Qualified Independent Contractor (QIC) Jurisdictions (as of March 2005

38 - Qualified Independent Contractor (QIC) Jurisdictions (as of March 2005 (Rev. 118, Issued: 08-12-05; Effective/Implementation: 09-12-05) Task Order Contractor Covered States Part A EAST QIC Maximus, Inc. Colorado, New Mexico, Texas, Oklahoma, Arkansas, Louisiana, Mississippi, Alabama, Georgia, Florida, Tennessee, South Carolina, North Carolina, Virginia, West Virginia, Puerto Rico, Virgin Islands, Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, Connecticut, New Jersey, New York, Delaware, Maryland, Pennsylvania, Washington DC Part A WEST QIC First Coast Service Options, Inc. (FCSO) Washington, Idaho, Montana, North Dakota, South Dakota, Iowa, Missouri, Kansas, Nebraska, Wyoming, Utah, Arizona, Nevada, California, Alaska, Hawaii, Oregon, Kentucky, Ohio, Indiana, Illinois, Minnesota, Michigan, Wisconsin, Guam, Northern Mariana Islands, American Samoa Administrative QIC (AD QIC) Q2A N/A-Administrative QIC does not process reconsiderations. Exhibit 39 - Carrier Record Requirements (Rev. 141, Issued: 02-24-06; Effective/Implementation: N/A) Carrier Record Requirements Field M.D.s/D.O.s Other Doctor's Number Item Record Record 1. Record Code Required Required 2. Record Status Required Required 3. Last Name Required Required 4 First Name Required Required 5. Middle Name/Initial Required Required 6. Name Suffix Required Required 7. Street (Billing Address) Required Required 8. City (Billing Address) Required Required 9. State (Billing Address) Required Required 10. ZIP Code (Billing Address/ show 9 digits) Required Required 11. Street (Business Address) Required Required 12. City (Business Address) Required Required 13. State (Business Address) Required Required 14. ZIP Code (Business Address/ show 9 digits) Required Required 15. State Licensed In Required Required 16. Physician/Health Care Practitioner State License number Required Required 17. Date of Birth Required Required 18. Medical School Graduated Required Required 19. Medical School Year Graduated Required Required 20. Date of Death If Available If Available 21. Credentials Required Required 22. Primary Specialty Code Required Required 23. Primary Board Certification Indicator If Available If Available 24. Secondary Specialty Code If Available If Available 25. Secondary Board Certification Indicator If Available If Available 26. Type of Sanction Code If Available If Available 27. Effective Date of Sanction If Available If Available 28. Number of Sanctioned Years If Available If Available 29. Deactivate Resident/Intern Practice/Opt Out code Required Required 30. Group Practice Indicator Required Required 31. Physician/Health Care Practitioner Participation Required Required Indicator 32. Tax Identification Number Required Required 33. Carrier Provider Number Required Required 34 Registry's Assigned UPIN N/A N/A 35. NHIC Number N/A N/A 36. Incoming Carrier Number Required Required 37. Registry Assigned Error Codes/ Notification Codes Required Required 38. Record Validation Field N/A N/A 39. Special Processing Indicator N/A N/A 40. Special Processing Data N/A N/A 41. Individual Social Security Number Required * N/A Required 42. Filler N/A = Not Applicable on initial data submission * Health Care Practitioners Only Exhibit 40 - UPIN Carrier Record Layout (Rev. 141, Issued: 02-24-06; Effective/Implementation: N/A) UPIN CARRIER RECORD LAYOUT Fld. No. Position No. of Cols. Item Description Comments 1. 001 1 Record Code 9 1 = Add 2 = Add Develop/Return 3 = Assigned UPIN 4 = Registry Usage 5 = MPIER Update 6 = Update Develop/Return 7 = Notifications 2. 002 1 Record Status 9 1 = Medical Doctor 2 = Other Doctor 3 = Non Physician/ Practitioner 4 = Group Practice 3. 003-022 20 Last Name X(20) Physician/Health Care Practitioner's Professional Last Name. Valid Characters A-Z and Blanks. Left justify Use Fields 3, 4, 5, and 6 for group name 4. 023-036 14 First Name X(14) Physician/Practitioner's Professional First Name. Valid Characters A-Z and Blank. Left justify 5. 037-042 6 Middle Name/Initial X(06) Physician/Health Care Practitioner's Professional Middle Name or Initial. Valid Characters A-Z and Blank Left justify 6. 043-045 3 X(03) Name Suffix. Practitioner’s Name Suffix Example: JR, SR, III.. Valid Characters A-Z and Blank. Physician/Health Care Left justify 7. 046-070 25 Street X(25) Billing Street Address Left justify NOTE: For "9" numeric fields, show zeroes if blank. For all "X" alpha numeric fields, if no info leave field blank Fld. No. Position No. of Cols. Item Description Comments 8. 071-085 15 City X(15) City of Billing Address Left justify 9. 086-087 2 State X(02) State of Billing Address Standard U.S. post office State abbreviations. 10. 088-096 9 ZIP Code 9(09) ZIP Code of Billing Address Must report 9 position zip code 11. 097-121 25 Street X(25) Business Street Address The practice or physical site address. Left justify 12. 122-136 15 City X(15) City of Business Address Left justify 13. 137-138 2 State X(02) State of Business Address Standard U.S. post office State abbreviations. 14. 139-147 9 ZIP Code 9(09) ZIP Code of Business Address Must report 9 position zip code. 15. 148-149 2 State Licensed or operating in X (02) State in which the physician/Health Care Practitioner is Licensed or This Practice Setting. Standard U.S. post office State abbreviations. 16. 150-161 12 Physician/ Health Care Practitioner State License/ Registration Number X (12) The State License Number or Registration Number for this Practice Setting. Right justify and precede with zeroes. 17. 162-169 8 Date of Birth 9(08) (MMDDYYYY) ** 18. 169-173 5 Medical School Graduated Code X(05) Medical School Code Refer to Exhibit 3. 19. 174-177 4 Medical School Year Graduated 9(04) (YYYY) Year of Graduation Fld. No. Position No. of Cols. Item Description Comments 20. 178-185 8 Date of Death 9(08) (MMDDYYYY) ** 21. 186-188 3 Credentials X (03) MD= Medical Doctor DO=Doctor of Osteopathy CH=Chiropractor DDM=Doctor of Dental Medicine DDS=Doctor of Dental Surgery DPM=Podiatrist OD= Doctor of Optometry CSW=Clinical Social Worker PT=Physical Therapist CP=Clinical Psychologist CNA=Certified Nurse Anesthetist AA= Anesthesia Assistant NP= Nurse Practitioner OT= Occupational Therapist GRP= Group Practice (USE ONLY WITH RECORD STATUS 5) RNA=Certified Registered Nurse Anesthetist PSY=Psychologist PA= Physician Assistant RN= Registered Nurse LPN= Licensed Practical Nurse CNM= Certified Nurse Midwife MSC=Mammography Screening Center AMB=Ambulance Service Supplier IDF=Independent Diagnostic Screening facility CNS = Clinical Nurse Specialist AU= Audiologist PXS= Portable X-Ray Supplier IPL=Independent Physiological Laboratory 22. 189-190 2 Primary Specialty 9(02) Specialty Code Code Specified in Part 4 of MCM §2207 23. 191 1 Primary Board Certification Indicator X(01) Y or N or U for Unknown Fld. No. Position No. of Cols. Item Description Comments 24. 192-193 2 Secondary Specialty Code 9(02) Secondary Specialty Code For This Practice Setting. 25. 194 1 Secondary Board Certification Indicator X(01) Y=Yes N = No U = Unknown 26. 195 1 Type of Sanction Code X(01) Refer to Exhibit 4 27. 196-199 4 Effective Date of Sanction 9(06) (MMYY) Windowing 28. 200-201 2 Number of Sanctioned Yrs 9(02) Length of Sanction 01-99 29. 202 1 Deactivate Resident/Inte rn Practice Code X(01) D=Deactivate R =Resident I =Intern P =Practice O =OPT Out 30. 203 1 Group Practice Indicator 9(01) 1=Group 4 =Solo 31. 204 1 Physician/ Health Care Practitioner/ Group Practice Participation Indicator X(01) Y=Yes The participation N=No decision is the latest recorded. 32. 205-218 14 Tax Identification Employer Identification no. X(14) Any number Number you assigned which permits Identifying cross- referencing Records For One Individual 33. 219-232 14 Carrier Provider Number X(14) (Use UPIN for Record Status 5 only) The number you have provided the Physician/Practitioner for billing Medicare Fld. No. Position No. of Cols. Item Description Comments 34. 233-238 6 Registry's Number the Assigned UPIN Registry X(06) Leave blank This space reserved for UPIN assignment 35. 239-248 10 NHIC Number 9(10) Exception Turnaround Numbering Assigned by Registry and correction process 36. 249-253 5 Incoming Carrier Number 9(05) CMS Contractor Number; Multi-state Contractor Use The Distinct Number of Each Jurisdiction. 37. 254-268 15 Registry Assigned Error Codes Or Notification Codes X(15) Leave blank Used for Registry error resolution/auto notification 38. 269 1 Record Validation Field X(1) Y=Yes N=No Indicate that you have validated the record with State Licensure Board 39. 270 1 Special Processing X(1) Used to indicate special processing record is being submitted. Acceptable Values: Y = Indicates additional settings being added. 1 = Indicates change to Providers Name. Record Code "1" with UPIN Record Code “5” OLD LAST NAME in Field 40. 271-290 20 Special Processing Data X(20) Used to cross check the change to a Provider’s name or Provider Number. Name Change Include the Providers LAST name only as it appears on the MPIER prior to the change. Record Code "5" Providers NEW name in Fields 3, 4, 5, 6. UPIN Field 34. Provider Number Change Include the Carrier assigned Number as it appears on the MPIER prior to the change. Record Code "5" includes the NEW provider Number in Field 33 UPIN in Field 34. Individual Social Security Number Physician/Health Care Practitioner Personal SSN Record returned To you will contain the 10 Digit UPIN 41. 292-301 10 10 X(10) Physician/Health Care Practitioner/Group Record will contain 10-digit UPIN 42 302-306 5 5 Digit X(5) Filler Return record NOTE: For "9" numeric fields, show zeroes if blank. For all "X" alpha numeric fields, if no information leave field blank.