100 X 108AttentionName of person that a mailing would be delivered to.Practice InformationAddressAttentionvarchar50 X 109Address TypeIndicates the type of address - Answering Service, Billing, Claims Payment, or CorrespondencePractice InformationAddressAddressType_AddressTypeDescriptionvarchar25X XX X X 110Country NameName of countryPractice InformationAddressCountry_CountryNamevarchar50 111Provider IDWhole NumberID Number (assigned by system) in the Provider data table for each provider’s attestationPersonal InformationOther NameProviderAttestIDint4XXXXXXXXXXXXXX112Other NameProvider IDWhole NumberID Number (assigned by system) for each other namePersonal InformationOther NameProviderOtherNameIDsmallint2X XIs there any other name under which you have been known or have used (e.g. maiden name)? XXXXXXXXXXX113Last NameLast name of providerPersonal InformationOther NameLastNamevarchar70XLast Name XXLast Name XLast Name XLast Name XLast Name XLast Name XLast Name XMaiden Name XLast Name XLast Name XLast Name XMaiden Last Name XLast Name XLast Name 114First NameFirst name of providerPersonal InformationOther NameFirstNamevarchar30XFirst Name XXFirst Name XFirst XFirst Name XFirst Name XFirst Name XFirst  XFirst Name XFirst Name XFirst Name XMaiden First Name XFirst Name XFirst Name 115Middle NameMiddle name of providerPersonal InformationOther NameMiddleNamevarchar25XMiddle Name XMiddle Name XMiddle XMiddle Name XMiddle Name XMiddle Name XMiddle  XMiddle Name XMiddle Name XMiddle Name XMaiden Middle Name XMiddle Name XMiddle Name 116SuffixGenerational suffix of providerPersonal InformationOther NameSuffixvarchar10XSuffix XSuffix X(include suffix; Jr., Sr., III)  XSuffix  XSuffix XSuffix  XMaiden Suffix  117Start DateDate provider began using other name (format YYYY-MM-DD HH:MM:SS)Personal InformationOther NameStartDatedatetime8XStart Date XStart Date XStart Date  XEffective Date XFrom XFrom XMaiden Name Start Date  XFrom 118End DateDate provider ended using other name. (format YYYY-MM-DD HH:MM:SS)Personal InformationOther NameEndDatedatetime8XEnd Date XEnd Date XEnd Date  XTo XTo XMaiden Name End Date  XTo 119Other Name ExplanationAn explanation of how the other name is used (i.e., maiden).Personal InformationOther NameOtherNameExplanationvarchar500 XPlease explain why your name changed  X X120Provider IDWhole NumberID Number (assigned by system) in the Provider data table for each provider’s attestationPersonal InformationLanguageProviderAttestIDint4XXXXXXXXXXXXXX121LanguageProvider IDWhole NumberID Number (assigned by system)Personal InformationLanguageProviderLanguageIDsmallint2XXXXX XX122Language TypeSpecifies whether the language Written or SpokenPersonal InformationLanguageLanguageTypevarchar20 X 123LanguageLanguage SpokenPersonal InformationLanguageLanguage_LanguageNamevarchar50XXNon-English languages spoken by provider XLanguage Fluency of Applicant XNon-English languages spoken by provider XIf yes, specify languages  XLanguages Spoken by practitioner XLanguage(s) Spoken (other than English) 124Provider IDWhole NumberID Number (assigned by system) in the Provider data table for each provider’s attestationProfessional IDsLicenseProviderAttestIDint4XXXXXXXXXXXXXX125LicenseProvider IDWhole NumberID Number (assigned by system)Professional IDsLicenseProviderLicenseIDsmallint2X XXXXXXXXXXXX126License NumberSingle Line of TextMedical license number of providerProfessional IDsLicenseLicenseNumbervarchar15XState License Number XXState License Number XGeorgia License Number XIllinois Professional License Number XNumber XLicense Number XXLicense Number XNevada Medical/Dental/AHP License Number XOklahoma License Number XOregon License or Registration Number XXWashington State License/Registration/Cert Number XLicense # 127StateLookupName of stateProfessional IDsLicenseStatechar2XLicense State XXLicense State XState XState of Registration XState XState XXState XLicense State XState  XXState XState 128Current?Two OptionsFlag indicating the provider is currently practicing in the State of the License numberProfessional IDsLicenseCurrentlyPracticingFlagchar1XDo you currently practice in this state? X X 129Expiration DateDate & TimeExpiration date of certification specified by CertificationID (format YYYY-MM-DD HH:MM:SS)Professional IDsLicenseExpirationDatedatetime19XExpiration Date XXExpiration Date XExpiration Date XExp. Date XExpiration Date XExpiration Date XXExpiration Date XExpiration Date XExpiration Date XExpiration Date XXExpiration Date XExpiration Date 130License TypeOption SetSpecifies the type of license such as medical, dental, etc.Professional IDsLicenseLicenseTypevarchar25XLicense Type  XType (full, limited, temporary)  XType XType X 131Issue DateDate & TimeIssue date of license (format YYYY-MM-DD HH:MM:SS)Professional IDsLicenseIssueDatedatetime19XIssue Date XYear Obtained  XDate Issued XXDate of License XIssue Date XExpiration Date  XXIssue Date XIssue Date 132License Restricted?Two OptionsSpecifiies whether the license has limitationsProfessional IDsLicenseLicenseUnlimitedFlagchar1 XLicense Unlimited?  XIs/was license restricted? 133Restriction DetailsMultiple Lines of TextAn explanation of any license limitationProfessional IDsLicenseLicenseLimitationExplanationvarchar500 XIf No, please explain limitation  XReason License is/was Inactive or Restricted? 134Sponsor NameSingle Line of TextName of sponsor if required by licensure (i.e., Physician's Assistant)Professional IDsLicenseSponsorNamevarchar100 XName of Sponsor if required by licensure (i.e. Physician's Assistant)  135Relinquish DateDate & TimeDate license was relinquishedProfessional IDsLicenseRelinquishDatedatetime19XYear Relinquished  XYear Relinquished  136Relinquish ExplanationSingle Line of TextExplanation of the relinquished licenseProfessional IDsLicenseRelinquishExplanationvarchar100 XReason  137License StatusSingle Line of TextIndicates the status of the license, such as active, inactive, etc.Professional IDsLicenseLicenseStatus_LicenseStatusDescriptionvarchar30XLicense Status XType  XXLicense Status XXStatus  XStatus 138Provider IDWhole NumberID Number (assigned by system) in the Provider data table for each provider’s attestationProfessional IDsCDSProviderAttestIDint4XXXXXXXXXXXXXX139CDSProvider CDSIDWhole NumberID Number (assigned by system) for each CDS numberProfessional IDsCDSProviderCDSIDsmallint2XXXXXXXXXXXRegistration Certificate Number  X140CDS NumberSingle Line of TextCDS NumberProfessional IDsCDSCDSNumbervarchar15XRegistration Certificate Number XXControlled Substance Registration Number XCS License # XMassachusetts Controlled Substance Registration Certificate - Registration Number XNumber XXRegistration Certificate Number XState License Number XNumber XControlled Substance Registration (CSR) Number (if applicable) XDPS Number  XCertificate # 141StateLookupName of stateProfessional IDsCDSStatechar2XState of Registration X XXXIssued By  XState of Registration XLicense State XState  XState of Registration  142Expiration DateDate & TimeExpiration date of certification specified by CertificationID (format YYYY-MM-DD HH:MM:SS)Professional IDsCDSExpirationDatedatetime19XExpiration Date X XExpiration Date  XExpiration Date XXExpiration Date XExpiration Date XExpiration Date  XExpiration Date  XExpiration Date 143Issue DateDate & TimeIssue date of license (format YYYY-MM-DD HH:MM:SS)Professional IDsCDSIssueDatedatetime19XIssue Date XDate Issued (if applicable)  XIssue Date  XOriginal Date of Issue XDate Issued XIssue Date  144Currently FlagTwo OptionsIs the provider practicing in the CDS state of issue.Professional IDsCDSCurrentlyPracticingFlagchar1 XAre you currently practicing in this state?  145CDSLimitation ExplanationMultiple Lines of TextSpecifies any CDS limitationsProfessional IDsCDSCDSLimitationExplanationvarchar500 XPlease identify all limitations related to the above Controlled Substances Number(s) and explain limitation.  XIf