1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 1 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 SHORT TERM 02 LONG TERM 03 CHRISTIAN SCIENCE 04 PSYCHIATRIC 05 REHABILITATION 06 CHILDRENS' 07 ALCOHOL/DRUG 08 PPS EXEMPT REHABILITATION 09 PPS EXEMPT PSYCHIATRIC 10 PPS EXEMPT ALCOHOL/DRUG CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 01 HOSPITALS CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY AND STATE 31 13 43 C PROV0115 THE CITY AND STATE WHERE A PROVIDER IS LOCATED. COBOL NAME: CITY-STATE COMPLIANCE: PLAN OF CORRECTION 1 44 44 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 45 45 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 2 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COUNTY CODE 3 46 48 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 49 58 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 59 64 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 CURRENT SURVEY DATE 6 65 70 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 71 71 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 38 72 109 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME * INTERMEDIARY NUMBER 5 110 114 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 3 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICAID VENDOR NUMBER 12 115 126 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A MEDICAID FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 6 127 132 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 4 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR CHANGE OF OWNERSHIP 6 133 138 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 139 143 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 144 153 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE: MASTER/TRANSACTION 1 154 154 C PROV1720 INDICATES IF A RECORD IS CURRENTLY ON THE MASTER FILE OR THE TRANSACTION FILE. COBOL NAME: RECORD-TYPE VALUES: M MASTER FILE T TRANSACTION FILE REGION CODE 2 155 156 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 157 157 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE CODE (SSA) 2 158 159 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 5 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 6 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 52 WISCONSIN 53 WYOMING 54 AFRICA 55 CALIFORNIA 56 CANADA 57 WEST INDIES 58 EUROPE 59 MEXICO 60 OCEANIA 61 PHILIPPINES 62 SOUTH AMERICA 63 UNITED STATES POSSESSIONS 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN 67 TEXAS STATES REGION CODE 3 160 162 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 163 200 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 201 210 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE 1 211 211 C PROV2805 THE REASON A FACILITY HAS BEEN TERMINATED FROM THE MEDICARE AND/OR MEDICAID PROGRAMS COBOL NAME: TERM-CD VALUES: 0 ACTIVE 1 VOL-MERG,CLOSE 2 VOL-REIMBURSE 3 VOL-RISK INVOL 4 VOL-OTHER 5 INVOL-FAIL REQ 6 INVOL-AGREEMNT 7 OTH-STATUS CHG TERMINATION DATE 6 212 217 C PROV2810 THE EFFECTIVE DATE OF TERMINATION OF CERTIFICATION OF A FACILITY. COBOL NAME: TERM-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 7 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF ACTION 1 218 218 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP 5 VALIDATION (ACCREDITED HOSPITAL ONLY) 6 COMPLAINT SURVEY TYPE OF CONTROL 2 219 220 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 VOLUNTARY NON-PROFIT - CHURCH 02 VOLUNTARY NON-PROFIT - PRIVATE 03 VOLUNTARY NON-PROFIT - OTHER 04 PROPRIETARY 05 GOVERNMENT - FEDERAL 06 GOVERNMENT - STATE 07 GOVERNMENT - LOCAL 08 GOV. - HOSP. DIST. OR AUTH. ZIP CODE 5 221 225 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 226 227 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 228 230 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 231 233 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 234 234 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE * ACCREDITATION EFFECTIVE DATE 6 235 240 C PROV0000 THE EFFECTIVE DATE OF THE CURRENT PERIOD OF ACCREDITATION BY THE JOINT COMMISSION ON ACCREDITATION OF HEALTH CARE ORGANIZATIONS (JCAHO) OR THE AMERICAN OSTEOPATHIC ASSOCIATION (AOA). COBOL NAME: ACCRED-EFF-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 8 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ACCREDITATION EXPIRATION DATE 6 241 246 C PROV0005 THE EXPIRATION DATE OF THE CURRENT PERIOD OF ACCREDITATION BY THE JOINT COMMITTEE ON ACCREDITATION OF HEALTH CARE ORGANIZATIONS (JCAHO) OR THE AMERICAN OSTEOPATHIC ASSOCIATION (AOA). COBOL NAME: ACCRED-EXP-DT ACCREDITATION INDICATOR 1 247 247 C PROV0010 INDICATES IF A HOSPITAL IS ACCREDITED BY THE JOINT COMMISSION ON ACCREDITATION OF HEALTH CARE ORGANIZATION (JCAHO) OR THE AMERICAN OSTEOPATHIC ORGANIZATION (AOA). COBOL NAME: ACCRED-STAT VALUES: 0 NONE 1 JCAHO 2 AOA ALCOHOL/DRUG UNIT BEDS 3 248 250 N PROV0040 THE NUMBER OF BEDS IN A PPS EXEMPT ALCOHOL/DRUG UNIT OF A HOSPITAL. COBOL NAME: ALCOH-DRG-UNIT-BED-SZ ALCOHOL/DRUG UNIT EFFECTIVE DATE 6 251 256 C PROV0045 THE DATE AN ALCOHOL/DRUG UNIT BECAME EXEMPT FROM THE PROSPECTIVE PAYMENT SYSTEM (PPS). COBOL NAME: ALCOH-DRG-UNIT-EFF-DT ALCOHOL/DRUG UNIT INDICATOR 1 257 257 C PROV0050 INDICATES IF A HOSPITAL HAS A PPS EXEMPT ALCOHOL/DRUG UNIT. COBOL NAME: ALCOH-DRG-UNIT-IND VALUES: Y ALC/DRG UNIT ALCOHOL/DRUG UNIT TERMINATION CODE 1 258 258 C PROV0055 INDICATES THE REASON THAT AN ALCOHOL/DRUG UNIT IS NO LONGER EXEMPT FROM THE PROSPECTIVE PAYMENT SYSTEM. COBOL NAME: ALCOH-DRG-UNIT-TERM-CD VALUES: 0 ACTIVE 1 VOLUNTARY-MERGER OR CLOSURE 2 VOLUNTARY-DISSATISFACTION WITH REIMBURSEMENT 3 RISK OF INVOLUNTARY TERMINATION 4 VOLUNTARY-OTHER 5 FAILURE TO MEET HEALTH/SAFETY 6 FAILURE TO MEET AGREEMENT ALCOHOL/DRUG UNIT TERMINATION DATE 6 259 264 C PROV0060 THE DATE AN ALCOHOL/DRUG UNIT'S EXEMPTION FROM THE PROSPECTIVE PAYMENT SYSTEM IS TERMINATED. COBOL NAME: ALCOH-DRG-UNIT-TERM-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 9 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME BEDS - TOTAL 5 265 269 N PROV0740 TOTAL NUMBER OF BEDS IN A FACILITY, INCLUDING THOSE IN NON-PARTICIPATING OR NON-LICENSED AREAS. COBOL NAME: NUM-BEDS BEDS - TOTAL CERTIFIED 5 270 274 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS CERTIFIED RN ANESTHETISTS 7.2 275 281 N PROV0760 NUMBER OF FULL-TIME EQUIVALENT CERTIFIED REGISTERED NURSE ANESTHETISTS (CRNA) EMPLOYED BY A HOSPITAL. COBOL NAME: NUM-CERT-RN-ANEST CLIA - HOSP LAB ID #1 10 282 291 C PROV0130 NUMBER ASSIGNED TO A HOSPITAL LABORATORY LICENSED IN ACCORDANCE WITH THE CLINICAL LABORATORY IMPROVEMENT ACT (CLIA). COBOL NAME: CLIA-ID-NUM-A CLIA - HOSP LAB ID #2 10 292 301 C PROV0135 NUMBER ASSIGNED TO A HOSPITAL LABORATORY LICENSED IN ACCORDANCE WITH THE CLINICAL LABORATORY IMPROVEMENT ACT (CLIA). COBOL NAME: CLIA-ID-NUM-B CLIA - HOSP LAB ID #3 10 302 311 C PROV0140 NUMBER ASSIGNED TO A HOSPITAL LABORATORY LICENSED IN ACCORDANCE WITH THE CLINICAL LABORATORY IMPROVEMENT ACT (CLIA). COBOL NAME: CLIA-ID-NUM-C CLIA - HOSP LAB ID #4 10 312 321 C PROV0145 NUMBER ASSIGNED TO A HOSPITAL LABORATORY LICENSED IN ACCORDANCE WITH THE CLINICAL LABORATORY IMPROVEMENT ACT (CLIA). COBOL NAME: CLIA-ID-NUM-D CLIA - HOSP LAB ID #5 10 322 331 C PROV0150 NUMBER ASSIGNED TO A HOSPITAL LABORATORY LICENSED IN ACCORDANCE WITH THE CLINICAL LABORATORY IMPROVEMENT ACT (CLIA). COBOL NAME: CLIA-ID-NUM-E COMPLIANCE: LIFE SAFETY CODE 1 332 332 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: 1 WAIVER RECOMMENDED COMPLIANCE: SCOPE OF SERVICE 1 333 333 C PROV0280 INDICATES IF A WAIVER OF THE SCOPE OF SERVICES REQUIREMENT HAS BEEN RECOMMENDED FOR A HOSPITAL. COBOL NAME: COMPL-SCOPE-OF-SERV VALUES: 1 WAIVER RECOMMENDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 10 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COMPLIANCE: TECHNICAL PERSONNEL 1 334 334 C PROV0285 INDICATES IF A WAIVER OF THE TECHNICAL PERSONNEL REQUIREMENT HAS BEEN RECOMMENDED FOR A HOSPITAL. COBOL NAME: COMPL-TECH-PERSNL VALUES: 1 WAIVER RECOMMENDED COMPLIANCE: 24 HR REGISTERED NURSE 1 335 335 C PROV0290 INDICATES IF A WAIVER OF THE 24 HOUR REGISTERED NURSE REQUIREMENT HAS BEEN RECOMMENDED FOR A HOSPITAL. COBOL NAME: COMPL-24-HR-RN VALUES: 1 WAIVER RECOMMENDED DATE OF VALIDATION SURVEY 6 336 341 C PROV0450 DATE A VALIDATION SURVEY IS PERFORMED BY THE STATE AGENCY IN A JCAH OR AOA ACCREDITED HOSPITAL. COBOL NAME: DT-VALID-SURVEY DIETITIANS 7.2 342 348 N PROV0820 NUMBER OF FULL-TIME EQUIVALENT DIETITIANS EMPLOYED BY A FACILITY. COBOL NAME: NUM-DIETICIANS FISCAL YEAR ENDING DATE 4 349 352 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT INHALATION THERAPISTS 7.2 353 359 N PROV0950 NUMBER OF FULLTIME EQUIVALENT INHALATION THERAPISTS EMPLOYED BY A HOSPITAL. COBOL NAME: NUM-INHAL-THERAPY LICENSED PRACTICAL NURSES 7.2 360 366 N PROV0955 NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL OR VOCATIONAL NURSES EMPLOYED BY A FACILITY. COBOL NAME: NUM-LPN-LVN MEDICAL SCHOOL AFFILIATION 1 367 367 C PROV0645 THE TYPE OF AFFILIATION THAT A HOSPITAL MAY HAVE WITH A MEDICAL SCHOOL. COBOL NAME: MED-SCHL-AFF VALUES: 1 MAJOR 2 LIMITED 3 GRADUATE 4 NO AFFILIATION MEETS 1861 DEFINITION 1 368 368 C PROV0670 INDICATES IF AN EMERGENCY HOSPITAL MEETS THE DEFINITION OF "HOSPITAL" CONTAINED IN SECTION 1861 OF THE SOCIAL SECURITY ACT. COBOL NAME: MEETS-1861 VALUES: Y MEETS 1861(E)(1) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 11 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OCCUPATIONAL THERAPISTS 7.2 369 375 N PROV1050 THE NUMBER OF FULL TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-OCCUP-THERAPISTS OTHER PERSONNEL 7.2 376 382 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL PARTICIPATING CODE (Y,N) 1 383 383 C PROV1575 THIS CODE INDICATES WHETHER A PROVIDER IS PARTICIPATING IN THE MEDICAID OR MEDICARE PROGRAM. COBOL NAME: PARTICIPATING-CD VALUES: N NON-PARTICIPATING PROVIDER Y PARTICIPATING PROVIDER PHARMACISTS 7.2 384 390 N PROV1100 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PHARMACISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHARMACIST-REG PHYSICAL THERAPISTS 7.2 391 397 N PROV1125 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS-THERAPY PHYSICIAN ASSISTANTS 7.2 398 404 N PROV1115 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIAN ASSISTANTS EMPLOYED BY A HOSPITAL OR RURAL HEALTH CLINIC. COBOL NAME: NUM-PHYS-ASSIST PPS PREVIOUS PROVIDER NUMBER 6 405 410 C PROV1520 A PROVIDER NUMBER PREVIOUSLY ASSIGNED TO A PPS EXEMPT PROVIDER OR UNIT. COBOL NAME: OLD-PROV-NUM PROGRAM PARTICIPATION 1 411 411 C PROV1670 INDICATES IF THE PROVIDER PARTICIPATES IN MEDICARE, MEDICAID, OR BOTH PROGRAMS. COBOL NAME: PROG-PARTCI VALUES: 1 MEDICARE ONLY 2 MEDICAID ONLY 3 MEDICARE AND MEDICAID PSYCHIATRIC UNIT BEDS 3 412 414 N PROV1690 THE NUMBER OF BEDS IN A PPS EXEMPT PSYCHIATRIC UNIT OF A HOSPITAL. COBOL NAME: PSY-UNIT-BED-SZ PSYCHIATRIC UNIT EFFECTIVE DATE 6 415 420 C PROV1695 THE DATE A PSYCHIATRIC UNIT BECAME EXEMPT FROM THE PROSPECTIVE PAYMENT SYSTEM (PPS). COBOL NAME: PSY-UNIT-EFF-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 12 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PSYCHIATRIC UNIT INDICATOR 1 421 421 C PROV1700 INDICATES IF A HOSPITAL HAS A PPS EXEMPT PSYCHIATRIC UNIT. COBOL NAME: PSY-UNIT-IND VALUES: Y PSYCH UNIT PSYCHIATRIC UNIT TERMINATION CODE 1 422 422 C PROV1705 INDICATES THE REASON THAT A PSYCHIATRIC UNIT IS NO LONGER EXEMPT FROM PPS. COBOL NAME: PSY-UNIT-TERM-CD VALUES: 0 ACTIVE 1 VOLUNTARY-MERGER OR CLOSURE 2 VOLUNTARY-DISSATISFIED WITH REIMBURSEMENT 3 RISK OF INVOLUNTARY TERMINATION 4 VOLUNTARY-OTHER 5 FAILURE TO MEET HEALTH/SAFETY 6 FAILURE TO MEET AGREEMENT 7 PROVIDER STATUS CHANGE PSYCHIATRIC UNIT TERMINATION DATE 6 423 428 C PROV1710 THE DATE A PSYCHIATRIC UNIT IS NO LONGER EXEMPT FROM THE PROSPECTIVE PAYMENT SYSTEM. COBOL NAME: PSY-UNIT-TERM-DT REGIONAL OVERRIDE #1 (NUMBER BEDS) 1 429 429 C PROV1545 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-1 VALUES: Y RECORD HAS BEEN APPROVED REGIONAL OVERRIDE #2 (STAFFING) 1 430 430 C PROV1550 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-2 VALUES: Y RECORD HAS BEEN APPROVED REGIONAL OVERRIDE #3 (NURSE - BED) 1 431 431 C PROV1555 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-3 VALUES: Y RECORD HAS BEEN APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 13 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME REGISTERED NURSES 7.2 432 438 N PROV1145 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PROFESSIONAL NURSES EMPLOYED BY A PROVIDER. COBOL NAME: NUM-REG-NURS REHABILITATION UNIT BEDS 3 439 441 N PROV1730 THE NUMBER OF BEDS IN A PPS EXEMPT REHABILITATION UNIT OF A HOSPITAL. COBOL NAME: REHAB-UNIT-BED-SZ REHABILITATION UNIT EFFECT DATE 6 442 447 C PROV1735 THE DATE A REHABILITATION UNIT BECAME EXEMPT FROM THE PROSPECTIVE PAYMENT SYSTEM. COBOL NAME: REHAB-UNIT-EFF-DT REHABILITATION UNIT INDICATOR 1 448 448 C PROV1740 INDICATES IF A HOSPITAL HAS A PPS EXEMPT REHABILITATION UNIT. COBOL NAME: REHAB-UNIT-IND VALUES: Y REHAB UNIT REHABILITATION UNIT TERMINAT CODE 1 449 449 C PROV1745 THIS ELEMENT INDICATES THE REASON FOR A HOSPITAL REHABILITATION UNIT'S TERMINATION OF ITS EXCLUSION STATUS UNDER PROSPECTIVE PAYMENT SYSTEM. COBOL NAME: REHAB-UNIT-TERM-CD VALUES: 0 ACTIVE 1 VOLUNTARY-MERGER OR CLOSURE 2 VOLUNTARY-DISSATISFIED WITH REIMBURSEMENT 3 RISK OF INVOLUNTARY TERMINATION 4 VOLUNTARY-OTHER 5 FAILURE TO MEET HEALTH/SAFETY 6 FAILURE TO MEET AGREEMENT 7 PROVIDER STATUS CHANGE REHABILITATION UNIT TERMINAT DATE 6 450 455 C PROV1750 THIS ELEMENT IS THE DATE THE HOSPITAL'S PSYCHIATRIC UNIT IS NO LONGER EXCLUDED FROM PROSPECTIVE PAYMENT SYSTEM. COBOL NAME: REHAB-UNIT-TERM-DT * RELATED PROVIDER NUMBER 10 456 465 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM RESIDENT PROGRAM APPROVED BY ADA 1 466 466 C PROV1805 INDICATES IF THE RESIDENT PROGRAM AT A HOSPITAL IS APPROVED BY THE AMERICAN DENTAL ASSOCIATION COBOL NAME: RES-PGM-APPR-ADA VALUES: N NOT APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 14 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME Y APPROVED RESIDENT PROGRAM APPROVED BY AMA 1 467 467 C PROV1810 INDICATES IF THE RESIDENT PROGRAM AT A HOSPITAL IS APPROVED BY THE AMERICAN MEDICAL ASSOCIATION. COBOL NAME: RES-PGM-APPR-AMA VALUES: N NOT APPROVED Y APPROVED RESIDENT PROGRAM APPROVED BY AOA 1 468 468 C PROV1815 INDICATES IF THE RESIDENT PROGRAM AT A HOSPITAL IS APPROVED BY THE AMERICAN OSTEOPATHIC ASSOCIATION. COBOL NAME: RES-PGM-APPR-AOA VALUES: N NOT APPROVED Y APPROVED RESIDENT PROGRAM APPROVED BY OTHER 1 469 469 C PROV1820 INDICATES IF THE RESIDENT PROGRAM AT A HOSPITAL IS APPROVED BY OTHER PROFESSIONAL ORGANIZATIONS. COBOL NAME: RES-PGM-APPR-OTHER VALUES: N NOT APPROVED Y APPROVED * RESIDENTS (PHYSICIANS) 7.2 470 476 N PROV1165 THE NUMBER OF FULL-TIME EQUIVALENT RESIDENTS (PHYSICIANS) EMPLOYED BY A HOSPITAL. COBOL NAME: NUM-RESID-PHYS SEPARATE COST ENTITY INDICATOR 1 477 477 C PROV2040 INDICATES IF A HOSPITAL HAS A UNIT IDENTIFIED AS A SEPARATE COST ENTITY. COBOL NAME: SEP-COST-ENTITY-IND VALUES: Y SEPARATE COST ENTITY SRV: ACUTE RENAL DIALYSIS 1 478 478 C PROV2055 INDICATES HOW ACUTE RENAL DIALYSIS SERVICES ARE PROVIDED IN A HOSPITAL. COBOL NAME: SP-ACUTE-REN-DIAL VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: ALCOHOL AND/OR DRUG 1 479 479 C PROV2065 INDICATES HOW ALCOHOL AND/OR DRUG SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-ALCOH-DRUG VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 15 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: ANESTHESIA 1 480 480 C PROV2070 INDICATES HOW ANESTHESIA SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-ANESTH VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: BLOOD BANK 1 481 481 C PROV2080 INDICATES HOW BLOOD BANK SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-BLOOD-BANK VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: BURN CARE UNIT 1 482 482 C PROV2090 INDICATES HOW BURN CARE UNIT SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-BURN-UNIT VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: CHIROPRACTIC 1 483 483 C PROV2100 INDICATES HOW CHIROPRACTIC SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-CHIROPRATIC VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: CORONARY CARE UNIT 1 484 484 C PROV2110 INDICATES HOW CORONARY CARE UNIT SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-CORONARY-CARE VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 16 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: DENTAL 1 485 485 C PROV2120 INDICATES HOW DENTAL SERVICES ARE PROVIDED. COBOL NAME: SP-DENTAL VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: DIETARY 1 486 486 C PROV2130 INDICATES HOW DIETARY SERVICES ARE PROVIDED. COBOL NAME: SP-DIETARY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: EMERGENCY SERVICES(ORGANIZED) 1 487 487 C PROV2140 INDICATES HOW ORGANIZED EMERGENCY SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-EMERG-DEPT VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: HOME CARE UNIT 1 488 488 C PROV2160 INDICATES HOW HOME CARE SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-HOME-CARE-UNIT VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: HOSPICE 1 489 489 C PROV2175 INDICATES HOW HOSPICE SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-HOSPICE VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: INPATIENT SURGICAL 1 490 490 C PROV2190 INDICATES HOW INPATIENT SURGICAL SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-INPAT-SURG VALUES: 0 NOT PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 17 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: INTENSIVE CARE UNIT 1 491 491 C PROV2185 INDICATES HOW INTENSIVE CARE UNIT SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-ICU VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: LABORATORY (ANATOMICAL) 1 492 492 C PROV2205 INDICATES HOW ANATOMICAL LABORATORY SERVICES ARE PROVIDED IN A HOSPITAL. COBOL NAME: SP-LABORATORY-ANATOM VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: LABORATORY (CLINICAL) 1 493 493 C PROV2210 INDICATES HOW CLINICAL LABORATORY SERVICES ARE PROVIDED IN A HOSPITAL. COBOL NAME: SP-LABORATORY-CLINIC VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: LONG TERM CARE UNIT 1 494 494 C PROV2215 INDICATES HOW LONG TERM CARE UNIT SERVICES ARE PROVIDED IN A HOSPITAL. COBOL NAME: SP-LTC-UNIT VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: NEONATAL NURSERY 1 495 495 C PROV2235 INDICATES HOW NEONATAL NURSERY SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-NEONATAL-NURS VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 18 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: NUCLEAR MEDICINE 1 496 496 C PROV2245 INDICATES HOW NUCLEAR MEDICINE SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-NUCLEAR-MED VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: OBSTETRICS 1 497 497 C PROV2265 INDICATES HOW OBSTETRICS SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-OBSTETRICS VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: OPEN HEART SURGERY FACILITY 1 498 498 C PROV2285 INDICATES HOW OPEN HEART SURGERY FACILITY SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-OPEN-HEART-SURG VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: OPERATING ROOMS 1 499 499 C PROV2300 INDICATES HOW OPERATING ROOM SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-OR-ROOMS VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: OPTOMETRIC 1 500 500 C PROV2295 INDICATES HOW OPTOMETRIC SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-OPTOMETRIC VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 19 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: ORGAN BANK 1 501 501 C PROV2310 INDICATES HOW ORGAN BANK SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-ORGAN-BANK VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: ORGAN TRANSPLANT 1 502 502 C PROV2315 INDICATES HOW ORGAN TRANSPLANT SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-ORGAN-TRANS VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: OUTPATIENT 1 503 503 C PROV2350 INDICATES HOW OUTPATIENT SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-OUTPAT VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: OUTPATIENT SURGERY UNIT 1 504 504 C PROV2355 INDICATES HOW OUTPATIENT SURGERY UNIT SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-OUTPAT-SURG VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: PEDIATRIC 1 505 505 C PROV2360 INDICATES HOW PEDIATRIC SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-PEDIATRIC VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 20 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: POSTOPERATIVE RECOVERY ROOM 1 506 506 C PROV2410 INDICATES HOW POSTOPERATIVE RECOVERY ROOM SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-POSTOP-REC-RM VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: PSYCHIATRIC 1 507 507 C PROV2415 INDICATES HOW PSYCHIATRIC SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-PSYCHIATRIC VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: RADIOLOGY (DIAGNOSTIC) 1 508 508 C PROV2440 INDICATES HOW DIAGNOSTIC RADIOLOGY SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-RADIOLOGY-DIAG VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: RADIOLOGY (THERAPEUTIC) 1 509 509 C PROV2445 INDICATES HOW THERAPEUTIC RADIOLOGY SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-RADIOLOGY-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT * SRV: REHABILITATION 1 510 510 C PROV2450 INDICATES HOW REHABILITATION SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-REHABIL VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 21 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: SELF CARE UNIT 1 511 511 C PROV2470 INDICATES HOW SELF CARE UNIT SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-SELF-CARE VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: SHOCK TRAUMA 1 512 512 C PROV2475 INDICATES HOW SHOCK TRAUMA SERVICES ARE PROVIDED BY A HOSPITAL. COBOL NAME: SP-SHOCK-TRAUMA VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SRV: SOCIAL 1 513 513 C PROV2485 INDICATES HOW SOCIAL SERVICES ARE PROVIDED. COBOL NAME: SP-SOCIAL VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT SWING BED INDICATOR 1 514 514 C PROV2795 INDICATES IF A HOSPITAL PROVIDES SWING BED SERVICES - BEDS CAN BE USED FOR EITHER HOSPITAL OR LONG TERM CARE SERVICES. COBOL NAME: SWINGBED-IND VALUES: N NO Y YES SWING BED SIZE CODE 1 515 515 C PROV2800 INDICATES THE SIZE OF A HOSPITAL PROVIDING SWING BED SERVICES. COBOL NAME: SWINGBED-SIZE-CD VALUES: 1 49 OR FEWER BEDS 2 50 TO 99 BEDS TYPE OF FACILITY 2 516 517 C PROV2890 INDICATES THE CATEGORY WHICH REPRESENTS THE TYPE OF FACILITY. COBOL NAME: TYPE-FACILITY VALUES: 01 SHORT - TERM 02 LONG - TERM 03 CHRISTIAN SCIENCE SANITORIUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 22 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 04 PSYCHIATRIC 05 REHABILITATION 06 CHILDRENS 07 ALCOHOL AND/OR DRUG HOSPITAL TYPE OF NON-PARTICIPATING PROVIDER 1 518 518 C PROV0690 INDICATES WHETHER A NON-PARTICIPATING HOSPITAL IS FEDERAL OR OTHER THAN FEDERAL. COBOL NAME: NON-PARTICIPATING-TYPE VALUES: E EMERGENCY HOSPITAL NON-FEDERAL F EMERGENCY HOSPITAL FEDERAL PHYSICAL THERAPISTS 7.2 1118 1124 N PROV1120 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS-THERAPISTS SPEECH PATHOLOGISTS, AUDIOLOGISTS 7.2 1132 1138 N PROV1220 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS OR AUDIOLOGISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-SPEECH-PATH-AUDIO PHYSICIANS 7.2 1470 1476 N PROV1110 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIANS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS SRV: OCCUPATIONAL THERAPY 1 1504 1504 C PROV2270 INDICATES HOW OCCUPATIONAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-OCCUP-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: PHYSICAL THERAPY 1 1510 1510 C PROV2370 INDICATES HOW PHYSICAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICAL-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: RESPIRATORY CARE 1 1519 1519 C PROV2455 INDICATES HOW RESPIRATORY CARE SERVICES ARE PROVIDED. COBOL NAME: SP-RESP-CARE VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 23 HOSPITALS, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: SPEECH PATHOLOGY 1 1524 1524 C PROV2505 INDICATES HOW SPEECH PATHOLOGY SERVICES ARE PROVIDED. COBOL NAME: SP-SPEECH-PATH VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: PHARMACY 1 1552 1552 C PROV2365 INDICATES HOW PHARMACY SERVICES ARE PROVIDED. COBOL NAME: SP-PHARMACY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY STAFF AND UNDER ARRANGEMENT MEDICAL SOCIAL WORKERS 7.2 1597 1603 N PROV0975 NUMBER OF FULL-TIME EQUIVALENT MEDICAL SOCIAL WORKERS EMPLOYED BY A HOSPITAL OR HOSPICE. COBOL NAME: NUM-MED-SOCIAL-WRKS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 1 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 TITLE 18 ONLY 02 TITLE 19 ONLY 03 TITLE 18/19 CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 02 SNF/NF (DUALLY CERTIFIED) CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY AND STATE 31 13 43 C PROV0115 THE CITY AND STATE WHERE A PROVIDER IS LOCATED. COBOL NAME: CITY-STATE COMPLIANCE: PLAN OF CORRECTION 1 44 44 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 45 45 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 46 48 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 49 58 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 2 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT FMS SURVEY DATE 6 59 64 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 CURRENT SURVEY DATE 6 65 70 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 71 71 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 38 72 109 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME * INTERMEDIARY NUMBER 5 110 114 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 3 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICAID VENDOR NUMBER 12 115 126 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A MEDICAID FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 6 127 132 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 133 138 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 139 143 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 4 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PROVIDER NUMBER 10 144 153 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE: MASTER/TRANSACTION 1 154 154 C PROV1720 INDICATES IF A RECORD IS CURRENTLY ON THE MASTER FILE OR THE TRANSACTION FILE. COBOL NAME: RECORD-TYPE VALUES: M MASTER FILE T TRANSACTION FILE REGION CODE 2 155 156 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 157 157 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE CODE (SSA) 2 158 159 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 5 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 54 AFRICA 55 CALIFORNIA 56 CANADA 57 WEST INDIES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 6 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 58 EUROPE 59 MEXICO 60 OCEANIA 61 PHILIPPINES 62 SOUTH AMERICA 63 UNITED STATES POSSESSIONS 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN 67 TEXAS STATES REGION CODE 3 160 162 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 163 200 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 201 210 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE 1 211 211 C PROV2805 THE REASON A FACILITY HAS BEEN TERMINATED FROM THE MEDICARE AND/OR MEDICAID PROGRAMS COBOL NAME: TERM-CD VALUES: 0 ACTIVE 1 VOL-MERG,CLOSE 2 VOL-REIMBURSE 3 VOL-RISK INVOL 4 VOL-OTHER 5 INVOL-FAIL REQ 6 INVOL-AGREEMNT 7 OTH-STATUS CHG TERMINATION DATE 6 212 217 C PROV2810 THE EFFECTIVE DATE OF TERMINATION OF CERTIFICATION OF A FACILITY. COBOL NAME: TERM-DT TYPE OF ACTION 1 218 218 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 7 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 6 COMPLAINT SURVEY TYPE OF CONTROL 2 219 220 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 FOR PROFIT - INDIVIDUAL 02 FOR PROFIT - PARTNERSHIP 03 FOR PROFIT - CORPORATION 04 NONPROFIT - CHURCH RELATED 05 NONPROFIT - CORPORATION 06 NONPROFIT - OTHER 07 GOVERNMENT - STATE 08 GOVERNMENT - COUNTY 09 GOVERNMENT - CITY 10 GOVERNMENT - CITY/COUNTY 11 GOVERNMENT - HOSPITAL DISTRICT 12 GOVERNMENT - FEDERAL ZIP CODE 5 221 225 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 226 227 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 228 230 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 231 233 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 234 234 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE BEDS - TOTAL 5 265 269 N PROV0740 TOTAL NUMBER OF BEDS IN A FACILITY, INCLUDING THOSE IN NON-PARTICIPATING OR NON-LICENSED AREAS. COBOL NAME: NUM-BEDS BEDS - TOTAL CERTIFIED 5 270 274 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS COMPLIANCE: LIFE SAFETY CODE 1 332 332 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: 1 WAIVER RECOMMENDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 8 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FISCAL YEAR ENDING DATE 4 349 352 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT PROGRAM PARTICIPATION 1 411 411 C PROV1670 INDICATES IF THE PROVIDER PARTICIPATES IN MEDICARE, MEDICAID, OR BOTH PROGRAMS. COBOL NAME: PROG-PARTCI VALUES: 1 MEDICARE ONLY 2 MEDICAID ONLY 3 MEDICARE AND MEDICAID REGIONAL OVERRIDE #1 (NUMBER BEDS) 1 429 429 C PROV1545 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-1 VALUES: Y RECORD HAS BEEN APPROVED REGIONAL OVERRIDE #2 (STAFFING) 1 430 430 C PROV1550 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-2 VALUES: Y RECORD HAS BEEN APPROVED REGIONAL OVERRIDE #3 (NURSE - BED) 1 431 431 C PROV1555 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-3 VALUES: Y RECORD HAS BEEN APPROVED * RELATED PROVIDER NUMBER 10 456 465 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM SRV: DENTAL 1 485 485 C PROV2120 INDICATES HOW DENTAL SERVICES ARE PROVIDED. COBOL NAME: SP-DENTAL VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 9 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: DIETARY 1 486 486 C PROV2130 INDICATES HOW DIETARY SERVICES ARE PROVIDED. COBOL NAME: SP-DIETARY VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NON RESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION TYPE OF FACILITY 2 516 517 C PROV2890 INDICATES THE CATEGORY WHICH REPRESENTS THE TYPE OF FACILITY. COBOL NAME: TYPE-FACILITY VALUES: 01 SKILLED NURSING FACILITY (SNF) 03 SNF/NF ACTIVITY THERAPISTS - CONTRACT 7.2 519 525 N PROV0695 THE NUMBER OF FULL TIME EQUIVALENT ACTIVITIES THERAPISTS UNDER CONTRACT TO THE FACILITY COBOL NAME: NUM-ACT-THER-CONTRACT ACTIVITY THERAPISTS - FULL TIME 7.2 526 532 N PROV0700 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES THERAPISTS EMPLOYED FULL TIME BY THE FACILITY COBOL NAME: NUM-ACT-THER-FULL-TIME ACTIVITY THERAPISTS - PART TIME 7.2 533 539 N PROV0705 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES THERAPISTS EMPLOYED PART-TIME BY THE FACILITY. COBOL NAME: NUM-ACT-THER-PART-TIME ADMINISTRATOR - CONTRACT 7.2 540 546 N PROV0710 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-ADMN-CONTRACT ADMINISTRATOR - FULL TIME 7.2 547 553 N PROV0715 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS EMPLOYED ON A FULL TIME BASIS BY THE FACILITY. COBOL NAME: NUM-ADMN-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 10 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ADMINISTRATOR - PART TIME 7.2 554 560 N PROV0720 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS EMPLOYED ON A PART-TIME BASIS BY THE FACILITY. COBOL NAME: NUM-ADMN-PART-TIME ADMISSION SUSPENSION DATE 6 561 566 C PROV0030 THE DATE THAT PAYMENTS FOR NEW ADMISSIONS IN A LONG TERM CARE FACILITY WILL BE DENIED IF AN INTERMEDIATE SANCTION IS TAKEN AGAINST THE FACILITY. COBOL NAME: ADMIN-SUSP-DT AIDES/ORDERLIES - CONTRACT 7.2 567 573 N PROV1000 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-NURSE-AID-CONTRACT AIDES/ORDERLIES - FULL TIME 7.2 574 580 N PROV1005 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES EMPLOYED BY THE FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-AID-FULL-TIME * AIDES/ORDERLIES - PART TIME 7.2 581 587 N PROV1010 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES EMPLOYED BY THE FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-AID-PART-TIME BEDS - MEDICARE SNF 4 588 591 N PROV1445 NUMBER OF MEDICARE CERTIFIED SNF BEDS IN A FACILITY. COBOL NAME: NUM-T18-SNF-BEDS BEDS - NURSING FACILITY 4 592 595 N PROV1455 NUMBER OF MEDICAID CERTIFIED SKILLED NURSING CARE BEDS IN A FACILITY. COBOL NAME: NUM-T19-SNF-BEDS BEDS - SNF/NF 4 596 599 N PROV1450 NUMBER OF BEDS CERTIFIED FOR BOTH MEDICARE AND MEDICAID SKILLED NURSING CARE IN A LONG TERM CARE FACILITY. COBOL NAME: NUM-T1819-SNF-BEDS CHRISTIAN SCIENCE INDICATOR 1 600 600 C PROV0110 INDICATES IF A PROVIDER IS A CHRISTIAN SCIENCE FACILITY COBOL NAME: CHRISTIAN-SCIENCE-IND VALUES: Y CHRISTIAN SCIENCE COMPLIANCE: BEDS PER ROOM WAIVER 1 601 601 C PROV0225 INDICATES IF A WAIVER OF THE BEDS PER ROOM REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-BEDS-PER-ROOM VALUES: 1 WAIVER RECOMMENDED COMPLIANCE: PATIENT ROOM SIZE 1 602 602 C PROV0270 INDICATES IF A WAIVER OF PATIENT ROOM SIZE HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-PATIENT-ROOM-SZ VALUES: 1 WAIVER RECOMMENDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 11 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COMPLIANCE: 7 DAY REGISTERED NURSE 1 603 603 C PROV0295 INDICATES IF A WAIVER OF THE 7 DAY REGISTERED NURSE REQUIREMENTS HAS BEEN RECOMMENDED FOR A SNF OR NF. COBOL NAME: COMPL-7-DAY-RN VALUES: 1 WAIVER RECOMMENDED * DENTISTS - CONTRACT 7.2 604 610 N PROV0785 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DENTIST-CONTRACT * DENTISTS - FULL TIME 7.2 611 617 N PROV0790 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-DENTIST-FULL-TIME * DENTISTS - PART TIME 7.2 618 624 N PROV0795 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-DENTIST-PART-TIME DIETITIANS - CONTRACT 7.2 625 631 N PROV0805 THE NUMBER OF FULL-TIME EQUIVALENT UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DIET-CONTRACT DIETITIANS - FULL TIME 7.2 632 638 N PROV0810 THE NUMBER OF FULL-TIME EQUIVALENT DIETITIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-DIET-FULL-TIME DIETITIANS - PART TIME 7.2 639 645 N PROV0815 THE NUMBER OF FULL-TIME EQUIVALENT DIETITIANS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-DIET-PART-TIME EXPERIMENTAL RESEARCH CONDUCTED 1 646 646 C PROV0465 INDICATES IF A FACILITY USES RESIDENTS TO DEVELOP AND TEST CLINICAL TREATMENTS. COBOL NAME: EXPER-RESEARCH VALUES: N NO Y YES FOOD SERVICE - CONTRACT 7.2 647 653 N PROV0860 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-FOOD-SRV-CONTRACT FOOD SERVICE - FULL TIME 7.2 654 660 N PROV0865 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERIVCE PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-FOOD-SRV-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 12 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FOOD SERVICE - PART TIME 7.2 661 667 N PROV0870 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-FOOD-SRV-PART-TIME HOUSEKEEPING - CONTRACT 7.2 668 674 N PROV0925 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-HOUSE-CONTRACT HOUSEKEEPING - FULL TIME 7.2 675 681 N PROV0930 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-HOUSE-FULL-TIME HOUSEKEEPING - PART TIME 7.2 682 688 N PROV0935 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-HOUSE-PART-TIME LPN/LVN - CONTRACT 7.2 689 695 N PROV1465 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES UNDER CONTRACT TO A FACILITY COBOL NAME: NUM-VOC-NURSE-CONTRACT LPN/LVN - FULL TIME 7.2 696 702 N PROV1470 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-VOC-NURSE-FULL-TIME LPN/LVN - PART TIME 7.2 703 709 N PROV1475 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-VOC-NURSE-PART-TIME LTC AGREEMENT BEGINNING DATE 6 710 715 C PROV0620 THE BEGINNING DATE OF A CERTIFIED LONG TERM CARE FACILI TY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-BEGIN-DT LTC AGREEMENT ENDING DATE 6 716 721 C PROV0625 THE ENDING DATE OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-END-DT LTC AGREEMENT EXTENSION DATE 6 722 727 C PROV0630 THE LAST DATE OF AN EXTENSION OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-EXT-DT LTC CROSS REFERENCE PROVIDER # 6 728 733 C PROV0640 THIS CROSS REFERENCE NUMBER IDENTIFIES LTC PROVIDER NUMBERS THAT WERE TERMINATED IN 1985 BECAUSE OF POLICY CHANGES WHICH STATES THAT SNF/ICF DISTINCT PARTS OR DUA LLY CERTIFIED PORTIONS ARE ASSIGNED SINGLE SNF PROV NO. COBOL NAME: LTC-CROSS-REF-PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 13 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MEDICAL DIRECTOR - CONTRACT 7.2 734 740 N PROV0960 NUMBER OF MEDICAL DIRECTORS UNDER CONTRACT. COBOL NAME: NUM-MED-CONTRACT MEDICAL DIRECTOR - FULL TIME 7.2 741 747 N PROV0965 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MED-FULL-TIME MEDICAL DIRECTOR - PART TIME 7.2 748 754 N PROV0970 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MED-PART-TIME MEDICAL SOCIAL WORKER - CONTRACT 7.2 755 761 N PROV1170 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL SOCIAL WORKERS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-SOCIAL-CONTRACT MEDICAL SOCIAL WORKER - FULL TIME 7.2 762 768 N PROV1175 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL SOCIAL WORKERS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-SOCIAL-FULL-TIME MEDICAL SOCIAL WORKER - PART TIME 7.2 769 775 N PROV1180 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL SOCIAL WORKERS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-SOCIAL-PART-TIME MENTAL HEALTH SERVICES - CONTRACT 7.2 776 782 N PROV0980 THE NUMBER OF FULL-TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-MEN-HLTH-CONTRACT MENTAL HEALTH SERVICES - FULL TIME 7.2 783 789 N PROV0985 THE NUMBER OF FULL-TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MEN-HLTH-FULL-TIME MENTAL HEALTH SERVICES - PART TIME 7.2 790 796 N PROV0990 THE NUMBER OF FULL TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MEN-HLTH-PART-TIME MULTI-FACILITY ORGANIZATION NAME 38 797 834 C PROV0680 THE NAME OF THE MULTI-FACILITY ORGANIZATION THAT OWNS THE FACILITY. COBOL NAME: NAME-MULT-FACL-ORG MULTI-FACILITY ORGANIZATION OWNED 1 835 835 C PROV0675 INDICATES IF A FACILITY IS OWNED BY AN ORGANIZATION THAT OWNS (OR LEASES) TWO OR MORE NURSING FACILITIES. COBOL NAME: MULT-FACL-ORG VALUES: N NO Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 14 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OCCUPATIONAL THERAPIST - CONTRACT 7.2 836 842 N PROV1035 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-THER-CONTRACT OCCUPATIONAL THERAPIST - FULL TIME 7.2 843 849 N PROV1040 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-THER-FULL-TIME OCCUPATIONAL THERAPIST - PART TIME 7.2 850 856 N PROV1045 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-THER-PART-TIME OCCUPATIONAL THERAPY ASST-CONTRACT 7.2 857 863 N PROV1020 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-AID-CONTRACT OCCUPATIONAL THERAPY ASST-FULL 7.2 864 870 N PROV1025 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-AID-FULL-TIME OCCUPATIONAL THERAPY ASST-PART 7.2 871 877 N PROV1030 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-AID-PART-TIME ORGANIZED FAMILY GROUP 1 878 878 C PROV1535 INDICATES IF THE FACILITY HAS AN ORGANIZED GROUP OF FAMILY MEMBERS OF RESIDENTS. COBOL NAME: ORG-FAMILY-GRP VALUES: N NO Y YES * ORGANIZED RESIDENT GROUP 1 879 879 C PROV1540 INDICATES IF THE FACILITY HAS AN ORGANIZED RESIDENTS GROUP. COBOL NAME: ORG-RESID-GRP VALUES: N NO Y YES OTHER PHYSICIAN - CONTRACT 7.2 880 886 N PROV1060 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS UNDER CONTRACT TO A FACILITY COBOL NAME: NUM-OTH-PHY-CONTRACT OTHER PHYSICIAN - FULL TIME 7.2 887 893 N PROV1065 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OTH-PHY-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 15 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OTHER PHYSICIAN - PART TIME 7.2 894 900 N PROV1070 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OTH-PHY-PART-TIME PHARMACISTS - CONTRACT 7.2 901 907 N PROV1085 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-PHAR-CONTRACT PHARMACISTS - FULL TIME 7.2 908 914 N PROV1090 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-PHAR-FULL-TIME PHARMACISTS - PART TIME 7.2 915 921 N PROV1095 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-PHAR-PART-TIME PHYSICAL THERAPISTS - CONTRACT 7.2 922 928 N PROV1430 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-CONTRACT PHYSICAL THERAPISTS - FULL TIME 7.2 929 935 N PROV1435 THE NUMBER OF FULL TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-FULL-TIME PHYSICAL THERAPISTS - PART TIME 7.2 936 942 N PROV1440 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-PART-TIME PHYSICAL THERAPY ASST - CONTRACT 7.2 943 949 N PROV1415 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-AID-CONTRACT PHYSICAL THERAPY ASST - FULL TIME 7.2 950 956 N PROV1420 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-AID-FULL-TIME PHYSICAL THERAPY ASST - PART TIME 7.2 957 963 N PROV1425 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-AID-PART-TIME PODIATRISTS - CONTRACT 7.2 964 970 N PROV1130 THE NUMBER OF FULL TIME EQUIVALENT PODIATRISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-POD-CONTRACT PODIATRISTS - FULL TIME 7.2 971 977 N PROV1135 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A AFCILITY ON A FULL TIME BASIS. COBOL NAME: NUM-POD-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 16 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PODIATRISTS - PART TIME 7.2 978 984 N PROV1140 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-POD-PART-TIME PRIOR ADMISSION SUSPENSION DATE 6 985 990 C PROV1610 PREVIOUS DATE A SUSPENSION OF ADMISSIONS WAS INVOKED FOR A PROVIDER. COBOL NAME: PRIOR-ADMIN-SUSP-DT PRIOR LTC END DATE 6 991 996 C PROV1630 THE LAST DATE OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT FOR A PRIOR SURVEY. COBOL NAME: PRIOR-LTC-END-DT PRIOR LTC EXTENSION DATE 6 997 1002 C PROV1635 THE LAST DATE OF AN EXTENSION OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT FOR A PRIOR SURVEY. COBOL NAME: PRIOR-LTC-EXT-DT PRIOR RESCIND SUSPENSION DATE 6 1003 1008 C PROV1640 THE EFFECTIVE DATE OF A PREVIOUS SUSPENSION OF ADMISSIONS TO A LTC FACILITY. COBOL NAME: PRIOR-RESC-SUSP-DT PROVIDER BASED FACILITY 1 1009 1009 C PROV1675 INDICATES IF A LONG TERM CARE FACILITY IS PROVIDER BASED. COBOL NAME: PROV-BASED-FACILITY VALUES: N NOT HOSPITAL BASED Y HOSPITAL BASED REGISTERED NURSE - CONTRACT 7.2 1010 1016 N PROV1150 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-REG-NURSE-CONTRACT REGISTERED NURSE - FULL TIME 7.2 1017 1023 N PROV1155 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-REG-NURSE-FULL-TIME REGISTERED NURSE - PART TIME 7.2 1024 1030 N PROV1160 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-REG-NURSE-PART-TIME RESCIND SUSPENSION DATE 6 1031 1036 C PROV1825 DATE THAT THE SUPENSION OF PAYMENTS FOR NEW ADMISSIONS TO A LONG TERM CARE FACILITY (LTC) IS RESCINDED. COBOL NAME: RESC-SUSP-DT SPECIAL CARE BEDS-AIDS 3 1037 1039 N PROV0725 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH AIDS. COBOL NAME: NUM-AIDS-BEDS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 17 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPECIAL CARE BEDS-ALZHEIMERS 3 1040 1042 N PROV0730 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH ALZEHEIMERS. COBOL NAME: NUM-ALZHEIMERS-BEDS SPECIAL CARE BEDS-DIALYSIS 3 1043 1045 N PROV0800 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS NEEDING DIALYSIS. COBOL NAME: NUM-DIAL-BEDS SPECIAL CARE BEDS-DISABLED CHILD 3 1046 1048 N PROV0855 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR DEISCABLED CHILDREN. COBOL NAME: NUM-DIS-CHILD-BEDS SPECIAL CARE BEDS-HEAD TRAUMA 3 1049 1051 N PROV0905 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILTY FOR RESIDENTS WITH HEAD TRAUMA. COBOL NAME: NUM-HEAD-TRAUMA-BEDS SPECIAL CARE BEDS-HOSPICE 3 1052 1054 N PROV0920 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY A FACILITY FOR RESIDENTS NEEDING HOSPICE SERVICES. COBOL NAME: NUM-HOSPICE-BEDS SPECIAL CARE BEDS-HUNTINGTONS 3 1055 1057 N PROV0940 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH HUNTINGTON'S DISEASE COBOL NAME: NUM-HUNTING-DIS-BEDS SPECIAL CARE BEDS-SPEC REHAB 3 1058 1060 N PROV1205 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH SPECIALIZED REHAB NEEDS. COBOL NAME: NUM-SPEC-REHAB-BEDS SPECIAL CARE BEDS-VENTILATOR 3 1061 1063 N PROV1460 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH VENTILATOR/ RESIPIRATORY CARE NEEDS. COBOL NAME: NUM-VENT-RESP-BEDS SPEECH PATHOLOGIST - CONTRACT 7.2 1064 1070 N PROV1190 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-SPCH-PATH-CONTRACT SPEECH PATHOLOGIST - FULL TIME 7.2 1071 1077 N PROV1195 THE NUMBER OF FULL-TIME EQUIVALENT SPPECH PATHOLOGISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-SPCH-PATH-FULL-TIME SPEECH PATHOLOGIST - PART TIME 7.2 1078 1084 N PROV1200 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-SPCH-PATH-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 18 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: ACTIVITIES THERAPY 1 1085 1085 C PROV2050 INDICATES HOW ACTIVITIES THERAPY SERIVICES ARE PROVIDED IN A FACILITY. COBOL NAME: SP-ACT-THERAPISTS VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF & UNDER ARRANGEMENT 7 COMBINATION SRV: ADMINISTRATION/STORAGE BLOOD 1 1086 1086 C PROV2060 INDICATES HOW ADMINISTRATION AND STORAGE OF BLOOD SERVICES ARE PROVIDED IN A LONG TERM CARE FACILITY. COBOL NAME: SP-ADMIN-STORE-BLOOD VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: CLINICAL LABS 1 1087 1087 C PROV2105 INDICATES HOW CLINICAL LABORATORY SERVICES ARE PROVIDED BY A FACILITY. COBOL NAME: SP-CLINICAL-LAB VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: DIAGNOSTIC X-RAY 1 1088 1088 C PROV2125 INDICATES HOW DIAGNOSTIC XRAY SERVICES ARE PROVIDED BY A LONG TERM CARE FACILITY. COBOL NAME: SP-DIAGN-XRAY VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 19 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: HOUSEKEEPING 1 1089 1089 C PROV2180 INDICATES HOW HOUSEKEEPING SERVICES ARE PROVIDED. COBOL NAME: SP-HOUSE-KEEP VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 7 COMBINATION SRV: MENTAL HEALTH 1 1090 1090 C PROV2230 INDICATES HOW MENTAL HEALTH SERVICES ARE PROVIDED. COBOL NAME: SP-MEN-HLTH VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: PODIATRY 1 1091 1091 C PROV2405 INDICATES HOW PODIATRY SERVICES ARE PROVIDED BY A LONG TERM CARE FACILITY. COBOL NAME: SP-PODIATRY VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NON RESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: MEDICAL SOCIAL 1 1142 1142 C PROV2220 INDICATES HOW MEDICAL SOCIAL SERVICES ARE PROVIDED COBOL NAME: SP-MEDICAL-SOCIAL VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 20 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 7 COMBINATION SRV: NURSING 1 1143 1143 C PROV2250 INDICATES HOW NURSING SERVICES ARE PROVIDED. COBOL NAME: SP-NURSING VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: VOCATIONAL GUIDANCE 1 1146 1146 C PROV2535 INDICATES HOW VOCATIONAL GUIDANCE SERVICES ARE PROVIDED COBOL NAME: SP-VOCAT-GUIDANCE VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION DIRECT CARE PERSONNEL 7.2 1436 1442 N PROV0780 NUMBER OF FULL-TIME EQUIVALENT DIRECT CARE PERSONNEL EMPLOYED BY AN INTERMEDIATE CARE FACILITY FOR THE MENTALLY RETARDED. COBOL NAME: NUM-DCARE-PERSNL SRV: OCCUPATIONAL THERAPY 1 1504 1504 C PROV2270 INDICATES HOW OCCUPATIONAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-OCCUP-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NON RESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: PHYSICAL THERAPY 1 1510 1510 C PROV2370 INDICATES HOW PHYSICAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICAL-THERAPY VALUES: 0 NOT PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 21 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: PHYSICIAN 1 1513 1513 C PROV2385 INDICATES HOW PHYSICIAN SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICIAN VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: SPEECH PATHOLOGY 1 1524 1524 C PROV2505 INDICATES HOW SPEECH PATHOLOGY SERVICES ARE PROVIDED. COBOL NAME: SP-SPEECH-PATH VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: OTHER 1 1551 1551 C PROV2340 INDICATES HOW OTHER (NOT SPECIFIED) SERVICES ARE PROVIDED. COBOL NAME: SP-OTHER VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: PHARMACY 1 1552 1552 C PROV2365 INDICATES HOW PHARMACY SERVICES ARE PROVIDED. COBOL NAME: SP-PHARMACY VALUES: 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 22 SNF/NF (DUALLY CERTIFIED), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 1 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 TITLE 18 ONLY 02 TITLE 19 ONLY 03 TITLE 18/19 CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 03 SNF/NF (DISTINCT PART) CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY AND STATE 31 13 43 C PROV0115 THE CITY AND STATE WHERE A PROVIDER IS LOCATED. COBOL NAME: CITY-STATE COMPLIANCE: PLAN OF CORRECTION 1 44 44 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 45 45 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 46 48 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 49 58 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 2 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT FMS SURVEY DATE 6 59 64 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 CURRENT SURVEY DATE 6 65 70 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 71 71 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 38 72 109 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME * INTERMEDIARY NUMBER 5 110 114 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 3 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICAID VENDOR NUMBER 12 115 126 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A MEDICAID FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 6 127 132 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 133 138 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 139 143 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 4 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PROVIDER NUMBER 10 144 153 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE: MASTER/TRANSACTION 1 154 154 C PROV1720 INDICATES IF A RECORD IS CURRENTLY ON THE MASTER FILE OR THE TRANSACTION FILE. COBOL NAME: RECORD-TYPE VALUES: M MASTER FILE T TRANSACTION FILE REGION CODE 2 155 156 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 157 157 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE CODE (SSA) 2 158 159 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 5 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 54 AFRICA 55 CALIFORNIA 56 CANADA 57 WEST INDIES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 6 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 58 EUROPE 59 MEXICO 60 OCEANIA 61 PHILIPPINES 62 SOUTH AMERICA 63 UNITED STATES POSSESSIONS 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN 67 TEXAS STATES REGION CODE 3 160 162 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 163 200 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 201 210 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE 1 211 211 C PROV2805 THE REASON A FACILITY HAS BEEN TERMINATED FROM THE MEDICARE AND/OR MEDICAID PROGRAMS COBOL NAME: TERM-CD VALUES: 0 ACTIVE 1 VOL-MERG,CLOSE 2 VOL-REIMBURSE 3 VOL-RISK INVOL 4 VOL-OTHER 5 INVOL-FAIL REQ 6 INVOL-AGREEMNT 7 OTH-STATUS CHG TERMINATION DATE 6 212 217 C PROV2810 THE EFFECTIVE DATE OF TERMINATION OF CERTIFICATION OF A FACILITY. COBOL NAME: TERM-DT TYPE OF ACTION 1 218 218 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 7 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 6 COMPLAINT SURVEY TYPE OF CONTROL 2 219 220 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 FOR PROFIT - INDIVIDUAL 02 FOR PROFIT - PARTNERSHIP 03 FOR PROFIT - CORPORATION 04 NONPROFIT - CHURCH RELATED 05 NONPROFIT - CORPORATION 06 NONPROFIT - OTHER 07 GOVERNMENT - STATE 08 GOVERNMENT - COUNTY 09 GOVERNMENT - CITY 10 GOVERNMENT - CITY/COUNTY 11 GOVERNMENT - HOSPITAL DISTRICT 12 GOVERNMENT - FEDERAL ZIP CODE 5 221 225 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 226 227 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 228 230 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 231 233 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 234 234 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE BEDS - TOTAL 5 265 269 N PROV0740 TOTAL NUMBER OF BEDS IN A FACILITY, INCLUDING THOSE IN NON-PARTICIPATING OR NON-LICENSED AREAS. COBOL NAME: NUM-BEDS BEDS - TOTAL CERTIFIED 5 270 274 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS COMPLIANCE: LIFE SAFETY CODE 1 332 332 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: 1 WAIVER RECOMMENDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 8 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FISCAL YEAR ENDING DATE 4 349 352 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT PROGRAM PARTICIPATION 1 411 411 C PROV1670 INDICATES IF THE PROVIDER PARTICIPATES IN MEDICARE, MEDICAID, OR BOTH PROGRAMS. COBOL NAME: PROG-PARTCI VALUES: 1 MEDICARE ONLY 2 MEDICAID ONLY 3 MEDICARE AND MEDICAID REGIONAL OVERRIDE #1 (NUMBER BEDS) 1 429 429 C PROV1545 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-1 VALUES: Y RECORD HAS BEEN APPROVED REGIONAL OVERRIDE #2 (STAFFING) 1 430 430 C PROV1550 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-2 VALUES: Y RECORD HAS BEEN APPROVED REGIONAL OVERRIDE #3 (NURSE - BED) 1 431 431 C PROV1555 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-3 VALUES: Y RECORD HAS BEEN APPROVED * RELATED PROVIDER NUMBER 10 456 465 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM SRV: DENTAL 1 485 485 C PROV2120 INDICATES HOW DENTAL SERVICES ARE PROVIDED. COBOL NAME: SP-DENTAL VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 9 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: DIETARY 1 486 486 C PROV2130 INDICATES HOW DIETARY SERVICES ARE PROVIDED. COBOL NAME: SP-DIETARY VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NON RESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION TYPE OF FACILITY 2 516 517 C PROV2890 INDICATES THE CATEGORY WHICH REPRESENTS THE TYPE OF FACILITY. COBOL NAME: TYPE-FACILITY VALUES: 01 SKILLED NURSING FACILITY (SNF) 03 SNF/NF ACTIVITY THERAPISTS - CONTRACT 7.2 519 525 N PROV0695 THE NUMBER OF FULL TIME EQUIVALENT ACTIVITIES THERAPISTS UNDER CONTRACT TO THE FACILITY COBOL NAME: NUM-ACT-THER-CONTRACT ACTIVITY THERAPISTS - FULL TIME 7.2 526 532 N PROV0700 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES THERAPISTS EMPLOYED FULL TIME BY THE FACILITY COBOL NAME: NUM-ACT-THER-FULL-TIME ACTIVITY THERAPISTS - PART TIME 7.2 533 539 N PROV0705 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES THERAPISTS EMPLOYED PART-TIME BY THE FACILITY. COBOL NAME: NUM-ACT-THER-PART-TIME ADMINISTRATOR - CONTRACT 7.2 540 546 N PROV0710 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-ADMN-CONTRACT ADMINISTRATOR - FULL TIME 7.2 547 553 N PROV0715 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS EMPLOYED ON A FULL TIME BASIS BY THE FACILITY. COBOL NAME: NUM-ADMN-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 10 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ADMINISTRATOR - PART TIME 7.2 554 560 N PROV0720 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS EMPLOYED ON A PART-TIME BASIS BY THE FACILITY. COBOL NAME: NUM-ADMN-PART-TIME ADMISSION SUSPENSION DATE 6 561 566 C PROV0030 THE DATE THAT PAYMENTS FOR NEW ADMISSIONS IN A LONG TERM CARE FACILITY WILL BE DENIED IF AN INTERMEDIATE SANCTION IS TAKEN AGAINST THE FACILITY. COBOL NAME: ADMIN-SUSP-DT AIDES/ORDERLIES - CONTRACT 7.2 567 573 N PROV1000 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-NURSE-AID-CONTRACT AIDES/ORDERLIES - FULL TIME 7.2 574 580 N PROV1005 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES EMPLOYED BY THE FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-AID-FULL-TIME * AIDES/ORDERLIES - PART TIME 7.2 581 587 N PROV1010 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES EMPLOYED BY THE FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-AID-PART-TIME BEDS - MEDICARE SNF 4 588 591 N PROV1445 NUMBER OF MEDICARE CERTIFIED SNF BEDS IN A FACILITY. COBOL NAME: NUM-T18-SNF-BEDS BEDS - NURSING FACILITY 4 592 595 N PROV1455 NUMBER OF MEDICAID CERTIFIED SKILLED NURSING CARE BEDS IN A FACILITY. COBOL NAME: NUM-T19-SNF-BEDS BEDS - SNF/NF 4 596 599 N PROV1450 NUMBER OF BEDS CERTIFIED FOR BOTH MEDICARE AND MEDICAID SKILLED NURSING CARE IN A LONG TERM CARE FACILITY. COBOL NAME: NUM-T1819-SNF-BEDS CHRISTIAN SCIENCE INDICATOR 1 600 600 C PROV0110 INDICATES IF A PROVIDER IS A CHRISTIAN SCIENCE FACILITY COBOL NAME: CHRISTIAN-SCIENCE-IND VALUES: Y CHRISTIAN SCIENCE COMPLIANCE: BEDS PER ROOM WAIVER 1 601 601 C PROV0225 INDICATES IF A WAIVER OF THE BEDS PER ROOM REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-BEDS-PER-ROOM VALUES: 1 WAIVER RECOMMENDED COMPLIANCE: PATIENT ROOM SIZE 1 602 602 C PROV0270 INDICATES IF A WAIVER OF PATIENT ROOM SIZE HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-PATIENT-ROOM-SZ VALUES: 1 WAIVER RECOMMENDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 11 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COMPLIANCE: 7 DAY REGISTERED NURSE 1 603 603 C PROV0295 INDICATES IF A WAIVER OF THE 7 DAY REGISTERED NURSE REQUIREMENTS HAS BEEN RECOMMENDED FOR A SNF OR NF. COBOL NAME: COMPL-7-DAY-RN VALUES: 1 WAIVER RECOMMENDED * DENTISTS - CONTRACT 7.2 604 610 N PROV0785 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DENTIST-CONTRACT * DENTISTS - FULL TIME 7.2 611 617 N PROV0790 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-DENTIST-FULL-TIME * DENTISTS - PART TIME 7.2 618 624 N PROV0795 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-DENTIST-PART-TIME DIETITIANS - CONTRACT 7.2 625 631 N PROV0805 THE NUMBER OF FULL-TIME EQUIVALENT UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DIET-CONTRACT DIETITIANS - FULL TIME 7.2 632 638 N PROV0810 THE NUMBER OF FULL-TIME EQUIVALENT DIETITIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-DIET-FULL-TIME DIETITIANS - PART TIME 7.2 639 645 N PROV0815 THE NUMBER OF FULL-TIME EQUIVALENT DIETITIANS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-DIET-PART-TIME EXPERIMENTAL RESEARCH CONDUCTED 1 646 646 C PROV0465 INDICATES IF A FACILITY USES RESIDENTS TO DEVELOP AND TEST CLINICAL TREATMENTS. COBOL NAME: EXPER-RESEARCH VALUES: N NO Y YES FOOD SERVICE - CONTRACT 7.2 647 653 N PROV0860 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-FOOD-SRV-CONTRACT FOOD SERVICE - FULL TIME 7.2 654 660 N PROV0865 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERIVCE PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-FOOD-SRV-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 12 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FOOD SERVICE - PART TIME 7.2 661 667 N PROV0870 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-FOOD-SRV-PART-TIME HOUSEKEEPING - CONTRACT 7.2 668 674 N PROV0925 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-HOUSE-CONTRACT HOUSEKEEPING - FULL TIME 7.2 675 681 N PROV0930 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-HOUSE-FULL-TIME HOUSEKEEPING - PART TIME 7.2 682 688 N PROV0935 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-HOUSE-PART-TIME LPN/LVN - CONTRACT 7.2 689 695 N PROV1465 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES UNDER CONTRACT TO A FACILITY COBOL NAME: NUM-VOC-NURSE-CONTRACT LPN/LVN - FULL TIME 7.2 696 702 N PROV1470 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-VOC-NURSE-FULL-TIME LPN/LVN - PART TIME 7.2 703 709 N PROV1475 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-VOC-NURSE-PART-TIME LTC AGREEMENT BEGINNING DATE 6 710 715 C PROV0620 THE BEGINNING DATE OF A CERTIFIED LONG TERM CARE FACILI TY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-BEGIN-DT LTC AGREEMENT ENDING DATE 6 716 721 C PROV0625 THE ENDING DATE OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-END-DT LTC AGREEMENT EXTENSION DATE 6 722 727 C PROV0630 THE LAST DATE OF AN EXTENSION OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-EXT-DT LTC CROSS REFERENCE PROVIDER # 6 728 733 C PROV0640 THIS CROSS REFERENCE NUMBER IDENTIFIES LTC PROVIDER NUMBERS THAT WERE TERMINATED IN 1985 BECAUSE OF POLICY CHANGES WHICH STATES THAT SNF/ICF DISTINCT PARTS OR DUA LLY CERTIFIED PORTIONS ARE ASSIGNED SINGLE SNF PROV NO. COBOL NAME: LTC-CROSS-REF-PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 13 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MEDICAL DIRECTOR - CONTRACT 7.2 734 740 N PROV0960 NUMBER OF MEDICAL DIRECTORS UNDER CONTRACT. COBOL NAME: NUM-MED-CONTRACT MEDICAL DIRECTOR - FULL TIME 7.2 741 747 N PROV0965 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MED-FULL-TIME MEDICAL DIRECTOR - PART TIME 7.2 748 754 N PROV0970 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MED-PART-TIME MEDICAL SOCIAL WORKER - CONTRACT 7.2 755 761 N PROV1170 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL SOCIAL WORKERS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-SOCIAL-CONTRACT MEDICAL SOCIAL WORKER - FULL TIME 7.2 762 768 N PROV1175 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL SOCIAL WORKERS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-SOCIAL-FULL-TIME MEDICAL SOCIAL WORKER - PART TIME 7.2 769 775 N PROV1180 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL SOCIAL WORKERS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-SOCIAL-PART-TIME MENTAL HEALTH SERVICES - CONTRACT 7.2 776 782 N PROV0980 THE NUMBER OF FULL-TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-MEN-HLTH-CONTRACT MENTAL HEALTH SERVICES - FULL TIME 7.2 783 789 N PROV0985 THE NUMBER OF FULL-TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MEN-HLTH-FULL-TIME MENTAL HEALTH SERVICES - PART TIME 7.2 790 796 N PROV0990 THE NUMBER OF FULL TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MEN-HLTH-PART-TIME MULTI-FACILITY ORGANIZATION NAME 38 797 834 C PROV0680 THE NAME OF THE MULTI-FACILITY ORGANIZATION THAT OWNS THE FACILITY. COBOL NAME: NAME-MULT-FACL-ORG MULTI-FACILITY ORGANIZATION OWNED 1 835 835 C PROV0675 INDICATES IF A FACILITY IS OWNED BY AN ORGANIZATION THAT OWNS (OR LEASES) TWO OR MORE NURSING FACILITIES. COBOL NAME: MULT-FACL-ORG VALUES: N NO Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 14 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OCCUPATIONAL THERAPIST - CONTRACT 7.2 836 842 N PROV1035 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-THER-CONTRACT OCCUPATIONAL THERAPIST - FULL TIME 7.2 843 849 N PROV1040 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-THER-FULL-TIME OCCUPATIONAL THERAPIST - PART TIME 7.2 850 856 N PROV1045 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-THER-PART-TIME OCCUPATIONAL THERAPY ASST-CONTRACT 7.2 857 863 N PROV1020 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-AID-CONTRACT OCCUPATIONAL THERAPY ASST-FULL 7.2 864 870 N PROV1025 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-AID-FULL-TIME OCCUPATIONAL THERAPY ASST-PART 7.2 871 877 N PROV1030 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-AID-PART-TIME ORGANIZED FAMILY GROUP 1 878 878 C PROV1535 INDICATES IF THE FACILITY HAS AN ORGANIZED GROUP OF FAMILY MEMBERS OF RESIDENTS. COBOL NAME: ORG-FAMILY-GRP VALUES: N NO Y YES * ORGANIZED RESIDENT GROUP 1 879 879 C PROV1540 INDICATES IF THE FACILITY HAS AN ORGANIZED RESIDENTS GROUP. COBOL NAME: ORG-RESID-GRP VALUES: N NO Y YES OTHER PHYSICIAN - CONTRACT 7.2 880 886 N PROV1060 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS UNDER CONTRACT TO A FACILITY COBOL NAME: NUM-OTH-PHY-CONTRACT OTHER PHYSICIAN - FULL TIME 7.2 887 893 N PROV1065 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OTH-PHY-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 15 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OTHER PHYSICIAN - PART TIME 7.2 894 900 N PROV1070 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OTH-PHY-PART-TIME PHARMACISTS - CONTRACT 7.2 901 907 N PROV1085 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-PHAR-CONTRACT PHARMACISTS - FULL TIME 7.2 908 914 N PROV1090 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-PHAR-FULL-TIME PHARMACISTS - PART TIME 7.2 915 921 N PROV1095 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-PHAR-PART-TIME PHYSICAL THERAPISTS - CONTRACT 7.2 922 928 N PROV1430 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-CONTRACT PHYSICAL THERAPISTS - FULL TIME 7.2 929 935 N PROV1435 THE NUMBER OF FULL TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-FULL-TIME PHYSICAL THERAPISTS - PART TIME 7.2 936 942 N PROV1440 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-PART-TIME PHYSICAL THERAPY ASST - CONTRACT 7.2 943 949 N PROV1415 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-AID-CONTRACT PHYSICAL THERAPY ASST - FULL TIME 7.2 950 956 N PROV1420 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-AID-FULL-TIME PHYSICAL THERAPY ASST - PART TIME 7.2 957 963 N PROV1425 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-AID-PART-TIME PODIATRISTS - CONTRACT 7.2 964 970 N PROV1130 THE NUMBER OF FULL TIME EQUIVALENT PODIATRISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-POD-CONTRACT PODIATRISTS - FULL TIME 7.2 971 977 N PROV1135 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A AFCILITY ON A FULL TIME BASIS. COBOL NAME: NUM-POD-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 16 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PODIATRISTS - PART TIME 7.2 978 984 N PROV1140 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-POD-PART-TIME PRIOR ADMISSION SUSPENSION DATE 6 985 990 C PROV1610 PREVIOUS DATE A SUSPENSION OF ADMISSIONS WAS INVOKED FOR A PROVIDER. COBOL NAME: PRIOR-ADMIN-SUSP-DT PRIOR LTC END DATE 6 991 996 C PROV1630 THE LAST DATE OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT FOR A PRIOR SURVEY. COBOL NAME: PRIOR-LTC-END-DT PRIOR LTC EXTENSION DATE 6 997 1002 C PROV1635 THE LAST DATE OF AN EXTENSION OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT FOR A PRIOR SURVEY. COBOL NAME: PRIOR-LTC-EXT-DT PRIOR RESCIND SUSPENSION DATE 6 1003 1008 C PROV1640 THE EFFECTIVE DATE OF A PREVIOUS SUSPENSION OF ADMISSIONS TO A LTC FACILITY. COBOL NAME: PRIOR-RESC-SUSP-DT PROVIDER BASED FACILITY 1 1009 1009 C PROV1675 INDICATES IF A LONG TERM CARE FACILITY IS PROVIDER BASED. COBOL NAME: PROV-BASED-FACILITY VALUES: N NOT HOSPITAL BASED Y HOSPITAL BASED REGISTERED NURSE - CONTRACT 7.2 1010 1016 N PROV1150 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-REG-NURSE-CONTRACT REGISTERED NURSE - FULL TIME 7.2 1017 1023 N PROV1155 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-REG-NURSE-FULL-TIME REGISTERED NURSE - PART TIME 7.2 1024 1030 N PROV1160 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-REG-NURSE-PART-TIME RESCIND SUSPENSION DATE 6 1031 1036 C PROV1825 DATE THAT THE SUPENSION OF PAYMENTS FOR NEW ADMISSIONS TO A LONG TERM CARE FACILITY (LTC) IS RESCINDED. COBOL NAME: RESC-SUSP-DT SPECIAL CARE BEDS-AIDS 3 1037 1039 N PROV0725 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH AIDS. COBOL NAME: NUM-AIDS-BEDS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 17 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPECIAL CARE BEDS-ALZHEIMERS 3 1040 1042 N PROV0730 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH ALZEHEIMERS. COBOL NAME: NUM-ALZHEIMERS-BEDS SPECIAL CARE BEDS-DIALYSIS 3 1043 1045 N PROV0800 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS NEEDING DIALYSIS. COBOL NAME: NUM-DIAL-BEDS SPECIAL CARE BEDS-DISABLED CHILD 3 1046 1048 N PROV0855 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR DEISCABLED CHILDREN. COBOL NAME: NUM-DIS-CHILD-BEDS SPECIAL CARE BEDS-HEAD TRAUMA 3 1049 1051 N PROV0905 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILTY FOR RESIDENTS WITH HEAD TRAUMA. COBOL NAME: NUM-HEAD-TRAUMA-BEDS SPECIAL CARE BEDS-HOSPICE 3 1052 1054 N PROV0920 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY A FACILITY FOR RESIDENTS NEEDING HOSPICE SERVICES. COBOL NAME: NUM-HOSPICE-BEDS SPECIAL CARE BEDS-HUNTINGTONS 3 1055 1057 N PROV0940 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH HUNTINGTON'S DISEASE COBOL NAME: NUM-HUNTING-DIS-BEDS SPECIAL CARE BEDS-SPEC REHAB 3 1058 1060 N PROV1205 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH SPECIALIZED REHAB NEEDS. COBOL NAME: NUM-SPEC-REHAB-BEDS SPECIAL CARE BEDS-VENTILATOR 3 1061 1063 N PROV1460 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH VENTILATOR/ RESIPIRATORY CARE NEEDS. COBOL NAME: NUM-VENT-RESP-BEDS SPEECH PATHOLOGIST - CONTRACT 7.2 1064 1070 N PROV1190 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-SPCH-PATH-CONTRACT SPEECH PATHOLOGIST - FULL TIME 7.2 1071 1077 N PROV1195 THE NUMBER OF FULL-TIME EQUIVALENT SPPECH PATHOLOGISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-SPCH-PATH-FULL-TIME SPEECH PATHOLOGIST - PART TIME 7.2 1078 1084 N PROV1200 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-SPCH-PATH-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 18 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: ACTIVITIES THERAPY 1 1085 1085 C PROV2050 INDICATES HOW ACTIVITIES THERAPY SERIVICES ARE PROVIDED IN A FACILITY. COBOL NAME: SP-ACT-THERAPISTS VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF & UNDER ARRANGEMENT 7 COMBINATION SRV: ADMINISTRATION/STORAGE BLOOD 1 1086 1086 C PROV2060 INDICATES HOW ADMINISTRATION AND STORAGE OF BLOOD SERVICES ARE PROVIDED IN A LONG TERM CARE FACILITY. COBOL NAME: SP-ADMIN-STORE-BLOOD VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: CLINICAL LABS 1 1087 1087 C PROV2105 INDICATES HOW CLINICAL LABORATORY SERVICES ARE PROVIDED BY A FACILITY. COBOL NAME: SP-CLINICAL-LAB VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: DIAGNOSTIC X-RAY 1 1088 1088 C PROV2125 INDICATES HOW DIAGNOSTIC XRAY SERVICES ARE PROVIDED BY A LONG TERM CARE FACILITY. COBOL NAME: SP-DIAGN-XRAY VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 19 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: HOUSEKEEPING 1 1089 1089 C PROV2180 INDICATES HOW HOUSEKEEPING SERVICES ARE PROVIDED. COBOL NAME: SP-HOUSE-KEEP VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 7 COMBINATION SRV: MENTAL HEALTH 1 1090 1090 C PROV2230 INDICATES HOW MENTAL HEALTH SERVICES ARE PROVIDED. COBOL NAME: SP-MEN-HLTH VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: PODIATRY 1 1091 1091 C PROV2405 INDICATES HOW PODIATRY SERVICES ARE PROVIDED BY A LONG TERM CARE FACILITY. COBOL NAME: SP-PODIATRY VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NON RESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: MEDICAL SOCIAL 1 1142 1142 C PROV2220 INDICATES HOW MEDICAL SOCIAL SERVICES ARE PROVIDED COBOL NAME: SP-MEDICAL-SOCIAL VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 20 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 7 COMBINATION SRV: NURSING 1 1143 1143 C PROV2250 INDICATES HOW NURSING SERVICES ARE PROVIDED. COBOL NAME: SP-NURSING VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: VOCATIONAL GUIDANCE 1 1146 1146 C PROV2535 INDICATES HOW VOCATIONAL GUIDANCE SERVICES ARE PROVIDED COBOL NAME: SP-VOCAT-GUIDANCE VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION DIRECT CARE PERSONNEL 7.2 1436 1442 N PROV0780 NUMBER OF FULL-TIME EQUIVALENT DIRECT CARE PERSONNEL EMPLOYED BY AN INTERMEDIATE CARE FACILITY FOR THE MENTALLY RETARDED. COBOL NAME: NUM-DCARE-PERSNL SRV: OCCUPATIONAL THERAPY 1 1504 1504 C PROV2270 INDICATES HOW OCCUPATIONAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-OCCUP-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NON RESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: PHYSICAL THERAPY 1 1510 1510 C PROV2370 INDICATES HOW PHYSICAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICAL-THERAPY VALUES: 0 NOT PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 21 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: PHYSICIAN 1 1513 1513 C PROV2385 INDICATES HOW PHYSICIAN SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICIAN VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: SPEECH PATHOLOGY 1 1524 1524 C PROV2505 INDICATES HOW SPEECH PATHOLOGY SERVICES ARE PROVIDED. COBOL NAME: SP-SPEECH-PATH VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: OTHER 1 1551 1551 C PROV2340 INDICATES HOW OTHER (NOT SPECIFIED) SERVICES ARE PROVIDED. COBOL NAME: SP-OTHER VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: PHARMACY 1 1552 1552 C PROV2365 INDICATES HOW PHARMACY SERVICES ARE PROVIDED. COBOL NAME: SP-PHARMACY VALUES: 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 22 SNF/NF (DISTINCT PART), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 1 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 TITLE 18 ONLY 02 TITLE 19 ONLY 03 TITLE 18/19 CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 04 SKILLED NURSING FACILITIES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY AND STATE 31 13 43 C PROV0115 THE CITY AND STATE WHERE A PROVIDER IS LOCATED. COBOL NAME: CITY-STATE COMPLIANCE: PLAN OF CORRECTION 1 44 44 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 45 45 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 46 48 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 49 58 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 2 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT FMS SURVEY DATE 6 59 64 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 CURRENT SURVEY DATE 6 65 70 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 71 71 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 38 72 109 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME * INTERMEDIARY NUMBER 5 110 114 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 3 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICAID VENDOR NUMBER 12 115 126 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A MEDICAID FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 6 127 132 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 133 138 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 139 143 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 4 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PROVIDER NUMBER 10 144 153 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE: MASTER/TRANSACTION 1 154 154 C PROV1720 INDICATES IF A RECORD IS CURRENTLY ON THE MASTER FILE OR THE TRANSACTION FILE. COBOL NAME: RECORD-TYPE VALUES: M MASTER FILE T TRANSACTION FILE REGION CODE 2 155 156 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 157 157 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE CODE (SSA) 2 158 159 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 5 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 54 AFRICA 55 CALIFORNIA 56 CANADA 57 WEST INDIES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 6 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 58 EUROPE 59 MEXICO 60 OCEANIA 61 PHILIPPINES 62 SOUTH AMERICA 63 UNITED STATES POSSESSIONS 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN 67 TEXAS STATES REGION CODE 3 160 162 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 163 200 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 201 210 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE 1 211 211 C PROV2805 THE REASON A FACILITY HAS BEEN TERMINATED FROM THE MEDICARE AND/OR MEDICAID PROGRAMS COBOL NAME: TERM-CD VALUES: 0 ACTIVE 1 VOL-MERG,CLOSE 2 VOL-REIMBURSE 3 VOL-RISK INVOL 4 VOL-OTHER 5 INVOL-FAIL REQ 6 INVOL-AGREEMNT 7 OTH-STATUS CHG TERMINATION DATE 6 212 217 C PROV2810 THE EFFECTIVE DATE OF TERMINATION OF CERTIFICATION OF A FACILITY. COBOL NAME: TERM-DT TYPE OF ACTION 1 218 218 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 7 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 6 COMPLAINT SURVEY TYPE OF CONTROL 2 219 220 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 FOR PROFIT - INDIVIDUAL 02 FOR PROFIT - PARTNERSHIP 03 FOR PROFIT - CORPORATION 04 NONPROFIT - CHURCH RELATED 05 NONPROFIT - CORPORATION 06 NONPROFIT - OTHER 07 GOVERNMENT - STATE 08 GOVERNMENT - COUNTY 09 GOVERNMENT - CITY 10 GOVERNMENT - CITY/COUNTY 11 GOVERNMENT - HOSPITAL DISTRICT 12 GOVERNMENT - FEDERAL ZIP CODE 5 221 225 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 226 227 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 228 230 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 231 233 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 234 234 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE BEDS - TOTAL 5 265 269 N PROV0740 TOTAL NUMBER OF BEDS IN A FACILITY, INCLUDING THOSE IN NON-PARTICIPATING OR NON-LICENSED AREAS. COBOL NAME: NUM-BEDS BEDS - TOTAL CERTIFIED 5 270 274 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS COMPLIANCE: LIFE SAFETY CODE 1 332 332 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: 1 WAIVER RECOMMENDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 8 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FISCAL YEAR ENDING DATE 4 349 352 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT PROGRAM PARTICIPATION 1 411 411 C PROV1670 INDICATES IF THE PROVIDER PARTICIPATES IN MEDICARE, MEDICAID, OR BOTH PROGRAMS. COBOL NAME: PROG-PARTCI VALUES: 1 MEDICARE ONLY 2 MEDICAID ONLY 3 MEDICARE AND MEDICAID REGIONAL OVERRIDE #1 (NUMBER BEDS) 1 429 429 C PROV1545 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-1 VALUES: Y RECORD HAS BEEN APPROVED REGIONAL OVERRIDE #2 (STAFFING) 1 430 430 C PROV1550 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-2 VALUES: Y RECORD HAS BEEN APPROVED REGIONAL OVERRIDE #3 (NURSE - BED) 1 431 431 C PROV1555 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-3 VALUES: Y RECORD HAS BEEN APPROVED * RELATED PROVIDER NUMBER 10 456 465 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM SRV: DENTAL 1 485 485 C PROV2120 INDICATES HOW DENTAL SERVICES ARE PROVIDED. COBOL NAME: SP-DENTAL VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 9 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: DIETARY 1 486 486 C PROV2130 INDICATES HOW DIETARY SERVICES ARE PROVIDED. COBOL NAME: SP-DIETARY VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NON RESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION TYPE OF FACILITY 2 516 517 C PROV2890 INDICATES THE CATEGORY WHICH REPRESENTS THE TYPE OF FACILITY. COBOL NAME: TYPE-FACILITY VALUES: 01 SKILLED NURSING FACILITY (SNF) 03 SNF/NF ACTIVITY THERAPISTS - CONTRACT 7.2 519 525 N PROV0695 THE NUMBER OF FULL TIME EQUIVALENT ACTIVITIES THERAPISTS UNDER CONTRACT TO THE FACILITY COBOL NAME: NUM-ACT-THER-CONTRACT ACTIVITY THERAPISTS - FULL TIME 7.2 526 532 N PROV0700 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES THERAPISTS EMPLOYED FULL TIME BY THE FACILITY COBOL NAME: NUM-ACT-THER-FULL-TIME ACTIVITY THERAPISTS - PART TIME 7.2 533 539 N PROV0705 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES THERAPISTS EMPLOYED PART-TIME BY THE FACILITY. COBOL NAME: NUM-ACT-THER-PART-TIME ADMINISTRATOR - CONTRACT 7.2 540 546 N PROV0710 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-ADMN-CONTRACT ADMINISTRATOR - FULL TIME 7.2 547 553 N PROV0715 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS EMPLOYED ON A FULL TIME BASIS BY THE FACILITY. COBOL NAME: NUM-ADMN-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 10 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ADMINISTRATOR - PART TIME 7.2 554 560 N PROV0720 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS EMPLOYED ON A PART-TIME BASIS BY THE FACILITY. COBOL NAME: NUM-ADMN-PART-TIME ADMISSION SUSPENSION DATE 6 561 566 C PROV0030 THE DATE THAT PAYMENTS FOR NEW ADMISSIONS IN A LONG TERM CARE FACILITY WILL BE DENIED IF AN INTERMEDIATE SANCTION IS TAKEN AGAINST THE FACILITY. COBOL NAME: ADMIN-SUSP-DT AIDES/ORDERLIES - CONTRACT 7.2 567 573 N PROV1000 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-NURSE-AID-CONTRACT AIDES/ORDERLIES - FULL TIME 7.2 574 580 N PROV1005 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES EMPLOYED BY THE FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-AID-FULL-TIME * AIDES/ORDERLIES - PART TIME 7.2 581 587 N PROV1010 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES EMPLOYED BY THE FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-AID-PART-TIME BEDS - MEDICARE SNF 4 588 591 N PROV1445 NUMBER OF MEDICARE CERTIFIED SNF BEDS IN A FACILITY. COBOL NAME: NUM-T18-SNF-BEDS BEDS - NURSING FACILITY 4 592 595 N PROV1455 NUMBER OF MEDICAID CERTIFIED SKILLED NURSING CARE BEDS IN A FACILITY. COBOL NAME: NUM-T19-SNF-BEDS BEDS - SNF/NF 4 596 599 N PROV1450 NUMBER OF BEDS CERTIFIED FOR BOTH MEDICARE AND MEDICAID SKILLED NURSING CARE IN A LONG TERM CARE FACILITY. COBOL NAME: NUM-T1819-SNF-BEDS CHRISTIAN SCIENCE INDICATOR 1 600 600 C PROV0110 INDICATES IF A PROVIDER IS A CHRISTIAN SCIENCE FACILITY COBOL NAME: CHRISTIAN-SCIENCE-IND VALUES: Y CHRISTIAN SCIENCE COMPLIANCE: BEDS PER ROOM WAIVER 1 601 601 C PROV0225 INDICATES IF A WAIVER OF THE BEDS PER ROOM REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-BEDS-PER-ROOM VALUES: 1 WAIVER RECOMMENDED COMPLIANCE: PATIENT ROOM SIZE 1 602 602 C PROV0270 INDICATES IF A WAIVER OF PATIENT ROOM SIZE HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-PATIENT-ROOM-SZ VALUES: 1 WAIVER RECOMMENDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 11 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME COMPLIANCE: 7 DAY REGISTERED NURSE 1 603 603 C PROV0295 INDICATES IF A WAIVER OF THE 7 DAY REGISTERED NURSE REQUIREMENTS HAS BEEN RECOMMENDED FOR A SNF OR NF. COBOL NAME: COMPL-7-DAY-RN VALUES: 1 WAIVER RECOMMENDED * DENTISTS - CONTRACT 7.2 604 610 N PROV0785 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DENTIST-CONTRACT * DENTISTS - FULL TIME 7.2 611 617 N PROV0790 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-DENTIST-FULL-TIME * DENTISTS - PART TIME 7.2 618 624 N PROV0795 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-DENTIST-PART-TIME DIETITIANS - CONTRACT 7.2 625 631 N PROV0805 THE NUMBER OF FULL-TIME EQUIVALENT UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DIET-CONTRACT DIETITIANS - FULL TIME 7.2 632 638 N PROV0810 THE NUMBER OF FULL-TIME EQUIVALENT DIETITIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-DIET-FULL-TIME DIETITIANS - PART TIME 7.2 639 645 N PROV0815 THE NUMBER OF FULL-TIME EQUIVALENT DIETITIANS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-DIET-PART-TIME EXPERIMENTAL RESEARCH CONDUCTED 1 646 646 C PROV0465 INDICATES IF A FACILITY USES RESIDENTS TO DEVELOP AND TEST CLINICAL TREATMENTS. COBOL NAME: EXPER-RESEARCH VALUES: N NO Y YES FOOD SERVICE - CONTRACT 7.2 647 653 N PROV0860 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-FOOD-SRV-CONTRACT FOOD SERVICE - FULL TIME 7.2 654 660 N PROV0865 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERIVCE PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-FOOD-SRV-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 12 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME FOOD SERVICE - PART TIME 7.2 661 667 N PROV0870 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-FOOD-SRV-PART-TIME HOUSEKEEPING - CONTRACT 7.2 668 674 N PROV0925 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-HOUSE-CONTRACT HOUSEKEEPING - FULL TIME 7.2 675 681 N PROV0930 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-HOUSE-FULL-TIME HOUSEKEEPING - PART TIME 7.2 682 688 N PROV0935 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-HOUSE-PART-TIME LPN/LVN - CONTRACT 7.2 689 695 N PROV1465 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES UNDER CONTRACT TO A FACILITY COBOL NAME: NUM-VOC-NURSE-CONTRACT LPN/LVN - FULL TIME 7.2 696 702 N PROV1470 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-VOC-NURSE-FULL-TIME LPN/LVN - PART TIME 7.2 703 709 N PROV1475 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-VOC-NURSE-PART-TIME LTC AGREEMENT BEGINNING DATE 6 710 715 C PROV0620 THE BEGINNING DATE OF A CERTIFIED LONG TERM CARE FACILI TY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-BEGIN-DT LTC AGREEMENT ENDING DATE 6 716 721 C PROV0625 THE ENDING DATE OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-END-DT LTC AGREEMENT EXTENSION DATE 6 722 727 C PROV0630 THE LAST DATE OF AN EXTENSION OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-EXT-DT LTC CROSS REFERENCE PROVIDER # 6 728 733 C PROV0640 THIS CROSS REFERENCE NUMBER IDENTIFIES LTC PROVIDER NUMBERS THAT WERE TERMINATED IN 1985 BECAUSE OF POLICY CHANGES WHICH STATES THAT SNF/ICF DISTINCT PARTS OR DUA LLY CERTIFIED PORTIONS ARE ASSIGNED SINGLE SNF PROV NO. COBOL NAME: LTC-CROSS-REF-PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 13 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MEDICAL DIRECTOR - CONTRACT 7.2 734 740 N PROV0960 NUMBER OF MEDICAL DIRECTORS UNDER CONTRACT. COBOL NAME: NUM-MED-CONTRACT MEDICAL DIRECTOR - FULL TIME 7.2 741 747 N PROV0965 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MED-FULL-TIME MEDICAL DIRECTOR - PART TIME 7.2 748 754 N PROV0970 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MED-PART-TIME MEDICAL SOCIAL WORKER - CONTRACT 7.2 755 761 N PROV1170 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL SOCIAL WORKERS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-SOCIAL-CONTRACT MEDICAL SOCIAL WORKER - FULL TIME 7.2 762 768 N PROV1175 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL SOCIAL WORKERS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-SOCIAL-FULL-TIME MEDICAL SOCIAL WORKER - PART TIME 7.2 769 775 N PROV1180 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL SOCIAL WORKERS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-SOCIAL-PART-TIME MENTAL HEALTH SERVICES - CONTRACT 7.2 776 782 N PROV0980 THE NUMBER OF FULL-TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-MEN-HLTH-CONTRACT MENTAL HEALTH SERVICES - FULL TIME 7.2 783 789 N PROV0985 THE NUMBER OF FULL-TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MEN-HLTH-FULL-TIME MENTAL HEALTH SERVICES - PART TIME 7.2 790 796 N PROV0990 THE NUMBER OF FULL TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MEN-HLTH-PART-TIME MULTI-FACILITY ORGANIZATION NAME 38 797 834 C PROV0680 THE NAME OF THE MULTI-FACILITY ORGANIZATION THAT OWNS THE FACILITY. COBOL NAME: NAME-MULT-FACL-ORG MULTI-FACILITY ORGANIZATION OWNED 1 835 835 C PROV0675 INDICATES IF A FACILITY IS OWNED BY AN ORGANIZATION THAT OWNS (OR LEASES) TWO OR MORE NURSING FACILITIES. COBOL NAME: MULT-FACL-ORG VALUES: N NO Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 14 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OCCUPATIONAL THERAPIST - CONTRACT 7.2 836 842 N PROV1035 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-THER-CONTRACT OCCUPATIONAL THERAPIST - FULL TIME 7.2 843 849 N PROV1040 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-THER-FULL-TIME OCCUPATIONAL THERAPIST - PART TIME 7.2 850 856 N PROV1045 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-THER-PART-TIME OCCUPATIONAL THERAPY ASST-CONTRACT 7.2 857 863 N PROV1020 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-AID-CONTRACT OCCUPATIONAL THERAPY ASST-FULL 7.2 864 870 N PROV1025 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-AID-FULL-TIME OCCUPATIONAL THERAPY ASST-PART 7.2 871 877 N PROV1030 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-AID-PART-TIME ORGANIZED FAMILY GROUP 1 878 878 C PROV1535 INDICATES IF THE FACILITY HAS AN ORGANIZED GROUP OF FAMILY MEMBERS OF RESIDENTS. COBOL NAME: ORG-FAMILY-GRP VALUES: N NO Y YES * ORGANIZED RESIDENT GROUP 1 879 879 C PROV1540 INDICATES IF THE FACILITY HAS AN ORGANIZED RESIDENTS GROUP. COBOL NAME: ORG-RESID-GRP VALUES: N NO Y YES OTHER PHYSICIAN - CONTRACT 7.2 880 886 N PROV1060 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS UNDER CONTRACT TO A FACILITY COBOL NAME: NUM-OTH-PHY-CONTRACT OTHER PHYSICIAN - FULL TIME 7.2 887 893 N PROV1065 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OTH-PHY-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 15 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OTHER PHYSICIAN - PART TIME 7.2 894 900 N PROV1070 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OTH-PHY-PART-TIME PHARMACISTS - CONTRACT 7.2 901 907 N PROV1085 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-PHAR-CONTRACT PHARMACISTS - FULL TIME 7.2 908 914 N PROV1090 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-PHAR-FULL-TIME PHARMACISTS - PART TIME 7.2 915 921 N PROV1095 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-PHAR-PART-TIME PHYSICAL THERAPISTS - CONTRACT 7.2 922 928 N PROV1430 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-CONTRACT PHYSICAL THERAPISTS - FULL TIME 7.2 929 935 N PROV1435 THE NUMBER OF FULL TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-FULL-TIME PHYSICAL THERAPISTS - PART TIME 7.2 936 942 N PROV1440 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-PART-TIME PHYSICAL THERAPY ASST - CONTRACT 7.2 943 949 N PROV1415 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-AID-CONTRACT PHYSICAL THERAPY ASST - FULL TIME 7.2 950 956 N PROV1420 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-AID-FULL-TIME PHYSICAL THERAPY ASST - PART TIME 7.2 957 963 N PROV1425 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-AID-PART-TIME PODIATRISTS - CONTRACT 7.2 964 970 N PROV1130 THE NUMBER OF FULL TIME EQUIVALENT PODIATRISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-POD-CONTRACT PODIATRISTS - FULL TIME 7.2 971 977 N PROV1135 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A AFCILITY ON A FULL TIME BASIS. COBOL NAME: NUM-POD-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 16 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PODIATRISTS - PART TIME 7.2 978 984 N PROV1140 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-POD-PART-TIME PRIOR ADMISSION SUSPENSION DATE 6 985 990 C PROV1610 PREVIOUS DATE A SUSPENSION OF ADMISSIONS WAS INVOKED FOR A PROVIDER. COBOL NAME: PRIOR-ADMIN-SUSP-DT PRIOR LTC END DATE 6 991 996 C PROV1630 THE LAST DATE OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT FOR A PRIOR SURVEY. COBOL NAME: PRIOR-LTC-END-DT PRIOR LTC EXTENSION DATE 6 997 1002 C PROV1635 THE LAST DATE OF AN EXTENSION OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT FOR A PRIOR SURVEY. COBOL NAME: PRIOR-LTC-EXT-DT PRIOR RESCIND SUSPENSION DATE 6 1003 1008 C PROV1640 THE EFFECTIVE DATE OF A PREVIOUS SUSPENSION OF ADMISSIONS TO A LTC FACILITY. COBOL NAME: PRIOR-RESC-SUSP-DT PROVIDER BASED FACILITY 1 1009 1009 C PROV1675 INDICATES IF A LONG TERM CARE FACILITY IS PROVIDER BASED. COBOL NAME: PROV-BASED-FACILITY VALUES: N NOT HOSPITAL BASED Y HOSPITAL BASED REGISTERED NURSE - CONTRACT 7.2 1010 1016 N PROV1150 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-REG-NURSE-CONTRACT REGISTERED NURSE - FULL TIME 7.2 1017 1023 N PROV1155 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-REG-NURSE-FULL-TIME REGISTERED NURSE - PART TIME 7.2 1024 1030 N PROV1160 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-REG-NURSE-PART-TIME RESCIND SUSPENSION DATE 6 1031 1036 C PROV1825 DATE THAT THE SUPENSION OF PAYMENTS FOR NEW ADMISSIONS TO A LONG TERM CARE FACILITY (LTC) IS RESCINDED. COBOL NAME: RESC-SUSP-DT SPECIAL CARE BEDS-AIDS 3 1037 1039 N PROV0725 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH AIDS. COBOL NAME: NUM-AIDS-BEDS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 17 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPECIAL CARE BEDS-ALZHEIMERS 3 1040 1042 N PROV0730 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH ALZEHEIMERS. COBOL NAME: NUM-ALZHEIMERS-BEDS SPECIAL CARE BEDS-DIALYSIS 3 1043 1045 N PROV0800 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS NEEDING DIALYSIS. COBOL NAME: NUM-DIAL-BEDS SPECIAL CARE BEDS-DISABLED CHILD 3 1046 1048 N PROV0855 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR DEISCABLED CHILDREN. COBOL NAME: NUM-DIS-CHILD-BEDS SPECIAL CARE BEDS-HEAD TRAUMA 3 1049 1051 N PROV0905 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILTY FOR RESIDENTS WITH HEAD TRAUMA. COBOL NAME: NUM-HEAD-TRAUMA-BEDS SPECIAL CARE BEDS-HOSPICE 3 1052 1054 N PROV0920 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY A FACILITY FOR RESIDENTS NEEDING HOSPICE SERVICES. COBOL NAME: NUM-HOSPICE-BEDS SPECIAL CARE BEDS-HUNTINGTONS 3 1055 1057 N PROV0940 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH HUNTINGTON'S DISEASE COBOL NAME: NUM-HUNTING-DIS-BEDS SPECIAL CARE BEDS-SPEC REHAB 3 1058 1060 N PROV1205 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH SPECIALIZED REHAB NEEDS. COBOL NAME: NUM-SPEC-REHAB-BEDS SPECIAL CARE BEDS-VENTILATOR 3 1061 1063 N PROV1460 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH VENTILATOR/ RESIPIRATORY CARE NEEDS. COBOL NAME: NUM-VENT-RESP-BEDS SPEECH PATHOLOGIST - CONTRACT 7.2 1064 1070 N PROV1190 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-SPCH-PATH-CONTRACT SPEECH PATHOLOGIST - FULL TIME 7.2 1071 1077 N PROV1195 THE NUMBER OF FULL-TIME EQUIVALENT SPPECH PATHOLOGISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-SPCH-PATH-FULL-TIME SPEECH PATHOLOGIST - PART TIME 7.2 1078 1084 N PROV1200 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-SPCH-PATH-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 18 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: ACTIVITIES THERAPY 1 1085 1085 C PROV2050 INDICATES HOW ACTIVITIES THERAPY SERIVICES ARE PROVIDED IN A FACILITY. COBOL NAME: SP-ACT-THERAPISTS VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF & UNDER ARRANGEMENT 7 COMBINATION SRV: ADMINISTRATION/STORAGE BLOOD 1 1086 1086 C PROV2060 INDICATES HOW ADMINISTRATION AND STORAGE OF BLOOD SERVICES ARE PROVIDED IN A LONG TERM CARE FACILITY. COBOL NAME: SP-ADMIN-STORE-BLOOD VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: CLINICAL LABS 1 1087 1087 C PROV2105 INDICATES HOW CLINICAL LABORATORY SERVICES ARE PROVIDED BY A FACILITY. COBOL NAME: SP-CLINICAL-LAB VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: DIAGNOSTIC X-RAY 1 1088 1088 C PROV2125 INDICATES HOW DIAGNOSTIC XRAY SERVICES ARE PROVIDED BY A LONG TERM CARE FACILITY. COBOL NAME: SP-DIAGN-XRAY VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 19 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: HOUSEKEEPING 1 1089 1089 C PROV2180 INDICATES HOW HOUSEKEEPING SERVICES ARE PROVIDED. COBOL NAME: SP-HOUSE-KEEP VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 7 COMBINATION SRV: MENTAL HEALTH 1 1090 1090 C PROV2230 INDICATES HOW MENTAL HEALTH SERVICES ARE PROVIDED. COBOL NAME: SP-MEN-HLTH VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: PODIATRY 1 1091 1091 C PROV2405 INDICATES HOW PODIATRY SERVICES ARE PROVIDED BY A LONG TERM CARE FACILITY. COBOL NAME: SP-PODIATRY VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NON RESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: MEDICAL SOCIAL 1 1142 1142 C PROV2220 INDICATES HOW MEDICAL SOCIAL SERVICES ARE PROVIDED COBOL NAME: SP-MEDICAL-SOCIAL VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 20 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 7 COMBINATION SRV: NURSING 1 1143 1143 C PROV2250 INDICATES HOW NURSING SERVICES ARE PROVIDED. COBOL NAME: SP-NURSING VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: VOCATIONAL GUIDANCE 1 1146 1146 C PROV2535 INDICATES HOW VOCATIONAL GUIDANCE SERVICES ARE PROVIDED COBOL NAME: SP-VOCAT-GUIDANCE VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION DIRECT CARE PERSONNEL 7.2 1436 1442 N PROV0780 NUMBER OF FULL-TIME EQUIVALENT DIRECT CARE PERSONNEL EMPLOYED BY AN INTERMEDIATE CARE FACILITY FOR THE MENTALLY RETARDED. COBOL NAME: NUM-DCARE-PERSNL SRV: OCCUPATIONAL THERAPY 1 1504 1504 C PROV2270 INDICATES HOW OCCUPATIONAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-OCCUP-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NON RESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: PHYSICAL THERAPY 1 1510 1510 C PROV2370 INDICATES HOW PHYSICAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICAL-THERAPY VALUES: 0 NOT PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 21 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: PHYSICIAN 1 1513 1513 C PROV2385 INDICATES HOW PHYSICIAN SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICIAN VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: SPEECH PATHOLOGY 1 1524 1524 C PROV2505 INDICATES HOW SPEECH PATHOLOGY SERVICES ARE PROVIDED. COBOL NAME: SP-SPEECH-PATH VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: OTHER 1 1551 1551 C PROV2340 INDICATES HOW OTHER (NOT SPECIFIED) SERVICES ARE PROVIDED. COBOL NAME: SP-OTHER VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: PHARMACY 1 1552 1552 C PROV2365 INDICATES HOW PHARMACY SERVICES ARE PROVIDED. COBOL NAME: SP-PHARMACY VALUES: 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 22 SKILLED NURSING FACILITIES, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 1 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 HOME HEALTH AGENCY CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 05 HOME HEALTH AGENCIES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY AND STATE 31 13 43 C PROV0115 THE CITY AND STATE WHERE A PROVIDER IS LOCATED. COBOL NAME: CITY-STATE COMPLIANCE: PLAN OF CORRECTION 1 44 44 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 45 45 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 46 48 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 49 58 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 59 64 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 2 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 6 65 70 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 71 71 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 38 72 109 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME * INTERMEDIARY NUMBER 5 110 114 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00040 BLUE CROSS (CALIFORNIA) 00121 HEALTH CARE SERVICE CORPORATION 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00180 BLUE CROSS (MAINE) 00290 BLUE CROSS (NEW MEXICO) 00362 BLUE CROSS (INDEPENDENCE) 00380 BLUE CROSS (SOUTH CAROLINA) 00450 BLUE CROSS (WISCONSIN) 51100 AETNA (CLEARWATER) 57400 COOPERATIVA (PUERTO RICO) MEDICAID VENDOR NUMBER 12 115 126 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A MEDICAID FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 6 127 132 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 133 138 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 139 143 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 3 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PROVIDER NUMBER 10 144 153 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE: MASTER/TRANSACTION 1 154 154 C PROV1720 INDICATES IF A RECORD IS CURRENTLY ON THE MASTER FILE OR THE TRANSACTION FILE. COBOL NAME: RECORD-TYPE VALUES: M MASTER FILE T TRANSACTION FILE REGION CODE 2 155 156 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 157 157 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE CODE (SSA) 2 158 159 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 4 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 54 AFRICA 55 CALIFORNIA 56 CANADA 57 WEST INDIES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 5 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 58 EUROPE 59 MEXICO 60 OCEANIA 61 PHILIPPINES 62 SOUTH AMERICA 63 UNITED STATES POSSESSIONS 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN 67 TEXAS STATES REGION CODE 3 160 162 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 163 200 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 201 210 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE 1 211 211 C PROV2805 THE REASON A FACILITY HAS BEEN TERMINATED FROM THE MEDICARE AND/OR MEDICAID PROGRAMS COBOL NAME: TERM-CD VALUES: 0 ACTIVE 1 VOL-MERG,CLOSE 2 VOL-REIMBURSE 3 VOL-RISK INVOL 4 VOL-OTHER 5 INVOL-FAIL REQ 6 INVOL-AGREEMNT 7 OTH-STATUS CHG TERMINATION DATE 6 212 217 C PROV2810 THE EFFECTIVE DATE OF TERMINATION OF CERTIFICATION OF A FACILITY. COBOL NAME: TERM-DT TYPE OF ACTION 1 218 218 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 6 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 6 COMPLAINT SURVEY TYPE OF CONTROL 2 219 220 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 VOL. NON-PROF. - RELIGIOUS AFF. 02 VOLUNTARY NON-PROFIT - PRIVATE 03 VOLUNTARY NON-PROFIT - OTHER 04 PROPRIETARY 05 GOVERNMENT - STATE/COUNTY 06 GOVERNMENT - COMB. GOVT & VOL. 07 GOVERNMENT - LOCAL ZIP CODE 5 221 225 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 226 227 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 228 230 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 231 233 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 234 234 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE ACCREDITATION EXPIRATION DATE 6 241 246 C PROV0005 THE EXPIRATION DATE OF THE CURRENT PERIOD OF ACCREDITATION BY THE JOINT COMMITTEE ON ACCREDITATION OF HEALTH CARE ORGANIZATIONS (JCAHO) OR THE AMERICAN OSTEOPATHIC ASSOCIATION (AOA). COBOL NAME: ACCRED-EXP-DT DIETITIANS 7.2 342 348 N PROV0820 NUMBER OF FULL-TIME EQUIVALENT DIETITIANS EMPLOYED BY A FACILITY. COBOL NAME: NUM-DIETICIANS FISCAL YEAR ENDING DATE 4 349 352 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT LICENSED PRACTICAL NURSES 7.2 360 366 N PROV0955 NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL OR VOCATIONAL NURSES EMPLOYED BY A FACILITY. COBOL NAME: NUM-LPN-LVN * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 7 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OCCUPATIONAL THERAPISTS 7.2 369 375 N PROV1050 THE NUMBER OF FULL TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-OCCUP-THERAPISTS OTHER PERSONNEL 7.2 376 382 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL PHARMACISTS 7.2 384 390 N PROV1100 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PHARMACISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHARMACIST-REG PROGRAM PARTICIPATION 1 411 411 C PROV1670 INDICATES IF THE PROVIDER PARTICIPATES IN MEDICARE, MEDICAID, OR BOTH PROGRAMS. COBOL NAME: PROG-PARTCI VALUES: 1 MEDICARE ONLY 2 MEDICAID ONLY 3 MEDICARE AND MEDICAID REGIONAL OVERRIDE #2 (STAFFING) 1 430 430 C PROV1550 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-2 VALUES: Y RECORD HAS BEEN APPROVED REGISTERED NURSES 7.2 432 438 N PROV1145 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PROFESSIONAL NURSES EMPLOYED BY A PROVIDER. COBOL NAME: NUM-REG-NURS * RELATED PROVIDER NUMBER 10 456 465 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM TYPE OF FACILITY 2 516 517 C PROV2890 INDICATES THE CATEGORY WHICH REPRESENTS THE TYPE OF FACILITY. COBOL NAME: TYPE-FACILITY VALUES: 01 VISITING NURSE ASSOCIATION 02 COMBINATION GOVERNMENT VOLUNTARY 03 OFFICIAL HEALTH AGENCY 04 REHABILITATION FACILITY BASED PROGRAM 05 HOSPITAL BASED PROGRAM 06 SKILLED NURSING FACILITY BASED PROGRAM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 8 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 07 OTHER AIDE TRAINING/COMPETENCY PROGRAMS 1 1092 1092 C PROV0555 INDICATES HOW THE AGENCY PROVIDES HOME HEALTH AIDE TRAINING AND COMPETENCY EVALUATION PROGRAMS. COBOL NAME: HHA-PROVIDES-DIRECT VALUES: 1 AIDE TRAINING 2 COMPETENCY EVALUATION PROG. 3 BOTH 4 NEITHER BRANCH OPERATION INDICATOR 1 1093 1093 C PROV1525 INDICATES IF THE AGENCY OPERATES ANY BRANCHES. COBOL NAME: OPERS-BRANCHES VALUES: N NO Y YES BRANCHES 2 1094 1095 N PROV0745 THE NUMBER OF BRANCHES OPERATED BY THE AGENCY. COBOL NAME: NUM-BRANCHES CHANGE OF OWNERSHIP INDICATOR 1 1096 1096 C PROV0105 INDICATES IF A HOME HEALTH AGENCY HAS UNDERGONE A CHANGE OF OWNERSHIP SINCE THE LAST SURVEY. COBOL NAME: CHOW-IND VALUES: N NO Y YES HHA QUALIFIED FOR OPT 1 1097 1097 C PROV0560 INDICATES IF A HOME HEALTH AGENCY IS QUALIFIED TO PROVIDE OUTPATIENT PHYSICAL THERAPY/SPEECH SERVICES. COBOL NAME: HHA-QUAL-FOR-OPT VALUES: N NO Y YES HOME HEALTH AIDES 7.2 1098 1104 N PROV0910 NUMBER OF FULL-TIME EQUIVALENT HOME HEALTH AIDES EMPLOYED BY A HOME HEALTH AGENCY OR HOSPICE. COBOL NAME: NUM-HOME-HEALTH-AIDES HOSPICE INDICATOR 1 1105 1105 C PROV0665 INDICATES IF THE HOME HEALTH AGENCY ALSO PARTICIPATES IN THE MEDICARE PROGRAM AS A HOSPICE. COBOL NAME: MEDICARE-CERT-HOSPICE VALUES: N NO Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 9 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MEDICARE HOSPICE PROVIDER NUMBER 6 1106 1111 C PROV0570 IF THE AGENCY ALSO PARTICIPATES IN THE MEDICARE PROGRAM AS A HOSPICE, THE HOSPICE PROVIDER NUMBER. COBOL NAME: HOSPICE-PROV-NUM MEDICARE/MEDICAID PROVIDER NUMBER 6 1112 1117 C PROV0650 IF THE AGENCY IS BASED IN ANOTHER MEDICARE OR MEDICAID FACILITY, THE PROVIDER NUMBER OF THAT FACILITY. COBOL NAME: MEDICAID-CARE-VEND-NUM PHYSICAL THERAPISTS 7.2 1118 1124 N PROV1120 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS-THERAPISTS SOCIAL WORKERS 7.2 1125 1131 N PROV1185 THE NUMBER OF FULL TIME EQUIVALENT SOCIAL WORKERS EMPLOYED BY THE AGENCY. COBOL NAME: NUM-SOCIAL-WRKS SPEECH PATHOLOGISTS, AUDIOLOGISTS 7.2 1132 1138 N PROV1220 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS OR AUDIOLOGISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-SPEECH-PATH-AUDIO SRV: APPLIANCE AND EQUIPMENT 1 1139 1139 C PROV2075 INDICATES HOW APPLIANCE AND EQUIPMENT SERVICES ARE PROVIDED BY A HOME HEALTH AGENCY. COBOL NAME: SP-APPLIANCE-EQUIP VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: HOME HEALTH AIDE/HOMEMAKER 1 1140 1140 C PROV2155 INDICATES HOW HOME HEALTH AIDE SERVICES ARE PROVIDED BY A HOME HEALTH AGENCY. COBOL NAME: SP-HH-AIDE-HOMEMAKER VALUES: 0 NOT PROVIDED 1 PROVIDED BY AGENCY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: INTERNS AND RESIDENTS 1 1141 1141 C PROV2195 INDICATES HOW INTERN AND RESIDENT SERVICES ARE PROVIDED BY A HOME HEALTH AGENCY. COBOL NAME: SP-INTERNS-RESIDENTS VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 10 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: MEDICAL SOCIAL 1 1142 1142 C PROV2220 INDICATES HOW MEDICAL SOCIAL SERVICES ARE PROVIDED COBOL NAME: SP-MEDICAL-SOCIAL VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: NURSING 1 1143 1143 C PROV2250 INDICATES HOW NURSING SERVICES ARE PROVIDED. COBOL NAME: SP-NURSING VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION 7 COMBINATION SRV: NUTRITIONAL GUIDANCE 1 1144 1144 C PROV2255 INDICATES HOW NUTRITIONAL GUIDANCE SERVICES ARE PROVIDED. COBOL NAME: SP-NUTRITION-GUIDANCE VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: SPEECH THERAPY 1 1145 1145 C PROV2520 INDICATES HOW SPEECH THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-SPEECH-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: VOCATIONAL GUIDANCE 1 1146 1146 C PROV2535 INDICATES HOW VOCATIONAL GUIDANCE SERVICES ARE PROVIDED COBOL NAME: SP-VOCAT-GUIDANCE VALUES: 0 NOT PROVIDED 1 PROVIDED BY AGENCY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SUBUNIT INDICATOR 1 1147 1147 C PROV2725 INDICATES IF THE AGENCY IS A SUBUNIT OF ANOTHER AGENCY. COBOL NAME: SUBUNIT-IND VALUES: N NO Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 11 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SUBUNIT OPERATION INDICATOR 1 1148 1148 C PROV1530 INDICATES IF THE AGENCY OPERATES ANY SUBUNITS. COBOL NAME: OPERS-SUBUNITS VALUES: N NO Y YES SUBUNITS 2 1149 1150 N PROV1240 THE NUMBER OF SUBUNITS OPERATED BY THE AGENCY. COBOL NAME: NUM-SUBUNITS SRV: OCCUPATIONAL THERAPY 1 1504 1504 C PROV2270 INDICATES HOW OCCUPATIONAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-OCCUP-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: PHYSICAL THERAPY 1 1510 1510 C PROV2370 INDICATES HOW PHYSICAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICAL-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: LABORATORY 1 1550 1550 C PROV2200 INDICATES HOW LABORATORY SERVICES ARE PROVIDED. COBOL NAME: SP-LABORATORY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: OTHER 1 1551 1551 C PROV2340 INDICATES HOW OTHER (NOT SPECIFIED) SERVICES ARE PROVIDED. COBOL NAME: SP-OTHER VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: PHARMACY 1 1552 1552 C PROV2365 INDICATES HOW PHARMACY SERVICES ARE PROVIDED. COBOL NAME: SP-PHARMACY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 12 HOME HEALTH AGENCIES, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 1 INDEPENDENT LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 LABORATORY CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 06 INDEPENDENT LABORATORIES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY AND STATE 31 13 43 C PROV0115 THE CITY AND STATE WHERE A PROVIDER IS LOCATED. COBOL NAME: CITY-STATE COMPLIANCE: PLAN OF CORRECTION 1 44 44 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 45 45 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 46 48 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 49 58 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 59 64 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 2 INDEPENDENT LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 6 65 70 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 71 71 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 38 72 109 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME * INTERMEDIARY NUMBER 5 110 114 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00510 BLUE SHIELD (ALABAMA) 00520 BLUE SHIELD (ARKANSAS) 00528 BLUE SHIELD (ARKANSAS/LOUISIANA) 00542 BLUE SHIELD (CALIFORNIA) 00550 BLUE SHIELD (COLORADO) 00570 BLUE SHIELD (DELAWARE) 00580 BLUE SHIELD (DISTRICT OF COLUMBIA) 00590 BLUE SHIELD (FLORIDA) 00621 BLUE SHIELD (ILLINOIS) 00630 BLUE SHIELD (INDIANA) 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 BLUE SHIELD (KENTUCKY) 00690 BLUE SHIELD (MARYLAND) 00700 BLUE SHIELD (MASSACHUSETTS) 00710 BLUE SHIELD (MICHIGAN) 00720 BLUE SHIELD (MINNESOTA) 00740 BLUE SHIELD (KANSAS CITY) 00751 BLUE SHIELD (MONTANA) 00770 BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780 BLUE SHIELD (TRI-STATE) 00801 BLUE SHIELD (BUFFALO) 00803 BLUE SHIELD (EMPIRE) 00820 BLUE SHIELD (NORTH DAKOTA) 00825 BLUE SHIELD (NORTH DAKOTA/WYOMING) 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865 BLUE SHIELD (PENNSYLVANIA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 3 INDEPENDENT LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00900 BLUE SHIELD (TEXAS) 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 00973 BLUE SHIELD (PUERTO RICO) 00974 BLUE SHIELD (VIRGIN ISLANDS) 01010 AETNA (PEORIA) 01020 AETNA (ALASKA) 01030 AETNA (ARIZONA) 01040 AETNA (GEORGIA) 01120 AETNA (HAWAII) 01290 AETNA (NEVADA) 01360 AETNA (NEW MEXICO) 01370 AETNA (OKLAHOMA) 01380 AETNA (OREGON) 02050 OCCIDENTAL (CALIFORNIA) 05130 EQICOR (IDAHO) 05440 EQICOR (TENNESSEE) 05535 EQICOR (NORTH CAROLINA) 10071 TRAVELERS (RRB) 10230 TRAVELERS (CONNECTICUT) 10240 TRAVELERS (MINNESOTA) 10250 TRAVELERS (MISSISSIPPI) 10490 TRAVELERS (VIRGINIA) 10492 TRAVELERS - VIRGINIA SPECIAL PROJECT 11260 GENERAL AMERICAN 14330 GROUP HEALTH INC (NEW YORK) 16360 NATIONWIDE (OHIO) 16510 NATIONWIDE (WEST VIRGINIA) 21200 MASSACHUSETTS/MAINE MEDICAID VENDOR NUMBER 12 115 126 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A MEDICAID FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 6 127 132 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 133 138 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 4 INDEPENDENT LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR INTERMEDIARY NUMBER 5 139 143 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 144 153 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE: MASTER/TRANSACTION 1 154 154 C PROV1720 INDICATES IF A RECORD IS CURRENTLY ON THE MASTER FILE OR THE TRANSACTION FILE. COBOL NAME: RECORD-TYPE VALUES: M MASTER FILE T TRANSACTION FILE REGION CODE 2 155 156 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 157 157 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE CODE (SSA) 2 158 159 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 5 INDEPENDENT LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 54 AFRICA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 6 INDEPENDENT LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 55 CALIFORNIA 56 CANADA 57 WEST INDIES 58 EUROPE 59 MEXICO 60 OCEANIA 61 PHILIPPINES 62 SOUTH AMERICA 63 UNITED STATES POSSESSIONS 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN 67 TEXAS STATES REGION CODE 3 160 162 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 163 200 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 201 210 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE 1 211 211 C PROV2805 THE REASON A FACILITY HAS BEEN TERMINATED FROM THE MEDICARE AND/OR MEDICAID PROGRAMS COBOL NAME: TERM-CD VALUES: 0 ACTIVE 1 VOL-MERG,CLOSE 2 VOL-REIMBURSE 3 VOL-RISK INVOL 4 VOL-OTHER 5 INVOL-FAIL REQ 6 INVOL-AGREEMNT 7 OTH-STATUS CHG TERMINATION DATE 6 212 217 C PROV2810 THE EFFECTIVE DATE OF TERMINATION OF CERTIFICATION OF A FACILITY. COBOL NAME: TERM-DT TYPE OF ACTION 1 218 218 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 7 INDEPENDENT LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP 6 COMPLAINT SURVEY TYPE OF CONTROL 2 219 220 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 VOL. NON-PROF. - RELIGIOUS AFF. 02 VOLUNTARY NON-PROFIT - PRIVATE 03 VOLUNTARY NON-PROFIT - OTHER 04 PROPRIETARY 05 GOVERNMENT - CITY 06 GOVERNMENT - COUNTY 07 GOVERNMENT - STATE 08 GOVERNMENT - FEDERAL 09 GOVERNMENT - OTHER 10 OTHER (SURVEYED PRIOR TO 040491) 11 UNKNOWN (PRIOR TO 040491 SURVEYS) ZIP CODE 5 221 225 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 226 227 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 228 230 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 231 233 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 234 234 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE CALENDAR YEAR TEST VOLUME 2 1151 1152 C PROV2615 THE NUMBER OF TESTS PERFORMED BY A LAB FOR THE PRE- VIOUS CALENDAR YEAR FOR ALL SPECIALTIES AND SUB- SPECIALTIES COBOL NAME: SPEC-CALENDAR-YEAR CLIA LAB PROGRAM STATUS 1 1153 1153 C PROV0615 THE TYPE OF LABORATORY, I.E. HOSPITAL OR INDEPEDENT, AND THE PROGRAM(S) (MEDICARE, CLIA) IN WHICH THE LAB PARTICIPATES COBOL NAME: LAB-PROGRAM-STATUS VALUES: 1 INDEPENDENT MEDICARE LAB 3 INDEPENDENT MEDICARE/CLIA LAB * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 8 INDEPENDENT LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CYTOTECHNOLOGISTS-PROF EXAM 3 1154 1156 N PROV0775 NUMBER OF CYTOTECHNOLOGISTS QUALIFIED UNDER CFR 405.1437(B)(3) WHICH REQUIRES SATISFACTORY GRADES IN PROFICIENCY EXAMINATIONS. COBOL NAME: NUM-CYTOTECHS-3 CYTOTECHNOLOGISTS-2 YR COLL 3 1157 1159 N PROV0765 NUMBER OF CYTOTECHNOLOGISTS QUALIFIED UNDER CFR 493.1437(B)(1) WHICH REQUIRES TWO YEARS OF COLLEGE, TWELVE MONTHS OF CYTOTECHNOLOGY TRAINING AND SIX MONTHS OF FORMAL TRAINING. COBOL NAME: NUM-CYTOTECHS-1 CYTOTECHNOLOGISTS-6 MO TRAIN 3 1160 1162 N PROV0770 # OF CYTOTECHNOLOGISTS QUALIFIED UNDER CFR CFR 493.1437(B)(2) WHICH REQUIRES THAT PRIOR TO 1/1/69, THE CYTOTECH IS A HS GRAD WITH 6 MTHS TRNG IN CYTOTECH, AND 2 YRS FULLTIME SUPERVISORY EXPER IN CYTOTECHNOLOGY COBOL NAME: NUM-CYTOTECHS-2 GENERAL SUPERVISOR - CYTOTECH 3 1163 1165 N PROV0880 THE NUMBER OF LAB GENERAL SUPERVISORS, QUALIFIED UNDER CFR 493.1427(B)(5), WHO HAVE FOUR YEARS EXPERIENCE AS CYTOTECHNOLOGISTS. COBOL NAME: NUM-GN-SUP-CYTOTECH GENERAL SUPERVISOR - GRANDFATHERED 3 1166 1168 N PROV0885 THE NUMBER OF LAB GENERAL SUPERVISORS QUALIFIED PRIOR TO 7/1/71 WITH AT LEAST 15 YEARS FULL-TIME EXPERIENCE PRIOR TO 1/1/68. (SEE CFR 493.1427(B)(6). COBOL NAME: NUM-GN-SUP-GRFATHER GENERAL SUPERVISOR - MD/DOCTORATE 3 1169 1171 N PROV0895 THE NUMBER OF LAB GENERAL SUPERVISORS, QUALIFIED UNDER CFR 493.1427(B)(2) WHO ARE PHYSICIANS OR HAVE DOCTORAL DEGREES IN A CLINICAL, PHYSICAL OR BIOLOGICAL SCIENCE AND 2 YEARS EXPERIENCE IN A LABORATORY. COBOL NAME: NUM-GN-SUP-PHYS-DOCT GENERAL SUPERVISOR - QUALIFIED DIR 3 1172 1174 N PROV0900 THE NUMBER OF GENERAL SUPERVISORS QUALIFIED UNDER CFR 493.1427(B)(1) WHO MAY ALSO SERVE AS THE LABORATORY DIRECTOR COBOL NAME: NUM-GN-SUP-QUALIF GENERAL SUPERVISOR - 6 YRS EXP 3 1175 1177 N PROV0875 THE NUMBER OF LAB GENERAL SUPERVISORS, QUALIFIED UNDER CFR 493.1427(B)(4), WHO ARE LAB TECHNOLOGISTS WITH AT LEAST 6 YRS FULL-TIME LAB EXPERIENCE. COBOL NAME: NUM-GN-SUP-CLT-PLUS6 GENERAL SUPERVISOR-MASTERS DEGREE 3 1178 1180 N PROV0890 THE NUMBER OF LAB GENERAL SUPERVISORS QUALIFIED UNDER CFR 493.1427(B)32) WHO POSSESS MASTER'S DEGREES IN A CHEMICAL, PHYSICAL OR BIOLOGICAL SCIENCE AND HAVE AT LEAST 4 YEARS LAB EXPERIENCE. COBOL NAME: NUM-GN-SUP-MST-DEGREE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 9 INDEPENDENT LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME IMMUNOHEMATOLOGY TEST FOR TRANSFUS 1 1181 1181 C PROV2085 INDICATES IF A LABORATORY PERFORMS IMMUNOHEMATOLOGY TESTS FOR TRANSFUSION PURPOSES COBOL NAME: SP-BLOOD-BANK-IMMUN VALUES: N NO Y YES LAB DIRECTORS - DOCTORATES 3 1182 1184 N PROV0830 THE NUMBER OF LAB DIRECTORS QUALIFIED UNDER CFR 493.1415(B)(4), WHICH REQUIRES DOCTORAL DEGREES AND BOARD CERTIFICATION OR 4 OR MORE YEARS EXPERIENCE IN AN APPROVED CLINICAL LABORATORY. COBOL NAME: NUM-DIR-DOCT-DEGREE LAB DIRECTORS - GRANDFATHERED 3 1185 1187 N PROV0835 THE NUMBER OF LAB DIRECTORS QUALIFIED UNDER CFR 493.1415(B)(5) WHO QUALIFIED PRIOR TO JULY 1, 1971, UNDER THE GRANDFATHER CLAUSE. COBOL NAME: NUM-DIR-GRFATHER LAB DIRECTORS - MD PATHOLOGISTS 3 1188 1190 N PROV0840 THE NUMBER OF LAB DIRECTORS QUALIFIED UNDER CFR 493.1415(B)(1) WHO ARE PHYSICIANS BOARD CERTIFIED IN ANATOMICAL AND/OR CLINICAL PATHOLOGY OR POSSESS EQUIVALENT QUALIFICATIONS. COBOL NAME: NUM-DIR-PATHOLOGIST LAB DIRECTORS - MD SPECIALTY 3 1191 1193 N PROV0845 THE NUMBER OF LAB DIRECTORS QUALIFIED UNDER CFR 493.1415(B)(2), WHO ARE PHYSICIANS BOARD CERTIFIED IN ONE OF THE LAB SPECIALTIES OR WHO HAVE 4 YEARS OF FT EXPERIENCE IN A LAB, INCLUDING 2 YEARS SPECIALIZED TRNG COBOL NAME: NUM-DIR-PHYS-BOARD LAB DIRECTORS - ORAL PATHOLOGY 3 1194 1196 N PROV0825 NUMBER OF LABORATORY DIRECTORS WHO ARE BOARD CERTIFIED IN ORAL PATHOLOGY OR_WHO POSSESS EQUIVALENT QUALIFICATIONS._SEE CFR 493.1415(B)(3) COBOL NAME: NUM-DIR-DENTIST LAB DIRECTORS - STATE DEEMED 3 1197 1199 N PROV0850 NUMBER OF DIRECTORS THAT QUALIFY UNDER STATE LAW TO DIRECT THE LABORATORY (CFR 493.1415(B)(6)). COBOL NAME: NUM-DIR-STATE-DEEMED TECH SUPER - BA/BS CHEMISTRY 3 1200 1202 N PROV1275 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(S) TO PERFORM CHEMISTRY TESTS, WHO ARE DIRECTORS WITH A BS IN CHEMICAL SCIENCE AND 6 YEARS RELATED EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-CHEM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 10 INDEPENDENT LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TECH SUPER - BA/BS HEMATOLOGY 3 1203 1205 N PROV1285 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER_CFR 493.1421(O) TO PERFORM HEMATOLOGY TESTS, WHO ARE DIRECTORS WITH A BS IN BIOLOGY, IMMUNOLOGY OR MICRO- BIOLOGY, AND HAVE 6 YEARS EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-HEM TECH SUPER - BA/BS IMMUNOHEM 3 1206 1208 N PROV1290 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(R) TO PERFORM BLOOD GROUPING TESTS, WHO ARE DIRECTORS WITH A BS IN BIOLOGY, IMMUNOLOGY OR MICRO- BIOLOGY, AND 6 YEARS EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-IMHE TECH SUPER - BA/BS IMMUNOLOGY 3 1209 1211 N PROV1295 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(P) TO PERFORM DIAGNOSTIC IMMUNOLOGY TESTS, WHO ARE DIRECTORS WITH A BS IN BIOLOGY, CHEMISTRY, IMMU- NOLOGY OR MICROBIOLOGY, AND HAVE 6 YEARS EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-IMM TECH SUPER - BA/BS MICROBIO 3 1212 1214 N PROV1300 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(N) TO PERFORM MICROBIOLOGY TESTS WHO ARE DIRECTORS WITH A BS IN BIOLOGY AND 6 YEARS MICROBIOLOGY EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-MICR TECH SUPER - BA/BS RADIOBIO 3 1215 1217 N PROV1305 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(Q) TO PERFORM RADIOBIOASSAY TESTS WHO ARE DIRECTORS WITH A BS IN CHEMICAL, PHYSICAL OR BIOLOGICAL SCIENCE AND HAVE 6 YEARS EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-RADI TECH SUPER - BA/BS SPEC EXP 3 1218 1220 N PROV1280 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(T) TO PERFORM SPECIFIC LAB TESTS WHO ARE DIRECTORS WITH A BS IN MEDICAL TECHNOLOGY AND HAVE 6 YEARS SPECIALIZED EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-EXP TECH SUPER - CLINICAL CHEMISTRY 3 1221 1223 N PROV1310 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(D) TO PERFORM TESTS IN CHEM UNDER THE SUP OF A BOARD CERT MD OR HAVE EQUIV QUALIFS OR HAVE DOCT/MAST DEGREE IN CHEM AND 4 YRS EXP IN CLINICAL CHEMISTRY COBOL NAME: NUM-TECH-SUP-CHEMISTRY TECH SUPER - CYTOGENETICS 3 1224 1226 N PROV1315 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(K) TO PERFORM IN CLINICAL CYTOGENETICS WHO ARE DIRECTORS WITH A DOCTORAL DEGREE IN BIOLOGY OR PHYSICIANS AND HAVE 4 YEARS EXPERIENCE IN GENETICS COBOL NAME: NUM-TECH-SUP-CYTOGEN * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 11 INDEPENDENT LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TECH SUPER - CYTOLOGY 3 1227 1229 N PROV1320 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(F) TO PERFORM CYTOLOGY TESTS UNDER THE SUPERVISION OF A BOARD CERTIFIED PHYSICIAN OR WHO POSSESS EQUIVALENT QUALIFICATIONS COBOL NAME: NUM-TECH-SUP-CYTOLOGY TECH SUPER - DIAGNOSTIC IMMUN 3 1230 1232 N PROV1345 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(C) TO PERFORM TESTS IN DIAGNOSTIC IMMUN- OLOGY UNDER THE SUP OF A BOARD CERT MD OR HAVE EQUIV QUALIFS OR HAVE DOCT/MAST DEGREE IN RELATED SCIENCES COBOL NAME: NUM-TECH-SUP-IMMUNOL TECH SUPER - HEMATOLOGY 3 1233 1235 N PROV1330 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(E) TO PERFORM HEMATOLOGY TESTS UNDER SUPERVISION OF A BOARD CERT MD OR WHO POSSESS BS OR MS DEGREES IN RELATED SCIENCES AND 4 YRS HEMATOLOGY EXPER. COBOL NAME: NUM-TECH-SUP-HEMATOLOGY * TECH SUPER - HISTO PATHOLOGY 3 1236 1238 N PROV1325 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(G) TO PERFORM TESTS IN HISTOPATHOLOGY UNDER THE SUPERVISION OF A BOARD CERTIFIED MD OR WHO POSSESS EQUIVALENT QUALIFICATIONS COBOL NAME: NUM-TECH-SUP-DERMATOLGY TECH SUPER - HISTOCOMPATIBILITY 3 1239 1241 N PROV1335 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(J)TO PERFORM TESTS IN HISTO UNDER SUP OF MD OR WHO POSSESS DOCT DEGREES OR ARE MD'S WITH 4 YRS EXP IN IMMUNOLOGY INCLUDING 2 YRS OF HISTO TESTING COBOL NAME: NUM-TECH-SUP-HISTOCOM TECH SUPER - IMMUNOHEMATOLOGY 3 1242 1244 N PROV1340 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(L) TO PERFORM TESTS IN IMMUNOHEMATOLOGY UNDER SUP OF A BOARD CERT MD OR HAVE EQUIV QUALIFS OR ARE PHYSICIANS WITH 2 YRS EXP IN IMMUNOHEMATOLOGY COBOL NAME: NUM-TECH-SUP-IMMUNOHEM TECH SUPER - MICROBIOLOGY 3 1245 1247 N PROV1350 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(B) TO PERFORM MICRO TESTS UNDER SUPERV OF A BOARD CERT MD, OR WHO HOLD DOCTORAL OR MASTER DEGREES IN MICRO AND HAVE 4 YRS EXP IN CLINICAL MICROBIOLOGY COBOL NAME: NUM-TECH-SUP-MICROBIO TECH SUPER - ORAL PATHOLOGY 3 1248 1250 N PROV1355 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(H) TO PERFORM TESTS IN ORAL PATHOLOGY UNDER SUPERVISION OF A BOARD CERT MD OR WHO HAVE EQUIVALENT QUALIFICATIONS COBOL NAME: NUM-TECH-SUP-ORAL-PATH * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 12 INDEPENDENT LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TECH SUPER - PATHOLOGIST 3 1251 1253 N PROV1360 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(A) TO PERFORM ALL BUT HISTOCOMPATIBILITY AND CLINICAL CYTOGENETICS WHO ARE MD'S CERT IN BOTH ANATOMICAL AND CLINICAL PATH OR HAVE EQUIV QUALIFICATNS COBOL NAME: NUM-TECH-SUP-PATHOLOGY TECH SUPER - PHS EXAM 3 1254 1256 N PROV1365 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(M) WITH SATISFACTORY GRADES IN EXAMINATIONS CONDUCTED BY THE PUBLIC HEALTH SERVICE. COBOL NAME: NUM-TECH-SUP-PHS-EXAM TECH SUPER - RADIOBIOASSAY 3 1257 1259 N PROV1370 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(I) WHO ARE BOARD CERT MD'S OR WHO HAVE A DOCTORATE/MASTERS/BACH DEGREE IN RELATED SCIENCES OR ARE PHYSICIANS WITH 4 YEARS EXP IN RADIOBIOASSAY COBOL NAME: NUM-TECH-SUP-RADIOBIO TECHNICIAN TRAINEES 3 1260 1262 N PROV1375 THE NUMBER OF TECHNICIAN TRAINEES IN LABORATORIES WHO ARE HIGH SCHOOL GRADUATES AND WHO ARE RECEIVING THE REQUIRED 2 YEARS LAB EXPERIENCE AND ARE PARTICIPATING IN A STRUCTURED TRAINING PROGRAM.(CFR 493.1402) COBOL NAME: NUM-TECH-TRAINEES TECHNICIANS - GRANDFATHERED 3 1263 1265 N PROV1245 THE NUMBER OF TECHNICIANS QUALIFIED UNDER CFR 493.1441(B)(5) WHO WAS PERFORMING THE DUTIES OF A LAB TECHNICIAN BETWEEN 7/1/61 & 1/1/68 AND HAS AT LEAST 5 YEARS EXPERIENCE PRIOR TO 1/1/68. COBOL NAME: NUM-TECH-GRFATHER TECHNICIANS - MILITARY 3 1266 1268 N PROV1260 THE NUMBER OF TECHNICIANS QUALIFIED UNDER CFR 493.1441(B)(4) WHO COMPLETED AN OFFICIAL MILITARY MEDICAL LABORATORY PROCEDURES COURSE OF AT LEAST 50 WEEKS DURATION. COBOL NAME: NUM-TECH-MILITARY TECHNICIANS - PROFICIENCY EXAM 3 1269 1271 N PROV1265 THE NUMBER OF TECHNICIANS QUALIFIED UNDER CFR 493.1441(B)(6) WHO ACHIEVED A SATISFACTORY GRADE IN AN APPROVED PROFICIENCY EXAMINATION PRIOR TO 12/31/77. COBOL NAME: NUM-TECH-PES-EXAM TECHNICIANS-AA PLUS 60 CREDIT HRS 3 1272 1274 N PROV1380 THE NUMBER OF LABORATORY TECHNICIANS WHO HAVE COMPLETED EITHER 60 HOURS OF ACADEMIC CREDIT OR HAVE ASSOCIATE DEGREES IN A COURSE OF STUDY THAT INCLUDES MEDICAL LABORATORY TECHNIQUES (CFR 493.1441(B)(1). COBOL NAME: NUM-TECH-60-CREDITS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 13 INDEPENDENT LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TECHNICIANS-HIGH SCH + EXPERIENCE 3 1275 1277 N PROV1255 THE NUMBER OF TECHNICIANS QUALIFIED UNDER CFR 493.1441(B)(3) WHO ARE HIGH SCHOOL GRADUATES AND HAVE TWO YEARS OF PERTINENT LABORATORY EXPERIENCE. COBOL NAME: NUM-TECH-HS-AND-2YR TECHNICIANS-HIGH SCH + TRAINING 3 1278 1280 N PROV1250 THE NUMBER OF TECHNICIANS QUALIFIED UNDER CFR 493.1441(B)(2) WHO COMPLETED HIGH SCHOOL AND ONE YEAR IN A TECHNICIAN TRAINING PROGRAM. COBOL NAME: NUM-TECH-HS-AND-1YR TECHNOLOGIST - BACHELORS DEGREE 3 1281 1283 N PROV1385 THE NUMBER OF LAB TECHNOLOGISTS WHO HAVE EARNED BACHELOR'S DEGREES IN CHEMICAL, BIOLOGICAL, OR PHYSICAL SCIENCE AND HAVE ONE YEAR EXPERIENCE/TRAINING IN RELATED SPECIALTY (CFR 493.1433(B)(3)). COBOL NAME: NUM-TECHNOLO-BS-BA TECHNOLOGIST - BS MED TECH 3 1284 1286 N PROV1390 THE NUMBER OF TECHNOLOGISTS WHO HAVE EARNED BACHELOR'S DEGREES IN MEDICAL TECHNOLOGY (CFR 493.1433(B)(1)). COBOL NAME: NUM-TECHNOLO-BS-MT TECHNOLOGIST - GRANDFATHERED 3 1287 1289 N PROV1395 THE NUMBER OF TECHNOLOGISTS WHO QUALIFIED PRIOR TO JULY 1, 1971 & WHO WERE PERFORMING AS TECHNOLOGISTS BETWEEN 7/1/61 & 1/1/68 & HAVE AT LEAST TEN YEARS LAB EXPERIENCE PRIOR TO 1/1/68 (CFR 493.1433(B)(5)). COBOL NAME: NUM-TECHNOLO-GRFATHER TECHNOLOGIST - PROFICIENCY EXAM 3 1290 1292 N PROV1400 THE NUMBER OF TECHNOLOGISTS WHO HAVE ACHIEVED A SATISFACTORY GRADE IN A PROFICIENCY EXAM APPROVED BY THE SECRETARY (CFR 493.1433(B)(6)). COBOL NAME: NUM-TECHNOLO-PES-EXAM TECHNOLOGIST - 90 HRS + EXP 3 1293 1295 N PROV1410 THE NUMBER OF TECHNOLOGISTS WHO HAVE COMPLETED THREE YEARS (90 SEMESTER HOURS) OF PERTINENT ACADEMIC STUDIES OUTLINED IN CFR 493.1433(B)(4) AND HAVE ONE YEAR OF LAB EXPERIENCE COBOL NAME: NUM-TECHNOLO-90CR-1YR TECHNOLOGIST - 90 HRS + TRAINING 3 1296 1298 N PROV1405 THE NUMBER OF TECHNOLOGISTS WHO HAVE COMPLETED THREE YEARS (90 SEMESTER HOURS) OF ACADEMIC STUDY AND COM- PLETED AT LEAST ONE YEAR TRAINING IN A SCHOOL OF MEDICAL TECHNOLOGY (CFR 493.1433(B)(2). COBOL NAME: NUM-TECHNOLO-3YR-1YR 010 HISTOCOMPATIBILITY 1 1299 1299 C PROV1865 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-010-HISTOCOMPAT VALUES: N NOT APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 14 INDEPENDENT LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME Y APPROVED 010A TRANSPLANT 1 1300 1300 C PROV1870 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN THIS SUBSPECIALTY COBOL NAME: SC-010A-TRANSPLANT VALUES: N NOT APPROVED Y APPROVED 010B NON-TRANSPLANT 1 1301 1301 C PROV1875 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN THIS SUBSPECIALTY COBOL NAME: SC-010B-NON-TRANSPLANT VALUES: N NOT APPROVED Y APPROVED 100 MICROBIOLOGY 1 1302 1302 C PROV1880 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-100-MICROBIO VALUES: N NOT APPROVED Y APPROVED 110 BACTERIOLOGY 1 1303 1303 C PROV1885 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-110-BACTERIOLOGY VALUES: N NOT APPROVED Y APPROVED 110C MYCOBACTERIOLOGY 1 1304 1304 C PROV1890 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN MYCOBACTERIOLOGY, WHICH IS WITHIN THE BACTERIOLOGY SUBSPECIALTY COBOL NAME: SC-110C-MYCOBACT VALUES: N NOT APPROVED Y APPROVED 120 MYCOLOGY 1 1305 1305 C PROV1895 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-120-MYCOLOGY VALUES: N NOT APPROVED Y APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 15 INDEPENDENT LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 130 PARASITOLOGY 1 1306 1306 C PROV1900 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-130-PARASITOLOGY VALUES: N NOT APPROVED Y APPROVED 140 VIROLOGY 1 1307 1307 C PROV1910 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-140-VIROLOGY VALUES: N NOT APPROVED Y APPROVED 150 OTHER MICROBIOLOGY 1 1308 1308 C PROV1915 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-150-OTHER-MICROBIO VALUES: N NOT APPROVED Y APPROVED 200 DIAGNOSTIC IMMUNOLOGY 1 1309 1309 C PROV1920 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-200-DIAG-IMMUNOL VALUES: N NOT APPROVED Y APPROVED 210 SYPHILIS 1 1310 1310 C PROV1925 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-210-SYPHILIS VALUES: N NOT APPROVED Y APPROVED * 220 GEN IMMUNOLOGY 1 1311 1311 C PROV1930 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-220-GEN-IMMUNOL VALUES: N NOT APPROVED Y APPROVED 300 CHEMISTRY 1 1312 1312 C PROV1935 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-300-CHEMISTRY VALUES: N NOT APPROVED Y APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 16 INDEPENDENT LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 310 ROUTINE CHEMISTRY 1 1313 1313 C PROV1940 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-310-ROUTINE VALUES: N NOT APPROVED Y APPROVED 320 URINALYSIS 1 1314 1314 C PROV1945 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-320-URINALYSIS VALUES: N NOT APPROVED Y APPROVED 330 OTHER CHEMISTRY 1 1315 1315 C PROV1950 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-330-OTHER-CHEMISTRY VALUES: N NOT APPROVED Y APPROVED 330D ENDOCRINOLOGY 1 1316 1316 C PROV1955 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN ENDOCRINOLOGY, WHICH IS WITHIN THE OTHER CHEMISTRY SUBSPECIALTY COBOL NAME: SC-330D-ENDOCRINOLOGY VALUES: N NOT APPROVED Y APPROVED 330E TOXICOLOGY 1 1317 1317 C PROV1960 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN TOXICOLOGY, WHICH IS WITHIN THE OTHER CHEMISTRY SUBSPECIALTY COBOL NAME: SC-330E-TOXICOLOGY VALUES: N NOT APPROVED Y APPROVED 400 HEMATOLOGY 1 1318 1318 C PROV1965 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-400-HEMATOLOGY VALUES: N NOT APPROVED Y APPROVED 500 IMMUNOHEMATOLOGY 1 1319 1319 C PROV1970 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-500-IMMUNOHEM VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 17 INDEPENDENT LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME N NOT APPROVED Y APPROVED 510 ABO + RH GROUP 1 1320 1320 C PROV1975 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-510-ABO-RH-GROUP VALUES: N NOT APPROVED Y APPROVED 520 RH TITERS 1 1321 1321 C PROV1980 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-520-RH-TITERS VALUES: N NOT APPROVED Y APPROVED 530 COMPATIBILITY TEST 1 1322 1322 C PROV1985 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-530-CROSS-MATCH VALUES: N NOT APPROVED Y APPROVED 540 ANTIBODY DETECT + OTHER 1 1323 1323 C PROV1990 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-540-OTHER-IMMUNOHEM VALUES: N NOT APPROVED Y APPROVED 600 PATHOLOGY 1 1324 1324 C PROV1995 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-600-PATHOLOGY VALUES: N NOT APPROVED Y APPROVED 610 HISTOPATHOLOGY 1 1325 1325 C PROV2000 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-610-HISTOPATH VALUES: N NOT APPROVED Y APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 18 INDEPENDENT LABORATORIES, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 620 ORAL PATHOLOGY 1 1326 1326 C PROV2005 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-620-ORAL VALUES: N NOT APPROVED Y APPROVED 630 CYTOLOGY 1 1327 1327 C PROV2010 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-630-CYTOLOGY VALUES: N NOT APPROVED Y APPROVED 800 RADIOBIOASSAY 1 1328 1328 C PROV2015 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-800-RADIOBIO VALUES: N NOT APPROVED Y APPROVED 900 CYTOGENETICS 1 1329 1329 C PROV2020 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY COBOL NAME: SC-900-CYTOGENETICS VALUES: N NOT APPROVED Y APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 1 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 X-RAY CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 07 PORTABLE X-RAY SUPPLIERS CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY AND STATE 31 13 43 C PROV0115 THE CITY AND STATE WHERE A PROVIDER IS LOCATED. COBOL NAME: CITY-STATE COMPLIANCE: PLAN OF CORRECTION 1 44 44 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 45 45 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 46 48 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 49 58 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 59 64 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 2 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 6 65 70 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 71 71 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 38 72 109 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME * INTERMEDIARY NUMBER 5 110 114 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00510 BLUE SHIELD (ALABAMA) 00520 BLUE SHIELD (ARKANSAS) 00528 BLUE SHIELD (ARKANSAS/LOUISIANA) 00542 BLUE SHIELD (CALIFORNIA) 00550 BLUE SHIELD (COLORADO) 00570 BLUE SHIELD (DELAWARE) 00580 BLUE SHIELD (DISTRICT OF COLUMBIA) 00590 BLUE SHIELD (FLORIDA) 00621 BLUE SHIELD (ILLINOIS) 00630 BLUE SHIELD (INDIANA) 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 BLUE SHIELD (KENTUCKY) 00690 BLUE SHIELD (MARYLAND) 00700 BLUE SHIELD (MASSACHUSETTS) 00710 BLUE SHIELD (MICHIGAN) 00720 BLUE SHIELD (MINNESOTA) 00740 BLUE SHIELD (KANSAS CITY) 00751 BLUE SHIELD (MONTANA) 00770 BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780 BLUE SHIELD (TRI-STATE) 00801 BLUE SHIELD (BUFFALO) 00803 BLUE SHIELD (EMPIRE) 00820 BLUE SHIELD (NORTH DAKOTA) 00825 BLUE SHIELD (NORTH DAKOTA/WYOMING) 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865 BLUE SHIELD (PENNSYLVANIA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 3 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00900 BLUE SHIELD (TEXAS) 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 00973 BLUE SHIELD (PUERTO RICO) 00974 BLUE SHIELD (VIRGIN ISLANDS) 01010 AETNA (PEORIA) 01020 AETNA (ALASKA) 01030 AETNA (ARIZONA) 01040 AETNA (GEORGIA) 01120 AETNA (HAWAII) 01290 AETNA (NEVADA) 01360 AETNA (NEW MEXICO) 01370 AETNA (OKLAHOMA) 01380 AETNA (OREGON) 02050 OCCIDENTAL (CALIFORNIA) 05130 EQICOR (IDAHO) 05440 EQICOR (TENNESSEE) 05535 EQICOR (NORTH CAROLINA) 10071 TRAVELERS (RRB) 10230 TRAVELERS (CONNECTICUT) 10240 TRAVELERS (MINNESOTA) 10250 TRAVELERS (MISSISSIPPI) 10490 TRAVELERS (VIRGINIA) 10492 TRAVELERS - VIRGINIA SPECIAL PROJECT 11260 GENERAL AMERICAN 14330 GROUP HEALTH INC (NEW YORK) 16360 NATIONWIDE (OHIO) 16510 NATIONWIDE (WEST VIRGINIA) 21200 MASSACHUSETTS/MAINE MEDICAID VENDOR NUMBER 12 115 126 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A MEDICAID FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 6 127 132 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 133 138 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 4 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR INTERMEDIARY NUMBER 5 139 143 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 144 153 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE: MASTER/TRANSACTION 1 154 154 C PROV1720 INDICATES IF A RECORD IS CURRENTLY ON THE MASTER FILE OR THE TRANSACTION FILE. COBOL NAME: RECORD-TYPE VALUES: M MASTER FILE T TRANSACTION FILE REGION CODE 2 155 156 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 157 157 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE CODE (SSA) 2 158 159 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 5 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 54 AFRICA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 6 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 55 CALIFORNIA 56 CANADA 57 WEST INDIES 58 EUROPE 59 MEXICO 60 OCEANIA 61 PHILIPPINES 62 SOUTH AMERICA 63 UNITED STATES POSSESSIONS 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN 67 TEXAS STATES REGION CODE 3 160 162 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 163 200 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 201 210 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE 1 211 211 C PROV2805 THE REASON A FACILITY HAS BEEN TERMINATED FROM THE MEDICARE AND/OR MEDICAID PROGRAMS COBOL NAME: TERM-CD VALUES: 0 ACTIVE 1 VOL-MERG,CLOSE 2 VOL-REIMBURSE 3 VOL-RISK INVOL 4 VOL-OTHER 5 INVOL-FAIL REQ 6 INVOL-AGREEMNT 7 OTH-STATUS CHG TERMINATION DATE 6 212 217 C PROV2810 THE EFFECTIVE DATE OF TERMINATION OF CERTIFICATION OF A FACILITY. COBOL NAME: TERM-DT TYPE OF ACTION 1 218 218 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 7 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP 6 COMPLAINT SURVEY TYPE OF CONTROL 2 219 220 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 INDIVIDUAL 02 PARTNERSHIP 03 CORPORATION 04 OTHER THAN PRIVATE ZIP CODE 5 221 225 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 226 227 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 228 230 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 231 233 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 234 234 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE OTHER PERSONNEL 7.2 376 382 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL DIRECTOR QUALIFICATIONS 1 1330 1330 C PROV1715 INDICATES THE QUALIFICATIONS OF THE DIRECTOR OF A SUPPLIER OF PORTABLE X-RAY SERVICES. COBOL NAME: QUAL-OF-DIRECTOR VALUES: 1 PHYSICIAN 2 PHD/SCD 3 MS/MA 4 BS/BA 5 OTHER TECHNOLOGISTS - ASSOC DEGREE 7.2 1331 1337 N PROV0735 THE NUMBER OF TECHNOLOGISTS WITH ASSOCIATE DEGREES IN RADIOLOGIC TECHNOLOGY. COBOL NAME: NUM-AS-RADIO-TECH * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 8 PORTABLE X-RAY SUPPLIERS, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TECHNOLOGISTS - BS/BA DEGREE 7.2 1338 1344 N PROV0750 NUMBER OF TECHNOLOGISTS WITH BACHELOR OF SCIENCE OR BACHELOR OF ARTS DEGREES IN RADIOLOGIC TECHNOLOGY. COBOL NAME: NUM-BS-BA-RAD-TECH TECHNOLOGISTS - 2 YEAR RADIOLOGY 7.2 1345 1351 N PROV1515 THE NUMBER OF FULL-TIME EQUIVALENT TECHNOLOGISTS EMPLOYED BY A PORTABLE X-RAY PROVIDER WHO ARE GRADUATES OF A TWO YEAR APPROVED SCHOOL OF RADIOLOGIC TECHNOLOGY. COBOL NAME: NUM-2YR-RADIO-TECH * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 1 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 OPT OR SPECH PATHOLOGY CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 08 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY AND STATE 31 13 43 C PROV0115 THE CITY AND STATE WHERE A PROVIDER IS LOCATED. COBOL NAME: CITY-STATE COMPLIANCE: PLAN OF CORRECTION 1 44 44 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 45 45 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 46 48 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 49 58 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 59 64 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 2 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 6 65 70 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 71 71 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 38 72 109 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME * INTERMEDIARY NUMBER 5 110 114 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 3 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00510 BLUE SHIELD (ALABAMA) 00520 BLUE SHIELD (ARKANSAS) 00528 BLUE SHIELD (ARKANSAS/LOUISIANA) 00542 BLUE SHIELD (CALIFORNIA) 00550 BLUE SHIELD (COLORADO) 00570 BLUE SHIELD (DELAWARE) 00580 BLUE SHIELD (DISTRICT OF COLUMBIA) 00590 BLUE SHIELD (FLORIDA) 00621 BLUE SHIELD (ILLINOIS) 00630 BLUE SHIELD (INDIANA) 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 BLUE SHIELD (KENTUCKY) 00690 BLUE SHIELD (MARYLAND) 00700 BLUE SHIELD (MASSACHUSETTS) 00710 BLUE SHIELD (MICHIGAN) 00720 BLUE SHIELD (MINNESOTA) 00740 BLUE SHIELD (KANSAS CITY) 00751 BLUE SHIELD (MONTANA) 00770 BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780 BLUE SHIELD (TRI-STATE) 00801 BLUE SHIELD (BUFFALO) 00803 BLUE SHIELD (EMPIRE) 00820 BLUE SHIELD (NORTH DAKOTA) 00825 BLUE SHIELD (NORTH DAKOTA/WYOMING) 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865 BLUE SHIELD (PENNSYLVANIA) 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00900 BLUE SHIELD (TEXAS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 4 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 00973 BLUE SHIELD (PUERTO RICO) 00974 BLUE SHIELD (VIRGIN ISLANDS) 01010 AETNA (PEORIA) 01020 AETNA (ALASKA) 01030 AETNA (ARIZONA) 01040 AETNA (GEORGIA) 01120 AETNA (HAWAII) 01290 AETNA (NEVADA) 01360 AETNA (NEW MEXICO) 01370 AETNA (OKLAHOMA) 01380 AETNA (OREGON) 02050 OCCIDENTAL (CALIFORNIA) 05130 EQICOR (IDAHO) 05440 EQICOR (TENNESSEE) 05535 EQICOR (NORTH CAROLINA) 10071 TRAVELERS (RRB) 10230 TRAVELERS (CONNECTICUT) 10240 TRAVELERS (MINNESOTA) 10250 TRAVELERS (MISSISSIPPI) 10490 TRAVELERS (VIRGINIA) 10492 TRAVELERS - VIRGINIA SPECIAL PROJECT 11260 GENERAL AMERICAN 14330 GROUP HEALTH INC (NEW YORK) 16360 NATIONWIDE (OHIO) 16510 NATIONWIDE (WEST VIRGINIA) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 21200 MASSACHUSETTS/MAINE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICAID VENDOR NUMBER 12 115 126 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A MEDICAID FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 6 127 132 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 5 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR CHANGE OF OWNERSHIP 6 133 138 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 139 143 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 144 153 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE: MASTER/TRANSACTION 1 154 154 C PROV1720 INDICATES IF A RECORD IS CURRENTLY ON THE MASTER FILE OR THE TRANSACTION FILE. COBOL NAME: RECORD-TYPE VALUES: M MASTER FILE T TRANSACTION FILE REGION CODE 2 155 156 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 157 157 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE CODE (SSA) 2 158 159 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 6 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 7 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 52 WISCONSIN 53 WYOMING 54 AFRICA 55 CALIFORNIA 56 CANADA 57 WEST INDIES 58 EUROPE 59 MEXICO 60 OCEANIA 61 PHILIPPINES 62 SOUTH AMERICA 63 UNITED STATES POSSESSIONS 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN 67 TEXAS STATES REGION CODE 3 160 162 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 163 200 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 201 210 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE 1 211 211 C PROV2805 THE REASON A FACILITY HAS BEEN TERMINATED FROM THE MEDICARE AND/OR MEDICAID PROGRAMS COBOL NAME: TERM-CD VALUES: 0 ACTIVE 1 VOL-MERG,CLOSE 2 VOL-REIMBURSE 3 VOL-RISK INVOL 4 VOL-OTHER 5 INVOL-FAIL REQ 6 INVOL-AGREEMNT 7 OTH-STATUS CHG TERMINATION DATE 6 212 217 C PROV2810 THE EFFECTIVE DATE OF TERMINATION OF CERTIFICATION OF A FACILITY. COBOL NAME: TERM-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 8 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF ACTION 1 218 218 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP 6 COMPLAINT SURVEY TYPE OF CONTROL 2 219 220 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 VOL. NON-PROF. NOT CHURCH 02 VOLUNTARY NON PROFIT CHURCH 03 STATE GOVERNMENT 04 LOCAL GOVERNMENT 05 COMBINATION GOVERNMENT & VOL. 06 PROPRIETARY ZIP CODE 5 221 225 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 226 227 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 228 230 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 231 233 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 234 234 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE FISCAL YEAR ENDING DATE 4 349 352 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT OCCUPATIONAL THERAPISTS 7.2 369 375 N PROV1050 THE NUMBER OF FULL TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-OCCUP-THERAPISTS PHYSICAL THERAPISTS 7.2 391 397 N PROV1125 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS-THERAPY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 9 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME * RELATED PROVIDER NUMBER 10 456 465 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM TYPE OF FACILITY 2 516 517 C PROV2890 INDICATES THE CATEGORY WHICH REPRESENTS THE TYPE OF FACILITY. COBOL NAME: TYPE-FACILITY VALUES: 01 HOSPITAL 02 SKILLED NURSING FACILITY 03 HOME HEALTH AGENCY 04 REHABILITATION AGENCY 05 PUBLIC CLINIC 06 PRIVATE CLINIC 07 PUBLIC HEALTH AGENCY PHYSICAL THERAPISTS 7.2 1118 1124 N PROV1120 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS-THERAPISTS SPEECH PATHOLOGISTS, AUDIOLOGISTS 7.2 1132 1138 N PROV1220 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS OR AUDIOLOGISTS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-SPEECH-PATH-AUDIO DOES FACIL. PROVIDES OPT OCCUP 1 1352 1352 C PROV1685 DOES FACILITY PROVIDE OCCUPATIONAL THERAPY SERVICES ?? COBOL NAME: PROVIDES-OCCUP-THERAPY VALUES: N NO Y YES PHYSICAL THERAPIST - ARRANGEMENT 7.2 1353 1359 N PROV1105 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY ARRANGEMENT IN AN OUTPATIENT PHYSICAL THERAPY FACILITY. COBOL NAME: NUM-PHY-THER-ARGNM SPEECH PATHOLOGISTS - ARRANGEMENT 7.2 1360 1366 N PROV1215 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS EMPLOYED BY ARRANGEMENT IN AN OUTPATIENT PHYSICAL THERAPY FACILITY. COBOL NAME: NUM-SPEECH-PATH-AR SPEECH PATHOLOGISTS - TOTAL 7.2 1367 1373 N PROV1210 THE TOTAL NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS ON STAFF AND BY ARRANGEMENT IN AN OUTPATIENT PHYSICAL THERAPY FACILITY. COBOL NAME: NUM-SPEECH-PATH * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 10 OUTPATIENT PHYSICAL THERAPY/SPEECH PATHOLOGY, CATEGORY = "08" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: PHYSICAL THERAPY/SPEECH PATH 1 1374 1374 C PROV2500 INDICATES IF PHYSICAL THERAPY AND/OR SPEECH PATHOLOGY SERVICES ARE PROVIDED BY A OUTPATIENT PHYSICAL THERAPY PROVIDER. COBOL NAME: SP-SPEECH-AND-PATH VALUES: 1 PHYSICAL THERAPY 2 SPEECH PATHOLOGY 3 BOTH 4 OCCUPATIONAL THERAPY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 1 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 END STAGE RENAL DISEASE CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 09 END STAGE RENAL DISEASE FACILITIES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY AND STATE 31 13 43 C PROV0115 THE CITY AND STATE WHERE A PROVIDER IS LOCATED. COBOL NAME: CITY-STATE COMPLIANCE: PLAN OF CORRECTION 1 44 44 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 45 45 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 46 48 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 49 58 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 59 64 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 2 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 6 65 70 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 71 71 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 38 72 109 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME * INTERMEDIARY NUMBER 5 110 114 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 3 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICAID VENDOR NUMBER 12 115 126 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A MEDICAID FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 6 127 132 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 133 138 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 139 143 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 144 153 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 4 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RECORD TYPE: MASTER/TRANSACTION 1 154 154 C PROV1720 INDICATES IF A RECORD IS CURRENTLY ON THE MASTER FILE OR THE TRANSACTION FILE. COBOL NAME: RECORD-TYPE VALUES: M MASTER FILE T TRANSACTION FILE REGION CODE 2 155 156 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 157 157 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE CODE (SSA) 2 158 159 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 5 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 54 AFRICA 55 CALIFORNIA 56 CANADA 57 WEST INDIES 58 EUROPE 59 MEXICO 60 OCEANIA 61 PHILIPPINES 62 SOUTH AMERICA 63 UNITED STATES POSSESSIONS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 6 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN 67 TEXAS STATES REGION CODE 3 160 162 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 163 200 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 201 210 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE 1 211 211 C PROV2805 THE REASON A FACILITY HAS BEEN TERMINATED FROM THE MEDICARE AND/OR MEDICAID PROGRAMS COBOL NAME: TERM-CD VALUES: 0 ACTIVE 1 VOL-MERG,CLOSE 2 VOL-REIMBURSE 3 VOL-RISK INVOL 4 VOL-OTHER 5 INVOL-FAIL REQ 6 INVOL-AGREEMNT 7 OTH-STATUS CHG TERMINATION DATE 6 212 217 C PROV2810 THE EFFECTIVE DATE OF TERMINATION OF CERTIFICATION OF A FACILITY. COBOL NAME: TERM-DT TYPE OF ACTION 1 218 218 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP 6 COMPLAINT SURVEY TYPE OF CONTROL 2 219 220 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 7 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 01 FOR PROFIT - INDIVIDUAL 02 FOR PROFIT - PARTNERSHIP 03 FOR PROFIT - CORPORATION 04 FOR PROFIT - OTHER 05 NOT FOR PROFIT - INDIVIDUAL 06 NOT FOR PROFIT - PARTNERSHIP 07 NOT FOR PROFIT - CORPORATION 08 NOT FOR PROFIT - OTHER 09 GOVERNMENT - STATE 10 GOVERNMENT - COUNTY 11 GOVERNMENT - CITY 12 GOVERNMENT - CITY/COUNTY 13 GOV. - HOSP. DIST. OR AUTHORITY 14 GOVERNMENT - NON FEDERAL OTHER 15 GOV. - VETERANS ADMINISTRATION 16 GOVERNMENT - PHS HOSPITAL 17 GOVERNMENT - MILITARY 18 GOVERNMENT - FEDERAL OTHER ZIP CODE 5 221 225 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 226 227 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 228 230 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 231 233 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 234 234 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE FISCAL YEAR ENDING DATE 4 349 352 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT * RELATED PROVIDER NUMBER 10 456 465 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM TYPE OF FACILITY 2 516 517 C PROV2890 INDICATES THE CATEGORY WHICH REPRESENTS THE TYPE OF FACILITY. COBOL NAME: TYPE-FACILITY VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 8 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 01 RENAL TRANSPLANT CENTER 02 RENAL DIALYSIS CENTER 03 RENAL DIALYSIS FACILITY (HOSPITAL-BASED) 04 RENAL DIALYSIS FACILITY(NON-HOSPITAL-BASED) 05 RENAL TRANSPLANT & DIALYSIS CENTER 06 RENAL TRANSPLANT CENTER & DIALYSIS FACILITY CAPD CERTIFICATION 1 1375 1375 C PROV0070 INDICATES THE ELIGIBILITY OF AN END STAGE RENAL DISEASE FACILITY TO PROVIDE CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD) SERVICES. COBOL NAME: CAPD-CD VALUES: A ELIGIBLE B ELIGIBILITY BASED ON ACCEPTABLE PLAN OF CORR C ELIGIBILITY DEPENDS ON APPROVAL OF DIRECTOR E NOT ELIGIBLE CCPD CERTIFICATION 1 1376 1376 C PROV0090 INDICATES THE ELIGIBILITY OF AN END STAGE RENAL DISEASE FACILITY TO PROVIDE CONTINUOUS CYCLE PERITONEAL DIALYSIS (CCPD) SERVICES. COBOL NAME: CCPD-CD VALUES: A ELIGIBLE B ELIGIBILITY BASED ON ACCEPTABLE PLAN OF CORR C ELIGIBILITY DEPENDS ON APPROVAL OF DIRECTOR E NOT ELIGIBLE COMPLIANCE: FURNISH DATA TO MIS 1 1377 1377 C PROV0235 INDICATES IF AN ESRD FACILITY IS IN COMPLIANCE WITH THE REQUIREMENT TO FURNISH DATA TO A NATIONAL ESRD MEDICAL INFORMATION SYSTEM. COBOL NAME: COMPL-FURNISH-DATA VALUES: 4 MET 5 NOT MET COMPLIANCE: MEMBERSHIP IN NETWORK 1 1378 1378 C PROV0250 INDICATES IF AN ESRD FACILITY PARTICIPATES IN NETWORK ACTIVITIES. COBOL NAME: COMPL-MEMBER-NETWORK VALUES: 4 MET 5 NOT MET COMPLIANCE: PROVIDER STATUS 1 1379 1379 C PROV0275 INDICATES IF THE HOSPITAL OF WHICH A RENAL TRANSPLANTATION OR DIALYSIS CENTER IS A PART IS AN APPROVED PROVIDER IN THE MEDICARE PROGRAM. COBOL NAME: COMPL-PROV-STATUS VALUES: 4 MET * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 9 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 5 NOT MET ESRD NETWORK # 2 1380 1381 C PROV0685 THE NUMBER OF THE NETWORK TO WHICH THE END STAGE RENAL DIALYSIS FACILITY IS ASSIGNED. COBOL NAME: NETWORK-NUM VALUES: 01 CONN-MAINE-MASS-NEW HAMP-RHODE ISLAND-VERMONT 02 NEW YORK 03 NEW JERSEY, PUERTO RICO AND VIRGIN ISLAND 04 DELAWARE AND PENNSYLVANIA 05 DIST OF COLUM-MARYLAND-VIRGINIA-WEST VIRGINIA 06 GEORGIA, SOUTH CAROLINA AND NORTH CAROLINA 07 FLORIDA 08 ALABAMA, MISSISSIPPI AND TENNESSEE 09 INDIANA, KENTUCKY AND OHIO 10 ILLINOIS 11 MICH-MINN-NORTH DAKOTA-SOUTH DAKOTA-WISCONSIN 12 IOWA, KANSAS, MISSOURI AND NEBRASKA 13 ARKANSAS, LOUISIANA AND OKLAHOMA 14 TEXAS 15 ARIZONA-COLO-NEVADA-NEW MEXI-UTAH AND WYOMING 16 ALASKA, IDAHO, MONTANA, OREGON AND WASHINGTON 17 COUNTIES IN NORTHERN CALIF, HAWAII, AS, GUAM 18 COUNTIES IN SOUTHERN CALIFORNIA FACILITY ADMINISTRATION, LOCATION 1 1382 1382 C PROV0470 INDICATES HOW A FACILITY IS ADMINISTERED AND WHERE IT IS LOCATED. COBOL NAME: FACILITY-ADMIN-LOCTN VALUES: 1 HOSPITAL ADMINISTERED, HOSPITAL LOCATED 2 HOSPITAL ADMINISTERED, NON-HOSPITAL LOCATED 3 NON-HOSPITAL ADMINISTERED, HOSPITAL LOCATED 4 NON-HOSPITAL ADMINISTERED AND LOCATED MUR: TRANSPLANTATION 1 1383 1383 C PROV0265 INDICATES HOW A RENAL DIALYSIS CENTER MEETS MINIMAL UTILIZATION RATES FOR TRANSPLANTATION. COBOL NAME: COMPL-MUR-TRANSP VALUES: 1 CONDITIONAL 2 UNCONDITIONAL 3 EXCEPTION 5 NOT MET PATIENT DIALYSIS TRAINING CERT 1 1384 1384 C PROV1600 INDICATES HOW AN END STAGE RENAL DIALYSIS FACILITY IS CERTIFIED TO PROVIDE PATIENT DIALYSIS TRAINING. COBOL NAME: PATIENT-DIAL-TRN-CERT VALUES: A ELIGIBLE TO SUPPLY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 10 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME B ELIGIBILITY IS BASED ON PLAN OF CORRECTION C ELIGIBILITY DEPENDS ON APPROVAL OF PHYSICIAN E NOT ELIGIBLE TO SUPPLY SERVICES PATIENT DIALYSIS TRAINING CODE 1 1385 1385 C PROV1590 INDICATES THE ELIGIBITY OF AN END STAGE RENAL DIALYSIS TO PROVIDE PATIENT DIALYSIS TRAINING. COBOL NAME: PATIENT-DIAL-TRAIN-CD VALUES: A ELIGIBLE TO PROVIDE PATIENT DIALYSIS TRAINING B NOT ELIGIBLE TO PROVIDE PATIENT DIALYSIS TRNG C VOLUNTARY WITHDRAWAL TO PROVIDE PATIENT TRNG D TERMINATION TO RPOVIDE PATIENT DIALYSIS TRNG PATIENT DIALYSIS TRAINING DATE 6 1386 1391 C PROV1595 THE DATE OF THE DETERMINATION OF ELIGIBILITY OF AN END STAGE RENAL DISEASE FACILITY TO PROVIDE PATIENT DIALYSIS TRAINING. COBOL NAME: PATIENT-DIAL-TRAIN-DT RENAL DIALYSIS CENTER CODE 1 1392 1392 C PROV1760 INDICATES THE ELIGIBILITY OF AN END STAGE DIALYSIS FACILITY TO PROVIDE RENAL DIALYSIS CENTER SERVICES. COBOL NAME: RENAL-DIAL-CENTER-CD VALUES: A ELIGIBLE B NOT ELIGIBLE C VOLUNTARY WITHDRAWAL D TERMINATION RENAL DIALYSIS CENTER DATE 6 1393 1398 C PROV1765 DATE OF THE DETERMINATION OF ELIGIBILITY OF AN END STAGE RENAL DIALYSIS FACILITY TO PROVIDE DIALYSIS CENTER SERVICES. COBOL NAME: RENAL-DIAL-CENTER-DT RENAL DIALYSIS FACILITY CODE 1 1399 1399 C PROV1580 INDICATES THE ELIGIBILITY OF AN END STAGE RENAL DIALYSIS FACILITY TO PROVIDE RENAL DIALYSIS FACILITY SERVICES. COBOL NAME: PATIENT-DIAL-FACTY-CD VALUES: A ELIGIBLE B NOT ELIGIBLE C VOLUNTARY WITHDRAWAL D TERMINATION RENAL DIALYSIS FACILITY DATE 6 1400 1405 C PROV1585 DATE OF THE DETERMINATION OF ELIGIBILITY OF AN END STAGE RENAL DIALYSIS FACILITY TO PROVIDE DIALYSIS FACILITY SERVICES. COBOL NAME: PATIENT-DIAL-FACTY-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 11 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RENAL TRANSPLANT CENTER CODE 1 1406 1406 C PROV1770 INDICATES THE ELIGIBILITY OF AN END STAGE RENAL DIALYSIS FACILITY TO PROVIDE TRANSPLANTATION SERVICES. COBOL NAME: RENAL-TRANSP-CENTER-CD VALUES: A ELIGIBLE B NOT ELIGIBLE C VOLUNTARY WITHDRAWAL D TERMINATION RENAL TRANSPLANT CENTER DATE 6 1407 1412 C PROV1775 DATE OF THE DETERMINATION OF ELIGIBILITY OF AN END STAGE RENAL DIALYSIS FACILITY TO PROVIDE TRANSPLANTATION SERVICES. COBOL NAME: RENAL-TRANSP-CENTER-DT SELF DIALYSIS CERTIFICATION 1 1413 1413 C PROV2030 THE STATE AGENCY'S CERTIFICATION OF ELIGIBILITY OF AN END STAGE RENAL DIALYSIS FACILITY TO PROVIDE SELF DIALYSIS SERVICES. COBOL NAME: SELF-DIAL-CERT VALUES: A ELIGIBLE B ELIGIBILITY IS BASED ON ACCEPTABLE POC C ELIGIBILITY DEPENDS ON APPROVAL OF PHYSICIAN E NOT ELIGIBLE SELF DIALYSIS CODE 1 1414 1414 C PROV2025 INDICATES THE ELIGIBILITY OF AN END STAGE RENAL DIALYSIS FACILITY TO PROVIDE SELF DIALYSIS SERVICES. COBOL NAME: SELF-DIAL-CD VALUES: A ELIGIBLE B NOT ELIGIBLE C VOLUNTARY WITHDRAWAL D TERMINATION SELF DIALYSIS DATE 6 1415 1420 C PROV2035 DATE OF THE DETERMINATION OF ELIGIBILITY OF AN END STAGE RENAL DIALYSIS FACILITY TO PROVIDE SELF DIALYSIS SERVICES. COBOL NAME: SELF-DIAL-DT STAFF ASSISTED DIALYSIS CERT 1 1421 1421 C PROV2705 INDICATES HOW AN END STAGE RENAL DIALYSIS FACILITY IS CERTIFED TO PROVIDE STAFF ASSISTED RENAL DIALYSIS. COBOL NAME: STAFF-ASDIAL-CERT VALUES: A ELIGIBLE TO SUPPLY B ELIGIBILITY BASED ON ACCEPTABLE POC C ELIGIBILITY BASED ON APPROVAL OF MD DIRECTOR E NOT ELIGIBLE TO SUPPLY SERVICE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 12 END STAGE RENAL DISEASE FACILITIES, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME STATIONS - HEMODIALYSIS 3 1422 1424 N PROV1230 THE TOTAL NUMBER OF HEMODIALYSIS STATIONS IN AN END STAGE RENAL DISEASE (ESRD) FACILITY. COBOL NAME: NUM-STATION-HEMO STATIONS - PERITONEAL 3 1425 1427 N PROV1235 THE TOTAL NUMBER OF PERITONEAL STATIONS IN AN END STAGE RENAL DISEASE (ESRD) FACILITY. COBOL NAME: NUM-STATION-PERT STATIONS - TOTAL 3 1428 1430 N PROV2855 THE TOTAL NUMBER OF APPROVED DIALYSIS STATIONS IN AN END STAGE RENAL DIALYSIS FACILITY. COBOL NAME: TOT-STATIONS TRANSPLANTATION CERTIFICATION 1 1431 1431 C PROV2870 INDICATES HOW AN END STAGE RENAL DIALYSIS FACILITY IS CERTIFIED TO PROVIDE TRANSPLANTATION SERVICES SERVICES. COBOL NAME: TRANSP-CERT VALUES: A ELIGIBLE TO SUPPLY B ELIGIBILITY IS BASED ON ACCEPTABLE POC C ELIGIBILITY DEPENDS ON APPROVAL OF PHYSICIAN D ELIGIBILITY DEPENDS ON HISTO LAB ARRANGEMENTS E NOT ELIGIBLE TO SUPPLY SERVICES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 1 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 NURSING FACILITY CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 10 NURSING FACILITIES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY AND STATE 31 13 43 C PROV0115 THE CITY AND STATE WHERE A PROVIDER IS LOCATED. COBOL NAME: CITY-STATE COMPLIANCE: PLAN OF CORRECTION 1 44 44 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 45 45 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 46 48 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 49 58 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 59 64 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 2 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 6 65 70 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 71 71 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 38 72 109 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME * INTERMEDIARY NUMBER 5 110 114 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM MEDICAID VENDOR NUMBER 12 115 126 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A MEDICAID FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 6 127 132 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 133 138 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 139 143 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 144 153 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE: MASTER/TRANSACTION 1 154 154 C PROV1720 INDICATES IF A RECORD IS CURRENTLY ON THE MASTER FILE OR THE TRANSACTION FILE. COBOL NAME: RECORD-TYPE VALUES: M MASTER FILE T TRANSACTION FILE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 3 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME REGION CODE 2 155 156 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 157 157 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE CODE (SSA) 2 158 159 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 4 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 54 AFRICA 55 CALIFORNIA 56 CANADA 57 WEST INDIES 58 EUROPE 59 MEXICO 60 OCEANIA 61 PHILIPPINES 62 SOUTH AMERICA 63 UNITED STATES POSSESSIONS 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN 67 TEXAS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 5 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME STATES REGION CODE 3 160 162 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 163 200 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 201 210 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE 1 211 211 C PROV2805 THE REASON A FACILITY HAS BEEN TERMINATED FROM THE MEDICARE AND/OR MEDICAID PROGRAMS COBOL NAME: TERM-CD VALUES: 0 ACTIVE 1 VOL-MERG,CLOSE 2 VOL-REIMBURSE 3 VOL-RISK INVOL 4 VOL-OTHER 5 INVOL-FAIL REQ 6 INVOL-AGREEMNT 7 OTH-STATUS CHG TERMINATION DATE 6 212 217 C PROV2810 THE EFFECTIVE DATE OF TERMINATION OF CERTIFICATION OF A FACILITY. COBOL NAME: TERM-DT TYPE OF ACTION 1 218 218 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP 6 COMPLAINT SURVEY TYPE OF CONTROL 2 219 220 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 FOR PROFIT - INDIVIDUAL 02 FOR PROFIT - PARTNERSHIP 03 FOR PROFIT - CORPORATION 04 NONPROFIT - CHURCH RELATED 05 NONPROFIT - CORPORATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 6 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 06 NONPROFIT - OTHER 07 GOVERNMENT - STATE 08 GOVERNMENT - COUNTY 09 GOVERNMENT - CITY 10 GOVERNMENT - CITY/COUNTY 11 GOVERNMENT - HOSPITAL DISTRICT 12 GOVERNMENT - FEDERAL ZIP CODE 5 221 225 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 226 227 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 228 230 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 231 233 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 234 234 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE BEDS - TOTAL 5 265 269 N PROV0740 TOTAL NUMBER OF BEDS IN A FACILITY, INCLUDING THOSE IN NON-PARTICIPATING OR NON-LICENSED AREAS. COBOL NAME: NUM-BEDS BEDS - TOTAL CERTIFIED 5 270 274 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS COMPLIANCE: LIFE SAFETY CODE 1 332 332 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: 1 WAIVER RECOMMENDED FISCAL YEAR ENDING DATE 4 349 352 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT PROGRAM PARTICIPATION 1 411 411 C PROV1670 INDICATES IF THE PROVIDER PARTICIPATES IN MEDICARE, MEDICAID, OR BOTH PROGRAMS. COBOL NAME: PROG-PARTCI VALUES: 2 MEDICAID ONLY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 7 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME REGIONAL OVERRIDE #1 (NUMBER BEDS) 1 429 429 C PROV1545 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-1 VALUES: Y RECORD HAS BEEN APPROVED REGIONAL OVERRIDE #2 (STAFFING) 1 430 430 C PROV1550 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-2 VALUES: Y RECORD HAS BEEN APPROVED REGIONAL OVERRIDE #3 (NURSE - BED) 1 431 431 C PROV1555 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-3 VALUES: Y RECORD HAS BEEN APPROVED * RELATED PROVIDER NUMBER 10 456 465 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM SRV: DENTAL 1 485 485 C PROV2120 INDICATES HOW DENTAL SERVICES ARE PROVIDED. COBOL NAME: SP-DENTAL VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: DIETARY 1 486 486 C PROV2130 INDICATES HOW DIETARY SERVICES ARE PROVIDED. COBOL NAME: SP-DIETARY VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NON RESIDENTS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 8 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION TYPE OF FACILITY 2 516 517 C PROV2890 INDICATES THE CATEGORY WHICH REPRESENTS THE TYPE OF FACILITY. COBOL NAME: TYPE-FACILITY VALUES: 04 NURSING FACILITY ACTIVITY THERAPISTS - CONTRACT 7.2 519 525 N PROV0695 THE NUMBER OF FULL TIME EQUIVALENT ACTIVITIES THERAPISTS UNDER CONTRACT TO THE FACILITY COBOL NAME: NUM-ACT-THER-CONTRACT ACTIVITY THERAPISTS - FULL TIME 7.2 526 532 N PROV0700 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES THERAPISTS EMPLOYED FULL TIME BY THE FACILITY COBOL NAME: NUM-ACT-THER-FULL-TIME ACTIVITY THERAPISTS - PART TIME 7.2 533 539 N PROV0705 THE NUMBER OF FULL-TIME EQUIVALENT ACTIVITIES THERAPISTS EMPLOYED PART-TIME BY THE FACILITY. COBOL NAME: NUM-ACT-THER-PART-TIME ADMINISTRATOR - CONTRACT 7.2 540 546 N PROV0710 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-ADMN-CONTRACT ADMINISTRATOR - FULL TIME 7.2 547 553 N PROV0715 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS EMPLOYED ON A FULL TIME BASIS BY THE FACILITY. COBOL NAME: NUM-ADMN-FULL-TIME ADMINISTRATOR - PART TIME 7.2 554 560 N PROV0720 THE NUMBER OF FULL-TIME EQUIVALENT ADMINISTRATORS EMPLOYED ON A PART-TIME BASIS BY THE FACILITY. COBOL NAME: NUM-ADMN-PART-TIME ADMISSION SUSPENSION DATE 6 561 566 C PROV0030 THE DATE THAT PAYMENTS FOR NEW ADMISSIONS IN A LONG TERM CARE FACILITY WILL BE DENIED IF AN INTERMEDIATE SANCTION IS TAKEN AGAINST THE FACILITY. COBOL NAME: ADMIN-SUSP-DT AIDES/ORDERLIES - CONTRACT 7.2 567 573 N PROV1000 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-NURSE-AID-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 9 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME AIDES/ORDERLIES - FULL TIME 7.2 574 580 N PROV1005 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES EMPLOYED BY THE FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-NURSE-AID-FULL-TIME * AIDES/ORDERLIES - PART TIME 7.2 581 587 N PROV1010 THE NUMBER OF FULL-TIME EQUIVALENT AIDES/ORDERLIES EMPLOYED BY THE FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-NURSE-AID-PART-TIME BEDS - NURSING FACILITY 4 592 595 N PROV1455 NUMBER OF MEDICAID CERTIFIED SKILLED NURSING CARE BEDS IN A FACILITY. COBOL NAME: NUM-T19-SNF-BEDS COMPLIANCE: BEDS PER ROOM WAIVER 1 601 601 C PROV0225 INDICATES IF A WAIVER OF THE BEDS PER ROOM REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-BEDS-PER-ROOM VALUES: 1 WAIVER RECOMMENDED COMPLIANCE: PATIENT ROOM SIZE 1 602 602 C PROV0270 INDICATES IF A WAIVER OF PATIENT ROOM SIZE HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-PATIENT-ROOM-SZ VALUES: 1 WAIVER RECOMMENDED COMPLIANCE: 7 DAY REGISTERED NURSE 1 603 603 C PROV0295 INDICATES IF A WAIVER OF THE 7 DAY REGISTERED NURSE REQUIREMENTS HAS BEEN RECOMMENDED FOR A SNF OR NF. COBOL NAME: COMPL-7-DAY-RN VALUES: 1 WAIVER RECOMMENDED * DENTISTS - CONTRACT 7.2 604 610 N PROV0785 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DENTIST-CONTRACT * DENTISTS - FULL TIME 7.2 611 617 N PROV0790 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-DENTIST-FULL-TIME * DENTISTS - PART TIME 7.2 618 624 N PROV0795 THE NUMBER OF FULL-TIME EQUIVALENT DENTISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-DENTIST-PART-TIME DIETITIANS - CONTRACT 7.2 625 631 N PROV0805 THE NUMBER OF FULL-TIME EQUIVALENT UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-DIET-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 10 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME DIETITIANS - FULL TIME 7.2 632 638 N PROV0810 THE NUMBER OF FULL-TIME EQUIVALENT DIETITIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-DIET-FULL-TIME DIETITIANS - PART TIME 7.2 639 645 N PROV0815 THE NUMBER OF FULL-TIME EQUIVALENT DIETITIANS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-DIET-PART-TIME EXPERIMENTAL RESEARCH CONDUCTED 1 646 646 C PROV0465 INDICATES IF A FACILITY USES RESIDENTS TO DEVELOP AND TEST CLINICAL TREATMENTS. COBOL NAME: EXPER-RESEARCH VALUES: N NO Y YES FOOD SERVICE - CONTRACT 7.2 647 653 N PROV0860 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL UNDER CONTRACT TO THE FACILITY. COBOL NAME: NUM-FOOD-SRV-CONTRACT FOOD SERVICE - FULL TIME 7.2 654 660 N PROV0865 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERIVCE PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-FOOD-SRV-FULL-TIME FOOD SERVICE - PART TIME 7.2 661 667 N PROV0870 THE NUMBER OF FULL-TIME EQUIVALENT FOOD SERVICE PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-FOOD-SRV-PART-TIME HOUSEKEEPING - CONTRACT 7.2 668 674 N PROV0925 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-HOUSE-CONTRACT HOUSEKEEPING - FULL TIME 7.2 675 681 N PROV0930 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-HOUSE-FULL-TIME HOUSEKEEPING - PART TIME 7.2 682 688 N PROV0935 THE NUMBER OF FULL-TIME EQUIVALENT HOUSEKEEPING PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-HOUSE-PART-TIME LPN/LVN - CONTRACT 7.2 689 695 N PROV1465 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES UNDER CONTRACT TO A FACILITY COBOL NAME: NUM-VOC-NURSE-CONTRACT LPN/LVN - FULL TIME 7.2 696 702 N PROV1470 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-VOC-NURSE-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 11 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME LPN/LVN - PART TIME 7.2 703 709 N PROV1475 THE NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL/ VOCATIONAL NURSES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-VOC-NURSE-PART-TIME LTC AGREEMENT BEGINNING DATE 6 710 715 C PROV0620 THE BEGINNING DATE OF A CERTIFIED LONG TERM CARE FACILI TY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-BEGIN-DT LTC AGREEMENT ENDING DATE 6 716 721 C PROV0625 THE ENDING DATE OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-END-DT LTC AGREEMENT EXTENSION DATE 6 722 727 C PROV0630 THE LAST DATE OF AN EXTENSION OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-EXT-DT LTC CROSS REFERENCE PROVIDER # 6 728 733 C PROV0640 THIS CROSS REFERENCE NUMBER IDENTIFIES LTC PROVIDER NUMBERS THAT WERE TERMINATED IN 1985 BECAUSE OF POLICY CHANGES WHICH STATES THAT SNF/ICF DISTINCT PARTS OR DUA LLY CERTIFIED PORTIONS ARE ASSIGNED SINGLE SNF PROV NO. COBOL NAME: LTC-CROSS-REF-PROV-NUM MEDICAL DIRECTOR - CONTRACT 7.2 734 740 N PROV0960 NUMBER OF MEDICAL DIRECTORS UNDER CONTRACT. COBOL NAME: NUM-MED-CONTRACT MEDICAL DIRECTOR - FULL TIME 7.2 741 747 N PROV0965 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MED-FULL-TIME MEDICAL DIRECTOR - PART TIME 7.2 748 754 N PROV0970 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL DIRECTORS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MED-PART-TIME MEDICAL SOCIAL WORKER - CONTRACT 7.2 755 761 N PROV1170 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL SOCIAL WORKERS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-SOCIAL-CONTRACT MEDICAL SOCIAL WORKER - FULL TIME 7.2 762 768 N PROV1175 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL SOCIAL WORKERS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-SOCIAL-FULL-TIME MEDICAL SOCIAL WORKER - PART TIME 7.2 769 775 N PROV1180 THE NUMBER OF FULL-TIME EQUIVALENT MEDICAL SOCIAL WORKERS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-SOCIAL-PART-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 12 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME MENTAL HEALTH SERVICES - CONTRACT 7.2 776 782 N PROV0980 THE NUMBER OF FULL-TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-MEN-HLTH-CONTRACT MENTAL HEALTH SERVICES - FULL TIME 7.2 783 789 N PROV0985 THE NUMBER OF FULL-TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-MEN-HLTH-FULL-TIME MENTAL HEALTH SERVICES - PART TIME 7.2 790 796 N PROV0990 THE NUMBER OF FULL TIME EQUIVALENT MENTAL HEALTH SERVICES PERSONNEL EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-MEN-HLTH-PART-TIME MULTI-FACILITY ORGANIZATION NAME 38 797 834 C PROV0680 THE NAME OF THE MULTI-FACILITY ORGANIZATION THAT OWNS THE FACILITY. COBOL NAME: NAME-MULT-FACL-ORG MULTI-FACILITY ORGANIZATION OWNED 1 835 835 C PROV0675 INDICATES IF A FACILITY IS OWNED BY AN ORGANIZATION THAT OWNS (OR LEASES) TWO OR MORE NURSING FACILITIES. COBOL NAME: MULT-FACL-ORG VALUES: N NO Y YES OCCUPATIONAL THERAPIST - CONTRACT 7.2 836 842 N PROV1035 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-THER-CONTRACT OCCUPATIONAL THERAPIST - FULL TIME 7.2 843 849 N PROV1040 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-THER-FULL-TIME OCCUPATIONAL THERAPIST - PART TIME 7.2 850 856 N PROV1045 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-THER-PART-TIME OCCUPATIONAL THERAPY ASST-CONTRACT 7.2 857 863 N PROV1020 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-OCC-AID-CONTRACT OCCUPATIONAL THERAPY ASST-FULL 7.2 864 870 N PROV1025 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OCC-AID-FULL-TIME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 13 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME OCCUPATIONAL THERAPY ASST-PART 7.2 871 877 N PROV1030 THE NUMBER OF FULL-TIME EQUIVALENT OCCUPATIONAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OCC-AID-PART-TIME ORGANIZED FAMILY GROUP 1 878 878 C PROV1535 INDICATES IF THE FACILITY HAS AN ORGANIZED GROUP OF FAMILY MEMBERS OF RESIDENTS. COBOL NAME: ORG-FAMILY-GRP VALUES: N NO Y YES * ORGANIZED RESIDENT GROUP 1 879 879 C PROV1540 INDICATES IF THE FACILITY HAS AN ORGANIZED RESIDENTS GROUP. COBOL NAME: ORG-RESID-GRP VALUES: N NO Y YES OTHER PHYSICIAN - CONTRACT 7.2 880 886 N PROV1060 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS UNDER CONTRACT TO A FACILITY COBOL NAME: NUM-OTH-PHY-CONTRACT OTHER PHYSICIAN - FULL TIME 7.2 887 893 N PROV1065 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-OTH-PHY-FULL-TIME OTHER PHYSICIAN - PART TIME 7.2 894 900 N PROV1070 THE NUMBER OF FULL-TIME EQUIVALENT OTHER PHYSICIANS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-OTH-PHY-PART-TIME PHARMACISTS - CONTRACT 7.2 901 907 N PROV1085 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-PHAR-CONTRACT PHARMACISTS - FULL TIME 7.2 908 914 N PROV1090 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-PHAR-FULL-TIME PHARMACISTS - PART TIME 7.2 915 921 N PROV1095 THE NUMBER OF FULL-TIME EQUIVALENT PHARMACISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-PHAR-PART-TIME PHYSICAL THERAPISTS - CONTRACT 7.2 922 928 N PROV1430 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-CONTRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 14 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PHYSICAL THERAPISTS - FULL TIME 7.2 929 935 N PROV1435 THE NUMBER OF FULL TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-FULL-TIME PHYSICAL THERAPISTS - PART TIME 7.2 936 942 N PROV1440 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-PART-TIME PHYSICAL THERAPY ASST - CONTRACT 7.2 943 949 N PROV1415 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-THER-AID-CONTRACT PHYSICAL THERAPY ASST - FULL TIME 7.2 950 956 N PROV1420 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-THER-AID-FULL-TIME PHYSICAL THERAPY ASST - PART TIME 7.2 957 963 N PROV1425 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICAL THERAPY ASSISTANTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-THER-AID-PART-TIME PODIATRISTS - CONTRACT 7.2 964 970 N PROV1130 THE NUMBER OF FULL TIME EQUIVALENT PODIATRISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-POD-CONTRACT PODIATRISTS - FULL TIME 7.2 971 977 N PROV1135 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A AFCILITY ON A FULL TIME BASIS. COBOL NAME: NUM-POD-FULL-TIME PODIATRISTS - PART TIME 7.2 978 984 N PROV1140 THE NUMBER OF FULL-TIME EQUIVALENT PODIATRISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-POD-PART-TIME PRIOR ADMISSION SUSPENSION DATE 6 985 990 C PROV1610 PREVIOUS DATE A SUSPENSION OF ADMISSIONS WAS INVOKED FOR A PROVIDER. COBOL NAME: PRIOR-ADMIN-SUSP-DT PRIOR LTC END DATE 6 991 996 C PROV1630 THE LAST DATE OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT FOR A PRIOR SURVEY. COBOL NAME: PRIOR-LTC-END-DT PRIOR LTC EXTENSION DATE 6 997 1002 C PROV1635 THE LAST DATE OF AN EXTENSION OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT FOR A PRIOR SURVEY. COBOL NAME: PRIOR-LTC-EXT-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 15 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR RESCIND SUSPENSION DATE 6 1003 1008 C PROV1640 THE EFFECTIVE DATE OF A PREVIOUS SUSPENSION OF ADMISSIONS TO A LTC FACILITY. COBOL NAME: PRIOR-RESC-SUSP-DT PROVIDER BASED FACILITY 1 1009 1009 C PROV1675 INDICATES IF A LONG TERM CARE FACILITY IS PROVIDER BASED. COBOL NAME: PROV-BASED-FACILITY VALUES: N NOT HOSPITAL BASED Y HOSPITAL BASED REGISTERED NURSE - CONTRACT 7.2 1010 1016 N PROV1150 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-REG-NURSE-CONTRACT REGISTERED NURSE - FULL TIME 7.2 1017 1023 N PROV1155 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-REG-NURSE-FULL-TIME REGISTERED NURSE - PART TIME 7.2 1024 1030 N PROV1160 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED NURSES EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-REG-NURSE-PART-TIME RESCIND SUSPENSION DATE 6 1031 1036 C PROV1825 DATE THAT THE SUPENSION OF PAYMENTS FOR NEW ADMISSIONS TO A LONG TERM CARE FACILITY (LTC) IS RESCINDED. COBOL NAME: RESC-SUSP-DT SPECIAL CARE BEDS-AIDS 3 1037 1039 N PROV0725 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH AIDS. COBOL NAME: NUM-AIDS-BEDS SPECIAL CARE BEDS-ALZHEIMERS 3 1040 1042 N PROV0730 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH ALZEHEIMERS. COBOL NAME: NUM-ALZHEIMERS-BEDS SPECIAL CARE BEDS-DIALYSIS 3 1043 1045 N PROV0800 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS NEEDING DIALYSIS. COBOL NAME: NUM-DIAL-BEDS SPECIAL CARE BEDS-DISABLED CHILD 3 1046 1048 N PROV0855 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR DEISCABLED CHILDREN. COBOL NAME: NUM-DIS-CHILD-BEDS SPECIAL CARE BEDS-HEAD TRAUMA 3 1049 1051 N PROV0905 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILTY FOR RESIDENTS WITH HEAD TRAUMA. COBOL NAME: NUM-HEAD-TRAUMA-BEDS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 16 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPECIAL CARE BEDS-HOSPICE 3 1052 1054 N PROV0920 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY A FACILITY FOR RESIDENTS NEEDING HOSPICE SERVICES. COBOL NAME: NUM-HOSPICE-BEDS SPECIAL CARE BEDS-HUNTINGTONS 3 1055 1057 N PROV0940 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH HUNTINGTON'S DISEASE COBOL NAME: NUM-HUNTING-DIS-BEDS SPECIAL CARE BEDS-SPEC REHAB 3 1058 1060 N PROV1205 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH SPECIALIZED REHAB NEEDS. COBOL NAME: NUM-SPEC-REHAB-BEDS SPECIAL CARE BEDS-VENTILATOR 3 1061 1063 N PROV1460 THE NUMBER OF BEDS IN A UNIT IDENTIFIED AND DEDICATED BY THE FACILITY FOR RESIDENTS WITH VENTILATOR/ RESIPIRATORY CARE NEEDS. COBOL NAME: NUM-VENT-RESP-BEDS SPEECH PATHOLOGIST - CONTRACT 7.2 1064 1070 N PROV1190 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS UNDER CONTRACT TO A FACILITY. COBOL NAME: NUM-SPCH-PATH-CONTRACT SPEECH PATHOLOGIST - FULL TIME 7.2 1071 1077 N PROV1195 THE NUMBER OF FULL-TIME EQUIVALENT SPPECH PATHOLOGISTS EMPLOYED BY A FACILITY ON A FULL TIME BASIS. COBOL NAME: NUM-SPCH-PATH-FULL-TIME SPEECH PATHOLOGIST - PART TIME 7.2 1078 1084 N PROV1200 THE NUMBER OF FULL-TIME EQUIVALENT SPEECH PATHOLOGISTS EMPLOYED BY A FACILITY ON A PART TIME BASIS. COBOL NAME: NUM-SPCH-PATH-PART-TIME SRV: ACTIVITIES THERAPY 1 1085 1085 C PROV2050 INDICATES HOW ACTIVITIES THERAPY SERIVICES ARE PROVIDED IN A FACILITY. COBOL NAME: SP-ACT-THERAPISTS VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF & UNDER ARRANGEMENT 7 COMBINATION SRV: ADMINISTRATION/STORAGE BLOOD 1 1086 1086 C PROV2060 INDICATES HOW ADMINISTRATION AND STORAGE OF BLOOD SERVICES ARE PROVIDED IN A LONG TERM CARE FACILITY. COBOL NAME: SP-ADMIN-STORE-BLOOD VALUES: 0 NOT PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 17 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: CLINICAL LABS 1 1087 1087 C PROV2105 INDICATES HOW CLINICAL LABORATORY SERVICES ARE PROVIDED BY A FACILITY. COBOL NAME: SP-CLINICAL-LAB VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: DIAGNOSTIC X-RAY 1 1088 1088 C PROV2125 INDICATES HOW DIAGNOSTIC XRAY SERVICES ARE PROVIDED BY A LONG TERM CARE FACILITY. COBOL NAME: SP-DIAGN-XRAY VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: HOUSEKEEPING 1 1089 1089 C PROV2180 INDICATES HOW HOUSEKEEPING SERVICES ARE PROVIDED. COBOL NAME: SP-HOUSE-KEEP VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 7 COMBINATION SRV: MENTAL HEALTH 1 1090 1090 C PROV2230 INDICATES HOW MENTAL HEALTH SERVICES ARE PROVIDED. COBOL NAME: SP-MEN-HLTH VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 18 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: PODIATRY 1 1091 1091 C PROV2405 INDICATES HOW PODIATRY SERVICES ARE PROVIDED BY A LONG TERM CARE FACILITY. COBOL NAME: SP-PODIATRY VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NON RESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: MEDICAL SOCIAL 1 1142 1142 C PROV2220 INDICATES HOW MEDICAL SOCIAL SERVICES ARE PROVIDED COBOL NAME: SP-MEDICAL-SOCIAL VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: NURSING 1 1143 1143 C PROV2250 INDICATES HOW NURSING SERVICES ARE PROVIDED. COBOL NAME: SP-NURSING VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: VOCATIONAL GUIDANCE 1 1146 1146 C PROV2535 INDICATES HOW VOCATIONAL GUIDANCE SERVICES ARE PROVIDED COBOL NAME: SP-VOCAT-GUIDANCE VALUES: 0 NOT PROVIDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 19 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION DIRECT CARE PERSONNEL 7.2 1436 1442 N PROV0780 NUMBER OF FULL-TIME EQUIVALENT DIRECT CARE PERSONNEL EMPLOYED BY AN INTERMEDIATE CARE FACILITY FOR THE MENTALLY RETARDED. COBOL NAME: NUM-DCARE-PERSNL SRV: OCCUPATIONAL THERAPY 1 1504 1504 C PROV2270 INDICATES HOW OCCUPATIONAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-OCCUP-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NON RESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: PHYSICAL THERAPY 1 1510 1510 C PROV2370 INDICATES HOW PHYSICAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICAL-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: PHYSICIAN 1 1513 1513 C PROV2385 INDICATES HOW PHYSICIAN SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICIAN VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 20 NURSING FACILITIES, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 7 COMBINATION SRV: SPEECH PATHOLOGY 1 1524 1524 C PROV2505 INDICATES HOW SPEECH PATHOLOGY SERVICES ARE PROVIDED. COBOL NAME: SP-SPEECH-PATH VALUES: 0 NOT PROVIDED 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 3 PROVIDED OFF SITE TO RESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGEMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION SRV: OTHER 1 1551 1551 C PROV2340 INDICATES HOW OTHER (NOT SPECIFIED) SERVICES ARE PROVIDED. COBOL NAME: SP-OTHER VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: PHARMACY 1 1552 1552 C PROV2365 INDICATES HOW PHARMACY SERVICES ARE PROVIDED. COBOL NAME: SP-PHARMACY VALUES: 1 PROVIDED ON SITE TO RESIDENTS 2 PROVIDED ON SITE TO NONRESIDENTS 4 PROVIDED BY STAFF 5 PROVIDED UNDER ARRANGMENT 6 PROVIDED BY STAFF AND UNDER ARRANGEMENT 7 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 1 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 ICF/MR CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 11 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY AND STATE 31 13 43 C PROV0115 THE CITY AND STATE WHERE A PROVIDER IS LOCATED. COBOL NAME: CITY-STATE COMPLIANCE: PLAN OF CORRECTION 1 44 44 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 45 45 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 46 48 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 49 58 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 59 64 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 2 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 6 65 70 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 71 71 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 38 72 109 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME * INTERMEDIARY NUMBER 5 110 114 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM MEDICAID VENDOR NUMBER 12 115 126 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A MEDICAID FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 6 127 132 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 133 138 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 139 143 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 144 153 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE: MASTER/TRANSACTION 1 154 154 C PROV1720 INDICATES IF A RECORD IS CURRENTLY ON THE MASTER FILE OR THE TRANSACTION FILE. COBOL NAME: RECORD-TYPE VALUES: M MASTER FILE T TRANSACTION FILE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 3 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME REGION CODE 2 155 156 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 157 157 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE CODE (SSA) 2 158 159 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 4 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 54 AFRICA 55 CALIFORNIA 56 CANADA 57 WEST INDIES 58 EUROPE 59 MEXICO 60 OCEANIA 61 PHILIPPINES 62 SOUTH AMERICA 63 UNITED STATES POSSESSIONS 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN 67 TEXAS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 5 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME STATES REGION CODE 3 160 162 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 163 200 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 201 210 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE 1 211 211 C PROV2805 THE REASON A FACILITY HAS BEEN TERMINATED FROM THE MEDICARE AND/OR MEDICAID PROGRAMS COBOL NAME: TERM-CD VALUES: 0 ACTIVE 1 VOL-MERG,CLOSE 2 VOL-REIMBURSE 3 VOL-RISK INVOL 4 VOL-OTHER 5 INVOL-FAIL REQ 6 INVOL-AGREEMNT 7 OTH-STATUS CHG TERMINATION DATE 6 212 217 C PROV2810 THE EFFECTIVE DATE OF TERMINATION OF CERTIFICATION OF A FACILITY. COBOL NAME: TERM-DT TYPE OF ACTION 1 218 218 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP 6 COMPLAINT SURVEY TYPE OF CONTROL 2 219 220 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 PRIVATE NON PROFIT 02 PRIVATE PROPRIETARY 03 STATE 04 CITY/TOWN 05 COUNTY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 6 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME 06 CITY/COUNTY 07 OTHER ZIP CODE 5 221 225 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 226 227 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 228 230 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 231 233 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 234 234 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE BEDS - TOTAL 5 265 269 N PROV0740 TOTAL NUMBER OF BEDS IN A FACILITY, INCLUDING THOSE IN NON-PARTICIPATING OR NON-LICENSED AREAS. COBOL NAME: NUM-BEDS BEDS - TOTAL CERTIFIED 5 270 274 N PROV0755 NUMBER OF BEDS IN MEDICARE AND/OR MEDICAID CERTIFIED AREAS WITHIN A FACILITY. COBOL NAME: NUM-CERT-BEDS COMPLIANCE: LIFE SAFETY CODE 1 332 332 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: 1 WAIVER RECOMMENDED FISCAL YEAR ENDING DATE 4 349 352 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT LICENSED PRACTICAL NURSES 7.2 360 366 N PROV0955 NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL OR VOCATIONAL NURSES EMPLOYED BY A FACILITY. COBOL NAME: NUM-LPN-LVN PROGRAM PARTICIPATION 1 411 411 C PROV1670 INDICATES IF THE PROVIDER PARTICIPATES IN MEDICARE, MEDICAID, OR BOTH PROGRAMS. COBOL NAME: PROG-PARTCI VALUES: 2 MEDICAID ONLY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 7 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME REGIONAL OVERRIDE #1 (NUMBER BEDS) 1 429 429 C PROV1545 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-1 VALUES: Y RECORD HAS BEEN APPROVED REGIONAL OVERRIDE #2 (STAFFING) 1 430 430 C PROV1550 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-2 VALUES: Y RECORD HAS BEEN APPROVED REGIONAL OVERRIDE #3 (NURSE - BED) 1 431 431 C PROV1555 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-3 VALUES: Y RECORD HAS BEEN APPROVED REGISTERED NURSES 7.2 432 438 N PROV1145 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PROFESSIONAL NURSES EMPLOYED BY A PROVIDER. COBOL NAME: NUM-REG-NURS * RELATED PROVIDER NUMBER 10 456 465 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM ADMISSION SUSPENSION DATE 6 561 566 C PROV0030 THE DATE THAT PAYMENTS FOR NEW ADMISSIONS IN A LONG TERM CARE FACILITY WILL BE DENIED IF AN INTERMEDIATE SANCTION IS TAKEN AGAINST THE FACILITY. COBOL NAME: ADMIN-SUSP-DT COMPLIANCE: BEDS PER ROOM WAIVER 1 601 601 C PROV0225 INDICATES IF A WAIVER OF THE BEDS PER ROOM REQUIREMENT HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-BEDS-PER-ROOM VALUES: 1 WAIVER RECOMMENDED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 8 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME COMPLIANCE: PATIENT ROOM SIZE 1 602 602 C PROV0270 INDICATES IF A WAIVER OF PATIENT ROOM SIZE HAS BEEN RECOMMENDED FOR A FACILITY. COBOL NAME: COMPL-PATIENT-ROOM-SZ VALUES: 1 WAIVER RECOMMENDED LTC AGREEMENT BEGINNING DATE 6 710 715 C PROV0620 THE BEGINNING DATE OF A CERTIFIED LONG TERM CARE FACILI TY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-BEGIN-DT LTC AGREEMENT ENDING DATE 6 716 721 C PROV0625 THE ENDING DATE OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-END-DT LTC AGREEMENT EXTENSION DATE 6 722 727 C PROV0630 THE LAST DATE OF AN EXTENSION OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT. COBOL NAME: LTC-AGREE-EXT-DT LTC CROSS REFERENCE PROVIDER # 6 728 733 C PROV0640 THIS CROSS REFERENCE NUMBER IDENTIFIES LTC PROVIDER NUMBERS THAT WERE TERMINATED IN 1985 BECAUSE OF POLICY CHANGES WHICH STATES THAT SNF/ICF DISTINCT PARTS OR DUA LLY CERTIFIED PORTIONS ARE ASSIGNED SINGLE SNF PROV NO. COBOL NAME: LTC-CROSS-REF-PROV-NUM PRIOR ADMISSION SUSPENSION DATE 6 985 990 C PROV1610 PREVIOUS DATE A SUSPENSION OF ADMISSIONS WAS INVOKED FOR A PROVIDER. COBOL NAME: PRIOR-ADMIN-SUSP-DT PRIOR LTC END DATE 6 991 996 C PROV1630 THE LAST DATE OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT FOR A PRIOR SURVEY. COBOL NAME: PRIOR-LTC-END-DT PRIOR LTC EXTENSION DATE 6 997 1002 C PROV1635 THE LAST DATE OF AN EXTENSION OF A CERTIFIED LONG TERM CARE FACILITY'S TIME LIMITED AGREEMENT FOR A PRIOR SURVEY. COBOL NAME: PRIOR-LTC-EXT-DT PRIOR RESCIND SUSPENSION DATE 6 1003 1008 C PROV1640 THE EFFECTIVE DATE OF A PREVIOUS SUSPENSION OF ADMISSIONS TO A LTC FACILITY. COBOL NAME: PRIOR-RESC-SUSP-DT PROVIDER BASED FACILITY 1 1009 1009 C PROV1675 INDICATES IF A LONG TERM CARE FACILITY IS PROVIDER BASED. COBOL NAME: PROV-BASED-FACILITY VALUES: N NOT DISTINCT PART OF HOSP,SNF,ICF Y DISTINCT PART OF A HOSPITAL, SNF OR ICF * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 9 INTERMEDIATE CARE FACILITY-MENTALLY RETARDED, CATEGORY = "11" (SEE POSITIONS 3- SHORT DESCRIPTION LEN START END TYPE SAS NAME RESCIND SUSPENSION DATE 6 1031 1036 C PROV1825 DATE THAT THE SUPENSION OF PAYMENTS FOR NEW ADMISSIONS TO A LONG TERM CARE FACILITY (LTC) IS RESCINDED. COBOL NAME: RESC-SUSP-DT BEDS - ICF/MR 4 1432 1435 N PROV0945 NUMBER OF CERTIFIED BEDS IN AN INTERMEDIATE CARE FACILITY FOR THE MENTALLY RETARDED. COBOL NAME: NUM-ICF-MR-BEDS DIRECT CARE PERSONNEL 7.2 1436 1442 N PROV0780 NUMBER OF FULL-TIME EQUIVALENT DIRECT CARE PERSONNEL EMPLOYED BY AN INTERMEDIATE CARE FACILITY FOR THE MENTALLY RETARDED. COBOL NAME: NUM-DCARE-PERSNL TOTAL # OF EMPLOYEES 9.2 1443 1451 N PROV2850 THE TOTAL NUMBER OF FULL-TIME EMPLOYEES IN A HOSPICE OR AN INTERMEDIATE CARE FACILITY/MENTAL RETARDATION FACILITY. COBOL NAME: TOT-EMPLOYEES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 1 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 RURAL HEALTH CLINICS CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 12 RURAL HEALTH CLINICS CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY AND STATE 31 13 43 C PROV0115 THE CITY AND STATE WHERE A PROVIDER IS LOCATED. COBOL NAME: CITY-STATE COMPLIANCE: PLAN OF CORRECTION 1 44 44 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 45 45 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 46 48 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 49 58 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 59 64 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 2 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 6 65 70 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 71 71 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 38 72 109 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME * INTERMEDIARY NUMBER 5 110 114 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 3 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICAID VENDOR NUMBER 12 115 126 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A MEDICAID FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 6 127 132 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 133 138 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 139 143 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 144 153 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 4 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RECORD TYPE: MASTER/TRANSACTION 1 154 154 C PROV1720 INDICATES IF A RECORD IS CURRENTLY ON THE MASTER FILE OR THE TRANSACTION FILE. COBOL NAME: RECORD-TYPE VALUES: M MASTER FILE T TRANSACTION FILE REGION CODE 2 155 156 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 157 157 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE CODE (SSA) 2 158 159 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 5 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 54 AFRICA 55 CALIFORNIA 56 CANADA 57 WEST INDIES 58 EUROPE 59 MEXICO 60 OCEANIA 61 PHILIPPINES 62 SOUTH AMERICA 63 UNITED STATES POSSESSIONS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 6 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN 67 TEXAS STATES REGION CODE 3 160 162 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 163 200 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 201 210 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE 1 211 211 C PROV2805 THE REASON A FACILITY HAS BEEN TERMINATED FROM THE MEDICARE AND/OR MEDICAID PROGRAMS COBOL NAME: TERM-CD VALUES: 0 ACTIVE 1 VOL-MERG,CLOSE 2 VOL-REIMBURSE 3 VOL-RISK INVOL 4 VOL-OTHER 5 INVOL-FAIL REQ 6 INVOL-AGREEMNT 7 OTH-STATUS CHG TERMINATION DATE 6 212 217 C PROV2810 THE EFFECTIVE DATE OF TERMINATION OF CERTIFICATION OF A FACILITY. COBOL NAME: TERM-DT TYPE OF ACTION 1 218 218 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP 6 COMPLAINT SURVEY TYPE OF CONTROL 2 219 220 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 7 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 03 STATE GOVERNMENT 04 LOCAL GOVERNMENT 05 FEDERAL GOVERNMENT 1A FOR PROFIT INDIVIDUAL 1B FOR PROFIT CORPORATION 1C FOR PROFIT PARTNERSHIP 2A NON PROFIT INDIVIDUAL 2B NON PROFIT CORPORATION 2C NON PROFIT PARTNERSHIP ZIP CODE 5 221 225 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 226 227 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 228 230 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 231 233 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 234 234 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE OTHER PERSONNEL 7.2 376 382 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL PHYSICIAN ASSISTANTS 7.2 398 404 N PROV1115 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIAN ASSISTANTS EMPLOYED BY A HOSPITAL OR RURAL HEALTH CLINIC. COBOL NAME: NUM-PHYS-ASSIST FEDERAL PROGRAM SUPPORT 1 1452 1452 C PROV0480 INDICATES IF A CLINIC IS RECEIVING SUPPORT FROM A FEDERAL PROGRAM TO PROVIDE HEALTH SERVICES IN A MEDICALLY UNDERSERVED AREA OR IN AN AREA WITH A SHORTAGE OF PRIMARY CARE HEALTH MANPOWER. COBOL NAME: FED-PROG-SUPPORT VALUES: N NO Y YES NURSE PRACTITIONERS 7.2 1453 1459 N PROV1015 NUMBER OF FULL-TIME EQUIVALENT NURSE PRACTITIONERS IN A RURAL HEALTH CLINIC. COBOL NAME: NUM-NURSE-PRACT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 8 RURAL HEALTH CLINICS, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PARENT PROVIDER NUMBER 10 1460 1469 C PROV1560 THE IDENTIFICATION NUMBER OF THE PARENT PROVIDER WHEN A RURAL HEALTH CLINIC IS PART OF AN EXISTING MEDICARE PROVIDER. COBOL NAME: PARENT-PROV-NUM PHYSICIANS 7.2 1470 1476 N PROV1110 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIANS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS TITLE OF FEDERAL PROGRAM 26 1477 1502 C PROV2845 THE NAME OF A FEDERAL PROGRAM WHICH PROVIDES SUPPORT TO A RURAL HEALTH CLINIC TO PROVIDE SERVICES IN A MEDICALLY UNDERSERVED AREA OR AN AREA WITH A SHORTAGE OF PRIMARY CARE HEALTH MANPOWER. COBOL NAME: TITL-FED-PROGR VALUES: COMM HLTH PRG (330)COMMUNITY HEALTH PROGRAM (330) INDIAN HEALTH SERV INDIAN HEALTH SERVICE MIGRT HLTH PRG (329)MIGRANT HEALTH PROGRAM (329) NATNL HEALTH SRV DELNATIONAL HEALTH SERVICE DELIVERY PROGRAM RURAL OUTREACH DEMORURAL OUTREACH DEMO GRANT PROGRAM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 1 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 COMPREHENSIVE OUTPATIENT CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 14 COMPREHENSIVE OUTPATIENT REHAB FACILITIES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY AND STATE 31 13 43 C PROV0115 THE CITY AND STATE WHERE A PROVIDER IS LOCATED. COBOL NAME: CITY-STATE COMPLIANCE: PLAN OF CORRECTION 1 44 44 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 45 45 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 46 48 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 49 58 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 59 64 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 2 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 6 65 70 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 71 71 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 38 72 109 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME * INTERMEDIARY NUMBER 5 110 114 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 3 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICAID VENDOR NUMBER 12 115 126 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A MEDICAID FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 6 127 132 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 133 138 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 139 143 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 144 153 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 4 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RECORD TYPE: MASTER/TRANSACTION 1 154 154 C PROV1720 INDICATES IF A RECORD IS CURRENTLY ON THE MASTER FILE OR THE TRANSACTION FILE. COBOL NAME: RECORD-TYPE VALUES: M MASTER FILE T TRANSACTION FILE REGION CODE 2 155 156 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 157 157 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE CODE (SSA) 2 158 159 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 5 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 54 AFRICA 55 CALIFORNIA 56 CANADA 57 WEST INDIES 58 EUROPE 59 MEXICO 60 OCEANIA 61 PHILIPPINES 62 SOUTH AMERICA 63 UNITED STATES POSSESSIONS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 6 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN 67 TEXAS STATES REGION CODE 3 160 162 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 163 200 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 201 210 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE 1 211 211 C PROV2805 THE REASON A FACILITY HAS BEEN TERMINATED FROM THE MEDICARE AND/OR MEDICAID PROGRAMS COBOL NAME: TERM-CD VALUES: 0 ACTIVE 1 VOL-MERG,CLOSE 2 VOL-REIMBURSE 3 VOL-RISK INVOL 4 VOL-OTHER 5 INVOL-FAIL REQ 6 INVOL-AGREEMNT 7 OTH-STATUS CHG TERMINATION DATE 6 212 217 C PROV2810 THE EFFECTIVE DATE OF TERMINATION OF CERTIFICATION OF A FACILITY. COBOL NAME: TERM-DT TYPE OF ACTION 1 218 218 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP 6 COMPLAINT SURVEY TYPE OF CONTROL 2 219 220 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 7 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 01 PROPRIETARY 02 NON PROFIT CHURCH 03 NON PROFIT OTHER 04 GOVERNMENT ZIP CODE 5 221 225 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 226 227 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 228 230 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 231 233 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 234 234 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE FISCAL YEAR ENDING DATE 4 349 352 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT * RELATED PROVIDER NUMBER 10 456 465 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM SRV: SOCIAL 1 513 513 C PROV2485 INDICATES HOW SOCIAL SERVICES ARE PROVIDED. COBOL NAME: SP-SOCIAL VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR PARTICIPATION MEDICARE OPT/SP 1 1503 1503 C PROV1570 INDICATES IF A COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY ALSO PARTICIPATES IN MEDICARE AS A PROVIDER OF OUTPATIENT PHYSICAL THERAPY AND/OR SPEECH PATHOLOGY. COBOL NAME: PARTIC-OPT-SP VALUES: N NO Y YES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 8 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: OCCUPATIONAL THERAPY 1 1504 1504 C PROV2270 INDICATES HOW OCCUPATIONAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-OCCUP-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: OCCUPATIONAL THERAPY #2 1 1505 1505 C PROV2275 INDICATES HOW OCCUPATIONAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-OCCUP-THERAPY-2 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: OCCUPATIONAL THERAPY #3 1 1506 1506 C PROV2280 INDICATES HOW OCCUPATIONAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-OCCUP-THERAPY-3 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: ORTHOTIC/PROSTHETIC 1 1507 1507 C PROV2325 INDICATES HOW ORTHOTIC/PROSTHETIC SERVICES ARE PROVIDED BY A COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY. COBOL NAME: SP-ORTHOTIC-PROSTHET VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: ORTHOTIC/PROSTHETIC #2 1 1508 1508 C PROV2330 INDICATES HOW ORTHOTIC/PROSTHETIC SERVICES ARE PROVIDED BY A COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY. COBOL NAME: SP-ORTHOTIC-PROSTHET-2 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 9 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: ORTHOTIC/PROSTHETIC #3 1 1509 1509 C PROV2335 INDICATES HOW ORTHOTIC/PROSTHETIC SERVICES ARE PROVIDED BY A COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY. COBOL NAME: SP-ORTHOTIC-PROSTHET-3 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: PHYSICAL THERAPY 1 1510 1510 C PROV2370 INDICATES HOW PHYSICAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICAL-THERAPY VALUES: 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: PHYSICAL THERAPY #2 1 1511 1511 C PROV2375 INDICATES HOW PHYSICAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICAL-THERAPY-2 VALUES: 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: PHYSICAL THERAPY #3 1 1512 1512 C PROV2380 INDICATES HOW PHYSICAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICAL-THERAPY-3 VALUES: 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: PHYSICIAN 1 1513 1513 C PROV2385 INDICATES HOW PHYSICIAN SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICIAN VALUES: 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: PHYSICIAN #2 1 1514 1514 C PROV2390 INDICATES HOW PHYSICIAN SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICIAN-2 VALUES: 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: PHYSICIAN #3 1 1515 1515 C PROV2395 INDICATES HOW PHYSICIAN SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICIAN-3 VALUES: 1 PROVIDED BY EMPLOYEES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 10 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: PSYCHOLOGICAL 1 1516 1516 C PROV2420 INDICATES HOW PSYCHOLOGICAL SERVICES ARE PROVIDED. COBOL NAME: SP-PSYCHOLOGICAL VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: PSYCHOLOGICAL #2 1 1517 1517 C PROV2425 INDICATES HOW PSYCHOLOGICAL SERVICES ARE PROVIDED. COBOL NAME: SP-PSYCHOLOGICAL-2 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: PSYCHOLOGICAL #3 1 1518 1518 C PROV2430 INDICATES HOW PSYCHOLOGICAL SERVICES ARE PROVIDED. COBOL NAME: SP-PSYCHOLOGICAL-3 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: RESPIRATORY CARE 1 1519 1519 C PROV2455 INDICATES HOW RESPIRATORY CARE SERVICES ARE PROVIDED. COBOL NAME: SP-RESP-CARE VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: RESPIRATORY CARE #2 1 1520 1520 C PROV2460 INDICATES HOW RESPIRATORY CARE SERVICES ARE PROVIDED. COBOL NAME: SP-RESP-CARE-2 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: RESPIRATORY CARE #3 1 1521 1521 C PROV2465 INDICATES HOW RESPIRATORY CARE SERVICES ARE PROVIDED. COBOL NAME: SP-RESP-CARE-3 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 11 COMPREHENSIVE OUTPATIENT REHAB FACILITIES, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: SOCIAL #2 1 1522 1522 C PROV2490 INDICATES HOW SOCIAL SERVICES ARE PROVIDED. COBOL NAME: SP-SOCIAL-2 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: SOCIAL #3 1 1523 1523 C PROV2495 INDICATES HOW SOCIAL SERVICES ARE PROVIDED. COBOL NAME: SP-SOCIAL-3 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: SPEECH PATHOLOGY 1 1524 1524 C PROV2505 INDICATES HOW SPEECH PATHOLOGY SERVICES ARE PROVIDED. COBOL NAME: SP-SPEECH-PATH VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: SPEECH PATHOLOGY #2 1 1525 1525 C PROV2510 INDICATES HOW SPEECH PATHOLOGY SERVICES ARE PROVIDED. COBOL NAME: SP-SPEECH-PATH-2 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR SRV: SPEECH PATHOLOGY #3 1 1526 1526 C PROV2515 INDICATES HOW SPEECH PATHOLOGY SERVICES ARE PROVIDED. COBOL NAME: SP-SPEECH-PATH-3 VALUES: 0 NOT PROVIDED 1 PROVIDED BY EMPLOYEES 2 PROVIDED UNDER ARRANGEMENT 3 PROVIDED BY INDEPENDENT CONTRACTOR * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 1 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 AMBULATORY SURGICAL CENTER CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 15 AMBULATORY SURGICAL CENTERS CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY AND STATE 31 13 43 C PROV0115 THE CITY AND STATE WHERE A PROVIDER IS LOCATED. COBOL NAME: CITY-STATE COMPLIANCE: PLAN OF CORRECTION 1 44 44 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 45 45 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 46 48 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 49 58 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 59 64 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 2 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 6 65 70 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 71 71 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 38 72 109 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME * INTERMEDIARY NUMBER 5 110 114 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 3 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00510 BLUE SHIELD (ALABAMA) 00520 BLUE SHIELD (ARKANSAS) 00528 BLUE SHIELD (ARKANSAS/LOUISIANA) 00542 BLUE SHIELD (CALIFORNIA) 00550 BLUE SHIELD (COLORADO) 00570 BLUE SHIELD (DELAWARE) 00580 BLUE SHIELD (DISTRICT OF COLUMBIA) 00590 BLUE SHIELD (FLORIDA) 00621 BLUE SHIELD (ILLINOIS) 00630 BLUE SHIELD (INDIANA) 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 BLUE SHIELD (KENTUCKY) 00690 BLUE SHIELD (MARYLAND) 00700 BLUE SHIELD (MASSACHUSETTS) 00710 BLUE SHIELD (MICHIGAN) 00720 BLUE SHIELD (MINNESOTA) 00740 BLUE SHIELD (KANSAS CITY) 00751 BLUE SHIELD (MONTANA) 00770 BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780 BLUE SHIELD (TRI-STATE) 00801 BLUE SHIELD (BUFFALO) 00803 BLUE SHIELD (EMPIRE) 00820 BLUE SHIELD (NORTH DAKOTA) 00825 BLUE SHIELD (NORTH DAKOTA/WYOMING) 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865 BLUE SHIELD (PENNSYLVANIA) 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00900 BLUE SHIELD (TEXAS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 4 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 00973 BLUE SHIELD (PUERTO RICO) 00974 BLUE SHIELD (VIRGIN ISLANDS) 01010 AETNA (PEORIA) 01020 AETNA (ALASKA) 01030 AETNA (ARIZONA) 01040 AETNA (GEORGIA) 01120 AETNA (HAWAII) 01290 AETNA (NEVADA) 01360 AETNA (NEW MEXICO) 01370 AETNA (OKLAHOMA) 01380 AETNA (OREGON) 02050 OCCIDENTAL (CALIFORNIA) 05130 EQICOR (IDAHO) 05440 EQICOR (TENNESSEE) 05535 EQICOR (NORTH CAROLINA) 10071 TRAVELERS (RRB) 10230 TRAVELERS (CONNECTICUT) 10240 TRAVELERS (MINNESOTA) 10250 TRAVELERS (MISSISSIPPI) 10490 TRAVELERS (VIRGINIA) 10492 TRAVELERS - VIRGINIA SPECIAL PROJECT 11260 GENERAL AMERICAN 14330 GROUP HEALTH INC (NEW YORK) 16360 NATIONWIDE (OHIO) 16510 NATIONWIDE (WEST VIRGINIA) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 21200 MASSACHUSETTS/MAINE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICAID VENDOR NUMBER 12 115 126 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A MEDICAID FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 6 127 132 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 5 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR CHANGE OF OWNERSHIP 6 133 138 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 139 143 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 144 153 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE: MASTER/TRANSACTION 1 154 154 C PROV1720 INDICATES IF A RECORD IS CURRENTLY ON THE MASTER FILE OR THE TRANSACTION FILE. COBOL NAME: RECORD-TYPE VALUES: M MASTER FILE T TRANSACTION FILE REGION CODE 2 155 156 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 157 157 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE CODE (SSA) 2 158 159 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 6 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 7 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 52 WISCONSIN 53 WYOMING 54 AFRICA 55 CALIFORNIA 56 CANADA 57 WEST INDIES 58 EUROPE 59 MEXICO 60 OCEANIA 61 PHILIPPINES 62 SOUTH AMERICA 63 UNITED STATES POSSESSIONS 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN 67 TEXAS STATES REGION CODE 3 160 162 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 163 200 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 201 210 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE 1 211 211 C PROV2805 THE REASON A FACILITY HAS BEEN TERMINATED FROM THE MEDICARE AND/OR MEDICAID PROGRAMS COBOL NAME: TERM-CD VALUES: 0 ACTIVE 1 VOL-MERG,CLOSE 2 VOL-REIMBURSE 3 VOL-RISK INVOL 4 VOL-OTHER 5 INVOL-FAIL REQ 6 INVOL-AGREEMNT 7 OTH-STATUS CHG TERMINATION DATE 6 212 217 C PROV2810 THE EFFECTIVE DATE OF TERMINATION OF CERTIFICATION OF A FACILITY. COBOL NAME: TERM-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 8 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF ACTION 1 218 218 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP 6 COMPLAINT SURVEY TYPE OF CONTROL 2 219 220 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 PROPRIETARY 02 NON PROFIT 03 GOVERNMENT ZIP CODE 5 221 225 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 226 227 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 228 230 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 231 233 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 234 234 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE COMPLIANCE: LIFE SAFETY CODE 1 332 332 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: 1 WAIVER RECOMMENDED FISCAL YEAR ENDING DATE 4 349 352 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT REGIONAL OVERRIDE #2 (STAFFING) 1 430 430 C PROV1550 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-2 VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 9 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 10 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME Y RECORD HAS BEEN APPROVED * RELATED PROVIDER NUMBER 10 456 465 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM DATE CENTER BEGAN PROVIDING SERV 6 1527 1532 C PROV0415 THE DATE AN AMBULATORY SURGICAL CENTER (ASC) BEGAN PROVIDING HEALTH CARE SERVICES. COBOL NAME: DT-SERVICE-BEGAN FREE STANDING INDICATOR (ASC) 1 1533 1533 C PROV0550 INDICATES IF THE AMBULATORY SURGICAL CENTER IS FREE STANDING. THIS INDICATOR IS USED BY SOME STANDARD REPORTS TO GET CERTAIN PROVIDER RANGES. COBOL NAME: FREE-STAND-IND VALUES: 1 FREE STANDING HOSPITAL BASED INDICATOR 1 1534 1534 C PROV0565 INDICATES IF AN AMBULATORY SURGICAL CENTER IS HOSPITAL BASED. THIS INDICATOR IS USED BY SOME STANDARD REPORTS TO GET CERTAIN PROVIDER RANGES. COBOL NAME: HOSP-BASED-IND VALUES: 1 HOSPITAL BASED OPERATING ROOMS 2 1535 1536 N PROV1055 THE NUMBER OF OPERATING ROOMS IN AN AMBULATORY SURGICAL CENTER. COBOL NAME: NUM-OPERATING-ROOMS SPEC: CARDIOVASCULAR 1 1537 1537 C PROV2095 INDICATES IF CARDIOVASCULAR SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-CARDIOVASCULAR VALUES: N NOT OFFERED Y OFFERED SPEC: FOOT 1 1538 1538 C PROV2145 INDICATES IF FOOT SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-FOOT VALUES: N NOT OFFERED Y OFFERED SPEC: GENERAL 1 1539 1539 C PROV2150 INDICATES IF GENERAL SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-GENERAL VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 11 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME N NOT OFFERED Y OFFERED SPEC: NEUROLOGICAL 1 1540 1540 C PROV2240 INDICATES IF NEUROLOGICAL SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-NEUROLOGICAL VALUES: N NOT OFFERED Y OFFERED SPEC: OBSTETRICS/GYNECOLOGY 1 1541 1541 C PROV2260 INDICATES IF OBSTETRICS/GYNECOLOGY SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-OBSTETR-GYNECOL VALUES: N NOT OFFERED Y OFFERED SPEC: OPTHAMOLOGY 1 1542 1542 C PROV2290 INDICATES IF OPTHAMOLOGY SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-OPTHAMOLOGY-SURG VALUES: N NOT OFFERED Y OFFERED SPEC: ORAL 1 1543 1543 C PROV2305 INDICATES IF ORAL SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-ORAL VALUES: N NOT OFFERED Y OFFERED SPEC: ORTHOPEDIC 1 1544 1544 C PROV2320 INDICATES IF ORTHOPEDIC SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-ORTHOPEDIC VALUES: N NOT OFFERED Y OFFERED SPEC: OTOLARYNGOLOGY 1 1545 1545 C PROV2345 INDICATES IF OTOLARYNGOLOGY SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-OTOLARYRGOLOGY VALUES: N NOT OFFERED Y OFFERED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 12 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SPEC: PLASTIC 1 1546 1546 C PROV2400 INDICATES IF PLASTIC SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-PLASTIC VALUES: N NOT OFFERED Y OFFERED SPEC: THORACIC 1 1547 1547 C PROV2525 INDICATES IF THORACIC SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-THORACIC VALUES: N NOT OFFERED Y OFFERED SPEC: UROLOGY 1 1548 1548 C PROV2530 INDICATES IF UROLOGY SURGERY IS OFFERED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-UROLOGY VALUES: N NOT OFFERED Y OFFERED SRV: EKG 1 1549 1549 C PROV2135 INDICATES IF EKG SERVICES ARE PROVIDED BY AN AMBULATORY SURGICAL CENTER. COBOL NAME: SP-EKG VALUES: 0 NOT PROVIDED 1 PROVIDED DIRECTLY BY THE FACILITY 2 PROVIDED THROUGH AN OUTSIDE SOURCE 3 COMBINATION SRV: LABORATORY 1 1550 1550 C PROV2200 INDICATES HOW LABORATORY SERVICES ARE PROVIDED. COBOL NAME: SP-LABORATORY VALUES: 1 PROVIDED DIRECTLY BY THE FACILITY 2 PROVIDED THROUGH AN OUTSIDE SOURCE 3 COMBINATION SRV: OTHER 1 1551 1551 C PROV2340 INDICATES HOW OTHER (NOT SPECIFIED) SERVICES ARE PROVIDED. COBOL NAME: SP-OTHER VALUES: N NOT OFFERED Y OFFERED SRV: PHARMACY 1 1552 1552 C PROV2365 INDICATES HOW PHARMACY SERVICES ARE PROVIDED. COBOL NAME: SP-PHARMACY VALUES: 1 PROVIDED DIRECTLY BY THE FACILITY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 13 AMBULATORY SURGICAL CENTERS, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 2 PROVIDED THROUGH AN OUTSIDE SOURCE 3 COMBINATION SRV: RADIOLOGY 1 1553 1553 C PROV2435 INDICATES HOW RADIOLOGY SERVICES ARE PROVIDED. COBOL NAME: SP-RADIOLOGY VALUES: 1 PROVIDED DIRECTLY BY THE FACILITY 2 PROVIDED THROUGH AN OUTSIDE SOURCE 3 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 1 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 HOSPICE CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 16 HOSPICES CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY AND STATE 31 13 43 C PROV0115 THE CITY AND STATE WHERE A PROVIDER IS LOCATED. COBOL NAME: CITY-STATE COMPLIANCE: PLAN OF CORRECTION 1 44 44 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 45 45 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 46 48 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 49 58 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 59 64 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 2 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 6 65 70 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 71 71 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 38 72 109 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME * INTERMEDIARY NUMBER 5 110 114 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 3 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICAID VENDOR NUMBER 12 115 126 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A MEDICAID FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 6 127 132 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 133 138 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 139 143 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 144 153 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 4 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RECORD TYPE: MASTER/TRANSACTION 1 154 154 C PROV1720 INDICATES IF A RECORD IS CURRENTLY ON THE MASTER FILE OR THE TRANSACTION FILE. COBOL NAME: RECORD-TYPE VALUES: M MASTER FILE T TRANSACTION FILE REGION CODE 2 155 156 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 157 157 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE CODE (SSA) 2 158 159 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 5 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 54 AFRICA 55 CALIFORNIA 56 CANADA 57 WEST INDIES 58 EUROPE 59 MEXICO 60 OCEANIA 61 PHILIPPINES 62 SOUTH AMERICA 63 UNITED STATES POSSESSIONS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 6 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN 67 TEXAS STATES REGION CODE 3 160 162 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 163 200 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 201 210 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE 1 211 211 C PROV2805 THE REASON A FACILITY HAS BEEN TERMINATED FROM THE MEDICARE AND/OR MEDICAID PROGRAMS COBOL NAME: TERM-CD VALUES: 0 ACTIVE 1 VOL-MERG,CLOSE 2 VOL-REIMBURSE 3 VOL-RISK INVOL 4 VOL-OTHER 5 INVOL-FAIL REQ 6 INVOL-AGREEMNT 7 OTH-STATUS CHG TERMINATION DATE 6 212 217 C PROV2810 THE EFFECTIVE DATE OF TERMINATION OF CERTIFICATION OF A FACILITY. COBOL NAME: TERM-DT TYPE OF ACTION 1 218 218 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP 6 COMPLAINT SURVEY TYPE OF CONTROL 2 219 220 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 7 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 01 VOLUNTARY NON-PROFIT - CHURCH 02 VOLUNTARY NON-PROFIT - PRIVATE 03 VOLUNTARY NON-PROFIT - OTHER 04 PROPRIETARY - INDIVIDUAL 05 PROPRIETARY - PARTNERSHIP 06 PROPRIETARY - CORPORATION 07 PROPRIETARY - OTHER 08 GOVERNMENT - STATE 09 GOVERNMENT - COUNTY 10 GOVERNMENT - CITY 11 GOVERNMENT - CITY-COUNTY 12 COMBINATION GOV. & NONPROFIT 13 OTHER ZIP CODE 5 221 225 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 226 227 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 228 230 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 231 233 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 234 234 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE COMPLIANCE: LIFE SAFETY CODE 1 332 332 C PROV0240 INDICATES IF A WAIVER OF THE LIFE SAFETY CODE HAS BEEN RECOMMENDED FOR A PROVIDER. COBOL NAME: COMPL-LSC VALUES: 1 WAIVER RECOMMENDED FISCAL YEAR ENDING DATE 4 349 352 C PROV0485 THE ENDING DATE (MONTH AND DAY) OF A FACILITY'S FISCAL YEAR. COBOL NAME: FISC-YR-END-DT LICENSED PRACTICAL NURSES 7.2 360 366 N PROV0955 NUMBER OF FULL-TIME EQUIVALENT LICENSED PRACTICAL OR VOCATIONAL NURSES EMPLOYED BY A FACILITY. COBOL NAME: NUM-LPN-LVN OTHER PERSONNEL 7.2 376 382 N PROV1075 THE NUMBER OF FULL-TIME EQUIVALENT OTHER SALARIED PERSONNEL EMPLOYED BY A FACILITY. COBOL NAME: NUM-OTHER-PERSNL * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 8 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME REGIONAL OVERRIDE #2 (STAFFING) 1 430 430 C PROV1550 THIS FIELD IS SET TO "Y" WHEN THE REGIONAL OFFICE HAS TO OK A PENDING RECORD IN THE SPECIAL FIELDS SCREEN. THIS FIELD ONLY APPLIES TO CATEGORIES IN THE ODIE DATA ENTRY SYSTEM. COBOL NAME: OVERRIDE-2 VALUES: Y RECORD HAS BEEN APPROVED REGISTERED NURSES 7.2 432 438 N PROV1145 THE NUMBER OF FULL-TIME EQUIVALENT REGISTERED PROFESSIONAL NURSES EMPLOYED BY A PROVIDER. COBOL NAME: NUM-REG-NURS * RELATED PROVIDER NUMBER 10 456 465 C PROV1755 THIS FIELD IS USED WHEN A PROVIDER'S FACILITY CONTAINS MORE THAN ONE DISTINCT PROVIDER,SUCH AS A HOSPITAL WITH DISTINCT PART LONG TERM CARE. THE NUMBER IN THIS FIELD WILL BE THE PROVIDER NMBR OF THE HIGHEST LEVEL OF CARE. COBOL NAME: RELATED-PROV-NUM TYPE OF FACILITY 2 516 517 C PROV2890 INDICATES THE CATEGORY WHICH REPRESENTS THE TYPE OF FACILITY. COBOL NAME: TYPE-FACILITY VALUES: 01 HOSPITAL 02 SKILLED NURSING FACILITY 03 NURSING FACILITY 04 HOME HEALTH AGENCY 05 FREESTANDING HOSPICE HOME HEALTH AIDES 7.2 1098 1104 N PROV0910 NUMBER OF FULL-TIME EQUIVALENT HOME HEALTH AIDES EMPLOYED BY A HOME HEALTH AGENCY OR HOSPICE. COBOL NAME: NUM-HOME-HEALTH-AIDES SRV: MEDICAL SOCIAL 1 1142 1142 C PROV2220 INDICATES HOW MEDICAL SOCIAL SERVICES ARE PROVIDED COBOL NAME: SP-MEDICAL-SOCIAL VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: NURSING 1 1143 1143 C PROV2250 INDICATES HOW NURSING SERVICES ARE PROVIDED. COBOL NAME: SP-NURSING VALUES: 1 PROVIDED BY STAFF 7 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 9 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TOTAL # OF EMPLOYEES 9.2 1443 1451 N PROV2850 THE TOTAL NUMBER OF FULL-TIME EMPLOYEES IN A HOSPICE OR AN INTERMEDIATE CARE FACILITY/MENTAL RETARDATION FACILITY. COBOL NAME: TOT-EMPLOYEES PHYSICIANS 7.2 1470 1476 N PROV1110 THE NUMBER OF FULL-TIME EQUIVALENT PHYSICIANS EMPLOYED BY A PROVIDER. COBOL NAME: NUM-PHYS SRV: OCCUPATIONAL THERAPY 1 1504 1504 C PROV2270 INDICATES HOW OCCUPATIONAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-OCCUP-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: PHYSICAL THERAPY 1 1510 1510 C PROV2370 INDICATES HOW PHYSICAL THERAPY SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICAL-THERAPY VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: PHYSICIAN 1 1513 1513 C PROV2385 INDICATES HOW PHYSICIAN SERVICES ARE PROVIDED. COBOL NAME: SP-PHYSICIAN VALUES: 1 PROVIDED BY STAFF SRV: SPEECH PATHOLOGY 1 1524 1524 C PROV2505 INDICATES HOW SPEECH PATHOLOGY SERVICES ARE PROVIDED. COBOL NAME: SP-SPEECH-PATH VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: OTHER 1 1551 1551 C PROV2340 INDICATES HOW OTHER (NOT SPECIFIED) SERVICES ARE PROVIDED. COBOL NAME: SP-OTHER VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 10 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ACUTE/RESPITE CARE INDICATOR 1 1554 1554 C PROV0015 INDICATES IF THE HOSPICE PROVIDES ACUTE AND/OR RESPITE SHORT TERM INPATIENT CARE. COBOL NAME: ACUTE-RESPITE VALUES: A SHORT TERM INPATIENT ACUTE CARE PROV'D IN HSP B SHORT TERM INPATIENT RESPITE CARE PROV IN HSP C ST INPATIENT ACUTE & RESPITE CARE PROV IN HSP COUNSELORS - STAFF 7.2 1555 1561 N PROV1225 THE NUMBER OF FULL-TIME EQUIVALENT COUNSELORS EMPLOYED BY A HOSPICE. COBOL NAME: NUM-STAFF-COUNSL COUNSELORS - VOLUNTEER 7.2 1562 1568 N PROV1480 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER COUNSELORS IN A HOSPICE. COBOL NAME: NUM-VOL-COUNSL HOME HEALTH AIDES - VOLUNTEER 7.2 1569 1575 N PROV1485 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER HOME HEALTH AIDES IN A HOSPICE. COBOL NAME: NUM-VOL-HHA HOMEMAKERS - STAFF 7.2 1576 1582 N PROV0915 THE NUMBER OF FULL-TIME EQUIVALENT HOMEMAKERS EMPLOYED BY A HOSPICE. COBOL NAME: NUM-HOMEMAKERS HOMEMAKERS - VOLUNTEER 7.2 1583 1589 N PROV1490 THE NUMBER OF FULL-TIME EQUIVALENT HOMEMAKERS IN A HOSPICE. COBOL NAME: NUM-VOL-HOMEMKR LPNS/LVNS - VOLUNTEER 7.2 1590 1596 N PROV1495 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER LICENSED PRACTICAL/VOCATIONAL NURSES IN A HOSPICE. COBOL NAME: NUM-VOL-LPN-LVN MEDICAL SOCIAL WORKERS 7.2 1597 1603 N PROV0975 NUMBER OF FULL-TIME EQUIVALENT MEDICAL SOCIAL WORKERS EMPLOYED BY A HOSPITAL OR HOSPICE. COBOL NAME: NUM-MED-SOCIAL-WRKS MEDICAL SOCIAL WORKERS - VOLUNTEER 7.2 1604 1610 N PROV1510 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER MEDICAL SOCIAL WORKERS IN A HOSPICE. COBOL NAME: NUM-VOL-SOC-WORK PHYSICIANS - VOLUNTEER 7.2 1611 1617 N PROV1500 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER PHYSICIANS IN A HOSPICE. COBOL NAME: NUM-VOL-PHYS REGISTERED NURSES - VOLUNTEER 7.2 1618 1624 N PROV1505 THE NUMBER OF FULL-TIME EQUIVALENT VOLUNTEER REGISTERED NURSES IN A HOSPICE. COBOL NAME: NUM-VOL-REG-NURS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 11 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME SRV: COUNSELING 1 1625 1625 C PROV2115 INDICATES HOW COUNSELING SERVICES ARE PROVIDED BY A HOSPICE. COBOL NAME: SP-COUNSELING VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: HOME HEALTH AIDE 1 1626 1626 C PROV2165 INDICATES HOW HOME HEALTH AIDE SERVICES ARE PROVIDED BY A HOSPICE. COBOL NAME: SP-HOME-HEALTH-AIDE VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: HOMEMAKER 1 1627 1627 C PROV2170 INDICATES HOW HOMEMAKER SERVICES ARE PROVIDED BY A HOSPICE. COBOL NAME: SP-HOMEMAKER VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: MEDICAL SUPPLIES 1 1628 1628 C PROV2225 INDICATES HOW MEDICAL SUPPLIES SERVICES ARE PROVIDED BY A HOSPICE. COBOL NAME: SP-MEDICAL-SUPPLIES VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION SRV: SHORT TERM INPATIENT CARE 1 1629 1629 C PROV2480 INDICATES HOW SHORT TERM INPATIENT CARE SERVICES ARE PROVIDED BY A HOSPICE. COBOL NAME: SP-SHORT-TERM-INCARE VALUES: 0 NOT PROVIDED 1 PROVIDED BY STAFF 2 PROVIDED UNDER ARRANGEMENT 3 COMBINATION * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 12 HOSPICES, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME VOLUNTEERS - OTHER 7.2 1630 1636 N PROV1080 THE NUMBER OF FULL-TIME EQUIVALENT OTHER VOLUNTEERS IN A HOSPICE. COBOL NAME: NUM-OTHER-VOLS VOLUNTEERS - TOTAL 9.2 1637 1645 N PROV2860 THE NUMBER OF FULL-TIME VOLUNTEERS IN A HOSPICE. COBOL NAME: TOT-VOLS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 1 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 ORGAN PROCUREMENT CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 17 ORGAN PROCUREMENT ORGANIZATIONS CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY AND STATE 31 13 43 C PROV0115 THE CITY AND STATE WHERE A PROVIDER IS LOCATED. COBOL NAME: CITY-STATE COMPLIANCE: PLAN OF CORRECTION 1 44 44 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 45 45 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 46 48 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 49 58 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 59 64 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 2 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 6 65 70 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 71 71 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 38 72 109 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME * INTERMEDIARY NUMBER 5 110 114 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 3 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICAID VENDOR NUMBER 12 115 126 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A MEDICAID FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 6 127 132 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT PRIOR CHANGE OF OWNERSHIP 6 133 138 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 139 143 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 144 153 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 4 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME RECORD TYPE: MASTER/TRANSACTION 1 154 154 C PROV1720 INDICATES IF A RECORD IS CURRENTLY ON THE MASTER FILE OR THE TRANSACTION FILE. COBOL NAME: RECORD-TYPE VALUES: M MASTER FILE T TRANSACTION FILE REGION CODE 2 155 156 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 157 157 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE CODE (SSA) 2 158 159 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 5 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA 52 WISCONSIN 53 WYOMING 54 AFRICA 55 CALIFORNIA 56 CANADA 57 WEST INDIES 58 EUROPE 59 MEXICO 60 OCEANIA 61 PHILIPPINES 62 SOUTH AMERICA 63 UNITED STATES POSSESSIONS * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 6 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN 67 TEXAS STATES REGION CODE 3 160 162 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 163 200 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 201 210 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE 1 211 211 C PROV2805 THE REASON A FACILITY HAS BEEN TERMINATED FROM THE MEDICARE AND/OR MEDICAID PROGRAMS COBOL NAME: TERM-CD VALUES: 0 ACTIVE 1 VOL-MERG,CLOSE 2 VOL-REIMBURSE 3 VOL-RISK INVOL 4 VOL-OTHER 5 INVOL-FAIL REQ 6 INVOL-AGREEMNT 7 OTH-STATUS CHG TERMINATION DATE 6 212 217 C PROV2810 THE EFFECTIVE DATE OF TERMINATION OF CERTIFICATION OF A FACILITY. COBOL NAME: TERM-DT TYPE OF ACTION 1 218 218 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP 6 COMPLAINT SURVEY TYPE OF CONTROL 2 219 220 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 7 ORGAN PROCUREMENT ORGANIZATIONS, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME ZIP CODE 5 221 225 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 226 227 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 228 230 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 231 233 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 234 234 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 1 CLINICAL LABORATORY IMPROVEMENT ACT LABS, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CATEGORY - SUBTYPE OF PROVIDER 2 1 2 C PROV0085 A FURTHER BREAKDOWN OF PROVIDER CATEGORY FOR SKILLED NURSING FACILITIES AND HOSPITALS. COBOL NAME: CATEGORY-SUBTYPE-IND VALUES: 01 CLIA CATEGORY OF PROVIDER/SUPPLIER 2 3 4 C PROV0075 IDENTIFIES THE CATEGORY WHICH IS MOST INDICATIVE OF THE PROVIDER OR SUPPLIER. COBOL NAME: CATEGORY VALUES: 18 CLINICAL LABORATORY IMPROVEMENT ACT LABS CHANGE OF OWNERSHIP COUNTER 2 5 6 N PROV0095 THE NUMBER OF TIMES A CHANGE OF OWNERSHIP (CHOW) HAS TAKEN PLACE FOR A PARTICULAR PROVIDER. COBOL NAME: CHOW-CNT CHANGE OF OWNERSHIP DATE 6 7 12 C PROV0100 EFFECTIVE DATE OF A CHANGE OF OWNERSHIP. COBOL NAME: CHOW-DT CITY AND STATE 31 13 43 C PROV0115 THE CITY AND STATE WHERE A PROVIDER IS LOCATED. COBOL NAME: CITY-STATE COMPLIANCE: PLAN OF CORRECTION 1 44 44 C PROV0220 INDICATES IF A PROVIDER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS BASED ON AN ACCEPTABLE PLAN FOR CORRECTION OF DEFICIENCIES. COBOL NAME: COMPL-ACCEPT-PLAN-COR VALUES: 1 COMPLIANCE BASED ON ACCEPTABLE POC COMPLIANCE: STATUS 1 45 45 C PROV2715 INDICATES IF A PROVIDER OR SUPPLIER IS IN COMPLIANCE WITH PROGRAM REQUIREMENTS. COBOL NAME: STATUS-COMPL VALUES: A IN COMPLIANCE B NOT IN COMPLIANCE COUNTY CODE 3 46 48 C PROV2695 SSA GEOGRAPHIC CODE INDICATING COUNTY WHERE FACILITY IS LOCATED. COBOL NAME: SSA-COUNTY CROSS REFERENCE PROVIDER NUMBER 10 49 58 C PROV0300 NUMBER PREVIOUSLY ASSIGNED TO A PARTICULAR PROVIDER. COBOL NAME: CROSS-REF-PROV-NUM CURRENT FMS SURVEY DATE 6 59 64 C PROV0500 CURRENT FMS SURVEY DATE COBOL NAME: FMS-SURVEY-DT-1 * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 2 CLINICAL LABORATORY IMPROVEMENT ACT LABS, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CURRENT SURVEY DATE 6 65 70 C PROV2740 THE DATE OF THE HEALTH OR LIFE SAFETY CODE SURVEY, WHICHEVER IS LATER. THE "OFFICIAL" SURVEY DATE FOR THE PROVIDER. COBOL NAME: SURVEY-DT-1 ELIGIBILITY CODE 1 71 71 C PROV0455 INDICATES IF A FACILITY IS ELIGIBLE TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: ELIG-CD VALUES: 1 ELIGIBLE TO PARTICIPATE 2 NOT ELIGIBLE TO PARTICIPATE FACILITY NAME 38 72 109 C PROV0475 THE NAME OF A PROVIDER OR SUPPLIER CERTIFIED TO PARTICIPATE IN THE MEDICARE AND/OR MEDICAID PROGRAMS. COBOL NAME: FACILITY-NAME * INTERMEDIARY NUMBER 5 110 114 C PROV0605 A NUMBER ASSIGNED TO AN INTERMEDIARY OR CARRIER SERVICING A PROVIDER OR SUPPLIER. COBOL NAME: INTER-CARRIER-NUM VALUES: 00010 BLUE CROSS (ALABAMA) 00020 BLUE CROSS (ARKANSAS) 00030 BLUE CROSS (ARIZONA) 00040 BLUE CROSS (CALIFORNIA) 00060 BLUE CROSS (CONNECTICUT) 00070 BLUE CROSS (DELAWARE) 00090 BLUE CROSS (FLORIDA) 00101 BLUE CROSS (GEORGIA) 00121 HEALTH CARE SERVICE CORPORATION 00130 BLUE CROSS (INDIANA) 00140 BLUE CROSS (IOWA/SOUTH DAKOTA) 00150 BLUE CROSS (KANSAS) 00160 BLUE CROSS (KENTUCKY) 00180 BLUE CROSS (MAINE) 00190 BLUE CROSS (MARYLAND) 00200 BLUE CROSS (MASSACHUSETTS) 00210 BLUE CROSS (MICHIGAN) 00220 BLUE CROSS (MINNESOTA) 00230 BLUE CROSS (MISSISSIPPI) 00231 BLUE CROSS (LOUISIANA) 00241 BLUE CROSS (MISSOURI) 00250 BLUE CROSS (MONTANA) 00260 BLUE CROSS (NEBRASKA) 00270 NEW HAMPSHIRE-VERMONT HEALTH SERVICE 00280 BLUE CROSS (NEW JERSEY) 00290 BLUE CROSS (NEW MEXICO) 00308 BLUE CROSS (EMPIRE) 00310 BLUE CROSS (NORTH CAROLINA) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 3 CLINICAL LABORATORY IMPROVEMENT ACT LABS, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00320 BLUE CROSS (NORTH DAKOTA) 00332 COMMUNITY MUTUAL INSURANCE CO 00340 BLUE CROSS (OKLAHOMA) 00350 BLUE CROSS (OREGON) 00351 BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362 BLUE CROSS (INDEPENDENCE) 00363 BLUE CROSS (WESTERN PENNSYLVANIA) 00370 BLUE CROSS (RHODE ISLAND) 00380 BLUE CROSS (SOUTH CAROLINA) 00390 BLUE CROSS (TENNESSEE) 00400 BLUE CROSS (TEXAS) 00410 BLUE CROSS (UTAH) 00423 BLUE CROSS (VIRGINIA/WEST VA) 00430 BLUE CROSS (WASHINGTON & ALASKA) 00450 BLUE CROSS (WISCONSIN) 00460 BLUE CROSS (WYOMING) 00468 BLUE CROSS (NORTH CAROLINA FOR PR) 00510 BLUE SHIELD (ALABAMA) 00520 BLUE SHIELD (ARKANSAS) 00528 BLUE SHIELD (ARKANSAS/LOUISIANA) 00542 BLUE SHIELD (CALIFORNIA) 00550 BLUE SHIELD (COLORADO) 00570 BLUE SHIELD (DELAWARE) 00580 BLUE SHIELD (DISTRICT OF COLUMBIA) 00590 BLUE SHIELD (FLORIDA) 00621 BLUE SHIELD (ILLINOIS) 00630 BLUE SHIELD (INDIANA) 00640 BLUE SHIELD (IOWA) 00650 BLUE SHIELD (KANSAS) 00655 BLUE SHIELD (KANSAS/NEBRASKA) 00660 BLUE SHIELD (KENTUCKY) 00690 BLUE SHIELD (MARYLAND) 00700 BLUE SHIELD (MASSACHUSETTS) 00710 BLUE SHIELD (MICHIGAN) 00720 BLUE SHIELD (MINNESOTA) 00740 BLUE SHIELD (KANSAS CITY) 00751 BLUE SHIELD (MONTANA) 00770 BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780 BLUE SHIELD (TRI-STATE) 00801 BLUE SHIELD (BUFFALO) 00803 BLUE SHIELD (EMPIRE) 00820 BLUE SHIELD (NORTH DAKOTA) 00825 BLUE SHIELD (NORTH DAKOTA/WYOMING) 00860 BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865 BLUE SHIELD (PENNSYLVANIA) 00870 BLUE SHIELD (RHODE ISLAND) 00880 BLUE SHIELD (SOUTH CAROLINA) 00900 BLUE SHIELD (TEXAS) * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 4 CLINICAL LABORATORY IMPROVEMENT ACT LABS, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 00910 BLUE SHIELD (UTAH) 00930 BLUE SHIELD (WASHINGTON) 00951 WISCONSIN PHYSICIANS SERVICE 00973 BLUE SHIELD (PUERTO RICO) 00974 BLUE SHIELD (VIRGIN ISLANDS) 01010 AETNA (PEORIA) 01020 AETNA (ALASKA) 01030 AETNA (ARIZONA) 01040 AETNA (GEORGIA) 01120 AETNA (HAWAII) 01290 AETNA (NEVADA) 01360 AETNA (NEW MEXICO) 01370 AETNA (OKLAHOMA) 01380 AETNA (OREGON) 02050 OCCIDENTAL (CALIFORNIA) 05130 EQICOR (IDAHO) 05440 EQICOR (TENNESSEE) 05535 EQICOR (NORTH CAROLINA) 10071 TRAVELERS (RRB) 10230 TRAVELERS (CONNECTICUT) 10240 TRAVELERS (MINNESOTA) 10250 TRAVELERS (MISSISSIPPI) 10490 TRAVELERS (VIRGINIA) 10492 TRAVELERS - VIRGINIA SPECIAL PROJECT 11260 GENERAL AMERICAN 14330 GROUP HEALTH INC (NEW YORK) 16360 NATIONWIDE (OHIO) 16510 NATIONWIDE (WEST VIRGINIA) 17120 HAWAII MEDICAL SERVICE ASSOCIATION 21200 MASSACHUSETTS/MAINE 50333 TRAVELERS (NEW YORK) 51051 AETNA (PETALUMA) 51070 AETNA (FARMINGTON) 51100 AETNA (CLEARWATER) 51140 AETNA (PEORIA) 51390 AETNA (FORT WASHINGTON) 52280 MUTUAL OF OMAHA 57400 COOPERATIVA (PUERTO RICO) MEDICAID VENDOR NUMBER 12 115 126 C PROV0655 A NUMBER WHICH MAY BE ASSIGNED TO A MEDICAID FACILITY BY THE STATE MEDICAID AGENCY FOR EXTERNAL CONTROL OR BILLING PURPOSES. COBOL NAME: MEDICAID-VEND-NUM PARTICIPATION DATE 6 127 132 C PROV1565 THE DATE A FACILITY IS FIRST APPROVED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: PARTCI-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 5 CLINICAL LABORATORY IMPROVEMENT ACT LABS, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME PRIOR CHANGE OF OWNERSHIP 6 133 138 C PROV1615 THE DATE OF A PRIOR CHANGE OF OWNERSHIP. COBOL NAME: PRIOR-CHOW-DT PRIOR INTERMEDIARY NUMBER 5 139 143 C PROV1620 A PREVIOUS INTERMEDIARY NUMBER.WHEN COBOL NAME: PRIOR-INTER-CARRIER-NUM PROVIDER NUMBER 10 144 153 C PROV1680 A SIX OR TEN POSITION IDENTIFICATION NUMBER THAT IS AS- SIGNED TO A CERTIFIED PROVIDER OR SUPPLIER. A PROVIDER IS ISSUED A 6 POSITION NUMERIC OR ALPHANUMERIC NUMBER, A SUPPLIER IS ISSUED A 10 POSITION ALPHANUMERIC NUMBER. COBOL NAME: PROV-NUM RECORD TYPE: MASTER/TRANSACTION 1 154 154 C PROV1720 INDICATES IF A RECORD IS CURRENTLY ON THE MASTER FILE OR THE TRANSACTION FILE. COBOL NAME: RECORD-TYPE VALUES: M MASTER FILE T TRANSACTION FILE REGION CODE 2 155 156 C PROV1725 THE HCFA REGIONAL OFFICE HAVING RESPONSIBILITY FOR THE STATE IN WHICH THE PROVIDER IS LOCATED. COBOL NAME: REGION VALUES: 01 I BOSTON 02 II NEW YORK 03 III PHILADELPHIA 04 IV ATLANTA 05 V CHICAGO 06 VI DALLAS 07 VII KANSAS CITY 08 VIII DENVER 09 IX SAN FRANCISCO 10 X SEATTLE SKELETON RECORD INDICATOR 1 157 157 C PROV2045 INDICATES RECORD IS A SKELETON RECORD. THIS MEANS ONLY A LIMITED SET OF THE PROVIDER DATA IS AVAILABLE FOR THIS PROVIDER. COBOL NAME: SKELETON-IND VALUES: Y YES STATE CODE (SSA) 2 158 159 C PROV2700 TWO DIGIT CODE INDICATING STATE WHERE FACILITY IS LOCATED. COBOL NAME: SSA-STATE VALUES: 01 ALABAMA 02 ALASKA 03 ARIZONA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 6 CLINICAL LABORATORY IMPROVEMENT ACT LABS, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 04 ARKANSAS 05 CALIFORNIA 06 COLORADO 07 CONNECTICUT 08 DELAWARE 09 DISTRICT OF COLUMBIA 10 FLORIDA 11 GEORGIA 12 HAWAII 13 IDAHO 14 ILLINOIS 15 INDIANA 16 IOWA 17 KANSAS 18 KENTUCKY 19 LOUISIANA 20 MAINE 21 MARYLAND 22 MASSACHUSETTS 23 MICHIGAN 24 MINNESOTA 25 MISSISSIPPI 26 MISSOURI 27 MONTANA 28 NEBRASKA 29 NEVADA 30 NEW HAMPSHIRE 31 NEW JERSEY 32 NEW MEXICO 33 NEW YORK 34 NORTH CAROLINA 35 NORTH DAKOTA 36 OHIO 37 OKLAHOMA 38 OREGON 39 PENNSYLVANIA 40 PUERTO RICO 41 RHODE ISLAND 42 SOUTH CAROLINA 43 SOUTH DAKOTA 44 TENNESSEE 45 TEXAS 46 UTAH 47 VERMONT 48 VIRGIN ISLANDS 49 VIRGINIA 50 WASHINGTON 51 WEST VIRGINIA * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 7 CLINICAL LABORATORY IMPROVEMENT ACT LABS, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 52 WISCONSIN 53 WYOMING 54 AFRICA 55 CALIFORNIA 56 CANADA 57 WEST INDIES 58 EUROPE 59 MEXICO 60 OCEANIA 61 PHILIPPINES 62 SOUTH AMERICA 63 UNITED STATES POSSESSIONS 64 AMERICAN SAMOA 65 GUAM 66 SAIPAN 67 TEXAS STATES REGION CODE 3 160 162 C PROV2710 FOR SELECTED STATES, IDENTIFIES THE PARTICULAR REGION WITHIN THE STATE WHERE THE FACILITY IS LOCATED COBOL NAME: STATE-REGION-CD STREET ADDRESS 38 163 200 C PROV2720 STREET ADDRESS OF A PROVIDER THAT IS CERTIFIED TO PROVIDE MEDICARE AND/OR MEDICAID SERVICES. COBOL NAME: STREET-ADDRESS TELEPHONE NUMBER 10 201 210 C PROV1605 THE 10 DIGIT TELEPHONE NUMBER OF THE PRIMARY CONTACT OR THE OPERATOR OF A PROVIDER. COBOL NAME: PHONE-NUM TERMINATION CODE 1 211 211 C PROV2805 THE REASON A FACILITY HAS BEEN TERMINATED FROM THE MEDICARE AND/OR MEDICAID PROGRAMS COBOL NAME: TERM-CD VALUES: 0 ACTIVE 1 VOL-MERG,CLOSE 2 VOL-REIMBURSE 3 VOL-RISK INVOL 4 VOL-OTHER 5 INVOL-FAIL REQ 6 INVOL-AGREEMNT 7 OTH-STATUS CHG TERMINATION DATE 6 212 217 C PROV2810 THE EFFECTIVE DATE OF TERMINATION OF CERTIFICATION OF A FACILITY. COBOL NAME: TERM-DT * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 8 CLINICAL LABORATORY IMPROVEMENT ACT LABS, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TYPE OF ACTION 1 218 218 C PROV2880 IDENTIFIES THE PURPOSE FOR WHICH THE CERTIFICATION AND TRANSMITTAL FORM WAS PREPARED. COBOL NAME: TYPE-ACTION VALUES: 1 INITIAL 2 RECERTIFICATION 3 TERMINATION 4 CHANGE OF OWNERSHIP 6 COMPLAINT SURVEY TYPE OF CONTROL 2 219 220 C PROV2885 INDICATES THE NATURE OF THE ORGANIZATION THAT OPERATES A PROVIDER OF SERVICES. COBOL NAME: TYPE-CONTROL VALUES: 01 VOL. NON-PROF. - RELIGIOUS AFF. 02 VOLUNTARY NON-PROFIT - PRIVATE 03 VOLUNTARY NON-PROFIT - OTHER 04 PROPRIETARY 05 GOVERNMENT - CITY 06 GOVERNMENT - COUNTY 07 GOVERNMENT - STATE 08 GOVERNMENT - FEDERAL 09 GOVERNMENT - OTHER 10 OTHER (SURVEYED PRIOR TO 040491) 11 UNKNOWN (PRIOR TO 040491 SURVEYS) ZIP CODE 5 221 225 C PROV2905 THE FIVE DIGIT POSTAL CODE FOR THE PROVIDER. COBOL NAME: ZIP-CD FIPS STATE CODE 2 226 227 C FIPSTATE FIPS STATE CODE COBOL NAME: WS-FIPS-STATE FIPS COUNTY CODE 3 228 230 C FIPCNTY FIPS COUNTY CODE COBOL NAME: WS-FIPS-CNTY SSA MSA CODE 3 231 233 C SSAMSA SSA MSA CODE COBOL NAME: WS-SSA-MSA SSA MSA SIZE CODE 1 234 234 C SSAMSASZ SSA MSA SIZE CODE COBOL NAME: WS-SSA-MSA-SIZE CALENDAR YEAR TEST VOLUME 2 1151 1152 C PROV2615 THE NUMBER OF TESTS PERFORMED BY A LAB FOR THE PRE- VIOUS CALENDAR YEAR FOR ALL SPECIALTIES AND SUB- SPECIALTIES COBOL NAME: SPEC-CALENDAR-YEAR * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 9 CLINICAL LABORATORY IMPROVEMENT ACT LABS, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME CLIA LAB PROGRAM STATUS 1 1153 1153 C PROV0615 THE TYPE OF LABORATORY, I.E. HOSPITAL OR INDEPEDENT, AND THE PROGRAM(S) (MEDICARE, CLIA) IN WHICH THE LAB PARTICIPATES COBOL NAME: LAB-PROGRAM-STATUS VALUES: 2 INDEPENDENT CLIA LAB 3 INDEPENDENT MEDICARE/CLIA LAB 4 HOSPITAL BASED CLIA ONLY LAB CYTOTECHNOLOGISTS-PROF EXAM 3 1154 1156 N PROV0775 NUMBER OF CYTOTECHNOLOGISTS QUALIFIED UNDER CFR 405.1437(B)(3) WHICH REQUIRES SATISFACTORY GRADES IN PROFICIENCY EXAMINATIONS. COBOL NAME: NUM-CYTOTECHS-3 CYTOTECHNOLOGISTS-2 YR COLL 3 1157 1159 N PROV0765 NUMBER OF CYTOTECHNOLOGISTS QUALIFIED UNDER CFR 493.1437(B)(1) WHICH REQUIRES TWO YEARS OF COLLEGE, TWELVE MONTHS OF CYTOTECHNOLOGY TRAINING AND SIX MONTHS OF FORMAL TRAINING. COBOL NAME: NUM-CYTOTECHS-1 CYTOTECHNOLOGISTS-6 MO TRAIN 3 1160 1162 N PROV0770 # OF CYTOTECHNOLOGISTS QUALIFIED UNDER CFR CFR 493.1437(B)(2) WHICH REQUIRES THAT PRIOR TO 1/1/69, THE CYTOTECH IS A HS GRAD WITH 6 MTHS TRNG IN CYTOTECH, AND 2 YRS FULLTIME SUPERVISORY EXPER IN CYTOTECHNOLOGY COBOL NAME: NUM-CYTOTECHS-2 GENERAL SUPERVISOR - CYTOTECH 3 1163 1165 N PROV0880 THE NUMBER OF LAB GENERAL SUPERVISORS, QUALIFIED UNDER CFR 493.1427(B)(5), WHO HAVE FOUR YEARS EXPERIENCE AS CYTOTECHNOLOGISTS. COBOL NAME: NUM-GN-SUP-CYTOTECH GENERAL SUPERVISOR - GRANDFATHERED 3 1166 1168 N PROV0885 THE NUMBER OF LAB GENERAL SUPERVISORS QUALIFIED PRIOR TO 7/1/71 WITH AT LEAST 15 YEARS FULL-TIME EXPERIENCE PRIOR TO 1/1/68. (SEE CFR 493.1427(B)(6). COBOL NAME: NUM-GN-SUP-GRFATHER GENERAL SUPERVISOR - MD/DOCTORATE 3 1169 1171 N PROV0895 THE NUMBER OF LAB GENERAL SUPERVISORS, QUALIFIED UNDER CFR 493.1427(B)(2) WHO ARE PHYSICIANS OR HAVE DOCTORAL DEGREES IN A CLINICAL, PHYSICAL OR BIOLOGICAL SCIENCE AND 2 YEARS EXPERIENCE IN A LABORATORY. COBOL NAME: NUM-GN-SUP-PHYS-DOCT GENERAL SUPERVISOR - QUALIFIED DIR 3 1172 1174 N PROV0900 THE NUMBER OF GENERAL SUPERVISORS QUALIFIED UNDER CFR 493.1427(B)(1) WHO MAY ALSO SERVE AS THE LABORATORY DIRECTOR COBOL NAME: NUM-GN-SUP-QUALIF * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 10 CLINICAL LABORATORY IMPROVEMENT ACT LABS, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME GENERAL SUPERVISOR - 6 YRS EXP 3 1175 1177 N PROV0875 THE NUMBER OF LAB GENERAL SUPERVISORS, QUALIFIED UNDER CFR 493.1427(B)(4), WHO ARE LAB TECHNOLOGISTS WITH AT LEAST 6 YRS FULL-TIME LAB EXPERIENCE. COBOL NAME: NUM-GN-SUP-CLT-PLUS6 GENERAL SUPERVISOR-MASTERS DEGREE 3 1178 1180 N PROV0890 THE NUMBER OF LAB GENERAL SUPERVISORS QUALIFIED UNDER CFR 493.1427(B)32) WHO POSSESS MASTER'S DEGREES IN A CHEMICAL, PHYSICAL OR BIOLOGICAL SCIENCE AND HAVE AT LEAST 4 YEARS LAB EXPERIENCE. COBOL NAME: NUM-GN-SUP-MST-DEGREE IMMUNOHEMATOLOGY TEST FOR TRANSFUS 1 1181 1181 C PROV2085 INDICATES IF A LABORATORY PERFORMS IMMUNOHEMATOLOGY TESTS FOR TRANSFUSION PURPOSES COBOL NAME: SP-BLOOD-BANK-IMMUN VALUES: N NO Y YES LAB DIRECTORS - DOCTORATES 3 1182 1184 N PROV0830 THE NUMBER OF LAB DIRECTORS QUALIFIED UNDER CFR 493.1415(B)(4), WHICH REQUIRES DOCTORAL DEGREES AND BOARD CERTIFICATION OR 4 OR MORE YEARS EXPERIENCE IN AN APPROVED CLINICAL LABORATORY. COBOL NAME: NUM-DIR-DOCT-DEGREE LAB DIRECTORS - GRANDFATHERED 3 1185 1187 N PROV0835 THE NUMBER OF LAB DIRECTORS QUALIFIED UNDER CFR 493.1415(B)(5) WHO QUALIFIED PRIOR TO JULY 1, 1971, UNDER THE GRANDFATHER CLAUSE. COBOL NAME: NUM-DIR-GRFATHER LAB DIRECTORS - MD PATHOLOGISTS 3 1188 1190 N PROV0840 THE NUMBER OF LAB DIRECTORS QUALIFIED UNDER CFR 493.1415(B)(1) WHO ARE PHYSICIANS BOARD CERTIFIED IN ANATOMICAL AND/OR CLINICAL PATHOLOGY OR POSSESS EQUIVALENT QUALIFICATIONS. COBOL NAME: NUM-DIR-PATHOLOGIST LAB DIRECTORS - MD SPECIALTY 3 1191 1193 N PROV0845 THE NUMBER OF LAB DIRECTORS QUALIFIED UNDER CFR 493.1415(B)(2), WHO ARE PHYSICIANS BOARD CERTIFIED IN ONE OF THE LAB SPECIALTIES OR WHO HAVE 4 YEARS OF FT EXPERIENCE IN A LAB, INCLUDING 2 YEARS SPECIALIZED TRNG COBOL NAME: NUM-DIR-PHYS-BOARD LAB DIRECTORS - ORAL PATHOLOGY 3 1194 1196 N PROV0825 NUMBER OF LABORATORY DIRECTORS WHO ARE BOARD CERTIFIED IN ORAL PATHOLOGY OR_WHO POSSESS EQUIVALENT QUALIFICATIONS._SEE CFR 493.1415(B)(3) COBOL NAME: NUM-DIR-DENTIST * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 11 CLINICAL LABORATORY IMPROVEMENT ACT LABS, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME LAB DIRECTORS - STATE DEEMED 3 1197 1199 N PROV0850 NUMBER OF DIRECTORS THAT QUALIFY UNDER STATE LAW TO DIRECT THE LABORATORY (CFR 493.1415(B)(6)). COBOL NAME: NUM-DIR-STATE-DEEMED TECH SUPER - BA/BS CHEMISTRY 3 1200 1202 N PROV1275 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(S) TO PERFORM CHEMISTRY TESTS, WHO ARE DIRECTORS WITH A BS IN CHEMICAL SCIENCE AND 6 YEARS RELATED EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-CHEM TECH SUPER - BA/BS HEMATOLOGY 3 1203 1205 N PROV1285 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER_CFR 493.1421(O) TO PERFORM HEMATOLOGY TESTS, WHO ARE DIRECTORS WITH A BS IN BIOLOGY, IMMUNOLOGY OR MICRO- BIOLOGY, AND HAVE 6 YEARS EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-HEM TECH SUPER - BA/BS IMMUNOHEM 3 1206 1208 N PROV1290 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(R) TO PERFORM BLOOD GROUPING TESTS, WHO ARE DIRECTORS WITH A BS IN BIOLOGY, IMMUNOLOGY OR MICRO- BIOLOGY, AND 6 YEARS EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-IMHE TECH SUPER - BA/BS IMMUNOLOGY 3 1209 1211 N PROV1295 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(P) TO PERFORM DIAGNOSTIC IMMUNOLOGY TESTS, WHO ARE DIRECTORS WITH A BS IN BIOLOGY, CHEMISTRY, IMMU- NOLOGY OR MICROBIOLOGY, AND HAVE 6 YEARS EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-IMM TECH SUPER - BA/BS MICROBIO 3 1212 1214 N PROV1300 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(N) TO PERFORM MICROBIOLOGY TESTS WHO ARE DIRECTORS WITH A BS IN BIOLOGY AND 6 YEARS MICROBIOLOGY EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-MICR TECH SUPER - BA/BS RADIOBIO 3 1215 1217 N PROV1305 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(Q) TO PERFORM RADIOBIOASSAY TESTS WHO ARE DIRECTORS WITH A BS IN CHEMICAL, PHYSICAL OR BIOLOGICAL SCIENCE AND HAVE 6 YEARS EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-RADI TECH SUPER - BA/BS SPEC EXP 3 1218 1220 N PROV1280 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(T) TO PERFORM SPECIFIC LAB TESTS WHO ARE DIRECTORS WITH A BS IN MEDICAL TECHNOLOGY AND HAVE 6 YEARS SPECIALIZED EXPERIENCE COBOL NAME: NUM-TECH-SUP-BA-BS-EXP * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 12 CLINICAL LABORATORY IMPROVEMENT ACT LABS, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TECH SUPER - CLINICAL CHEMISTRY 3 1221 1223 N PROV1310 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(D) TO PERFORM TESTS IN CHEM UNDER THE SUP OF A BOARD CERT MD OR HAVE EQUIV QUALIFS OR HAVE DOCT/MAST DEGREE IN CHEM AND 4 YRS EXP IN CLINICAL CHEMISTRY COBOL NAME: NUM-TECH-SUP-CHEMISTRY TECH SUPER - CYTOGENETICS 3 1224 1226 N PROV1315 # OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(K) TO PERFORM IN CLINICAL CYTOGENETICS WHO ARE DIRECTORS WITH A DOCTORAL DEGREE IN BIOLOGY OR PHYSICIANS AND HAVE 4 YEARS EXPERIENCE IN GENETICS COBOL NAME: NUM-TECH-SUP-CYTOGEN TECH SUPER - CYTOLOGY 3 1227 1229 N PROV1320 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(F) TO PERFORM CYTOLOGY TESTS UNDER THE SUPERVISION OF A BOARD CERTIFIED PHYSICIAN OR WHO POSSESS EQUIVALENT QUALIFICATIONS COBOL NAME: NUM-TECH-SUP-CYTOLOGY TECH SUPER - DIAGNOSTIC IMMUN 3 1230 1232 N PROV1345 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(C) TO PERFORM TESTS IN DIAGNOSTIC IMMUN- OLOGY UNDER THE SUP OF A BOARD CERT MD OR HAVE EQUIV QUALIFS OR HAVE DOCT/MAST DEGREE IN RELATED SCIENCES COBOL NAME: NUM-TECH-SUP-IMMUNOL TECH SUPER - HEMATOLOGY 3 1233 1235 N PROV1330 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(E) TO PERFORM HEMATOLOGY TESTS UNDER SUPERVISION OF A BOARD CERT MD OR WHO POSSESS BS OR MS DEGREES IN RELATED SCIENCES AND 4 YRS HEMATOLOGY EXPER. COBOL NAME: NUM-TECH-SUP-HEMATOLOGY * TECH SUPER - HISTO PATHOLOGY 3 1236 1238 N PROV1325 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(G) TO PERFORM TESTS IN HISTOPATHOLOGY UNDER THE SUPERVISION OF A BOARD CERTIFIED MD OR WHO POSSESS EQUIVALENT QUALIFICATIONS COBOL NAME: NUM-TECH-SUP-DERMATOLGY TECH SUPER - HISTOCOMPATIBILITY 3 1239 1241 N PROV1335 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(J)TO PERFORM TESTS IN HISTO UNDER SUP OF MD OR WHO POSSESS DOCT DEGREES OR ARE MD'S WITH 4 YRS EXP IN IMMUNOLOGY INCLUDING 2 YRS OF HISTO TESTING COBOL NAME: NUM-TECH-SUP-HISTOCOM TECH SUPER - IMMUNOHEMATOLOGY 3 1242 1244 N PROV1340 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(L) TO PERFORM TESTS IN IMMUNOHEMATOLOGY UNDER SUP OF A BOARD CERT MD OR HAVE EQUIV QUALIFS OR ARE PHYSICIANS WITH 2 YRS EXP IN IMMUNOHEMATOLOGY COBOL NAME: NUM-TECH-SUP-IMMUNOHEM * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 13 CLINICAL LABORATORY IMPROVEMENT ACT LABS, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TECH SUPER - MICROBIOLOGY 3 1245 1247 N PROV1350 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(B) TO PERFORM MICRO TESTS UNDER SUPERV OF A BOARD CERT MD, OR WHO HOLD DOCTORAL OR MASTER DEGREES IN MICRO AND HAVE 4 YRS EXP IN CLINICAL MICROBIOLOGY COBOL NAME: NUM-TECH-SUP-MICROBIO TECH SUPER - ORAL PATHOLOGY 3 1248 1250 N PROV1355 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(H) TO PERFORM TESTS IN ORAL PATHOLOGY UNDER SUPERVISION OF A BOARD CERT MD OR WHO HAVE EQUIVALENT QUALIFICATIONS COBOL NAME: NUM-TECH-SUP-ORAL-PATH TECH SUPER - PATHOLOGIST 3 1251 1253 N PROV1360 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(A) TO PERFORM ALL BUT HISTOCOMPATIBILITY AND CLINICAL CYTOGENETICS WHO ARE MD'S CERT IN BOTH ANATOMICAL AND CLINICAL PATH OR HAVE EQUIV QUALIFICATNS COBOL NAME: NUM-TECH-SUP-PATHOLOGY TECH SUPER - PHS EXAM 3 1254 1256 N PROV1365 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(M) WITH SATISFACTORY GRADES IN EXAMINATIONS CONDUCTED BY THE PUBLIC HEALTH SERVICE. COBOL NAME: NUM-TECH-SUP-PHS-EXAM TECH SUPER - RADIOBIOASSAY 3 1257 1259 N PROV1370 THE NUMBER OF TECHNICAL SUPERVISORS QUALIFIED UNDER CFR 493.1421(I) WHO ARE BOARD CERT MD'S OR WHO HAVE A DOCTORATE/MASTERS/BACH DEGREE IN RELATED SCIENCES OR ARE PHYSICIANS WITH 4 YEARS EXP IN RADIOBIOASSAY COBOL NAME: NUM-TECH-SUP-RADIOBIO TECHNICIAN TRAINEES 3 1260 1262 N PROV1375 THE NUMBER OF TECHNICIAN TRAINEES IN LABORATORIES WHO ARE HIGH SCHOOL GRADUATES AND WHO ARE RECEIVING THE REQUIRED 2 YEARS LAB EXPERIENCE AND ARE PARTICIPATING IN A STRUCTURED TRAINING PROGRAM.(CFR 493.1402) COBOL NAME: NUM-TECH-TRAINEES TECHNICIANS - GRANDFATHERED 3 1263 1265 N PROV1245 THE NUMBER OF TECHNICIANS QUALIFIED UNDER CFR 493.1441(B)(5) WHO WAS PERFORMING THE DUTIES OF A LAB TECHNICIAN BETWEEN 7/1/61 & 1/1/68 AND HAS AT LEAST 5 YEARS EXPERIENCE PRIOR TO 1/1/68. COBOL NAME: NUM-TECH-GRFATHER TECHNICIANS - MILITARY 3 1266 1268 N PROV1260 THE NUMBER OF TECHNICIANS QUALIFIED UNDER CFR 493.1441(B)(4) WHO COMPLETED AN OFFICIAL MILITARY MEDICAL LABORATORY PROCEDURES COURSE OF AT LEAST 50 WEEKS DURATION. COBOL NAME: NUM-TECH-MILITARY * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 14 CLINICAL LABORATORY IMPROVEMENT ACT LABS, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TECHNICIANS - PROFICIENCY EXAM 3 1269 1271 N PROV1265 THE NUMBER OF TECHNICIANS QUALIFIED UNDER CFR 493.1441(B)(6) WHO ACHIEVED A SATISFACTORY GRADE IN AN APPROVED PROFICIENCY EXAMINATION PRIOR TO 12/31/77. COBOL NAME: NUM-TECH-PES-EXAM TECHNICIANS-AA PLUS 60 CREDIT HRS 3 1272 1274 N PROV1380 THE NUMBER OF LABORATORY TECHNICIANS WHO HAVE COMPLETED EITHER 60 HOURS OF ACADEMIC CREDIT OR HAVE ASSOCIATE DEGREES IN A COURSE OF STUDY THAT INCLUDES MEDICAL LABORATORY TECHNIQUES (CFR 493.1441(B)(1). COBOL NAME: NUM-TECH-60-CREDITS TECHNICIANS-HIGH SCH + EXPERIENCE 3 1275 1277 N PROV1255 THE NUMBER OF TECHNICIANS QUALIFIED UNDER CFR 493.1441(B)(3) WHO ARE HIGH SCHOOL GRADUATES AND HAVE TWO YEARS OF PERTINENT LABORATORY EXPERIENCE. COBOL NAME: NUM-TECH-HS-AND-2YR TECHNICIANS-HIGH SCH + TRAINING 3 1278 1280 N PROV1250 THE NUMBER OF TECHNICIANS QUALIFIED UNDER CFR 493.1441(B)(2) WHO COMPLETED HIGH SCHOOL AND ONE YEAR IN A TECHNICIAN TRAINING PROGRAM. COBOL NAME: NUM-TECH-HS-AND-1YR TECHNOLOGIST - BACHELORS DEGREE 3 1281 1283 N PROV1385 THE NUMBER OF LAB TECHNOLOGISTS WHO HAVE EARNED BACHELOR'S DEGREES IN CHEMICAL, BIOLOGICAL, OR PHYSICAL SCIENCE AND HAVE ONE YEAR EXPERIENCE/TRAINING IN RELATED SPECIALTY (CFR 493.1433(B)(3)). COBOL NAME: NUM-TECHNOLO-BS-BA TECHNOLOGIST - BS MED TECH 3 1284 1286 N PROV1390 THE NUMBER OF TECHNOLOGISTS WHO HAVE EARNED BACHELOR'S DEGREES IN MEDICAL TECHNOLOGY (CFR 493.1433(B)(1)). COBOL NAME: NUM-TECHNOLO-BS-MT TECHNOLOGIST - GRANDFATHERED 3 1287 1289 N PROV1395 THE NUMBER OF TECHNOLOGISTS WHO QUALIFIED PRIOR TO JULY 1, 1971 & WHO WERE PERFORMING AS TECHNOLOGISTS BETWEEN 7/1/61 & 1/1/68 & HAVE AT LEAST TEN YEARS LAB EXPERIENCE PRIOR TO 1/1/68 (CFR 493.1433(B)(5)). COBOL NAME: NUM-TECHNOLO-GRFATHER TECHNOLOGIST - PROFICIENCY EXAM 3 1290 1292 N PROV1400 THE NUMBER OF TECHNOLOGISTS WHO HAVE ACHIEVED A SATISFACTORY GRADE IN A PROFICIENCY EXAM APPROVED BY THE SECRETARY (CFR 493.1433(B)(6)). COBOL NAME: NUM-TECHNOLO-PES-EXAM TECHNOLOGIST - 90 HRS + EXP 3 1293 1295 N PROV1410 THE NUMBER OF TECHNOLOGISTS WHO HAVE COMPLETED THREE YEARS (90 SEMESTER HOURS) OF PERTINENT ACADEMIC STUDIES OUTLINED IN CFR 493.1433(B)(4) AND HAVE ONE YEAR OF LAB EXPERIENCE COBOL NAME: NUM-TECHNOLO-90CR-1YR * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 15 CLINICAL LABORATORY IMPROVEMENT ACT LABS, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME TECHNOLOGIST - 90 HRS + TRAINING 3 1296 1298 N PROV1405 THE NUMBER OF TECHNOLOGISTS WHO HAVE COMPLETED THREE YEARS (90 SEMESTER HOURS) OF ACADEMIC STUDY AND COM- PLETED AT LEAST ONE YEAR TRAINING IN A SCHOOL OF MEDICAL TECHNOLOGY (CFR 493.1433(B)(2). COBOL NAME: NUM-TECHNOLO-3YR-1YR 010 HISTOCOMPATIBILITY 1 1299 1299 C PROV1865 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-010-HISTOCOMPAT VALUES: N NOT APPROVED Y APPROVED 010A TRANSPLANT 1 1300 1300 C PROV1870 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN THIS SUBSPECIALTY COBOL NAME: SC-010A-TRANSPLANT VALUES: N NOT APPROVED Y APPROVED 010B NON-TRANSPLANT 1 1301 1301 C PROV1875 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN THIS SUBSPECIALTY COBOL NAME: SC-010B-NON-TRANSPLANT VALUES: N NOT APPROVED Y APPROVED 100 MICROBIOLOGY 1 1302 1302 C PROV1880 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-100-MICROBIO VALUES: N NOT APPROVED Y APPROVED 110 BACTERIOLOGY 1 1303 1303 C PROV1885 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-110-BACTERIOLOGY VALUES: N NOT APPROVED Y APPROVED 110C MYCOBACTERIOLOGY 1 1304 1304 C PROV1890 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN MYCOBACTERIOLOGY, WHICH IS WITHIN THE BACTERIOLOGY SUBSPECIALTY COBOL NAME: SC-110C-MYCOBACT VALUES: N NOT APPROVED Y APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 16 CLINICAL LABORATORY IMPROVEMENT ACT LABS, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 120 MYCOLOGY 1 1305 1305 C PROV1895 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-120-MYCOLOGY VALUES: N NOT APPROVED Y APPROVED 130 PARASITOLOGY 1 1306 1306 C PROV1900 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-130-PARASITOLOGY VALUES: N NOT APPROVED Y APPROVED 140 VIROLOGY 1 1307 1307 C PROV1910 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-140-VIROLOGY VALUES: N NOT APPROVED Y APPROVED 150 OTHER MICROBIOLOGY 1 1308 1308 C PROV1915 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-150-OTHER-MICROBIO VALUES: N NOT APPROVED Y APPROVED 200 DIAGNOSTIC IMMUNOLOGY 1 1309 1309 C PROV1920 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-200-DIAG-IMMUNOL VALUES: N NOT APPROVED Y APPROVED 210 SYPHILIS 1 1310 1310 C PROV1925 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-210-SYPHILIS VALUES: N NOT APPROVED Y APPROVED * 220 GEN IMMUNOLOGY 1 1311 1311 C PROV1930 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-220-GEN-IMMUNOL VALUES: N NOT APPROVED Y APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 17 CLINICAL LABORATORY IMPROVEMENT ACT LABS, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 300 CHEMISTRY 1 1312 1312 C PROV1935 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-300-CHEMISTRY VALUES: N NOT APPROVED Y APPROVED 310 ROUTINE CHEMISTRY 1 1313 1313 C PROV1940 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-310-ROUTINE VALUES: N NOT APPROVED Y APPROVED 320 URINALYSIS 1 1314 1314 C PROV1945 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-320-URINALYSIS VALUES: N NOT APPROVED Y APPROVED 330 OTHER CHEMISTRY 1 1315 1315 C PROV1950 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-330-OTHER-CHEMISTRY VALUES: N NOT APPROVED Y APPROVED 330D ENDOCRINOLOGY 1 1316 1316 C PROV1955 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN ENDOCRINOLOGY, WHICH IS WITHIN THE OTHER CHEMISTRY SUBSPECIALTY COBOL NAME: SC-330D-ENDOCRINOLOGY VALUES: N NOT APPROVED Y APPROVED 330E TOXICOLOGY 1 1317 1317 C PROV1960 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN TOXICOLOGY, WHICH IS WITHIN THE OTHER CHEMISTRY SUBSPECIALTY COBOL NAME: SC-330E-TOXICOLOGY VALUES: N NOT APPROVED Y APPROVED 400 HEMATOLOGY 1 1318 1318 C PROV1965 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-400-HEMATOLOGY VALUES: * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 18 CLINICAL LABORATORY IMPROVEMENT ACT LABS, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME N NOT APPROVED Y APPROVED 500 IMMUNOHEMATOLOGY 1 1319 1319 C PROV1970 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-500-IMMUNOHEM VALUES: N NOT APPROVED Y APPROVED 510 ABO + RH GROUP 1 1320 1320 C PROV1975 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-510-ABO-RH-GROUP VALUES: N NOT APPROVED Y APPROVED 520 RH TITERS 1 1321 1321 C PROV1980 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-520-RH-TITERS VALUES: N NOT APPROVED Y APPROVED 530 COMPATIBILITY TEST 1 1322 1322 C PROV1985 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-530-CROSS-MATCH VALUES: N NOT APPROVED Y APPROVED 540 ANTIBODY DETECT + OTHER 1 1323 1323 C PROV1990 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-540-OTHER-IMMUNOHEM VALUES: N NOT APPROVED Y APPROVED 600 PATHOLOGY 1 1324 1324 C PROV1995 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-600-PATHOLOGY VALUES: N NOT APPROVED Y APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91 1DATE: 01/06/92 POS RECORD LAYOUT PAGE: 19 CLINICAL LABORATORY IMPROVEMENT ACT LABS, CATEGORY = "18" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS NAME 610 HISTOPATHOLOGY 1 1325 1325 C PROV2000 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-610-HISTOPATH VALUES: N NOT APPROVED Y APPROVED 620 ORAL PATHOLOGY 1 1326 1326 C PROV2005 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-620-ORAL VALUES: N NOT APPROVED Y APPROVED 630 CYTOLOGY 1 1327 1327 C PROV2010 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-630-CYTOLOGY VALUES: N NOT APPROVED Y APPROVED 800 RADIOBIOASSAY 1 1328 1328 C PROV2015 INDICATES IF A LAB IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY. COBOL NAME: SC-800-RADIOBIO VALUES: N NOT APPROVED Y APPROVED 900 CYTOGENETICS 1 1329 1329 C PROV2020 INDICATES IF A LABORATORY IS APPROVED TO PERFORM TESTS IN THIS SPECIALTY COBOL NAME: SC-900-CYTOGENETICS VALUES: N NOT APPROVED Y APPROVED * INDICATES THIS FIELD HAS BEEN ADDED OR CHANGED SINCE: 10/08/91