Friday, 10 March 2017

Provider-Specific File

(Rev. 3431, Issued: 12-29-15, Effective: 10-01-15, Implementation: 10-05-15)

The PROV file contains needed information about each provider to enable the pricing software to calculate the payment amount. Updates are published annually or quarterly, as needed, to notify A/B MACs of any changes to payment systems requiring updates to the PSF. 

The A/B MACs maintain the accuracy of the data in accordance with the following criteria. 

Whenever the status of any element changes, the A/B MAC prepares an additional record showing the effective date. For example, when a hospital's FY beginning date changes as a result of a change in ownership or other "good cause," the A/B MAC makes an additional record showing the effective date of the change. 

The format and data required by the PRICER program and by the provider-specific file is found in Addendum A.

The A/B MACs submit a file of provider-specific payment data to CMS CO every three months for PPS and non-PPS hospitals, inpatient rehabilitation hospitals or units (referred to as IRFs), long term care hospitals (LTCHs), inpatient psychiatric facilities (IPFs), SNFs, and hospices, including those in Maryland. Regional home health A/B MACs (HH) submit a file of provider specific data for all home health agencies. A/B MACs serving as the audit A/B MAC for hospital based HHAs do not submit a file of provider specific data for HHAs. 

The A/B MACs create a new record any time a change occurs for a provider. Data must be reported for the following periods: October 2 - January 1, January 2 - April 1, April 2 - July 1, and July 2 - October 1. This file must be received in CO within seven business days after the end of the period being reported. 

NOTE: A/B MACs submit the latest available provider-specific data for the entire reporting period to CO by the seven-business day deadline. If CO fails to issue applicable instructions concerning changes or additions to the file fields by 10 calendar days before the end of the reporting period, the A/B MAC may delay reporting of data related to the CO instructions until the next file due date. For example, if CO instructions changing a file field are issued on or after September 21 with an effective date of October 1, the A/B MAC may exclude the October 1 CO-required changes from the file submitted by October 9. The A/B MAC includes the October 1 CO-required changes, and all subsequent changes through January 1 in the file submitted in January.

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