DATA DICTIONARY NEW YORK STATE DEPARTMENT OF HEALTH Office of Health Insurance Programs

Transcription

1 DATA DICTIONARY NEW YORK STATE DEPARTMENT OF HEALTH Office of Health Insurance Programs Provider Network Data System (PNDS) Version 7.0 (September 2015) V7.0, page 1

2 DATA DICTIONARY CONTENTS Provider Network Data System (PNDS) Table of Contents I. GENERAL INFORMATION... 3 A. About the Provider Network Data System... 4 B. Purpose... 4 C. Uses of PNDS Data... 4 D. Connection to the Health Commerce System (HCS) and Provider Network Data System (PNDS)... 5 E. Data Submission Schedule... 5 II. PHYSICIAN AND OTHER PROVIDERS DETAILED RECORD FORMAT... 6 III. ANCILLARY/SERVICE CENTERS DETAILED RECORD FORMAT IV. PHYSICIAN AND OTHER PROVIDERS ELEMENT DESCRIPTIONS V. ANCILLARY/SERVICE CENTERS ELEMENT DESCRIPTIONS VI. CODES BOROUGH/COUNTY CODES (FIPS) LANGUAGE CODES PROVIDER AND ANCILLARY/SERVICE SPECIALTY CODES NUMERICAL ORDER PROVIDER AND ANCILLARY/SERVICE SPECIALTY CODES ALPHABETICAL ORDER VII. ATTESTATION VIII. PROVIDER & ANCILLARY FILE ERROR CODES PHYSICIAN AND OTHER PROVIDER ERROR LISTING ANCILLARY/SERVICE CENTER ERROR LISTING IX. CODING SCHEME SUMMARY REPORTS Table 1 - Core Listing of Required Providers by Program Type Table 2 - Core Listing of Required Services by Program Type V7.0, page 2

3 Provider Network Data System I. GENERAL INFORMATION V7.0, page 3

4 A. About the Provider Network Data System The Provider Network Data System (PNDS) was implemented by the New York State Department of Health in December of 1996 to gather information about the provider and service networks contracted to Health Insurers operating in New York State. PNDS is accessed through an Internet connection to the Health Commerce System (HCS), also known as the Health Provider Network (HPN), a secure Intranet site requiring an ID and password. Health Insurers electronically submit provider network data quarterly for the following lines of business: Medicaid; Child Health Plus; FIDA; HIV Special Needs Plans (SNP); Managed Long Term Care Plans; Health and Recovery Plan(s) (HARP); New York State of Health (NYSOH) Qualified Health Plan(s) (QHP s) and Basic Health Plan(s) (BHP s), and annually for Commercial managed care networks outside of the NYSOH. B. Purpose The primary purpose for the PNDS is to collect data needed to evaluate the provider networks including physicians, hospitals, labs, home health agencies, durable medical equipment providers, etc., for all types of Health Insurers in New York State. C. Uses of PNDS Data 1. Provider eligibility assessment PNDS data is matched against information on professional licensing, Office of Professional Medical Care sanctions, and Medicaid and Medicare provider eligibility, to assure that only qualified providers are delivering health care to plan members. Facilities are checked for valid operating certificate numbers and that operating certificate numbers match the type of facility indicated. 2. Comprehensive services assessment The Department of Health conducts network assessments to assure that comprehensive health services are available as required under Section 4403 of the Public Health Law. The Office of Health Insurance Programs, Bureau of Managed Care Certification and Surveillance, and the NYSOH uses data from the PNDS to assess whether Insurers have contracted with an appropriate range of primary care practitioners, clinical specialists and service facilities (hospitals, labs, etc.) within the Insurer s service area. Evaluations are completed on insurers serving the above listed lines of business. 3. Access and travel assessment Managed care plans serving Medicaid recipients are evaluated against established access and travel standards using PNDS data. 4. Finding a plan provider Customized directories of providers by county are created from PNDS data. 5. Capacity analysis PNDS data is used to calculate the potential capacity of a managed care plan s primary care providers. The calculation estimates the number of full time equivalent primary V7.0, page 4

5 care providers and assumes that each FTE can serve up to 1,500 Medicaid members. 6. Investigation of Fraud Data from PNDS is matched with Medicaid Encounter Data System data to identify Medicaid providers who have been identified as unable to participate in Medicaid managed care but had an encounter with a patient during the quarter. The file of identified providers is sent to the Bureau of Certification and Surveillance for action. 7. County network review PNDS data is provided to county Departments of Social Services for use in local network reviews. D. Connection to the Health Commerce System (HCS) and Provider Network Data System (PNDS) Connection to the PNDS is through a secure connection to the HCS at All users must have an HCS account and access to the PNDS page. To obtain access to the HCS for new insurers wishing to participate in the NYSOH, please send an request to nyhxpm@health.ny.gov or call (518) It takes about ten days to obtain an HCS account once the notarized forms are received by the Department of Health. After the HCS account is created, the DOH will notify the Insurers about the accounts. DOH will then request any additional information regarding their HCS Administrators and HCS Coordinators. Once a user has HCS access, they can locate the PNDS application under the name Managed Care Network Data System. The first time a user attempts to access the PNDS page they will be prompted with an access permission form, for which they must fill out. PNDS access forms are processed daily. Plans having difficulty accessing the PNDS page can contact the Provider Network / MEDS Data Compliance Unit at pnds@health.ny.gov or (518) for further assistance. E. Data Submission Schedule Provider network data is collected quarterly for the following lines of business: Medicaid; Child Health Plus; FIDA; HIV Special Needs Plans (SNP); Managed Long Term Care Plans (MLTC); Health and Recovery Plans (HARP); New York State of Health (NYSOH) Qualified Health Plan(s) (QHP) and Basic Health Plan(s) (BHP s), and annually for Commercial managed care networks outside of the NYSOH. PNDS submissions are a snapshot of the network taken the week of the quarter in which the last day falls. Quarters end March 31, June 30, September 30, and December 31 for all non-nysoh submissions. The NYSOH quarters end on January 31, April 30, July 31 and October 31. The snapshot week includes the last day wherever it falls in the week. For example, if the 31st is a Wednesday, the week would be the 29th through the 2nd. Submission schedules may also be found on the PNDS homepage. Annual submissions are only for the week including December 31. This submission must include the Insurer s entire network. Insurers have at least 15 business days after the end of the quarter, to submit their regular data files. Test submissions may be submitted at any time. Other submissions include corrections and service area expansions which are on an as needed basis and may be requested by contacting your plan manager. Health providers with multiple products should report all programs in a single file except HIV/SNP which must be reported separately. Exchange programs should continue to be reported as previously instructed by the New York State of Health. V7.0, page 5

6 Provider Network Data System II. PHYSICIAN AND OTHER PROVIDERS DETAILED RECORD FORMAT V7.0, page 6

7 II. PHYSICIAN AND OTHER PROVIDERS DETAILED RECORD FORMAT KEY TO WHO SUBMITS? ALL REC = All Records for all payors ALL PCPs = All PCPs ALL Physician REC = all with type 01=MD or type 12=DO ALL MED & SNP REC = All Medicaid and HIV SNP Records KEY TO FORMAT A = Alpha format only N = Numeric format only A/N = Alpha Numeric Description/Field Name Record Position Field Size Format Who Submits? IDENTIFICATION V7.0, page 7 Critical? Comment Page# Last Name A ALL REC YES 36 First Name A ALL REC YES 37 National Provider Identifier (NPI) A/N ALL REC YES 10 digits only 38 License Number A/N ALL REC YES Medicaid Provider Identification / MEDS ID Managed Care Plans ID A/N ALL MED & SNP REC NO A/N Optional NO LOCATION Valid NYS License # zero-fill to the left Provider Identification. See edit application Unique Provider Identification for your Managed Care Plan Site Name A/N ALL REC YES Office or Professional Building 42 Room or Suite A/N ALL REC YES If Not Applicable enter NA 43 Street Address A/N ALL REC YES 44 Town/City A/N ALL REC YES 45 State A/N ALL REC YES 46 Borough/Cnty Code A/N ALL REC YES FIPS codes right justified and zero-fill 47 Zip Code A/N ALL REC YES 48 Zip Plus Four A/N ALL REC NO 49 Wheel Chair Accessibility Primary Designation A/N ALL REC YES 0=No 50 PRACTICE 1=Yes A/N ALL REC YES 1=PCP 51 2=Specialist 3=PCP and Specialist Provider Type A/N ALL REC YES 01=MD 55 02=CNP Nurse Practitioner 03=CNM 04=CSW 05=Clinical Psych 06=OD Optometrist 08=DDS 09=DPM Podiatrist 10=Chiropractor 11=Other 12=DO

8 Description/Field Name Record Position Field Size Format Who Submits? V7.0, page 8 Critical? Comment Page# 14=Psychologist 15=Counselor 16=Social Work 18=DMD 19=OMS 20=Acupuncturist 22=RN 23=Physician Assistant (PA) 30=Audiologist 40=CDN Dietician/Nutritionist 50=CM (not a nurse) 60=PT 61=OT 62=SLP 63=CFY 64=RT Primary Specialty A/N ALL REC YES See Appendix 57 Secondary Specialty A/N ALL REC NO See Appendix 58 ALL Board Status - 1=Not Board Cert; Residency A/N Physician YES Primary Specialty Incomplete REC 59 Board Status - Secondary Specialty Residents Attending Physicians License Number Residency Status - Primary Specialty A/N A/N A/N ALL Physician REC All Resident PCPs ALL Physician REC NO YES YES PCP ONLY 2=Not Board Certified; Residency Complete. 3=Board Certified 4=No Board Cert Avail 9=Not Applicable 1=Not Board Cert; Residency Incomplete 2=Not Board Certified; Residency Complete. 3=Board Certified 4=No Board Cert Avail 9=Not Applicable NYS Valid License Number Zero-fill to the left; nonresidents should 0 fill =PGY1 64 2=PGY2 3=PGY3 4=PGY4-8+ 9=Not Applicable (for noncurrent residents, i.e., physicians who have completed residency, etc)

9 Description/Field Name Residency Status - Secondary Specialty Record Position Field Size Format A/N Who Submits? ALL Physician REC V7.0, page 9 Critical? Comment Page# NO 1=PGY1 66 2=PGY2 3=PGY3 4=PGY4-8+ 9=Not Applicable (for noncurrent residents, i.e., physicians who have completed residency, etc) Provider s Gender A/N ALL REC YES 1=Male 68 Physician Extenders Commercial Provider Indicator Medicaid Provider Indicator Medicare Provider Indicator Child Health Plus (CHP) Provider Indicator 2=Female N ALL PCPs YES *For PCPs only* 69 Total #FTEs: PA/NP 99.99=Not Applicable (for non-pcps or NPs acting as PCPs) A/N ALL REC YES 0=No 70 1=Yes A/N ALL REC YES 0=No 71 1=Yes A/N ALL REC YES 0=No 72 1=Yes A/N ALL REC YES 0=No 73 1=Yes HARP Indicator A/N ALL REC YES 0=No 74 ` 1=Yes Medicaid Advantage A/N ALL REC YES 0=No 75 Indicator 1=Yes Partial CAPS Indicator A/N ALL REC YES 0=No 76 1=Yes MAP Indicator A/N ALL REC YES 0=No 77 1=Yes PACE Indicator A/N ALL REC YES 0=No 78 1=Yes FIDA Indicator A/N ALL REC YES 0=No 79 NYSOH Standard Basic Health Plan (BHP) Indicator 1=Yes A/N ALL REC YES 0=No 80 1=Yes

10 Description/Field Name NYSOH BHP Plus Adult Vision/Dental Indicator Record Position Field Size Format Who Submits? Critical? Comment Page# A/N ALL REC YES 0=No 81 1=Yes Filler A/N ALL REC YES N/A Filler A/N ALL REC YES Space-filled N/A Filler N ALL REC YES Space-filled N/A Commercial Panel Status Medicaid Panel Status Medicare Panel Status A/N A/N A/N CHP Panel Status A/N ALL COMM. PCPs ALL MED & SNP PCPs, & OB/GYNs ALL Medicare PCPs ALL CHP PCPs YES 1=Open to all new and existing 82 2=Open to existing only 3=Closed 9=NA (for non-pcps) YES 1=Open to all new and existing 83 2=Open to existing only 3=Closed 9=NA (for non-pcps) YES 1=Open to all new and existing 84 2=Open to existing only 3=Closed 9=NA (for non-pcps) YES 1=Open to all new and existing 85 2=Open to existing only 3=Closed 9=NA (for non-pcps) Filler A/N ALL REC YES N/A Medicaid Advantage Panel Status Partial CAPS Panel Status A/N A/N MAP Panel Status A/N ALL MA ADVAN PCPs ALL PARTIAL CAPS PCPs ALL MAP PCPs YES 1=Open to all new and existing 86 2=Open to existing only 3=Closed 9=NA (for non-pcps) YES 1=Open to all new and existing 87 2=Open to existing only 3=Closed 9=NA (for non-pcps) YES 1=Open to all new and existing 88 2=Open to existing only 3=Closed 9=NA (for non-pcps) V7.0, page 10

11 Description/Field Name Record Position Field Size Format PACE Panel Status A/N FIDA Panel Status A/N NYSOH Standard Basic Health Plan (BHP) Panel Status NYSOH BHP Plus Adult Vision/Dental Panel Status Who Submits? ALL PACE PCPs ALL FIDA PCPs Critical? Comment Page# YES 1=Open to all new and existing 89 2=Open to existing only 3=Closed 9=NA (for non-pcps) YES 1=Open to all new and existing 90 2=Open to existing only 3=Closed 9=NA (for non-pcps) A/N ALL REC YES 1=Open to all new and existing 91 2=Open to existing only 3=Closed 9=NA (for non-pcps) A/N ALL REC YES 1=Open to all new and existing 92 2=Open to existing only 3=Closed 9=NA (for non-pcps) Filler A/N ALL REC YES Space-filled N/A Filler A/N ALL REC YES Space-filled N/A Filler N ALL REC YES Space-filled N/A Total Covered commercial members assigned to this Commercial Panel ALL COMM. provider at your managed care N YES Size PCPs plan. Zero-fill to the left, =Not Applicable (for non- PCPs) Medicaid Panel Size Medicare Panel Size N N CHP Panel Size N ALL MED & SNP REC ALL Medicare PCPs ALL CHP PCPs YES YES YES Total Covered Medicaid members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non- PCPs) Total Covered Medicare members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non- PCPs) Total Covered CHP members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Filler N ALL REC YES Space-filled N/A V7.0, page 11

12 Description/Field Name Medicaid Advantage Panel Size Partial CAPS Panel Size Record Position Field Size Format N N MAP Panel Size N PACE Panel Size N FIDA Panel Size A/N NYSOH Standard Basic Health Plan (BHP) Panel Size NYSOH BHP Plus Adult Vision/Dental Panel Size A/N A/N Who Submits? ALL MA Advan. PCPs ALL Partial CAPS PCPs ALL MAP PCPs ALL PACE PCPs ALL FIDA PCPs ALL NYSOH Standard BHP PCP s ALL NYSOH BHP Plus Adult Vision/Dental PCP s Critical? Comment Page# YES YES YES YES YES YES YES Total Covered Medicaid Advantage members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Partial CAPS members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non- PCPs) Total Covered MAP members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered PACE members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered FIDA members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Standard BHP members assigned to this provider at your health plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered BHP plus Adult Vision & Dental members assigned to this provider at your health plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Filler A/N ALL REC YES Space-filled N/A Filler A/N ALL REC YES Space-filled N/A Filler N ALL REC YES Space-filled N/A Hospital Affiliation (HA) Operating Certificate (OPCERT) #1 HA Permanent Facility Identifier (PFI) #1 Hospital Affiliation (HA) Operating Certificate (OPCERT) # A/N A/N A/N ALL PCPs & OB/GYNs Optional for the others ALL PCPs & OB/GYNs Optional for the others ALL PCPs & OB/GYNs Optional for the others YES YES NO See Operating Facility codes =Not Applicable (for non-pcp, non-ob/gyn) Corresponds to HA OPCERT #1 See Operating Facility codes =Not Applicable (for non-pcp, non-ob/gyn) V7.0, page 12

13 Description/Field Name HA Permanent Facility Identifier (PFI) #2 Hospital Affiliation (HA) Operating Certificate (OPCERT) #3 HA Permanent Facility Identifier (PFI) #3 Provider Location Facility Operating Number Provider Location Permanent Facility Identifier (PFI) Record Position Field Size Format A/N A/N A/N Who Submits? ALL PCPs & OB/GYNs Optional for the others ALL PCPs & OB/GYNs Optional for the others ALL PCPs & OB/GYNs Optional for the others V7.0, page 13 Critical? Comment Page# NO NO NO Corresponds to HA OPCERT #2 See Operating Facility codes =Not Applicable (for non-pcp) Corresponds to HA OPCERT # A/N ALL PCPs NO A/N ALL PCPs NO Total Office Hours A/N After Hours Indicator A/N Language A/N Language A/N Language A/N Language A/N Language A/N Language A/N Language A/N OFFICE HOURS MED & SNP PCPs Only PCPs Only MED & SNP REC PCPs Only LANGUAGES MED & SNP PCPs Only MED & SNP PCPs Only MED & SNP PCPs Only MED & SNP PCPs Only MED & SNP PCPs Only MED & SNP PCPs Only MED & SNP PCPs Only CONTACT INFO YES For PCPs only See Operating Facility Codes Enter the Total hours worked per week during the submission period. Non- PCPs zero-fill YES 0=No 109 1=Yes 9=Not Applicable YES See Appendix VI 110 YES See Appendix VI 110 YES See Appendix VI 110 YES See Appendix VI 110 YES See Appendix VI 110 YES See Appendix VI 110 YES See Appendix VI 110 Area Code A/N ALL REC YES 111 Phone Number A/N ALL REC YES Do not include hyphen 112 Provider Address A/N ALL REC YES Enter valid address 113 Federal Employer Identification Number (FEIN) A/N ALL REC YES 9 digits. Do not include hyphen 114 EXCHANGE PRACTICE

14 Description/Field Name NYSOH Indiv St Bronze NYSOH Indiv St Silver NYSOH Indiv St Gold NYSOH Indiv St Platinum NYSOH Indiv Child Only Bronze NYSOH Indiv Child Only Silver NYSOH Indiv Child Only Gold NYSOH Indiv Child Only Platinum NYSOH Indiv Catastrophic NYSOH Indiv Pediatric Dental High NYSOH Indiv Pediatric Dental Low NYSOH Indiv Adult Dental NYSOH Indiv Family Dental NYSOH Indiv Non St Bronze 1 NYSOH Indiv Non St Silver 1 NYSOH Indiv Non St Gold 1 Record Position Field Size Format Who Submits? Critical? Comment Page# A/N ALL REC YES 0=No 115 1=Yes A/N ALL REC YES 0=No 116 1=Yes A/N ALL REC YES 0=No 117 1=Yes A/N ALL REC YES 0=No 118 1=Yes A/N ALL REC YES 0=No 119 1=Yes A/N ALL REC YES 0=No 120 1=Yes A/N ALL REC YES 0=No 121 1=Yes A/N ALL REC YES 0=No 122 1=Yes A/N ALL REC YES 0=No 123 1=Yes A/N ALL REC YES 0=No 124 1=Yes A/N ALL REC YES 0=No 125 1=Yes A/N ALL REC YES 0=No 126 1=Yes A/N ALL REC YES 0=No 127 1=Yes A/N ALL REC YES 0=No 128 1=Yes A/N ALL REC YES 0=No 129 1=Yes A/N ALL REC YES 0=No 130 1=Yes V7.0, page 14

15 Description/Field Name NYSOH Indiv Non St Platinum 1 NYSOH Indiv Non St Bronze 2 NYSOH Indiv Non St Silver 2 NYSOH Indiv Non St Gold 2 NYSOH Indiv Non St Platinum 2 NYSOH Indiv Non St Bronze 3 NYSOH Indiv Non St Silver 3 NYSOH Indiv Non St Gold 3 NYSOH Indiv Non St Platinum 3 NYSOH SHOP St Bronze NYSOH SHOP St Silver NYSOH SHOP St Gold NYSOH SHOP St Platinum NYSOH SHOP Pediatric Dental High NYSOH SHOP Pediatric Dental Low NYSOH SHOP Adult Dental Record Position Field Size Format Who Submits? Critical? Comment Page# A/N ALL REC YES 0=No 131 1=Yes A/N ALL REC YES 0=No 132 1=Yes A/N ALL REC YES 0=No 133 1=Yes A/N ALL REC YES 0=No 134 1=Yes A/N ALL REC YES 0=No 135 1=Yes A/N ALL REC YES 0=No 136 1=Yes A/N ALL REC YES 0=No 137 1=Yes A/N ALL REC YES 0=No 138 1=Yes A/N ALL REC YES 0=No 139 1=Yes A/N ALL REC YES 0=No 140 1=Yes A/N ALL REC YES 0=No 141 1=Yes A/N ALL REC YES 0=No 142 1=Yes A/N ALL REC YES 0=No 143 1=Yes A/N ALL REC YES 0=No 144 1=Yes A/N ALL REC YES 0=No 145 1=Yes A/N ALL REC YES 0=No 146 1=Yes V7.0, page 15

16 Description/Field Name NYSOH SHOP Family Dental NYSOH SHOP Non St Bronze 1 NYSOH SHOP Non St Silver 1 NYSOH SHOP Non St Gold 1 NYSOH SHOP Non St Platinum 1 NYSOH SHOP Non St Bronze 2 NYSOH SHOP Non St Silver 2 NYSOH SHOP Non St Gold 2 NYSOH SHOP Non St Platinum 2 NYSOH SHOP Non St Bronze 3 NYSOH SHOP Non St Silver 3 NYSOH SHOP Non St Gold 3 NYSOH SHOP Non St Platinum 3 NYSOH Indiv St Bronze PanelStat NYSOH Indiv St Silver PanelStat Record Position Field Size Format Who Submits? Critical? Comment Page# A/N ALL REC YES 0=No 147 1=Yes A/N ALL REC YES 0=No 148 1=Yes A/N ALL REC YES 0=No 149 1=Yes A/N ALL REC YES 0=No 150 1=Yes A/N ALL REC YES 0=No 151 1=Yes A/N ALL REC YES 0=No 152 1=Yes A/N ALL REC YES 0=No 153 1=Yes A/N ALL REC YES 0=No 154 1=Yes A/N ALL REC YES 0=No 155 1=Yes A/N ALL REC YES 0=No 156 1=Yes A/N ALL REC YES 0=No 157 1=Yes A/N ALL REC YES 0=No 158 1=Yes A/N ALL REC YES 0=No A/N A/N ALL Indiv St Bronze Product PCPs ALL Indiv St Silver Product PCPs 1=Yes YES 1=Open to all new and existing 160 2=Open to existing only 3=Closed 9=NA (for non-pcps) YES 1=Open to all new and existing 161 V7.0, page 16

17 Description/Field Name Record Position Field Size Format Who Submits? Critical? Comment Page# 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv St Gold PanelStat A/N ALL Indiv St Gold Product PCPs YES 1=Open to all new and existing 162 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv St Platinum PanelStat A/N ALL Indiv St Platinum Product PCPs YES 1=Open to all new and existing 163 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv Child Only Bronze PanelStat A/N ALL Indiv Child Only Bronze Product PCPs YES 1=Open to all new and existing 164 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv Child Only Silver PanelStat A/N ALL Indiv Child Only Silver Product PCPs YES 1=Open to all new and existing 168 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv Child Only Gold PanelStat A/N ALL Indiv Child Only Gold Product PCPs YES 1=Open to all new and existing 166 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv Child Only Platinum PanelStat A/N ALL Indiv Child Only Platinum Product PCPs YES 1=Open to all new and existing 167 2=Open to existing only 3=Closed 9=NA (for non-pcps) V7.0, page 17

18 Description/Field Name Record Position Field Size Format Who Submits? Critical? Comment Page# NYSOH Indiv Catastrophic PanelStat A/N ALL Indiv Catastrophic Product PCPs YES 1=Open to all new and existing 168 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv Pediatric Dental High PanelStat A/N ALL Indiv Pediatric Dental High Product PCPs YES 1=Open to all new and existing 169 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv Pediatric Dental Low PanelStat A/N ALL Indiv Pediatric Dental Low Product PCPs YES 1=Open to all new and existing 170 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv Adult Dental PanelStat A/N ALL Indiv Adult Dental Product PCPs YES 1=Open to all new and existing 171 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv Family Dental PanelStat A/N ALL Indiv Family Dental Product PCPs YES 1=Open to all new and existing 172 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv Non St Bronze 1 PanelStat A/N ALL Indiv Non St Bronze 1 Product PCPs YES 1=Open to all new and existing 173 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv Non St Silver 1 PanelStat A/N ALL Indiv Non St Silver 1 Product PCPs YES 1=Open to all new and existing 174 V7.0, page 18

19 Description/Field Name Record Position Field Size Format Who Submits? Critical? Comment Page# 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv Non St Gold 1 PanelStat A/N ALL Indiv Non St Gold 1 Product PCPs YES 1=Open to all new and existing 175 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv Non St Platinum 1 PanelStat A/N ALL Indiv Non St Platinum 1 Product PCPs YES 1=Open to all new and existing 176 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv Non St Bronze 2 PanelStat A/N ALL Indiv Non St Bronze 2 Product PCPs YES 1=Open to all new and existing 177 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv Non St Silver 2 PanelStat A/N ALL Indiv Non St Silver 2 Product PCPs YES 1=Open to all new and existing 178 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv Non St Gold 2 PanelStat A/N ALL Indiv Non St Gold 2 Product PCPs YES 1=Open to all new and existing 179 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv Non St Platinum 2 PanelStat A/N ALL Indiv Non St Platinum 2 Product PCPs YES 1=Open to all new and existing 180 2=Open to existing only 3=Closed 9=NA (for non-pcps) V7.0, page 19

20 Description/Field Name Record Position Field Size Format Who Submits? Critical? Comment Page# NYSOH Indiv Non St Bronze 3 PanelStat A/N ALL Indiv Non St Bronze 3 Product PCPs YES 1=Open to all new and existing 181 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv Non St Silver 3 PanelStat A/N ALL Indiv Non St Silver 3 Product PCPs YES 1=Open to all new and existing 182 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv Non St Gold 3 PanelStat A/N ALL Indiv Non St Gold 3 Product PCPs YES 1=Open to all new and existing 183 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH Indiv Non St Platinum 3 PanelStat A/N ALL Indiv Non St Platinum 3 Product PCPs YES 1=Open to all new and existing 184 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH SHOP St Bronze PanelStat A/N ALL SHOP St Bronze Product PCPs YES 1=Open to all new and existing 185 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH SHOP St Silver PanelStat A/N ALL SHOP St Silver Product PCPs YES 1=Open to all new and existing 186 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH SHOP St Gold PanelStat A/N ALL SHOP St Gold Product PCPs YES 1=Open to all new and existing 187 2=Open to existing only V7.0, page 20

21 Description/Field Name Record Position Field Size Format Who Submits? Critical? Comment Page# 3=Closed 9=NA (for non-pcps) NYSOH SHOP St Platinum PanelStat A/N ALL SHOP St Platinum Product PCPs YES 1=Open to all new and existing 188 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH SHOP Pediatric Dental High PanelStat A/N ALL SHOP Pediatric Dental High Product PCPs YES 1=Open to all new and existing 189 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH SHOP Pediatric Dental Low PanelStat A/N ALL SHOP Pediatric Dental Low Product PCPs YES 1=Open to all new and existing 190 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH SHOP Adult Dental PanelStat A/N ALL SHOP Adult Dental Product PCPs YES 1=Open to all new and existing 191 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH SHOP Family Dental PanelStat A/N ALL SHOP Family Dental Product PCPs YES 1=Open to all new and existing 192 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH SHOP Non St Bronze 1 PanelStat A/N ALL SHOP Non St Bronze 1 Product PCPs YES 1=Open to all new and existing 193 2=Open to existing only 3=Closed 9=NA (for non-pcps) V7.0, page 21

22 Description/Field Name NYSOH SHOP Non St Silver 1 PanelStat NYSOH SHOP Non St Gold 1 PanelStat NYSOH SHOP Non St Platinum 1 PanelStat NYSOH SHOP Non St Bronze 2 PanelStat NYSOH SHOP Non St Silver 2 PanelStat NYSOH SHOP Non St Gold 2 PanelStat NYSOH SHOP Non St Platinum 2 PanelStat Record Position Field Size Format A/N A/N A/N A/N A/N A/N A/N Who Submits? ALL SHOP Non St Silver 1 Product PCPs ALL SHOP Non St Gold 1 Product PCPs ALL SHOP Non St Platinum 1 Product PCPs ALL SHOP Non St Bronze 2 Product PCPs ALL SHOP Non St Silver 2 Product PCPs ALL SHOP Non St Gold 2 Product PCPs ALL SHOP Non St Platinum 2 Product PCPs V7.0, page 22 Critical? Comment Page# YES 1=Open to all new and existing 194 2=Open to existing only 3=Closed 9=NA (for non-pcps) YES 1=Open to all new and existing 195 2=Open to existing only 3=Closed 9=NA (for non-pcps) YES 1=Open to all new and existing 196 2=Open to existing only 3=Closed 9=NA (for non-pcps) YES 1=Open to all new and existing 197 2=Open to existing only 3=Closed 9=NA (for non-pcps) YES 1=Open to all new and existing 198 2=Open to existing only 3=Closed 9=NA (for non-pcp s) YES 1=Open to all new and existing 199 2=Open to existing only 3=Closed 9=NA (for non-pcps) YES 1=Open to all new and existing 200 2=Open to existing only

23 Description/Field Name Record Position Field Size Format Who Submits? Critical? Comment Page# 3=Closed 9=NA (for non-pcps) NYSOH SHOP Non St Bronze 3 PanelStat A/N ALL SHOP Non St Bronze 3 Product PCPs YES 1=Open to all new and existing 201 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH SHOP Non St Silver 3 PanelStat A/N ALL SHOP Non St Silver 3 Product PCPs YES 1=Open to all new and existing 202 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH SHOP Non St Gold 3 PanelStat A/N ALL SHOP Non St Gold 3 Product PCPs YES 1=Open to all new and existing 203 2=Open to existing only 3=Closed 9=NA (for non-pcps) NYSOH SHOP Non St Platinum 3 PanelStat A/N ALL SHOP Non St Platinum 3 Product PCPs YES 1=Open to all new and existing 204 NYSOH Indiv St Bronze Panel Size NYSOH Indiv St Silver Panel Size NYSOH Indiv St Gold Panel Size N N N ALL Indiv St Bronze PCPs ALL Indiv St Silver PCPs ALL Indiv St Gold PCPs YES YES YES 2=Open to existing only 3=Closed 9=NA (for non-pcps) Total Covered Indiv St Bronze Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non- PCPs) Total Covered Indiv St Silver Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non- PCPs) Total Covered Indiv St Gold Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non- PCPs) V7.0, page 23

24 Description/Field Name NYSOH Indiv St Platinum Panel Size NYSOH Indiv Child Only Bronze Panel Size NYSOH Indiv Child Only Silver Panel Size NYSOH Indiv Child Only Gold Panel Size NYSOH Indiv Child Only Platinum Panel Size NYSOH Indiv Catastrophic Panel Size NYSOH Indiv Pediatric Dental High Panel Size NYSOH Indiv Pediatric Dental Low Panel Size NYSOH Indiv Adult Dental Panel Size Record Position Field Size Format N N N N N N N N N Who Submits? ALL Indiv St Platinum PCPs ALL Indiv Child Only Bronze PCPs ALL Indiv Child Only Silver PCPs ALL Indiv Child Only Gold PCPs ALL Indiv Child Only Platinum PCPs ALL Indiv Catastrophic PCPs ALL Indiv Pediatric Dental High PCPs ALL Indiv Pediatric Dental Low PCPs ALL Indiv Adult Dental PCPs Critical? Comment Page# YES YES YES YES YES YES YES YES YES Total Covered Indiv St Platinum Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Indiv Child Only Bronze Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Indiv Child Only Silver Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Indiv Child Only Gold Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Indiv Child Only Platinum Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Indiv Catastrophic Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Indiv Pediatric Dental High Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Indiv Pediatric Dental Low Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Indiv Adult Dental Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) V7.0, page 24

25 Description/Field Name NYSOH Indiv Family Dental Panel Size NYSOH Indiv Non St Bronze 1 Panel Size NYSOH Indiv Non St Silver 1 Panel Size NYSOH Indiv Non St Gold 1 Panel Size NYSOH Indiv Non St Platinum 1 Panel Size NYSOH Indiv Non St Bronze 2 Panel Size NYSOH Indiv Non St Silver 2 Panel Size NYSOH Indiv Non St Gold 2 Panel Size NYSOH Indiv Non St Platinum 2 Panel Size Record Position Field Size Format N N N N N N N N N Who Submits? ALL Indiv Family Dental PCPs ALL Indiv Non St Bronze 1 PCPs ALL Indiv Non St Silver 1 PCPs ALL Indiv Non St Gold 1 PCPs ALL Indiv Non St Platinum 1 PCPs ALL Indiv Non St Bronze 2 PCPs ALL Indiv Non St Silver 2 PCPs ALL Indiv Non St Gold 2 PCPs ALL Indiv Non St Platinum 2 PCPs Critical? Comment Page# YES YES YES YES YES YES YES YES YES Total Covered Indiv Family Dental Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Indiv Non St Bronze 1 Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Indiv Non St Silver 1 Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Indiv Non St Gold 1 Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Indiv Non St 1 Platinum Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Indiv Non St Bronze 2 Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Indiv Non St Silver 2 Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Indiv Non St Gold 2 Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Indiv Non St 2 Platinum Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) V7.0, page 25

26 Description/Field Name NYSOH Indiv Non St Bronze 3 Panel Size NYSOH Indiv Non St Silver 3 Panel Size NYSOH Indiv Non St Gold 3 Panel Size NYSOH Indiv Non St Platinum 3 Panel Size NYSOH SHOP St Bronze Panel Size NYSOH SHOP St Silver Panel Size NYSOH SHOP St Gold Panel Size NYSOH SHOP St Platinum Panel Size NYSOH SHOP Pediatric Dental High Panel Size Record Position Field Size Format N N N N N N N N N Who Submits? ALL Indiv Non St Bronze 3 PCPs ALL Indiv Non St Silver 3 PCPs ALL Indiv Non St Gold 3 PCPs ALL Indiv Non St Platinum 3 PCPs ALL SHOP St Bronze PCPs ALL SHOP St Silver PCPs ALL SHOP St Gold PCPs ALL SHOP St Platinum PCPs ALL SHOP Pediatric Dental High PCPs Critical? Comment Page# YES YES YES YES YES YES YES YES YES Total Covered Indiv Non St Bronze 3 Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Indiv Non St Silver 3 Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Indiv Non St Gold 3 Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered Indiv Non St 3 Platinum Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered SHOP St Bronze Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered SHOP St Silver Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non- PCPs) Total Covered SHOP St Gold Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non- PCPs) Total Covered SHOP St Platinum Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered SHOP Pediatric Dental High Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) V7.0, page 26

27 Description/Field Name NYSOH SHOP Pediatric Dental Low Panel Size NYSOH SHOP Adult Dental Panel Size NYSOH SHOP Family Dental Panel Size NYSOH SHOP Non St Bronze 1 Panel Size NYSOH SHOP Non St Silver 1 Panel Size NYSOH SHOP Non St Gold 1 Panel Size NYSOH SHOP Non St Platinum 1 Panel Size NYSOH SHOP Non St Bronze 2 Panel Size NYSOH SHOP Non St Silver 2 Panel Size Record Position Field Size Format N N N N N N N N N Who Submits? ALL SHOP Pediatric Dental Low PCPs ALL SHOP Adult Dental PCPs ALL SHOP Family Dental PCPs ALL SHOP Non St Bronze 1 PCPs ALL SHOP Non St Silver 1 PCPs ALL SHOP Non St Gold 1 PCPs ALL SHOP Non St Platinum 1 PCPs ALL SHOP Non St Bronze 2 PCPs ALL SHOP Non St Silver 2 PCPs Critical? Comment Page# YES YES YES YES YES YES YES YES YES Total Covered SHOP Pediatric Dental Low Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered SHOP Adult Dental Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered SHOP Family Dental Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered SHOP Non St Bronze 1 Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered SHOP Non St Silver 1 Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered SHOP Non St Gold 1 Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered SHOP Non St 1 Platinum Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered SHOP Non St Bronze 2 Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered SHOP Non St Silver 2 Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) V7.0, page 27

28 Description/Field Name NYSOH SHOP Non St Gold 2 Panel Size NYSOH SHOP Non St Platinum 2 Panel Size NYSOH SHOP Non St Bronze 3 Panel Size NYSOH SHOP Non St Silver 3 Panel Size NYSOH SHOP Non St Gold 3 Panel Size NYSOH SHOP Non St Platinum 3 Panel Size Record Position Field Size Format N N N N N N Who Submits? ALL SHOP Non St Gold 2 PCPs ALL SHOP Non St Platinum 2 PCPs ALL SHOP Non St Bronze 3 PCPs ALL SHOP Non St Silver 3 PCPs ALL SHOP Non St Gold 3 PCPs ALL SHOP Non St Platinum 3 PCPs Critical? Comment Page# YES YES YES YES YES YES Total Covered SHOP Non St Gold 2 Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered SHOP Non St 2 Platinum Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered SHOP Non St Bronze 3 Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered SHOP Non St Silver 3 Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered SHOP Non St Gold 3 Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) Total Covered SHOP Non St 3 Platinum Product members assigned to this provider at your managed care plan. Zero-fill to the left, 9999=Not Applicable (for non-pcps) V7.0, page 28

29 Provider Network Data System III. ANCILLARY/SERVICE CENTERS DETAILED RECORD FORMAT V7.0, page 29

30 III. ANCILLARY/SERVICE CENTERS DETAILED RECORD FORMAT KEY TO WHO SUBMITS ALL REC=All Records ALL Hosp and Clinics = All Hospitals ((Designated Service 011) and (Designated Service 321, Article 28 Clinic)) KEY TO FORMAT A = Alpha format only N = Numeric format only Clinics A/N = Alpha Numeric (Numbers in text format) Description/Field Name Record Position Field Size Format Who Submits? LOCATION Site Name A/N ALL REC YES Room or Suite Number A/N ALL REC YES V7.0, page 30 Critical? Comment Page# Office or professional building If Not Applicable enter NA Street Address A/N ALL REC YES 253 Town/City A/N ALL REC YES 254 State A/N ALL REC YES 255 Borough/County A/N ALL REC YES 256 Zip Code A/N ALL REC YES 257 Zip Plus Four A/N ALL REC NO 258 SERVICE Designated Service A/N ALL REC YES See attached codes 259 Number of Providers at Service Center National Provider Identifier (NPI) License Number/Facility Operating Cert. Permanent Facility Identifier Medicaid Provider Identification Number Managed Care Plan s Facility ID Commercial Provider Indicator Medicaid Provider Indicator Medicare Provider Indicator Child Health Plus Indicator N ALL REC NO A/N All Records YES 10 digits only A/N ALL REC YES A/N ALL REC YES If Applicable to Service Provider If Applicable to Service Provider A/N ALL REC NO Provider Identification A/N ALL REC NO Unique Provider Identification A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES 270 HARP Indicator A/N ALL REC YES 271 Medicaid Advantage Indicator Partial CAPS Indicator A/N ALL REC YES A/N ALL REC YES 273 MAP Indicator A/N ALL REC YES 274 PACE Indicator A/N ALL REC YES 275 FIDA Indicator A/N ALL REC YES

31 Description/Field Name NYSOH Standard Basic Health Plan (BHP) Indicator NYSOH BHP Plus Adult Vision/Dental Indicator Record Position Field Size Format Who Submits? V7.0, page 31 Critical? Comment Page# A/N ALL REC YES A/N ALL REC YES 278 Filler A/N ALL REC YES Space-fiiled N/A Filler A/N ALL REC YES Space-fiiled N/A Filler N ALL REC YES Space-fiiled N/A PHONE Area Code A/N ALL REC YES 279 Phone Number A/N ALL REC YES Do not include hyphen 280 Service A/N Service A/N Service A/N Service A/N Service A/N Service A/N Service A/N Service A/N Service A/N Service A/N Service A/N Service A/N Service A/N Service A/N Service A/N Service A/N Service A/N Service A/N Service A/N ADDITIONAL SERVICES All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics YES See Appendix 281 YES See Appendix 281 YES See Appendix 281 YES See Appendix 281 YES See Appendix 281 YES See Appendix 281 YES See Appendix 281 YES See Appendix 281 YES See Appendix 281 YES See Appendix 281 YES See Appendix 281 YES See Appendix 281 YES See Appendix 281 YES See Appendix 281 YES See Appendix 281 YES See Appendix 281 YES See Appendix 281 YES See Appendix 281 YES See Appendix 281

32 Description/Field Name Record Position Field Size Format Service A/N Service A/N Service A/N Service A/N Service A/N Service A/N NYSOH Indiv St Bronze Indicator NYSOH Indiv St Silver Indicator NYSOH Indiv St Gold Indicator NYSOH Indiv St Platinum Indicator NYSOH Indiv Child Only Bronze Indicator NYSOH Indiv Child Only Silver Indicator NYSOH Indiv Child Only Gold Indicator NYSOH Indiv Child Only Platinum Indicator NYSOH Indiv Catastrophic Indicator NYSOH Indiv Pediatric Dental High Indicator NYSOH Indiv Pediatric Dental Low Indicator NYSOH Indiv Adult Dental Indicator NYSOH Indiv Family Dental Indicator NYSOH Indiv Non St Bronze 1 Indicator NYSOH Indiv Non St Silver 1 Indicator NYSOH Indiv Non St Gold 1 Indicator NYSOH Indiv Non St Platinum 1 Indicator Who Submits? All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics All Hosp & Clinics EXCHANGE SERVICE V7.0, page 32 Critical? Comment Page# YES See Appendix 281 YES See Appendix 281 YES See Appendix 281 YES See Appendix 281 YES See Appendix 281 YES See Appendix A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES 299

33 Description/Field Name NYSOH Indiv Non St Bronze 2 Indicator NYSOH Indiv Non St Silver 2 Indicator NYSOH Indiv Non St Gold 2 Indicator NYSOH Indiv Non St Platinum 2 Indicator NYSOH Indiv Non St Bronze 3 Indicator NYSOH Indiv Non St Silver 3 Indicator NYSOH Indiv Non St Gold 3 Indicator NYSOH Indiv Non St Platinum 3 Indicator NYSOH SHOP St Bronze Indicator NYSOH SHOP St Silver Indicator NYSOH SHOP St Gold Indicator NYSOH SHOP St Platinum Indicator NYSOH SHOP Pediatric Dental High Indicator NYSOH SHOP Pediatric Dental Low Indicator NYSOH SHOP Adult Dental Indicator NYSOH SHOP Family Dental Indicator NYSOH SHOP Non St Bronze 1 Indicator NYSOH SHOP Non St Silver 1 Indicator NYSOH SHOP Non St Gold 1 Indicator NYSOH SHOP Non St Platinum 1 Indicator NYSOH SHOP Non St Bronze 2 Indicator NYSOH SHOP Non St Silver 2 Indicator NYSOH SHOP Non St Gold 2 Indicator Record Position Field Size Format Who Submits? Critical? Comment Page# A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES A/N ALL REC YES 322 V7.0, page 33