Outpatient Provider Specific File

50.1 - Outpatient Provider Specific File (Rev. 12979; Issued: 11-22-24; Effective: 01-01-25; Implementation: 01-06-25) The Outpatient Provider Specific File (OPSF) contains the required information about each provider to enable the pricing software to calculate the payment amount. Data elements and formats are shown below. Contractors must maintain the accuracy of the data, and update the file as changes occur in data element values, e.g., changes in metropolitan statistical area (MSA), bed size, cost to charge ratio. An update is accomplished by preparing and adding an additional complete record showing new current values and the effective date of the change. The old record is retained without change. Contractors must also furnish CMS a quarterly file in the same format. NOTE: All data elements, whether required or optional, must have a default value of “0” (zero) if numerical, or blank if alphanumerical. File Position Format Title Description 1-10 X(10) National Provider Identifier (NPI) Alpha-numeric 10 character provider number. 11-16 X(6) Provider Oscar Number Alpha-numeric 6 character provider number. 17-24 9(8) Effective Date Must be numeric, CCYYMMDD. This is the effective date of the provider's first OPPS period. For subsequent OPPS periods, the effective date is the date of a change to the PROV file. If a termination date is present for this record, the effective date must be equal to or less than the termination date. 25-32 9(8) Fiscal Year Beginning Date Must be numeric, CCYYMMDD. Month: 01-12 Day: 01-31 The date must be greater than 19990630. 33-40 9(8) Report Date Must be numeric, CCYYMMDD. Month: 01-12 Day: 01-31 The created/run date of the PROV report for submittal to CO. 41-48 9(8) Termination Date Must be numeric, CCYYMMDD. Must be zeroes or contain a termination date. (Once the official “tie- out” notice from CMS is received). Must be equal to or greater than the effective date. (Termination date is the date on which the reporting contractor ceased servicing the provider in question). 49 X(1) Waiver Indicator Enter a “Y” or “N.” Y = waived (provider is not under OPPS) For End Stage Renal Disease (ESRD) facilities provider waived blended payment, pay full PPS. N = not waived (provider is under OPPS) For ESRD facilities provider did not waive blended payment. Pay according to transitional payment method for ESRD PPS through 2013. 50-54 9(5) Intermediary Number Enter the Contractor #. 55-56 X(2) Provider Type This identifies providers that require special handling. Enter one of the following codes as appropriate. 00 or blanks = Short Term Facility 02 Long Term 03 Psychiatric 04 Rehabilitation Facility 05 Pediatric 06 Reserved 07 Rural Referral Center 08 Indian Health Service 13 Cancer Facility 14 Medicare Dependent Hospital (during cost reporting periods that began on or after April 1, 1990. 15 Medicare Dependent Hospital/Referral Center (during cost reporting periods that began on or after April 1, 1990. Invalid October 1, 1994 through September 30, 1997). 16 Re-based Sole Community Hospital 17 Re-based Sole Community Hospital /Referral Center 18 Medical Assistance Facility 21 Essential Access Community Hospital 22 Essential Access Community Hospital/Referral Center 23 Rural Primary Care Hospital 24 Rural Emergency Hospitals 32 Nursing Home Case Mix Quality Demonstration Project – Phase II 33 Nursing Home Case Mix Quality Demonstration Project – Phase III – Step 1 34 Free-standing Opioid Treatment Program 35 Hospice 36 Home Health Agency 37 Critical Access Hospital 38 Skilled Nursing Facility (SNF) – For non-demo PPS SNFs – effective for cost reporting periods beginning on or after July 1, 1998 40 Hospital Based ESRD Facility 41 Independent ESRD Facility 42 Federally Qualified Health Centers 43 Religious Non-Medical Health Care Institutions 44 Rural Health Clinics-Free Standing 45 Rural Health Clinics-Provider Based 46 Comprehensive Outpatient Rehab Facilities 47 Community Mental Health Centers 48 Outpatient Physical Therapy Services 49 Psychiatric Distinct Part 50 Rehabilitation Distinct Part 51 Short-Term Hospital – Swing Bed 52 Long-Term Care Hospital – Swing Bed 53 Rehabilitation Facility – Swing Bed 54 Critical Access Hospital – Swing Bed 57 X(1) Special Locality Indicator Indicates the type of special locality provision that applies. For End Stage Renal Disease (ESRD) facilities: Dates of service prior to Jan 1, 2025: value “Y” equals low volume adjustment applicable. Dates of service on or after Jan 1, 2025: Value blank = No low volume adjustment applicable Value 1 or 2 = tier number applicable for low volume adjustment 58 X(1) Change Code For Wage Index Reclassification Enter “Y” if the hospital’s wage index location has been reclassified for the year. Enter “N” if it has not been reclassified for the year. Adjust annually. Does not apply to ESRD Facilities. 59-62 X(4) Actual Geographic Location—MSA Enter the appropriate code for MSA, 0040–9965, or the rural area, (blank) (blank) 2-digit numeric State code, such as _ _ 3 6 for Ohio, where the facility is physically located. 63-66 X(4) Wage Index Location—MSA The appropriate code for the MSA, 0040-9965, or the rural area, (blank)(blank) (2 digit numeric State code) such as _ _ 3 6 for Ohio, to which a hospital has been reclassified for wage index. Leave blank or enter the actual location MSA if not reclassified. Does not apply to ESRD Facilities. 67-70 9V9(3) Payment-to-Cost Ratio Enter the provider’s payment-to-cost ratio. Does not apply to ESRD Facilities. 71-72 9(2) State Code Enter the 2-digit state where the provider is located. Enter only the first (lowest) code for a given state. For example, effective October 1, 2005, Florida has the following State Codes: 10, 68 and 69. Contractors shall enter a “10” for Florida’s State Code. List of valid State Codes is located in Pub. 10007, Chapter 2, Section 2779A1. 73 X(1) TOPs Indicator Enter the code to indicate whether TOPs applies or not. Y = qualifies for TOPs N = does not qualify for TOPs 74 X(1) Quality Indicator Field Hospital: Enter the code to indicate whether the hospital meets data submission criteria per HOP QDRP requirements. 1 = Hospital quality reporting standards have been met or hospital is not required to submit quality data (e.g., hospitals that are specifically excluded from the IPPS or which are not paid under the OPPS, including psychiatric, rehabilitation, long-term care and children’s and cancer hospitals, Maryland hospitals, Indian Health Service hospitals, or hospital units; or hospitals that are located in Puerto Rico or the U.S. territories). The reduction does not apply to hospices, CORFs, HHAs, CMHCs, critical access hospitals or to any other provider type that is not a hospital. Blank = Hospital does not meet criteria. Independent and Hospital-based End Stage Renal Disease (ESRD)Facilities: Enter the code applicable to the ESRD Quality Incentive Program (QIP): Blank = no reduction 1 = ½ percent payment reduction 2 = 1 percent payment reduction 3 = 1 ½ percent payment reduction 4 = 2 percent payment reduction * Please refer to file position 101 for ESRD Children’s Hospitals Quality Indicator. 75 X(1) Filler Blank. 76-79 9V9(3) Outpatient Cost- to-Charge Ratio Derived from the latest available cost report data. See §10.11 of this chapter for instructions on how to calculate and report the Cost-to-Charge Ratio. Does not apply to ESRD Facilities. 80-84 X(5) Actual Geographic Location CBSA 00001-89999, or the rural area, (blank) (blank) (blank) 2 digit numeric State code such as _ _ _ 3 6 for Ohio, where the facility is physically located. 85-89 X(5) Wage Index Location CBSA Enter the appropriate code for the CBSA, 0000189999, or the rural area, (blank)(blank)(blank) (2 digit numeric State code) such as _ _ _ 3 6 for Ohio, to which a hospital has been reclassified due to its prevailing wage rates. Leave blank or enter the Actual Geographic Location CBSA, if not reclassified. Pricer will automatically default to the actual location CBSA if this field is left blank. Does not apply to ESRD Facilities. 90-95 9(2) V9(4) Special Wage Index Enter the special wage index that certain providers may be assigned. Enter zeroes unless the Special Payment Indicator equals a “1” or “2.” 96 X(1) Special Payment Indicator The following codes indicate the type of special payment provision that applies. Blank = not applicable Y = reclassified 1 = special wage index indicator 2 = both special wage index indicator and reclassified D = Dual Reclassified 97-100 9(4) Reduced Coinsurance Trailer Count Enter the number of APCs the provider has elected to reduce coinsurance for. The number cannot be greater than 999. 101 X(1) Quality Indicator ESRD Children’s Hospitals Children’s Hospitals for End Stage Renal Disease (ESRD) Facilities: Enter the code applicable to the ESRD Quality Incentive Program (QIP): Blank = no reduction 1 = ½ percent payment reduction 2 = 1 percent payment reduction 3 = 1 ½ percent payment reduction 4 = 2 percent payment reduction 102-105 9V9(3) Device department’s Cost-to-Charge Ratio Derived from the latest available cost report data. Does not apply to ESRD Facilities. 106-112 X(7) Carrier/Locality code The carrier/locality code for the provider service facility. The first five positions represent the carrier code and the last two positions represent the locality code. 113-117 9(5) County Code Enter the County Code. Must be 5 numbers. 118-122 X(5) Payment CBSA Enter the appropriate code for the CBSA, 0000189999, or the rural area, (blank)(blank)(blank) (2 digit numeric State code) such as _ _ _ 3 6 for Ohio, to which a hospital has been reclassified due to its prevailing wage rates. Leave blank or enter the Actual Geographic Location CBSA, if not reclassified. Pricer will automatically default to the actual location CBSA if this field is left blank. Does not apply to ESRD Facilities. 123-128 9V9(5) Payment Model Adjustment (PMA) Derived from payment model Technical Direction Letter. 129-133 9V9999 Medicare Performance Adjustment (MPA) Enter the MPA percentage calculated and published by the Centers for Medicare & Medicaid Services (CMS). 134-139 9(2) V9(4) Supplemental Wage Index Enter the supplemental wage index that certain providers may be assigned. Enter zeroes if it does not apply. 140-140 X(1) Supplemental Wage Index Flag Enter the supplemental wage index flag: 1=Prior Year Wage Index 2=Future use 3=Future use Enter blank if it does not apply. 141-162 X(22) FILLER The contractor enters the number of APCs for which the provider has elected to reduce coinsurance. Cannot be greater than 999. Reduced Coinsurance Trailer Record - Occurs 0- 999 times depending on the reduced Coinsurance Trailer Count in positions 97-100. Due to system’s capacity limitations the maximum number of reduced coinsurance trailers allowable is 999 at this time.