********************************************* * * * A T T E N T I O N * * * * THESE POS RECORD SPECIFICATIONS WERE * * PRODUCED FROM OUR DICTIONARY AT THE * * SAME TIME AS THE POS DATA FILE THAT * * YOU REQUESTED. YOU MAY WISH TO CHECK * * THESE SPECIFICATIONS TO SEE IF ANY * * CHANGES HAVE OCCURED SINCE YOUR RECEIPT * * OF ANY PRIOR DOCUMENTATION. * * * * FILE CREATION DATE = 01/03/2015 * * * ********************************************* DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 1 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Provider Category Subtype Code 2 1 2 VARCHAR2 Description: Identifies the subtype of the provider, within the primary category. Used in reporting to show the breakdown of provider categories, mainly for hospitals and SNFs. SAS Name: PRVDR_CTGRY_SBTYP_CD COBOL Name: PRVDR-CTGRY-SBTYP-CD VALUES: 01=Short Term 02=Long Term 03=Religious Non-Medical Health Care Institutions 04=Psychiatric 05=Rehabilitation 06=Childrens Hospitals 07=Distinct Part Psychiatric Hospital 11=Critical Access Hospitals 20=Transplant Hospitals 22=Medicaid Only Short-Term Hospitals 23=Medicaid Only Childrens Hospitals 24=Medicaid Only Children's Psychiatric 25=Medicaid Only Psychiatric Hospitals 26=Medicaid Only Rehabilitation Hospitals 27=Medicaid Only Long-Term Hospitals Provider Category Code 2 3 4 VARCHAR2 Description: Identifies the type of provider participating in the Medicare/Medicaid program. SAS Name: PRVDR_CTGRY_CD COBOL Name: PRVDR-CTGRY-CD VALUES: 01=Hospital CHOW Count 2 5 6 NUMBER Description: Number of times this provider has undergone a change of ownership. SAS Name: CHOW_CNT COBOL Name: CHOW-CNT CHOW Date 8 7 14 DATE Description: Effective date of the most recent change of ownership for this provider. SAS Name: CHOW_DT COBOL Name: CHOW-DT Address: City 28 15 42 VARCHAR2 Description: City in which the provider is physically located. SAS Name: CITY_NAME COBOL Name: CITY-NAME Compliance: Acceptable POC 1 43 43 VARCHAR2 Description: Indicates if a provider is in compliance with program DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 2 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE requirements based on an acceptable plan for correction of deficiencies. SAS Name: ACPTBL_POC_SW COBOL Name: ACPTBL-POC-SW Compliance: Status 1 44 44 VARCHAR2 Description: Compliance status of a provider at the time of certification survey. SAS Name: CMPLNC_STUS_CD COBOL Name: CMPLNC-STUS-CD VALUES: A=IN COMPLIANCE B=NOT IN COMPLIANCE SSA County Code 3 45 47 VARCHAR2 Description: Social Security Administration geographic code indicating the county where the provider is located. SAS Name: SSA_CNTY_CD COBOL Name: SSA-CNTY-CD Cross Ref Provider Number 10 48 57 CHAR Description: Cross reference provider number SAS Name: CROSS_REF_PROVIDER_NUMBER COBOL Name: CROSS-REF-PROVIDER-NUMBER Certification Date 8 58 65 DATE Description: Equal to the exit date of the initial visit of the Health survey for certifications completed after July 28, 2012. For certifications prior to that date, the certification date is equal to the exit date of the initial visit of the Health survey or LSC survey, whichever is later. SAS Name: CRTFCTN_DT COBOL Name: CRTFCTN-DT Eligibility Indicator 1 66 66 VARCHAR2 Description: Indicates if a facility is eligible to participate in the Medicare and/or Medicaid programs. SAS Name: ELGBLTY_SW COBOL Name: ELGBLTY-SW Facility Name 50 67 116 VARCHAR2 Description: Name of the provider certified to participate in the Medicare and/or Medicaid programs. SAS Name: FAC_NAME COBOL Name: FAC-NAME Medicare Administrative Contractor (MAC) or 5 117 121 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_CD COBOL Name: INTRMDRY-CARR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 3 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 4 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 5 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 6 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 50333=TRAVELERS (NEW YORK) 51051=AETNA (PETALUMA) 51070=AETNA (FARMINGTON) 51100=AETNA (CLEARWATER) 51140=AETNA (PEORIA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 7 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 51390=AETNA (FORT WASHINGTON) 52280=MUTUAL OF OMAHA 57400=COOPERATIVA (PUERTO RICO) Medicaid Vendor Number 15 122 136 VARCHAR2 Description: Number which may be assigned to a provider by the state Medicaid agency for external control or billing purposes. SAS Name: MDCD_VNDR_NUM COBOL Name: MDCD-VNDR-NUM Original Participation Date 8 137 144 DATE Description: Date a provider is first approved to provide Medicare and/or Medicaid services. SAS Name: ORGNL_PRTCPTN_DT COBOL Name: ORGNL-PRTCPTN-DT Prior CHOW Date 8 145 152 DATE Description: Effective date of the previous change of ownership for this provider. SAS Name: CHOW_PRIOR_DT COBOL Name: CHOW-PRIOR-DT Prior Medicare Administrative Contractor (MAC) or 5 153 157 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the previous Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_PRIOR_CD COBOL Name: INTRMDRY-CARR-PRIOR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 8 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 9 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 10 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 11 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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) CCN 10 158 167 VARCHAR2 Description: Six or ten position identification number that is assigned to a certified provider. This is the CMS Certification Number. SAS Name: PRVDR_NUM COBOL Name: PRVDR-NUM Region Code 2 168 169 VARCHAR2 Description: Indicates the CMS Regional Office responsible for the certification of the provider. SAS Name: RGN_CD COBOL Name: RGN-CD VALUES: 01=Boston 02=New York 03=Philadelphia 04=Atlanta 05=Chicago 06=Dallas 07=Kansas City DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 12 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 08=Denver 09=San Francisco 10=Seattle Skeleton Record Indicator 1 170 170 VARCHAR2 Description: Indicates if the record is a skeleton record. Only a limited set of data is available for this provider; no survey data exists. SAS Name: SKLTN_REC_SW COBOL Name: SKLTN-REC-SW State Abbreviation 2 171 172 VARCHAR2 Description: Two-character state abbreviation. SAS Name: STATE_CD COBOL Name: STATE-CD VALUES: AK=ALASKA AL=ALABAMA AR=ARKANSAS AS=AMERICAN SAMOA AZ=ARIZONA CA=CALIFORNIA CN=CANADA CO=COLORADO CT=CONNECTICUT DC=DISTRICT OF COLUMBIA DE=DELAWARE FL=FLORIDA FN=INTERNATIONAL GA=GEORGIA GU=GUAM HI=HAWAII IA=IOWA ID=IDAHO IL=ILLINOIS IN=INDIANA KS=KANSAS KY=KENTUCKY LA=LOUISIANA MA=MASSACHUSETTS MD=MARYLAND ME=MAINE MI=MICHIGAN MN=MINNESOTA MO=MISSOURI MP=SAIPAN MS=MISSISSIPPI MT=MONTANA MX=MEXICO NC=NORTH CAROLINA ND=NORTH DAKOTA NE=NEBRASKA NH=NEW HAMPSHIRE NJ=NEW JERSEY NM=NEW MEXICO NV=NEVADA NY=NEW YORK OH=OHIO OK=OKLAHOMA OR=OREGON PA=PENNSYLVANIA PR=PUERTO RICO RI=RHODE ISLAND SC=SOUTH CAROLINA SD=SOUTH DAKOTA DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 13 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE TN=TENNESSEE TX=TEXAS UT=UTAH VA=VIRGINIA VI=VIRGIN ISLANDS VT=VERMONT WA=WASHINGTON WI=WISCONSIN WV=WEST VIRGINIA WY=WYOMING SSA State Code 2 173 174 VARCHAR2 Description: Social Security Administration geographic code indicating the state where the provider is located. SAS Name: SSA_STATE_CD COBOL Name: SSA-STATE-CD 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 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 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 14 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 49=VIRGINIA 50=WASHINGTON 51=WEST VIRGINIA 52=WISCONSIN 53=WYOMING 54=AFRICA 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 99=INTERNATIONAL State Region Code 3 175 177 VARCHAR2 Description: Identifies the region within a state where the provider is located. SAS Name: STATE_RGN_CD COBOL Name: STATE-RGN-CD VALUES: AK/001=ALASKA AK/LAB=LABORATORIES AL/001=ALABAMA AL/LAB=LABORATORIES AR/001=ARKANSAS AR/LAB=LABORATORIES AS/001=AMERICAN SAMOA AS/LAB=LABORATORY AZ/AZ=PHOENIX AZ/LAB=ARIZONA LAB AZ/TUC=TUCSON CA/BAK=BAKERSFIELD CA/BER=SAN BERNARDINO CA/BK=BERKELEY CA/BK1=CONTRA COSTA CA/FR=FRESNO CA/L1=L.A. WEST CA/L2=L.A. NORTH CA/L3=L.A. CENTRAL CA/L4=L.A. EAST CA/L5=SAN GABRIEL CA/LAB=LABORATORIES CA/M1=LAB. SOUTH CA/M2=LAB. NORTH CA/ORG=ORANGE CO CA/RIV=RIVERSIDE CA/RWC=REDWOOD COAST CA/S1=SACRAMENTO CA/S2=SACTO SOUTH CA/S3=CHICO CA/SD=SAN DIEGO CA/SDS=SAN DIEGO SOUTH CA/SF=SAN FRANCISCO CA/SJ=SAN JOSE CA/SR=SANTA ROSA CA/VEN=VENTURA CN/001=CANADA CN/LAB=LABORATORY CO/001=COLORADO CO/LAB=LABORATORIES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 15 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE CT/001=CONNECTICUT CT/LAB=LABORATORIES DC/001=DISTRICT OF COLUMBIA DC/LAB=LABORATORIES DE/001=DELAWARE DE/LAB=LABORATORIES FL/FTM=FT. MYERS FL/GAI=GAINESVILLE FL/JAX=JACKSONVILLE FL/LAB=LABORATORIES FL/LAN=LANTANA FL/LAU=LAUDERHILL FL/MIA=MIAMI FL/ORL=ORLANDO FL/PEN=PENSACOLA FL/STP=ST. PETERSBURG FL/TAL=TALLAHASSEE FL/TAM=TAMPA FM/001=FEDERATED STATES OF MICRO FN/001=INTERNATIONAL FN/LAB=LABORATORIES GA/001=GEORGIA GA/GAA=GEORGIA ALL GA/GAC=GEORGIA CENTRAL GA/GAE=GEORGIA EASTERN GA/GAN=GEORGIA NORTH GA/GAS=GEORGIA SOUTH GA/GAW=GEORGIA WESTERN GA/LAB=LABORATORIES GU/001=GUAM GU/LAB=LABORATORIES HI/001=HAWAII HI/LAB=LABORATORIES IA/001=IOWA IA/LAB=LABORATORIES ID/001=IDAHO ID/LAB=LABORATORIES IL/001=ILLINOIS IL/LAB=LABORATORIES IN/001=INDIANA IN/LAB=LABORATORIES KS/KCK=KANSAS CITY KS/KDH=KDHE KS/LAB=LABORATORIES KS/LAW=LAWRENCE KS/NC=NORTH CENTRAL KANSAS KS/NE=NORTH EAST KANSAS KS/NW=NORTH WEST KANSAS KS/SC=SOUTH CENTRAL KANSAS KS/SE=SOUTH EAST KANSAS KS/SW=SOUTH WEST KANSAS KS/WST=WEST KY/2C1=HOPKINSVILLE KY/2C2=LOUISVILLE KY/2C3=LONDON KY/2C4=LEXINGTON KY/LAB=LABORATORIES LA/001=LOUISIANA LA/LA1=NEW ORLEANS LA/LA2=MANDEVILLE LA/LA3=LAFAYETTE LA/LA4=MONROE LA/LA5=SHREVEPORT LA/LA6=ALEXANDRIA DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 16 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE LA/LAB=LABORATORIES LA/LB1=CLIA NEW ORLEANS LA/LB5=CLIA SHREVEPORT LA/LB6=CLIA ALEXANDRIA MA/001=MASSACHUSETTS MA/LAB=LABORATORIES MD/001=MARYLAND MD/LAB=LABORATORIES ME/001=MAINE ME/LAB=LABORATORIES MH/001=MARSHALL ISLANDS MI/001=MICHIGAN MI/LAB=LABORATORIES MN/001=MINNESOTA MN/LAB=LABORATORIES MO/01=REGION01 MO/02=REGION02 MO/03=REGION 03 MO/04=REGION 04 MO/05=REGION 05 MO/06=REGION 06 MO/07=REGION 07 MO/1NH=REGION 1 NH MO/2NH=REGION 2 NH MO/3NH=REGION 3 NH MO/4NH=REGION 4 NH MO/5NH=REGION 5 NH MO/6NH=REGION 6 NH MO/7NH=REGION 7 NH MO/LAB=LABORATORIES MO/MO=STATEWIDE MP/001=NORTHERN MARIANA ISLANDS MP/LAB=LABORATORIES MS/001=MISSISSIPPI MS/LAB=LABORATORIES MT/001=MONTANA MT/LAB=LABORATORIES MX/001=MEXICO MX/LAB=LABORATORY NC/LAB=LABORATORIES NC/NCC=NORTH CAROLINA CENTRAL NC/NCE=NORTH CAROLINA EAST NC/NCN=NORTH CAROLINA NORTH NC/NCS=NORTH CAROLINA SOUTH NC/NCW=NORTH CAROLINA WEST ND/001=NORTH DAKOTA ND/LAB=LABORATORIES NE/1=NORTH CENTRAL NE/2=CENTRAL NE/3=NORTHEAST NE/4=SOUTHEAST NE/5=WESTERN NE/LAB=LABORATORIES NH/001=NEW HAMPSHIRE NH/LAB=LABORATORIES NJ/001=NEW JERSEY NJ/LAB=LABORATORIES NM/001=NEW MEXICO NM/LAB=LABORATORIES NV/CC=CARSON CITY NV/LAB=LABORATORIES NV/LV=LAS VEGAS NY/001=BUFFALO NY/002=ROCHESTER DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 17 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE NY/003=SYRACUSE NY/004=ALBANY NY/005=NEW ROCHELLE NY/006=NEW YORK CITY NY/007=SUFFOLK/NASSAU COUNTY NY/LAB=LABORATORIES OH/001=OHIO OH/LAB=LABORATORIES OK/001=OKLAHOMA OK/LAB=LABORATORIES OR/001=OFFICE #1 OR/002=OFFICE #2 OR/003=OFFICE #3 OR/LAB=LABORATORIES PA/001=PENNSYLVANIA PA/LAB=LABORATORIES PR/001=PUERTO RICO PR/LAB=LABORATORIES PW/001=PALAU RI/001=RHODE ISLAND RI/LAB=LABORATORIES SC/001=SOUTH CAROLINA SC/LAB=LABORATORIES SD/001=SOUTH DAKOTA SD/LAB=LABORATORIES TN/LAB=LABORATORIES TN/TNC=TENNESSEE COOKEVILLE TN/TNE=TENNESSEE EASTERN TN/TNM=TENNESSEE MIDDLE TN/TNW=TENNESSEE WESTERN TX/001=TEXAS TX/L01=AMARILLO-LTC TX/L02=ABILENE-LTC TX/L03=ARLINGTON-LTC TX/L04=TYLER-LTC TX/L05=BEAUMONT-LTC TX/L06=HOUSTON-LTC TX/L07=TEMPLE-LTC TX/L08=SAN ANTONIO-LTC TX/L09=SAN ANGELO-LTC TX/L10=EL PASO-LTC TX/L11=CORPUS CHRISTI-LTC TX/LAB=LABORATORIES TX/TX1=LUBBOCK TX/TX2=ARLINGTON TX/TX3=SAN ANTONIO TX/TX4=HOUSTON TX/TX5=TYLER TX/TX6=AUSTIN UT/001=UTAH UT/LAB=LABORATORIES VA/001=VIRGINIA VA/LAB=LABORATORIES VI/001=VIRGIN ISLANDS VI/LAB=LABORATORIES VT/001=VERMONT VT/LAB=LABORATORIES WA/001=ALL OTHERS (NON-LTC FAC) WA/D1=SPOKANE & YAKIMA AREAS WA/D1A=District 1, Unit A WA/D1B=District 1, Unit B WA/D1C=District 1, Unit C WA/D1D=District 1, Unit D WA/D2=SPOKANE & SE DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 18 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE WA/D2A=District 2, Unit A WA/D2B=District 2, Unit B WA/D2C=District 2, Unit C WA/D2D=District 2, Unit D WA/D2E=District 2, Unit E WA/D2F=District 2, Unit F WA/D2G=District 2, Unit G WA/D3=NW WASHINGTON WA/D3A=District 3, Unit A WA/D3B=District 3, Unit B WA/D3C=District 3, Unit C WA/D3D=District 3, Unit D WA/D3E=District 3, Unit E WA/D4A=GREATER SEATTLE AREA WA/D4B=S KING COUNTY WA/D5A=PIERCE CTY & PENINSULA WA/D5B=PIERCE CTY & GRAYS HARBOR WA/D6=OLYMPIA AREA WA/LAB=LABORATORIES WI/001=WISCONSIN WI/LAB=LABORATORIES WV/001=WEST VIRGINIA WV/LAB=LABORATORIES WY/001=WYOMING WY/LAB=LABORATORIES Address: Street 50 178 227 VARCHAR2 Description: Street address where the provider is located. SAS Name: ST_ADR COBOL Name: ST-ADR Telephone Number 10 228 237 VARCHAR2 Description: Telephone number of the provider. SAS Name: PHNE_NUM COBOL Name: PHNE-NUM Termination Code 2 238 239 VARCHAR2 Description: Indicates the current termination status for the provider. SAS Name: PGM_TRMNTN_CD COBOL Name: PGM-TRMNTN-CD VALUES: 00=ACTIVE PROVIDER 01=VOLUNTARY-MERGER, CLOSURE 02=VOLUNTARY-DISSATISFACTION WITH REIMBURSEMENT 03=VOLUNTARY-RISK OF INVOLUNTARY TERMINATION 04=VOLUNTARY-OTHER REASON FOR WITHDRAWAL 05=INVOLUNTARY-FAILURE TO MEET HEALTH/SAFETY REQ 06=INVOLUNTARY-FAILURE TO MEET AGREEMENT 07=OTHER-PROVIDER STATUS CHANGE 08=NONPAYMENT OF FEES - CLIA Only 09=REV/UNSUCCESSFUL PARTICIPATION IN PT - CLIA Only 10=REV/OTHER REASON - CLIA Only 11=INCOMPLETE CLIA APPLICATION INFORMATION - CLIA Only 12=NO LONGER PERFORMING TESTS - CLIA Only 13=MULTIPLE TO SINGLE SITE CERTIFICATE - CLIA Only 14=SHARED LABORATORY - CLIA Only 15=FAILURE TO RENEW WAIVER PPM CERTIFICATE - CLIA Only 16=DUPLICATE CLIA NUMBER - CLIA Only 17=MAIL RETURNED NO FORWARD ADDRESS CERT ENDED - CLIA Only 20=NOTIFICATION BANKRUPTCY - CLIA Only 33=ACCREDITATION NOT CONFIRMED - CLIA Only 80=AWAITING STATE APPROVAL 99=OIG ACTION - DO NOT ACTIVATE - CLIA Only DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 19 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Termination or Expiration Date 8 240 247 DATE Description: Date the provider was terminated. For CLIA providers, date the laboratory's certificate was terminated or the expiration date of the current CLIA certificate. SAS Name: TRMNTN_EXPRTN_DT COBOL Name: TRMNTN-EXPRTN-DT Type of Action Code 1 248 248 VARCHAR2 Description: Identifies the reason for the certification. Type of action from the official survey record, CMS 1539 form. SAS Name: CRTFCTN_ACTN_TYPE_CD COBOL Name: CRTFCTN-ACTN-TYPE-CD VALUES: 1=INITIAL 2=RECERTIFICATION 3=TERMINATION 4=CHANGE OF OWNERSHIP 5=VALIDATION 8=FULL SURVEY AFTER COMPLAINT Ownership Type Code 2 249 250 VARCHAR2 Description: Indicates the ownership type of the provider. SAS Name: GNRL_CNTL_TYPE_CD COBOL Name: GNRL-CNTL-TYPE-CD VALUES: 01=CHURCH 02=PRIVATE (NOT FOR PROFIT) 03=OTHER (SPECIFY) 04=PRIVATE (FOR PROFIT) 05=FEDERAL 06=STATE 07=LOCAL 08=HOSPITAL DISTRICT OR AUTHORITY 09=PHYSICIAN OWNERSHIP 10=TRIBAL Address: ZIP Code 5 251 255 VARCHAR2 Description: Five-digit ZIP code for a provider's physical address. SAS Name: ZIP_CD COBOL Name: ZIP-CD FIPS State Code 2 256 257 VARCHAR2 Description: FIPS State Code SAS Name: FIPS_STATE_CD COBOL Name: FIPS-STATE-CD VALUES: 01=ALABAMA 02=ALASKA 04=ARIZONA 05=ARKANSAS 06=CALIFORNIA 08=COLORADO 09=CONNECTICUT 10=DELAWARE 11=DISTRICT OF COLUMBIA 12=FLORIDA 13=GEORGIA 15=HAWAII 16=IDAHO 17=ILLINOIS 18=INDIANA 19=IOWA 20=KANSAS 21=KENTUCKY 22=LOUISIANA 23=MAINE 24=MARYLAND DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 20 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 25=MASSACHUSETTS 26=MICHIGAN 27=MINNESOTA 28=MISSISSIPPI 29=MISSOURI 30=MONTANA 31=NEBRASKA 32=NEVADA 33=NEW HAMPSHIRE 34=NEW JERSEY 35=NEW MEXICO 36=NEW YORK 37=NORTH CAROLINA 38=NORTH DAKOTA 39=OHIO 40=OKLAHOMA 41=OREGON 42=PENNSYLVANIA 43=PUERTO RICO 44=RHODE ISLAND 45=SOUTH CAROLINA 46=SOUTH DAKOTA 47=TENNESSEE 48=TEXAS 49=UTAH 50=VERMONT 51=VIRGINIA 53=WASHINGTON 54=WEST VIRGINIA 55=WISCONSIN 56=WYOMING 64=AMERICAN SAMOA 65=GUAM 66=SAIPAN/MARIANA IS. 78=VIRGIN ISLANDS FIPS County Code 3 258 260 VARCHAR2 Description: FIPS County Code SAS Name: FIPS_CNTY_CD COBOL Name: FIPS-CNTY-CD CBSA Urban Rural Indicator 1 261 261 VARCHAR2 Description: CBSA (Core Based Statistical Area) indicates whether the county is defined as Urban or Rural. SAS Name: CBSA_URBN_RRL_IND COBOL Name: CBSA-URBN-RRL-IND CBSA Code 5 262 266 VARCHAR2 Description: CBSA (Core Based Statistical Area) geographic entities defined by the U.S. Office of Management and Budget (OMB) on June 6, 2003 for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics. CBSA collectively refers to MSA. SAS Name: CBSA_CD COBOL Name: CBSA-CD Accreditation Effective Date 8 267 274 DATE Description: Effective date of the period of accreditation associated with this certification. SAS Name: ACRDTN_EFCTV_DT COBOL Name: ACRDTN-EFCTV-DT Accreditation Expiration Date 8 275 282 DATE Description: Expiration date of the period of accreditation associated DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 21 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE with this certification. SAS Name: ACRDTN_EXPRTN_DT COBOL Name: ACRDTN-EXPRTN-DT Accreditation Type Code 1 283 283 VARCHAR2 Description: Indicates an accrediting organization deeming the provider. If a provider is deemed by multiple accrediting organizations then the accrediting organization with the earliest active deeming effective date is displayed in this field. SAS Name: ACRDTN_TYPE_CD COBOL Name: ACRDTN-TYPE-CD VALUES: 0=NOT ACCREDITED 1=JC 2=AOA/HFAP 3=DNV 9=CIHQ Affiliated Count: Ambulance Services 2 284 285 NUMBER Description: Number of affiliated Medicare participating ambulance services. SAS Name: TOT_AFLTD_AMBLNC_SRVC_CNT COBOL Name: TOT-AFLTD-AMBLNC-SRVC-CNT Affiliated Count: ASC 2 286 287 NUMBER Description: Number of affiliated Medicare participating ambulatory surgery centers. SAS Name: TOT_AFLTD_ASC_CNT COBOL Name: TOT-AFLTD-ASC-CNT Affiliated Count: Co-Located Hospital 2 288 289 NUMBER Description: Number of affiliated Medicare participating co-located hospitals. SAS Name: TOT_COLCTD_HOSP_CNT COBOL Name: TOT-COLCTD-HOSP-CNT Affiliated Count: ESRD 2 290 291 NUMBER Description: Number of affiliated Medicare participating end-stage renal disease units. SAS Name: TOT_AFLTD_ESRD_CNT COBOL Name: TOT-AFLTD-ESRD-CNT Affiliated Count: FQHC 2 292 293 NUMBER Description: Number of affiliated Medicare participating federally qualified health centers. SAS Name: TOT_AFLTD_FQHC_CNT COBOL Name: TOT-AFLTD-FQHC-CNT Affiliated Count: HHA 2 294 295 NUMBER Description: Number of affiliated Medicare participating home health agencies. SAS Name: TOT_AFLTD_HHA_CNT COBOL Name: TOT-AFLTD-HHA-CNT Affiliated Count: Hospice 2 296 297 NUMBER Description: Number of affiliated Medicare participating hospices. SAS Name: TOT_AFLTD_HOSPC_CNT COBOL Name: TOT-AFLTD-HOSPC-CNT Affiliated Count: OPO 2 298 299 NUMBER Description: Number of affiliated Medicare participating organ procurement organizations. SAS Name: TOT_AFLTD_OPO_CNT COBOL Name: TOT-AFLTD-OPO-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 22 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Affiliated Count: PRTF 2 300 301 NUMBER Description: Number of affiliated Medicare participating psychiatric residential treatment facilities. SAS Name: TOT_AFLTD_PRTF_CNT COBOL Name: TOT-AFLTD-PRTF-CNT Affiliated Count: RHC 2 302 303 NUMBER Description: Number of affiliated Medicare participating rural health centers. SAS Name: TOT_AFLTD_RHC_CNT COBOL Name: TOT-AFLTD-RHC-CNT Affiliated Count: SNF 2 304 305 NUMBER Description: Number of affiliated Medicare participating skilled nursing facilities. SAS Name: TOT_AFLTD_SNF_CNT COBOL Name: TOT-AFLTD-SNF-CNT Affiliated Count: Total 2 306 307 NUMBER Description: Number of affiliated providers. SAS Name: AFLTD_PRVDR_CNT COBOL Name: AFLTD-PRVDR-CNT Affiliated Resident Program: Allopathic 1 308 308 VARCHAR2 Description: Indicates if the provider has an affiliated allopathic resident program. SAS Name: RSDNT_PGM_ALPTHC_SW COBOL Name: RSDNT-PGM-ALPTHC-SW Affiliated Resident Program: Dental 1 309 309 VARCHAR2 Description: Indicates if the provider has an affiliated dental resident program. SAS Name: RSDNT_PGM_DNTL_SW COBOL Name: RSDNT-PGM-DNTL-SW Affiliated Resident Program: Osteopathic 1 310 310 VARCHAR2 Description: Indicates if the provider has an affiliated osteopathic resident program. SAS Name: RSDNT_PGM_OSTPTHC_SW COBOL Name: RSDNT-PGM-OSTPTHC-SW Affiliated Resident Program: Other 1 311 311 VARCHAR2 Description: Indicates if the provider has any other affiliated resident program. SAS Name: RSDNT_PGM_OTHR_SW COBOL Name: RSDNT-PGM-OTHR-SW Affiliated Resident Program: Podiatric 1 312 312 VARCHAR2 Description: Indicates if the provider has an affiliated podiatric resident program. SAS Name: RSDNT_PGM_PDTRC_SW COBOL Name: RSDNT-PGM-PDTRC-SW Services: Pharmacy Code 1 314 314 CHAR Description: Indicates how pharmaceutical services are provided. SAS Name: PHRMCY_SRVC_CD COBOL Name: PHRMCY-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Bed Count Override Indicator 1 325 325 CHAR DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 23 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Indicates if the regional office has approved a significant bed count change from the previous certification. SAS Name: OVRRD_BED_CNT_SW COBOL Name: OVRRD-BED-CNT-SW Bed Count: Certified 4 326 329 NUMBER Description: Number of beds in Medicare and/or Medicaid certified areas within a facility. SAS Name: CRTFD_BED_CNT COBOL Name: CRTFD-BED-CNT Bed Count: Total 4 373 376 NUMBER Description: Total number of beds in a provider, including those in non-participating or non-licensed areas. SAS Name: BED_CNT COBOL Name: BED-CNT CAH Psychiatric DPU Indicator 1 381 381 VARCHAR2 Description: Indicates if a Critical Access Hospital has a psychiatric Prospective Payment System-excluded distinct part unit. SAS Name: CAH_PSYCH_DPU_SW COBOL Name: CAH-PSYCH-DPU-SW CAH Rehabilitation DPU Indicator 1 382 382 VARCHAR2 Description: Indicates if a Critical Access Hospital rehabilitation unit has a Prospective Payment System-excluded distinct part unit. SAS Name: CAH_REHAB_DPU_SW COBOL Name: CAH-REHAB-DPU-SW CAH Swing Bed Indicator 1 383 383 VARCHAR2 Description: Indicates if a Critical Access Hospital has been approved to provide nursing home and/or hospital services. SAS Name: CAH_SB_SW COBOL Name: CAH-SB-SW Cardiac Catheterization Procedure Room Count 4 384 387 NUMBER Description: Number of cardiac catheterization procedure rooms. SAS Name: CRDC_CTHRTZTN_PRCDR_ROOMS_CNT COBOL Name: CRDC-CTHRTZTN-PRCDR-ROOMS-CNT Category-specific Facility Type Code 2 388 389 VARCHAR2 Description: Indicates the category-specific facility type code, for certain provider categories only. SAS Name: GNRL_FAC_TYPE_CD COBOL Name: GNRL-FAC-TYPE-CD VALUES: 01=Short - Term 02=Long - Term 03=Religious Non-Medical Health Care Institution 04=Psychiatric 05=Rehabilitation 06=Childrens 07=Distinct Part Psychiatric Hospital 11=Critical Access Hospitals CLIA ID Number 1 10 391 400 CHAR Description: CLIA ID number 1 SAS Name: CLIA_ID_NUMBER_1 COBOL Name: CLIA-ID-NUMBER-1 CLIA ID Number 2 10 401 410 CHAR Description: CLIA ID number 2 SAS Name: CLIA_ID_NUMBER_2 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 24 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: CLIA-ID-NUMBER-2 CLIA ID Number 3 10 411 420 CHAR Description: CLIA ID number 3 SAS Name: CLIA_ID_NUMBER_3 COBOL Name: CLIA-ID-NUMBER-3 CLIA ID Number 4 10 421 430 CHAR Description: CLIA ID number 4 SAS Name: CLIA_ID_NUMBER_4 COBOL Name: CLIA-ID-NUMBER-4 CLIA ID Number 5 10 431 440 CHAR Description: CLIA ID number 5 SAS Name: CLIA_ID_NUMBER_5 COBOL Name: CLIA-ID-NUMBER-5 Co-Location Indicator 1 441 441 VARCHAR2 Description: Indicates if the facility shares a location with another hospital. SAS Name: COLCTN_STUS_SW COBOL Name: COLCTN-STUS-SW Compliance: 24-Hour RN Waiver Indicator 1 442 442 CHAR Description: Indicates if a waiver of the 24-hour registered nurse staffing requirements has been recommended for a Skilled Nursing Facility or Nursing Facility. SAS Name: RN_24_HR_WVR_SW COBOL Name: RN-24-HR-WVR-SW Compliance: LSC Waiver Indicator 1 445 445 CHAR Description: Indicates if a waiver of any life safety code provision has been recommended for a provider. SAS Name: LSC_WVR_SW COBOL Name: LSC-WVR-SW Endoscopy Procedure Room Count 4 447 450 NUMBER Description: Number of endoscopy procedure rooms. SAS Name: ENDSCPY_PRCDR_ROOMS_CNT COBOL Name: ENDSCPY-PRCDR-ROOMS-CNT Fax Phone Number 10 454 463 VARCHAR2 Description: 10-digit fax phone number of the primary contact or the operator of the provider. SAS Name: FAX_PHNE_NUM COBOL Name: FAX-PHNE-NUM Fiscal Year End Date (MMDD) 4 464 467 VARCHAR2 Description: End date, consisting of the month and day, of the provider's fiscal year. SAS Name: FY_END_MO_DAY_CD COBOL Name: FY-END-MO-DAY-CD Medical School Affiliation Code 1 495 495 VARCHAR2 Description: Type of affiliation that a hospital has with a medical school. SAS Name: MDCL_SCHL_AFLTN_CD COBOL Name: MDCL-SCHL-AFLTN-CD VALUES: 1=MAJOR 2=LIMITED 3=GRADUATE 4=NO AFFILIATION Medicare or Medicaid Participating Provider Indicator 1 506 506 VARCHAR2 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 25 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Indicates if a provider is participating in the Medicaid or Medicare or both programs. SAS Name: MDCD_MDCR_PRTCPTG_PRVDR_SW COBOL Name: MDCD-MDCR-PRTCPTG-PRVDR-SW Non-Participating Hospital Meets 1861(e) Indicator 1 552 552 VARCHAR2 Description: Indicates if an non-participating emergency hospital meets the definition of 'hospital' contained in Section 1861(e) of the Social Security Act. SAS Name: MEET_1861_SW COBOL Name: MEET-1861-SW Non-Participating Hospital Type Code 1 553 553 VARCHAR2 Description: Indicates if a non-participating hospital is classified as a federal hospital or an emergency non-federal hospital. SAS Name: NPP_TYPE_CD COBOL Name: NPP-TYPE-CD VALUES: E=Non-Participating Emergency Hospital F=Non-Participating Federal Hospital Off-Site Count: Cancer Hospital Satellites 4 554 557 NUMBER Description: Number of off-site satellites of a cancer hospital. SAS Name: TOT_OFSITE_CNCR_HOSP_CNT COBOL Name: TOT-OFSITE-CNCR-HOSP-CNT Off-Site Count: Childrens Hospital Satellites 4 558 561 NUMBER Description: Number of off-site satellites of a children's hospital. SAS Name: TOT_OFSITE_CHLDRN_HOSP_CNT COBOL Name: TOT-OFSITE-CHLDRN-HOSP-CNT Off-Site Count: Emergency Departments 4 562 565 NUMBER Description: Number of off-site emergency departments. SAS Name: TOT_OFSITE_EMER_DEPT_CNT COBOL Name: TOT-OFSITE-EMER-DEPT-CNT Off-Site Count: Inpatient Remote Locations 4 566 569 NUMBER Description: Number of inpatient remote locations. SAS Name: TOT_OFSITE_INPTNT_LCTN_CNT COBOL Name: TOT-OFSITE-INPTNT-LCTN-CNT Off-Site Count: LTC Hospital Satellites 4 570 573 NUMBER Description: Number of off-site satellites of a long term care hospital. SAS Name: TOT_OFSITE_LTC_HOSP_CNT COBOL Name: TOT-OFSITE-LTC-HOSP-CNT Off-Site Count: Ophthalmic Surgery Units 4 574 577 NUMBER Description: Number of off-site ophthalmic surgery units. SAS Name: TOT_OFSITE_OPTHLMC_SRGRY_CNT COBOL Name: TOT-OFSITE-OPTHLMC-SRGRY-CNT Off-Site Count: Other Locations 4 578 581 NUMBER Description: Number of other off-site locations. SAS Name: TOT_OFSITE_OTHR_LCTN_CNT COBOL Name: TOT-OFSITE-OTHR-LCTN-CNT Off-Site Count: Psychiatric Hospitals 4 582 585 NUMBER Description: Number of off-site psychiatric hospitals. SAS Name: TOT_OFSITE_PSYCH_HOSP_CNT COBOL Name: TOT-OFSITE-PSYCH-HOSP-CNT Off-Site Count: Psychiatric Units 4 586 589 NUMBER Description: Number of off-site psychiatric units. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 26 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: TOT_OFSITE_PSYCH_UNIT_CNT COBOL Name: TOT-OFSITE-PSYCH-UNIT-CNT Off-Site Count: Rehabilitation Hospitals 4 590 593 NUMBER Description: Number of off-site rehabilitation hospitals. SAS Name: TOT_OFSITE_REHAB_HOSP_CNT COBOL Name: TOT-OFSITE-REHAB-HOSP-CNT Off-Site Count: Rehabilitation Units 4 594 597 NUMBER Description: Number of off-site rehabilitation units. SAS Name: TOT_OFSITE_REHAB_UNIT_CNT COBOL Name: TOT-OFSITE-REHAB-UNIT-CNT Off-Site Count: Urgent Care Centers 4 598 601 NUMBER Description: Number of off-site urgent care centers. SAS Name: TOT_OFSITE_URGNT_CARE_CNTR_CNT COBOL Name: TOT-OFSITE-URGNT-CARE-CNTR-CNT Off-Site Location Count 3 602 604 NUMBER Description: Number of off-site locations. SAS Name: OFSITE_LCTN_CNT COBOL Name: OFSITE-LCTN-CNT Operating Room Count 4 605 608 NUMBER Description: Number of operating rooms in an ambulatory surgical center. SAS Name: OPRTG_ROOM_CNT COBOL Name: OPRTG-ROOM-CNT Program Participation Code 1 623 623 CHAR Description: Indicates if the provider participates in Medicare, Medicaid, or both programs. SAS Name: PGM_PRTCPTN_CD COBOL Name: PGM-PRTCPTN-CD VALUES: 1=MEDICARE ONLY 2=MEDICAID ONLY 3=MEDICARE AND MEDICAID Province Code 2 625 626 VARCHAR2 Description: Canadian province where a non-participating emergency hospital is located. SAS Name: PRVNC_CD COBOL Name: PRVNC-CD VALUES: AB=ALBERTA BC=BRITISH COLUMBIA LB=LABRADOR MB=MANITOBA NB=NEW BRUNSWICK NF=NEWFOUNDLAND NS=NOVA SCOTIA NT=NORTHWEST TERRITORIES ON=ONTARIO PE=PRINCE EDWARD ISLAND PQ=QUEBEC SK=SASKATCHEWAN YT=YUKON TERRITORY Psychiatric Unit Bed Count 3 627 629 NUMBER Description: Number of beds in a Prospective Payment System (PPS) -exempt psychiatric unit of a hospital. SAS Name: PSYCH_UNIT_BED_CNT COBOL Name: PSYCH-UNIT-BED-CNT Psychiatric Unit Effective Date 8 630 637 DATE DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 27 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Date a psychiatric unit of a hospital became exempt from the Prospective Payment System (PPS). SAS Name: PSYCH_UNIT_EFCTV_DT COBOL Name: PSYCH-UNIT-EFCTV-DT Psychiatric Unit Indicator 1 638 638 VARCHAR2 Description: Indicates if a hospital has a Prospective Payment System (PPS) -exempt psychiatric unit. SAS Name: PSYCH_UNIT_SW COBOL Name: PSYCH-UNIT-SW Psychiatric Unit Termination Code 1 639 639 VARCHAR2 Description: Indicates the reason that a psychiatric unit of a hospital is no longer exempt from Prospective Payment System (PPS). SAS Name: PSYCH_UNIT_TRMNTN_CD COBOL Name: PSYCH-UNIT-TRMNTN-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 8 640 647 DATE Description: Date a psychiatric unit of a hospital is no longer exempt from the Prospective Payment System (PPS). SAS Name: PSYCH_UNIT_TRMNTN_DT COBOL Name: PSYCH-UNIT-TRMNTN-DT Rehabilitation Unit Bed Count 3 648 650 NUMBER Description: Number of beds in a Prospective Payment System (PPS) -exempt rehabilitation unit of a hospital. SAS Name: REHAB_UNIT_BED_CNT COBOL Name: REHAB-UNIT-BED-CNT Rehabilitation Unit Effective Date 8 651 658 DATE Description: Date a rehabilitation unit of a hospital became exempt from the Prospective Payment System (PPS). SAS Name: REHAB_UNIT_EFCTV_DT COBOL Name: REHAB-UNIT-EFCTV-DT Rehabilitation Unit Indicator 1 659 659 VARCHAR2 Description: Indicates if a hospital has a Prospective Payment System (PPS) -exempt rehabilitation unit. SAS Name: REHAB_UNIT_SW COBOL Name: REHAB-UNIT-SW Rehabilitation Unit Termination Code 1 660 660 VARCHAR2 Description: Indicates the reason that a rehabilitation unit hospital is no longer exempt from Prospective Payment System (PPS). SAS Name: REHAB_UNIT_TRMNTN_CD COBOL Name: REHAB-UNIT-TRMNTN-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 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 28 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Rehabilitation Unit Termination Date 8 661 668 DATE Description: Date a rehabilitation unit of a hospital is no longer exempt from the Prospective Payment System (PPS). SAS Name: REHAB_UNIT_TRMNTN_DT COBOL Name: REHAB-UNIT-TRMNTN-DT Related Provider Number 10 669 678 CHAR Description: Related provider number SAS Name: RELATED_PROVIDER_NUMBER COBOL Name: RELATED-PROVIDER-NUMBER Services: Acute Renal Dialysis Code 1 679 679 VARCHAR2 Description: Indicates how acute renal dialysis services are provided. SAS Name: ACUTE_RNL_DLYS_SRVC_CD COBOL Name: ACUTE-RNL-DLYS-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Adult Inpatient Psychiatric Code 1 680 680 VARCHAR2 Description: Indicates how adult inpatient psychiatric services are provided. SAS Name: PSYCH_SRVC_CD COBOL Name: PSYCH-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Alcohol and/or Drug Code 1 682 682 VARCHAR2 Description: Indicates how alcohol and/or drug services are provided. SAS Name: ALCHL_DRUG_SRVC_CD COBOL Name: ALCHL-DRUG-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Anesthesia Code 1 683 683 VARCHAR2 Description: Indicates how anesthesia services are provided. SAS Name: ANSTHSA_SRVC_CD COBOL Name: ANSTHSA-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Audiology Code 1 685 685 VARCHAR2 Description: Indicates how audiology services are provided. SAS Name: AUDLGY_SRVC_CD COBOL Name: AUDLGY-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Burn Care Unit Code 1 689 689 VARCHAR2 Description: Indicates how burn care unit services are provided. SAS Name: BURN_CARE_UNIT_SRVC_CD COBOL Name: BURN-CARE-UNIT-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 29 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Cardiac Catheterization Lab Code 1 690 690 VARCHAR2 Description: Indicates how cardiac catheterization lab services are provided. SAS Name: CRDC_CTHRTZTN_LAB_SRVC_CD COBOL Name: CRDC-CTHRTZTN-LAB-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Cardiac Thoracic Surgery Code 1 691 691 VARCHAR2 Description: Indicates how cardiac thoracic surgery services are provided. SAS Name: OPEN_HRT_SRGRY_SRVC_CD COBOL Name: OPEN-HRT-SRGRY-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: CARF Inpatient Rehabilitation Code 1 692 692 VARCHAR2 Description: Indicates how Commission on Accreditation of Rehabilitation Facilities inpatient rehabilitation services are provided. SAS Name: CARF_IP_REHAB_SRVC_CD COBOL Name: CARF-IP-REHAB-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Chemotherapy Code 1 693 693 VARCHAR2 Description: Indicates how chemotherapy services are provided. SAS Name: CHMTHRPY_SRVC_CD COBOL Name: CHMTHRPY-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Chiropractic Code 1 694 694 VARCHAR2 Description: Indicates how chiropractic services are provided. SAS Name: CHRPRCTIC_SRVC_CD COBOL Name: CHRPRCTIC-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Clinical Laboratory Code 1 698 698 VARCHAR2 Description: Indicates how clinical laboratory services are provided. SAS Name: CL_SRVC_CD COBOL Name: CL-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Coronary Care Unit Code 1 699 699 VARCHAR2 Description: Indicates how Coronary Care Unit services are provided. SAS Name: CRNRY_CARE_UNIT_SRVC_CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 30 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: CRNRY-CARE-UNIT-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: CT Scan Code 1 701 701 VARCHAR2 Description: Indicates how CT scan services are provided. SAS Name: CT_SCAN_SRVC_CD COBOL Name: CT-SCAN-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Dental Code 1 702 702 VARCHAR2 Description: Indicates how dental services are provided. SAS Name: DNTL_SRVC_CD COBOL Name: DNTL-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Designated Trauma Center Code 1 706 706 VARCHAR2 Description: Indicates how designated trauma center services are provided. SAS Name: SHCK_TRMA_SRVC_CD COBOL Name: SHCK-TRMA-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Diagnostic Radiology Code 1 707 707 VARCHAR2 Description: Indicates how diagnostic radiology services are provided. SAS Name: DGNSTC_RDLGY_SRVC_CD COBOL Name: DGNSTC-RDLGY-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Dietary Code 1 708 708 VARCHAR2 Description: Indicates how dietary services are provided. SAS Name: DTRY_SRVC_CD COBOL Name: DTRY-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Emergency Department Code 1 712 712 VARCHAR2 Description: Indicates how dedicated emergency department services are provided. SAS Name: DCTD_ER_SRVC_CD COBOL Name: DCTD-ER-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Emergency Psychiatric Code 1 713 713 VARCHAR2 Description: Indicates how emergency psychiatric services are DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 31 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE provided. SAS Name: EMER_PSYCH_SRVC_CD COBOL Name: EMER-PSYCH-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: ESWL Code 1 714 714 VARCHAR2 Description: Indicates how extracorporeal shockwave lithotripter services are provided. SAS Name: XTRCRPRL_SHCK_LTHTRPTR_SRVC_CD COBOL Name: XTRCRPRL-SHCK-LTHTRPTR-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Forensic Psychiatric Code 1 715 715 VARCHAR2 Description: Indicates how forensic psychiatric services are provided. SAS Name: FRNSC_PSYCH_SRVC_CD COBOL Name: FRNSC-PSYCH-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Geriatric Psychiatric Code 1 716 716 VARCHAR2 Description: Indicates how geriatric psychiatric services are provided. SAS Name: GRTRC_PSYCH_SRVC_CD COBOL Name: GRTRC-PSYCH-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Gerontological Specialty Code 1 717 717 VARCHAR2 Description: Indicates how gerontological specialty services are provided. SAS Name: GRNTLGCL_SPCLTY_SRVC_CD COBOL Name: GRNTLGCL-SPCLTY-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Inpatient Surgical Code 1 724 724 VARCHAR2 Description: Indicates how inpatient surgical services are provided. SAS Name: IP_SRGCL_SRVC_CD COBOL Name: IP-SRGCL-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Medical Surgical ICU Code 1 728 728 VARCHAR2 Description: Indicates how medical surgical intensive care unit services are provided. SAS Name: ICU_SRVC_CD COBOL Name: ICU-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 32 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Medicare Certified Transplant Center Code 1 729 729 VARCHAR2 Description: Indicates how Medicare certified transplant center services are provided. SAS Name: MDCR_TRNSPLNT_CNTR_SRVC_CD COBOL Name: MDCR-TRNSPLNT-CNTR-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: MRI Code 1 733 733 VARCHAR2 Description: Indicates how magnetic resonance imaging services are provided. SAS Name: MGNTC_RSNC_IMG_SRVC_CD COBOL Name: MGNTC-RSNC-IMG-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Neonatal ICU Code 1 734 734 VARCHAR2 Description: Indicates how neonatal intensive care unit services are provided. SAS Name: NEONTL_ICU_SRVC_CD COBOL Name: NEONTL-ICU-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Neonatal Nursery Code 1 735 735 VARCHAR2 Description: Indicates how neonatal nursery services are provided. SAS Name: NEONTL_NRSRY_SRVC_CD COBOL Name: NEONTL-NRSRY-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Neurosurgical Code 1 736 736 VARCHAR2 Description: Indicates how neurosurgical services are provided. SAS Name: NRSRGCL_SRVC_CD COBOL Name: NRSRGCL-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Non-Medicare Organ Transplant Code 1 737 737 VARCHAR2 Description: Indicates how non-Medicare certified organ transplant services are provided. SAS Name: ORGN_TRNSPLNT_SRVC_CD COBOL Name: ORGN-TRNSPLNT-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Nuclear Medicine Code 1 738 738 VARCHAR2 Description: Indicates how nuclear medicine services are provided. SAS Name: NUCLR_MDCN_SRVC_CD COBOL Name: NUCLR-MDCN-SRVC-CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 33 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Obstetrics Code 1 747 747 VARCHAR2 Description: Indicates how obstetrics services are provided. SAS Name: OB_SRVC_CD COBOL Name: OB-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Ophthalmic Surgery Code 1 748 748 VARCHAR2 Description: Indicates how ophthalmic surgery services are provided. SAS Name: OPTHLMC_SRGY_SRVC_CD COBOL Name: OPTHLMC-SRGY-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Optometric Code 1 749 749 VARCHAR2 Description: Indicates how optometric services are provided. SAS Name: OPTMTRC_SRVC_CD COBOL Name: OPTMTRC-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: OR Code 1 750 750 VARCHAR2 Description: Indicates how operating room services are provided. SAS Name: OPRTG_ROOM_SRVC_CD COBOL Name: OPRTG-ROOM-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Orthopedic Surgery Code 1 751 751 VARCHAR2 Description: Indicates how orthopedic surgery services are provided. SAS Name: ORTHPDC_SRGY_SRVC_CD COBOL Name: ORTHPDC-SRGY-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: OT Code 1 758 758 CHAR Description: Indicates how occupational therapy services are provided. SAS Name: OT_SRVC_CD COBOL Name: OT-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Outpatient Code 1 763 763 VARCHAR2 Description: Indicates how outpatient services are provided. SAS Name: OP_SRVC_CD COBOL Name: OP-SRVC-CD VALUES: 0=NOT PROVIDED DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 34 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Outpatient Psychiatric Code 1 764 764 VARCHAR2 Description: Indicates how outpatient psychiatric services are provided. SAS Name: OP_PSYCH_SRVC_CD COBOL Name: OP-PSYCH-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Outpatient Rehabilitation Code 1 765 765 VARCHAR2 Description: Indicates how outpatient rehabilitation services are provided. SAS Name: OP_REHAB_SRVC_CD COBOL Name: OP-REHAB-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Outpatient Surgery Code 1 766 766 VARCHAR2 Description: Indicates how outpatient surgery services are provided. SAS Name: OP_SRGRY_UNIT_SRVC_CD COBOL Name: OP-SRGRY-UNIT-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Pediatric Code 1 767 767 VARCHAR2 Description: Indicates how pediatric services are provided. SAS Name: PED_SRVC_CD COBOL Name: PED-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Pediatric ICU Code 1 768 768 VARCHAR2 Description: Indicates how pediatric ICU services are provided. SAS Name: PED_ICU_SRVC_CD COBOL Name: PED-ICU-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: PET Scan Code 1 771 771 VARCHAR2 Description: Indicates how Positron Emissions Tomography scan services are provided. SAS Name: PET_SCAN_SRVC_CD COBOL Name: PET-SCAN-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Postoperative Recovery Room Code 1 788 788 VARCHAR2 Description: Indicates how postoperative recovery room services are provided. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 35 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: PSTOPRTV_RCVRY_SRVC_CD COBOL Name: PSTOPRTV-RCVRY-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Psychiatric Child and/or Adolescent Code 1 789 789 VARCHAR2 Description: Indicates how child and/or adolescent psychiatric services are provided. SAS Name: CHLD_ADLSCNT_PSYCH_SRVC_CD COBOL Name: CHLD-ADLSCNT-PSYCH-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: PT Code 1 796 796 CHAR Description: Indicates how physical therapy services are provided. SAS Name: PT_SRVC_CD COBOL Name: PT-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Reconstructive Surgery Code 1 800 800 VARCHAR2 Description: Indicates how reconstructive surgery services are provided. SAS Name: RCNSTRCTN_SRGY_SRVC_CD COBOL Name: RCNSTRCTN-SRGY-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Respiratory Care Code 1 804 804 VARCHAR2 Description: Indicates how respiratory care services are provided. SAS Name: RSPRTRY_CARE_SRVC_CD COBOL Name: RSPRTRY-CARE-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Social Code 1 809 809 VARCHAR2 Description: Indicates how social services are provided. SAS Name: SCL_SRVC_CD COBOL Name: SCL-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Speech Pathology Code 1 816 816 CHAR Description: Indicates how speech pathology services are provided. SAS Name: SPCH_PTHLGY_SRVC_CD COBOL Name: SPCH-PTHLGY-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Surgical ICU Code 1 821 821 VARCHAR2 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 36 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Indicates how surgical intensive care unit services are provided. SAS Name: SRGCL_ICU_SRVC_CD COBOL Name: SRGCL-ICU-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Therapeutic Radiology Code 1 831 831 VARCHAR2 Description: Indicates how therapeutic radiology services are provided. SAS Name: THRPTC_RDLGY_SRVC_CD COBOL Name: THRPTC-RDLGY-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Services: Urgent Care Center Code 1 835 835 VARCHAR2 Description: Indicates how urgent care center services are provided. SAS Name: URGNT_CARE_SRVC_CD COBOL Name: URGNT-CARE-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=PROVIDED BY STAFF AND UNDER ARRANGEMENT Staff Count Override Indicator 1 844 844 CHAR Description: Indicates if the regional office has approved a significant staff count change from the previous certification. SAS Name: OVRRD_STFG_SW COBOL Name: OVRRD-STFG-SW Staff Count: Other Personnel 8 885 892 NUMBER Description: Number of full-time equivalent other personnel employed by a provider SAS Name: PRSNEL_OTHR_CNT COBOL Name: PRSNEL-OTHR-CNT Staff Count: CRNA 8 933 940 NUMBER Description: Number of full-time equivalent Certified Registered Nurse Anesthetists employed by a provider. SAS Name: CRNA_CNT COBOL Name: CRNA-CNT Staff Count: Dietitian 8 965 972 NUMBER Description: Number of full-time equivalent dietitians employed by a provider. SAS Name: DIETN_CNT COBOL Name: DIETN-CNT Staff Count: Lab Technician 8 1077 1084 NUMBER Description: Number of full-time equivalent laboratory technicians employed by a provider. SAS Name: LAB_TCHNCN_CNT COBOL Name: LAB-TCHNCN-CNT Staff Count: LPN/LVN - Employee 8 1093 1100 NUMBER Description: Number of full-time equivalent licensed practical or vocational nurses employed by a provider. SAS Name: LPN_LVN_CNT COBOL Name: LPN-LVN-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 37 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Staff Count: Medical Social Worker - Employee 8 1157 1164 NUMBER Description: Number of full-time equivalent medical social workers employed by a provider. SAS Name: MDCL_SCL_WORKR_CNT COBOL Name: MDCL-SCL-WORKR-CNT Staff Count: Medical Technologist 8 1173 1180 NUMBER Description: Number of full-time equivalent medical technologists employed by a provider. SAS Name: MDCL_TCHNLGST_CNT COBOL Name: MDCL-TCHNLGST-CNT Staff Count: Nuclear Medicine Technician 8 1229 1236 NUMBER Description: Number of full-time equivalent nuclear medicine technicians employed by a provider. SAS Name: NUCLR_MDCN_TCHNCN_CNT COBOL Name: NUCLR-MDCN-TCHNCN-CNT Staff Count: Nurse Practitioner 8 1261 1268 NUMBER Description: Number of full-time equivalent nurse practitioners employed by a provider. SAS Name: NRS_PRCTNR_CNT COBOL Name: NRS-PRCTNR-CNT Staff Count: OT - Total 8 1293 1300 NUMBER Description: Total number of full-time equivalent occupational therapists employed by a provider. SAS Name: OCPTNL_THRPST_CNT COBOL Name: OCPTNL-THRPST-CNT Staff Count: Physician - Employee 8 1525 1532 NUMBER Description: Number of full-time equivalent physicians employed by a provider. SAS Name: PHYSN_CNT COBOL Name: PHYSN-CNT Staff Count: Physician Assistant 8 1541 1548 NUMBER Description: Number of full-time equivalent physician assistants employed by a provider. SAS Name: PHYSN_ASTNT_CNT COBOL Name: PHYSN-ASTNT-CNT Staff Count: Physician Resident 8 1573 1580 NUMBER Description: Number of full-time equivalent physician - residents employed by a provider. SAS Name: RSDNT_PHYSN_CNT COBOL Name: RSDNT-PHYSN-CNT Staff Count: Psychologist 8 1605 1612 NUMBER Description: Number of full-time equivalent psychologists employed by a provider. SAS Name: PSYCHLGST_CNT COBOL Name: PSYCHLGST-CNT Staff Count: PT 8 1621 1628 NUMBER Description: Number of full-time equivalent physical therapists employed by a provider. SAS Name: PHYS_THRPST_CNT COBOL Name: PHYS-THRPST-CNT Staff Count: Radiology Technician 8 1709 1716 NUMBER Description: Number of full-time equivalent radiology technicians employed by a provider. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 38 Hospital, CATEGORY = "01" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: RDLGY_TCHNCN_CNT COBOL Name: RDLGY-TCHNCN-CNT Staff Count: Registered Pharmacist 8 1717 1724 NUMBER Description: Number of full-time equivalent registered pharmacists employed by the provider. SAS Name: REG_PHRMCST_CNT COBOL Name: REG-PHRMCST-CNT Staff Count: Respiratory Therapist 8 1725 1732 NUMBER Description: Number of full-time equivalent respiratory therapists employed by a provider. SAS Name: INHLTN_THRPST_CNT COBOL Name: INHLTN-THRPST-CNT Staff Count: RN 8 1733 1740 NUMBER Description: Number of full-time equivalent registered nurses employed by a provider. SAS Name: RN_CNT COBOL Name: RN-CNT Staff Count: Speech Pathologist/Audiologist 8 1869 1876 NUMBER Description: Number of full-time equivalent speech pathologists or audiologists employed by the provider. SAS Name: SPCH_PTHLGST_AUDLGST_CNT COBOL Name: SPCH-PTHLGST-AUDLGST-CNT Swing Bed Indicator 1 1950 1950 VARCHAR2 Description: Indicates if a hospital provides swing bed services (beds can be used for either hospital or long term care services). SAS Name: SB_SW COBOL Name: SB-SW Swing Bed Size Code 1 1951 1951 VARCHAR2 Description: Indicates the size of a hospital providing swing bed services (beds can be used for either hospital or long term care services). SAS Name: SB_SIZE_CD COBOL Name: SB-SIZE-CD VALUES: 1=49 OR FEWER BEDS 2=50 TO 99 BEDS DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 1 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Provider Category Subtype Code 2 1 2 VARCHAR2 Description: Identifies the subtype of the provider, within the primary category. Used in reporting to show the breakdown of provider categories, mainly for hospitals and SNFs. SAS Name: PRVDR_CTGRY_SBTYP_CD COBOL Name: PRVDR-CTGRY-SBTYP-CD VALUES: 03=Title 18/19 Provider Category Code 2 3 4 VARCHAR2 Description: Identifies the type of provider participating in the Medicare/Medicaid program. SAS Name: PRVDR_CTGRY_CD COBOL Name: PRVDR-CTGRY-CD VALUES: 02=Skilled Nursing Facility/Nursing Facility (Dually Certified) CHOW Count 2 5 6 NUMBER Description: Number of times this provider has undergone a change of ownership. SAS Name: CHOW_CNT COBOL Name: CHOW-CNT CHOW Date 8 7 14 DATE Description: Effective date of the most recent change of ownership for this provider. SAS Name: CHOW_DT COBOL Name: CHOW-DT Address: City 28 15 42 VARCHAR2 Description: City in which the provider is physically located. SAS Name: CITY_NAME COBOL Name: CITY-NAME Compliance: Acceptable POC 1 43 43 VARCHAR2 Description: Indicates if a provider is in compliance with program requirements based on an acceptable plan for correction of deficiencies. SAS Name: ACPTBL_POC_SW COBOL Name: ACPTBL-POC-SW Compliance: Status 1 44 44 VARCHAR2 Description: Compliance status of a provider at the time of certification survey. SAS Name: CMPLNC_STUS_CD COBOL Name: CMPLNC-STUS-CD VALUES: A=IN COMPLIANCE B=NOT IN COMPLIANCE SSA County Code 3 45 47 VARCHAR2 Description: Social Security Administration geographic code indicating the county where the provider is located. SAS Name: SSA_CNTY_CD COBOL Name: SSA-CNTY-CD Cross Ref Provider Number 10 48 57 CHAR Description: Cross reference provider number SAS Name: CROSS_REF_PROVIDER_NUMBER COBOL Name: CROSS-REF-PROVIDER-NUMBER Certification Date 8 58 65 DATE Description: Equal to the exit date of the initial visit of the Health survey for certifications completed after July 28, 2012. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 2 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE For certifications prior to that date, the certification date is equal to the exit date of the initial visit of the Health survey or LSC survey, whichever is later. SAS Name: CRTFCTN_DT COBOL Name: CRTFCTN-DT Eligibility Indicator 1 66 66 VARCHAR2 Description: Indicates if a facility is eligible to participate in the Medicare and/or Medicaid programs. SAS Name: ELGBLTY_SW COBOL Name: ELGBLTY-SW Facility Name 50 67 116 VARCHAR2 Description: Name of the provider certified to participate in the Medicare and/or Medicaid programs. SAS Name: FAC_NAME COBOL Name: FAC-NAME Medicare Administrative Contractor (MAC) or 5 117 121 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_CD COBOL Name: INTRMDRY-CARR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 3 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 4 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 5 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 6 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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 15 122 136 VARCHAR2 Description: Number which may be assigned to a provider by the state Medicaid agency for external control or billing purposes. SAS Name: MDCD_VNDR_NUM COBOL Name: MDCD-VNDR-NUM Original Participation Date 8 137 144 DATE Description: Date a provider is first approved to provide Medicare and/or Medicaid services. SAS Name: ORGNL_PRTCPTN_DT COBOL Name: ORGNL-PRTCPTN-DT Prior CHOW Date 8 145 152 DATE Description: Effective date of the previous change of ownership for this provider. SAS Name: CHOW_PRIOR_DT COBOL Name: CHOW-PRIOR-DT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 7 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Prior Medicare Administrative Contractor (MAC) or 5 153 157 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the previous Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_PRIOR_CD COBOL Name: INTRMDRY-CARR-PRIOR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 8 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 9 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 10 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 11 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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) CCN 10 158 167 VARCHAR2 Description: Six or ten position identification number that is assigned to a certified provider. This is the CMS Certification Number. SAS Name: PRVDR_NUM COBOL Name: PRVDR-NUM Region Code 2 168 169 VARCHAR2 Description: Indicates the CMS Regional Office responsible for the certification of the provider. SAS Name: RGN_CD COBOL Name: RGN-CD VALUES: 01=Boston 02=New York 03=Philadelphia 04=Atlanta 05=Chicago 06=Dallas 07=Kansas City 08=Denver 09=San Francisco 10=Seattle Skeleton Record Indicator 1 170 170 VARCHAR2 Description: Indicates if the record is a skeleton record. Only a limited set of data is available for this provider; no survey data exists. SAS Name: SKLTN_REC_SW COBOL Name: SKLTN-REC-SW State Abbreviation 2 171 172 VARCHAR2 Description: Two-character state abbreviation. SAS Name: STATE_CD COBOL Name: STATE-CD VALUES: AK=ALASKA AL=ALABAMA DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 12 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE AR=ARKANSAS AS=AMERICAN SAMOA AZ=ARIZONA CA=CALIFORNIA CN=CANADA CO=COLORADO CT=CONNECTICUT DC=DISTRICT OF COLUMBIA DE=DELAWARE FL=FLORIDA FN=INTERNATIONAL GA=GEORGIA GU=GUAM HI=HAWAII IA=IOWA ID=IDAHO IL=ILLINOIS IN=INDIANA KS=KANSAS KY=KENTUCKY LA=LOUISIANA MA=MASSACHUSETTS MD=MARYLAND ME=MAINE MI=MICHIGAN MN=MINNESOTA MO=MISSOURI MP=SAIPAN MS=MISSISSIPPI MT=MONTANA MX=MEXICO NC=NORTH CAROLINA ND=NORTH DAKOTA NE=NEBRASKA NH=NEW HAMPSHIRE NJ=NEW JERSEY NM=NEW MEXICO NV=NEVADA NY=NEW YORK OH=OHIO OK=OKLAHOMA OR=OREGON PA=PENNSYLVANIA PR=PUERTO RICO RI=RHODE ISLAND SC=SOUTH CAROLINA SD=SOUTH DAKOTA TN=TENNESSEE TX=TEXAS UT=UTAH VA=VIRGINIA VI=VIRGIN ISLANDS VT=VERMONT WA=WASHINGTON WI=WISCONSIN WV=WEST VIRGINIA WY=WYOMING SSA State Code 2 173 174 VARCHAR2 Description: Social Security Administration geographic code indicating the state where the provider is located. SAS Name: SSA_STATE_CD COBOL Name: SSA-STATE-CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 13 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 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 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 56=CANADA 57=WEST INDIES 58=EUROPE 59=MEXICO 60=OCEANIA 61=PHILIPPINES 62=SOUTH AMERICA 63=UNITED STATES POSSESSIONS 64=AMERICAN SAMOA DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 14 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 65=GUAM 66=SAIPAN 99=INTERNATIONAL State Region Code 3 175 177 VARCHAR2 Description: Identifies the region within a state where the provider is located. SAS Name: STATE_RGN_CD COBOL Name: STATE-RGN-CD VALUES: AK/001=ALASKA AK/LAB=LABORATORIES AL/001=ALABAMA AL/LAB=LABORATORIES AR/001=ARKANSAS AR/LAB=LABORATORIES AS/001=AMERICAN SAMOA AS/LAB=LABORATORY AZ/AZ=PHOENIX AZ/LAB=ARIZONA LAB AZ/TUC=TUCSON CA/BAK=BAKERSFIELD CA/BER=SAN BERNARDINO CA/BK=BERKELEY CA/BK1=CONTRA COSTA CA/FR=FRESNO CA/L1=L.A. WEST CA/L2=L.A. NORTH CA/L3=L.A. CENTRAL CA/L4=L.A. EAST CA/L5=SAN GABRIEL CA/LAB=LABORATORIES CA/M1=LAB. SOUTH CA/M2=LAB. NORTH CA/ORG=ORANGE CO CA/RIV=RIVERSIDE CA/RWC=REDWOOD COAST CA/S1=SACRAMENTO CA/S2=SACTO SOUTH CA/S3=CHICO CA/SD=SAN DIEGO CA/SDS=SAN DIEGO SOUTH CA/SF=SAN FRANCISCO CA/SJ=SAN JOSE CA/SR=SANTA ROSA CA/VEN=VENTURA CN/001=CANADA CN/LAB=LABORATORY CO/001=COLORADO CO/LAB=LABORATORIES CT/001=CONNECTICUT CT/LAB=LABORATORIES DC/001=DISTRICT OF COLUMBIA DC/LAB=LABORATORIES DE/001=DELAWARE DE/LAB=LABORATORIES FL/FTM=FT. MYERS FL/GAI=GAINESVILLE FL/JAX=JACKSONVILLE FL/LAB=LABORATORIES FL/LAN=LANTANA FL/LAU=LAUDERHILL FL/MIA=MIAMI FL/ORL=ORLANDO DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 15 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE FL/PEN=PENSACOLA FL/STP=ST. PETERSBURG FL/TAL=TALLAHASSEE FL/TAM=TAMPA FM/001=FEDERATED STATES OF MICRO FN/001=INTERNATIONAL FN/LAB=LABORATORIES GA/001=GEORGIA GA/GAA=GEORGIA ALL GA/GAC=GEORGIA CENTRAL GA/GAE=GEORGIA EASTERN GA/GAN=GEORGIA NORTH GA/GAS=GEORGIA SOUTH GA/GAW=GEORGIA WESTERN GA/LAB=LABORATORIES GU/001=GUAM GU/LAB=LABORATORIES HI/001=HAWAII HI/LAB=LABORATORIES IA/001=IOWA IA/LAB=LABORATORIES ID/001=IDAHO ID/LAB=LABORATORIES IL/001=ILLINOIS IL/LAB=LABORATORIES IN/001=INDIANA IN/LAB=LABORATORIES KS/KCK=KANSAS CITY KS/KDH=KDHE KS/LAB=LABORATORIES KS/LAW=LAWRENCE KS/NC=NORTH CENTRAL KANSAS KS/NE=NORTH EAST KANSAS KS/NW=NORTH WEST KANSAS KS/SC=SOUTH CENTRAL KANSAS KS/SE=SOUTH EAST KANSAS KS/SW=SOUTH WEST KANSAS KS/WST=WEST KY/2C1=HOPKINSVILLE KY/2C2=LOUISVILLE KY/2C3=LONDON KY/2C4=LEXINGTON KY/LAB=LABORATORIES LA/001=LOUISIANA LA/LA1=NEW ORLEANS LA/LA2=MANDEVILLE LA/LA3=LAFAYETTE LA/LA4=MONROE LA/LA5=SHREVEPORT LA/LA6=ALEXANDRIA LA/LAB=LABORATORIES LA/LB1=CLIA NEW ORLEANS LA/LB5=CLIA SHREVEPORT LA/LB6=CLIA ALEXANDRIA MA/001=MASSACHUSETTS MA/LAB=LABORATORIES MD/001=MARYLAND MD/LAB=LABORATORIES ME/001=MAINE ME/LAB=LABORATORIES MH/001=MARSHALL ISLANDS MI/001=MICHIGAN MI/LAB=LABORATORIES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 16 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE MN/001=MINNESOTA MN/LAB=LABORATORIES MO/01=REGION01 MO/02=REGION02 MO/03=REGION 03 MO/04=REGION 04 MO/05=REGION 05 MO/06=REGION 06 MO/07=REGION 07 MO/1NH=REGION 1 NH MO/2NH=REGION 2 NH MO/3NH=REGION 3 NH MO/4NH=REGION 4 NH MO/5NH=REGION 5 NH MO/6NH=REGION 6 NH MO/7NH=REGION 7 NH MO/LAB=LABORATORIES MO/MO=STATEWIDE MP/001=NORTHERN MARIANA ISLANDS MP/LAB=LABORATORIES MS/001=MISSISSIPPI MS/LAB=LABORATORIES MT/001=MONTANA MT/LAB=LABORATORIES MX/001=MEXICO MX/LAB=LABORATORY NC/LAB=LABORATORIES NC/NCC=NORTH CAROLINA CENTRAL NC/NCE=NORTH CAROLINA EAST NC/NCN=NORTH CAROLINA NORTH NC/NCS=NORTH CAROLINA SOUTH NC/NCW=NORTH CAROLINA WEST ND/001=NORTH DAKOTA ND/LAB=LABORATORIES NE/1=NORTH CENTRAL NE/2=CENTRAL NE/3=NORTHEAST NE/4=SOUTHEAST NE/5=WESTERN NE/LAB=LABORATORIES NH/001=NEW HAMPSHIRE NH/LAB=LABORATORIES NJ/001=NEW JERSEY NJ/LAB=LABORATORIES NM/001=NEW MEXICO NM/LAB=LABORATORIES NV/CC=CARSON CITY NV/LAB=LABORATORIES NV/LV=LAS VEGAS NY/001=BUFFALO NY/002=ROCHESTER NY/003=SYRACUSE NY/004=ALBANY NY/005=NEW ROCHELLE NY/006=NEW YORK CITY NY/007=SUFFOLK/NASSAU COUNTY NY/LAB=LABORATORIES OH/001=OHIO OH/LAB=LABORATORIES OK/001=OKLAHOMA OK/LAB=LABORATORIES OR/001=OFFICE #1 OR/002=OFFICE #2 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 17 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE OR/003=OFFICE #3 OR/LAB=LABORATORIES PA/001=PENNSYLVANIA PA/LAB=LABORATORIES PR/001=PUERTO RICO PR/LAB=LABORATORIES PW/001=PALAU RI/001=RHODE ISLAND RI/LAB=LABORATORIES SC/001=SOUTH CAROLINA SC/LAB=LABORATORIES SD/001=SOUTH DAKOTA SD/LAB=LABORATORIES TN/LAB=LABORATORIES TN/TNC=TENNESSEE COOKEVILLE TN/TNE=TENNESSEE EASTERN TN/TNM=TENNESSEE MIDDLE TN/TNW=TENNESSEE WESTERN TX/001=TEXAS TX/L01=AMARILLO-LTC TX/L02=ABILENE-LTC TX/L03=ARLINGTON-LTC TX/L04=TYLER-LTC TX/L05=BEAUMONT-LTC TX/L06=HOUSTON-LTC TX/L07=TEMPLE-LTC TX/L08=SAN ANTONIO-LTC TX/L09=SAN ANGELO-LTC TX/L10=EL PASO-LTC TX/L11=CORPUS CHRISTI-LTC TX/LAB=LABORATORIES TX/TX1=LUBBOCK TX/TX2=ARLINGTON TX/TX3=SAN ANTONIO TX/TX4=HOUSTON TX/TX5=TYLER TX/TX6=AUSTIN UT/001=UTAH UT/LAB=LABORATORIES VA/001=VIRGINIA VA/LAB=LABORATORIES VI/001=VIRGIN ISLANDS VI/LAB=LABORATORIES VT/001=VERMONT VT/LAB=LABORATORIES WA/001=ALL OTHERS (NON-LTC FAC) WA/D1=SPOKANE & YAKIMA AREAS WA/D1A=District 1, Unit A WA/D1B=District 1, Unit B WA/D1C=District 1, Unit C WA/D1D=District 1, Unit D WA/D2=SPOKANE & SE WA/D2A=District 2, Unit A WA/D2B=District 2, Unit B WA/D2C=District 2, Unit C WA/D2D=District 2, Unit D WA/D2E=District 2, Unit E WA/D2F=District 2, Unit F WA/D2G=District 2, Unit G WA/D3=NW WASHINGTON WA/D3A=District 3, Unit A WA/D3B=District 3, Unit B WA/D3C=District 3, Unit C DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 18 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE WA/D3D=District 3, Unit D WA/D3E=District 3, Unit E WA/D4A=GREATER SEATTLE AREA WA/D4B=S KING COUNTY WA/D5A=PIERCE CTY & PENINSULA WA/D5B=PIERCE CTY & GRAYS HARBOR WA/D6=OLYMPIA AREA WA/LAB=LABORATORIES WI/001=WISCONSIN WI/LAB=LABORATORIES WV/001=WEST VIRGINIA WV/LAB=LABORATORIES WY/001=WYOMING WY/LAB=LABORATORIES Address: Street 50 178 227 VARCHAR2 Description: Street address where the provider is located. SAS Name: ST_ADR COBOL Name: ST-ADR Telephone Number 10 228 237 VARCHAR2 Description: Telephone number of the provider. SAS Name: PHNE_NUM COBOL Name: PHNE-NUM Termination Code 2 238 239 VARCHAR2 Description: Indicates the current termination status for the provider. SAS Name: PGM_TRMNTN_CD COBOL Name: PGM-TRMNTN-CD VALUES: 00=ACTIVE PROVIDER 01=VOLUNTARY-MERGER, CLOSURE 02=VOLUNTARY-DISSATISFACTION WITH REIMBURSEMENT 03=VOLUNTARY-RISK OF INVOLUNTARY TERMINATION 04=VOLUNTARY-OTHER REASON FOR WITHDRAWAL 05=INVOLUNTARY-FAILURE TO MEET HEALTH/SAFETY REQ 06=INVOLUNTARY-FAILURE TO MEET AGREEMENT 07=OTHER-PROVIDER STATUS CHANGE 08=NONPAYMENT OF FEES - CLIA Only 09=REV/UNSUCCESSFUL PARTICIPATION IN PT - CLIA Only 10=REV/OTHER REASON - CLIA Only 11=INCOMPLETE CLIA APPLICATION INFORMATION - CLIA Only 12=NO LONGER PERFORMING TESTS - CLIA Only 13=MULTIPLE TO SINGLE SITE CERTIFICATE - CLIA Only 14=SHARED LABORATORY - CLIA Only 15=FAILURE TO RENEW WAIVER PPM CERTIFICATE - CLIA Only 16=DUPLICATE CLIA NUMBER - CLIA Only 17=MAIL RETURNED NO FORWARD ADDRESS CERT ENDED - CLIA Only 20=NOTIFICATION BANKRUPTCY - CLIA Only 33=ACCREDITATION NOT CONFIRMED - CLIA Only 80=AWAITING STATE APPROVAL 99=OIG ACTION - DO NOT ACTIVATE - CLIA Only Termination or Expiration Date 8 240 247 DATE Description: Date the provider was terminated. For CLIA providers, date the laboratory's certificate was terminated or the expiration date of the current CLIA certificate. SAS Name: TRMNTN_EXPRTN_DT COBOL Name: TRMNTN-EXPRTN-DT Type of Action Code 1 248 248 VARCHAR2 Description: Identifies the reason for the certification. Type of action from the official survey record, CMS 1539 form. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 19 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: CRTFCTN_ACTN_TYPE_CD COBOL Name: CRTFCTN-ACTN-TYPE-CD VALUES: 1=INITIAL 2=RECERTIFICATION 3=TERMINATION 4=CHANGE OF OWNERSHIP 5=VALIDATION 8=FULL SURVEY AFTER COMPLAINT Ownership Type Code 2 249 250 VARCHAR2 Description: Indicates the ownership type of the provider. SAS Name: GNRL_CNTL_TYPE_CD COBOL Name: GNRL-CNTL-TYPE-CD 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 13=FOR PROFIT - LIMITED LIABILITY CORPORATION Address: ZIP Code 5 251 255 VARCHAR2 Description: Five-digit ZIP code for a provider's physical address. SAS Name: ZIP_CD COBOL Name: ZIP-CD FIPS State Code 2 256 257 VARCHAR2 Description: FIPS State Code SAS Name: FIPS_STATE_CD COBOL Name: FIPS-STATE-CD VALUES: 01=ALABAMA 02=ALASKA 04=ARIZONA 05=ARKANSAS 06=CALIFORNIA 08=COLORADO 09=CONNECTICUT 10=DELAWARE 11=DISTRICT OF COLUMBIA 12=FLORIDA 13=GEORGIA 15=HAWAII 16=IDAHO 17=ILLINOIS 18=INDIANA 19=IOWA 20=KANSAS 21=KENTUCKY 22=LOUISIANA 23=MAINE 24=MARYLAND 25=MASSACHUSETTS 26=MICHIGAN 27=MINNESOTA 28=MISSISSIPPI 29=MISSOURI 30=MONTANA DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 20 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 31=NEBRASKA 32=NEVADA 33=NEW HAMPSHIRE 34=NEW JERSEY 35=NEW MEXICO 36=NEW YORK 37=NORTH CAROLINA 38=NORTH DAKOTA 39=OHIO 40=OKLAHOMA 41=OREGON 42=PENNSYLVANIA 43=PUERTO RICO 44=RHODE ISLAND 45=SOUTH CAROLINA 46=SOUTH DAKOTA 47=TENNESSEE 48=TEXAS 49=UTAH 50=VERMONT 51=VIRGINIA 53=WASHINGTON 54=WEST VIRGINIA 55=WISCONSIN 56=WYOMING 64=AMERICAN SAMOA 65=GUAM 66=SAIPAN/MARIANA IS. 78=VIRGIN ISLANDS FIPS County Code 3 258 260 VARCHAR2 Description: FIPS County Code SAS Name: FIPS_CNTY_CD COBOL Name: FIPS-CNTY-CD CBSA Urban Rural Indicator 1 261 261 VARCHAR2 Description: CBSA (Core Based Statistical Area) indicates whether the county is defined as Urban or Rural. SAS Name: CBSA_URBN_RRL_IND COBOL Name: CBSA-URBN-RRL-IND CBSA Code 5 262 266 VARCHAR2 Description: CBSA (Core Based Statistical Area) geographic entities defined by the U.S. Office of Management and Budget (OMB) on June 6, 2003 for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics. CBSA collectively refers to MSA. SAS Name: CBSA_CD COBOL Name: CBSA-CD Bed Count Override Indicator 1 325 325 CHAR Description: Indicates if the regional office has approved a significant bed count change from the previous certification. SAS Name: OVRRD_BED_CNT_SW COBOL Name: OVRRD-BED-CNT-SW Bed Count: Certified 4 326 329 NUMBER Description: Number of beds in Medicare and/or Medicaid certified areas within a facility. SAS Name: CRTFD_BED_CNT COBOL Name: CRTFD-BED-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 21 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Bed Count: Medicaid NF 4 334 337 NUMBER Description: Number of Medicaid-certified Nursing Facility beds. SAS Name: MDCD_NF_BED_CNT COBOL Name: MDCD-NF-BED-CNT Bed Count: Medicare SNF 4 338 341 NUMBER Description: Number of Medicare-certified Skilled Nursing Facility beds. SAS Name: MDCR_SNF_BED_CNT COBOL Name: MDCR-SNF-BED-CNT Bed Count: Medicare/Medicaid SNF 4 342 345 NUMBER Description: Number of dually certified (Medicare/Medicaid) beds in a Skilled Nursing Facility. SAS Name: MDCR_MDCD_SNF_BED_CNT COBOL Name: MDCR-MDCD-SNF-BED-CNT Bed Count: Special Care - AIDS 3 346 348 NUMBER Description: Number of beds in a special care unit dedicated for residents with AIDS. SAS Name: AIDS_BED_CNT COBOL Name: AIDS-BED-CNT Bed Count: Special Care - Alzheimers 3 349 351 NUMBER Description: Number of beds in a special care unit dedicated for residents with Alzheimer's disease. SAS Name: ALZHMR_BED_CNT COBOL Name: ALZHMR-BED-CNT Bed Count: Special Care - Dialysis 3 352 354 NUMBER Description: Number of beds in a special care unit dedicated for residents who require dialysis. SAS Name: DLYS_BED_CNT COBOL Name: DLYS-BED-CNT Bed Count: Special Care - Disabled Children 3 355 357 NUMBER Description: Number of beds in a special care unit dedicated for disabled children. SAS Name: DSBL_CHLDRN_BED_CNT COBOL Name: DSBL-CHLDRN-BED-CNT Bed Count: Special Care - Head Trauma 3 358 360 NUMBER Description: Number of beds in a special care unit dedicated for residents with head trauma. SAS Name: HEAD_TRMA_BED_CNT COBOL Name: HEAD-TRMA-BED-CNT Bed Count: Special Care - Hospice 3 361 363 NUMBER Description: Number of beds in a special care unit dedicated for residents who require hospice care. SAS Name: HOSPC_BED_CNT COBOL Name: HOSPC-BED-CNT Bed Count: Special Care - Huntingtons Disease 3 364 366 NUMBER Description: Number of beds in a special care unit dedicated for residents with Huntington's disease. SAS Name: HNTGTN_DEASE_BED_CNT COBOL Name: HNTGTN-DEASE-BED-CNT Bed Count: Special Care - Specialized Rehab 3 367 369 NUMBER Description: Number of beds in a special care unit dedicated for residents with specialized rehab needs. SAS Name: REHAB_BED_CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 22 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: REHAB-BED-CNT Bed Count: Special Care - Ventilator 3 370 372 NUMBER Description: Number of beds in a special care unit dedicated for residents requiring a ventilator and/or respiratory care. SAS Name: VNTLTR_BED_CNT COBOL Name: VNTLTR-BED-CNT Bed Count: Total 4 373 376 NUMBER Description: Total number of beds in a provider, including those in non-participating or non-licensed areas. SAS Name: BED_CNT COBOL Name: BED-CNT Compliance: 24-Hour RN Waiver Indicator 1 442 442 CHAR Description: Indicates if a waiver of the 24-hour registered nurse staffing requirements has been recommended for a Skilled Nursing Facility or Nursing Facility. SAS Name: RN_24_HR_WVR_SW COBOL Name: RN-24-HR-WVR-SW Compliance: 7-Day RN Waiver Indicator 1 443 443 VARCHAR2 Description: Indicates if a waiver of the 7-day registered nurse staffing requirements has been recommended for a Skilled Nursing Facility. SAS Name: RN_7_DAY_WVR_SW COBOL Name: RN-7-DAY-WVR-SW Compliance: Beds Per Room Waiver Indicator 1 444 444 CHAR Description: Indicates if a waiver of the beds per room requirement has been recommended for a facility. SAS Name: BED_PER_ROOM_WVR_SW COBOL Name: BED-PER-ROOM-WVR-SW Compliance: LSC Waiver Indicator 1 445 445 CHAR Description: Indicates if a waiver of any life safety code provision has been recommended for a provider. SAS Name: LSC_WVR_SW COBOL Name: LSC-WVR-SW Compliance: Patient Room Size Waiver Indicator 1 446 446 CHAR Description: Indicates if a waiver of the patient room size provision has been recommended for a provider. SAS Name: ROOM_SIZE_WVR_SW COBOL Name: ROOM-SIZE-WVR-SW Experimental Research Conducted Indicator 1 453 453 VARCHAR2 Description: Indicates if a facility conducts experimental research. SAS Name: EXPRMT_RSRCH_CNDCTD_SW COBOL Name: EXPRMT-RSRCH-CNDCTD-SW Fiscal Year End Date (MMDD) 4 464 467 VARCHAR2 Description: End date, consisting of the month and day, of the provider's fiscal year. SAS Name: FY_END_MO_DAY_CD COBOL Name: FY-END-MO-DAY-CD LTC Cross Ref Provider Number 10 485 494 CHAR Description: LTC cross ref provider number SAS Name: LTC_CROSS_REF_PROVIDER_NUMBER COBOL Name: LTC-CROSS-REF-PROVIDER-NUMBER Multiple Facility Organization Name 38 513 550 CHAR DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 23 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Name of the multi-facility organization that owns the facility. SAS Name: MLT_FAC_ORG_NAME COBOL Name: MLT-FAC-ORG-NAME Multiple Facility Organization Owned Indicator 1 551 551 CHAR Description: Indicates if a facility is owned by an organization that owns (or leases) two or more long term care facilities. SAS Name: MLT_OWND_FAC_ORG_SW COBOL Name: MLT-OWND-FAC-ORG-SW Organized Family Group Indicator 1 609 609 VARCHAR2 Description: Indicates if the facility has an organized group of family members of residents. SAS Name: ORGNZ_FMLY_MBR_GRP_SW COBOL Name: ORGNZ-FMLY-MBR-GRP-SW Organized Resident Group Indicator 1 610 610 VARCHAR2 Description: Indicates if the facility has an organized residents group. SAS Name: ORGNZ_RSDNT_GRP_SW COBOL Name: ORGNZ-RSDNT-GRP-SW Program Participation Code 1 623 623 CHAR Description: Indicates if the provider participates in Medicare, Medicaid, or both programs. SAS Name: PGM_PRTCPTN_CD COBOL Name: PGM-PRTCPTN-CD VALUES: 1=MEDICARE ONLY 2=MEDICAID ONLY 3=MEDICARE AND MEDICAID Related Provider Number 10 669 678 CHAR Description: Related provider number SAS Name: RELATED_PROVIDER_NUMBER COBOL Name: RELATED-PROVIDER-NUMBER Services: Blood Administration Off-Site Residents 1 686 686 VARCHAR2 Indicator Description: Indicates if blood administration and storage services are provided off-site to residents. SAS Name: BLOOD_SRVC_OFSITE_RSDNT_SW COBOL Name: BLOOD-SRVC-OFSITE-RSDNT-SW Services: Blood Administration On-Site Nonresidents 1 687 687 VARCHAR2 Indicator Description: Indicates if blood administration and storage services are provided on-site to nonresidents. SAS Name: BLOOD_SRVC_ONST_NRSDNT_SW COBOL Name: BLOOD-SRVC-ONST-NRSDNT-SW Services: Blood Administration On-Site Residents 1 688 688 VARCHAR2 Indicator Description: Indicates if blood administration and storage services are provided on-site to residents. SAS Name: BLOOD_SRVC_ONST_RSDNT_SW COBOL Name: BLOOD-SRVC-ONST-RSDNT-SW Services: Clinical Laboratory - Off-Site Residents 1 695 695 VARCHAR2 Indicator Description: Indicates if clinical laboratory services are provided off-site to residents. SAS Name: CL_SRVC_OFSITE_RSDNT_SW DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 24 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: CL-SRVC-OFSITE-RSDNT-SW Services: Clinical Laboratory - On-Site Nonresidents 1 696 696 VARCHAR2 Indicator Description: Indicates if clinical laboratory services are provided on-site to nonresidents. SAS Name: CL_SRVC_ONST_NRSDNT_SW COBOL Name: CL-SRVC-ONST-NRSDNT-SW Services: Clinical Laboratory - On-Site Residents 1 697 697 VARCHAR2 Indicator Description: Indicates if clinical laboratory services are provided on-site to residents. SAS Name: CL_SRVC_ONST_RSDNT_SW COBOL Name: CL-SRVC-ONST-RSDNT-SW Services: Dental Off-Site Residents Indicator 1 703 703 VARCHAR2 Description: Indicates if dental services are provided off-site to residents. SAS Name: DNTL_SRVC_OFSITE_RSDNT_SW COBOL Name: DNTL-SRVC-OFSITE-RSDNT-SW Services: Dental On-Site Nonresidents Indicator 1 704 704 VARCHAR2 Description: Indicates if dental services are provided on-site to nonresidents. SAS Name: DNTL_SRVC_ONST_NRSDNT_SW COBOL Name: DNTL-SRVC-ONST-NRSDNT-SW Services: Dental On-Site Residents Indicator 1 705 705 VARCHAR2 Description: Indicates if dental services are provided on-site to residents. SAS Name: DNTL_SRVC_ONST_RSDNT_SW COBOL Name: DNTL-SRVC-ONST-RSDNT-SW Services: Dietary Off-Site Residents Indicator 1 709 709 VARCHAR2 Description: Indicates if dietary services are provided off-site to residents. SAS Name: DTRY_OFSITE_RSDNT_SW COBOL Name: DTRY-OFSITE-RSDNT-SW Services: Dietary On-Site Nonresidents Indicator 1 710 710 VARCHAR2 Description: Indicates if dietary services are provided on-site to nonresidents. SAS Name: DTRY_ONST_NRSDNT_SW COBOL Name: DTRY-ONST-NRSDNT-SW Services: Dietary On-Site Residents Indicator 1 711 711 VARCHAR2 Description: Indicates if dietary services are provided on-site to residents. SAS Name: DTRY_ONST_RSDNT_SW COBOL Name: DTRY-ONST-RSDNT-SW Services: Housekeeping Off-Site Residents Indicator 1 721 721 VARCHAR2 Description: Indicates if housekeeping services are provided off-site to residents. SAS Name: HSEKPNG_SRVC_OFSITE_RSDNT_SW COBOL Name: HSEKPNG-SRVC-OFSITE-RSDNT-SW Services: Housekeeping On-Site Nonresidents Indicator 1 722 722 VARCHAR2 Description: Indicates if housekeeping services are provided on-site to nonresidents. SAS Name: HSEKPNG_SRVC_ONST_NRSDNT_SW COBOL Name: HSEKPNG-SRVC-ONST-NRSDNT-SW DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 25 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Services: Housekeeping On-Site Residents Indicator 1 723 723 VARCHAR2 Description: Indicates if housekeeping services are provided on-site to residents. SAS Name: HSEKPNG_SRVC_ONST_RSDNT_SW COBOL Name: HSEKPNG-SRVC-ONST-RSDNT-SW Services: Mental Health Off-Site Residents Indicator 1 730 730 VARCHAR2 Description: Indicates if mental health services are provided off-site to residents. SAS Name: MENTL_HLTH_OFSITE_RSDNT_SW COBOL Name: MENTL-HLTH-OFSITE-RSDNT-SW Services: Mental Health On-Site Nonresidents 1 731 731 VARCHAR2 Indicator Description: Indicates if mental health services are provided on-site to nonresidents. SAS Name: MENTL_HLTH_ONST_NRSDNT_SW COBOL Name: MENTL-HLTH-ONST-NRSDNT-SW Services: Mental Health On-Site Residents Indicator 1 732 732 VARCHAR2 Description: Indicates if mental health services are provided on-site to residents. SAS Name: MENTL_HLTH_ONST_RSDNT_SW COBOL Name: MENTL-HLTH-ONST-RSDNT-SW Services: Nursing Off-Site Residents Indicator 1 743 743 VARCHAR2 Description: Indicates if nursing services are provided off-site to residents. SAS Name: NRSNG_SRVC_OFSITE_RSDNT_SW COBOL Name: NRSNG-SRVC-OFSITE-RSDNT-SW Services: Nursing On-Site Nonresidents Indicator 1 744 744 VARCHAR2 Description: Indicates if nursing services are provided on-site to nonresidents. SAS Name: NRSNG_SRVC_ONST_NRSDNT_SW COBOL Name: NRSNG-SRVC-ONST-NRSDNT-SW Services: Nursing On-Site Residents Indicator 1 745 745 VARCHAR2 Description: Indicates if nursing services are provided on-site to residents. SAS Name: NRSNG_SRVC_ONST_RSDNT_SW COBOL Name: NRSNG-SRVC-ONST-RSDNT-SW Services: OT Off-Site Residents Indicator 1 759 759 VARCHAR2 Description: Indicates if occupational therapy services are provided off-site to residents. SAS Name: OT_SRVC_OFSITE_RSDNT_SW COBOL Name: OT-SRVC-OFSITE-RSDNT-SW Services: OT On-Site Nonresidents Indicator 1 760 760 VARCHAR2 Description: Indicates if occupational therapy services are provided on-site to nonresidents. SAS Name: OT_SRVC_ONST_NRSDNT_SW COBOL Name: OT-SRVC-ONST-NRSDNT-SW Services: OT On-Site Residents Indicator 1 761 761 VARCHAR2 Description: Indicates if occupational therapy services are provided on-site to residents. SAS Name: OT_SRVC_ONST_RSDNT_SW COBOL Name: OT-SRVC-ONST-RSDNT-SW Services: Pharmacy Off-Site Residents Indicator 1 772 772 VARCHAR2 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 26 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Indicates if pharmacy services are provided off-site to residents. SAS Name: PHRMCY_SRVC_OFSITE_RSDNT_SW COBOL Name: PHRMCY-SRVC-OFSITE-RSDNT-SW Services: Pharmacy On-Site Nonresidents Indicator 1 773 773 VARCHAR2 Description: Indicates if pharmacy services are provided on-site to nonresidents. SAS Name: PHRMCY_SRVC_ONST_NRSDNT_SW COBOL Name: PHRMCY-SRVC-ONST-NRSDNT-SW Services: Pharmacy On-Site Residents Indicator 1 774 774 VARCHAR2 Description: Indicates if pharmacy services are provided on-site to residents. SAS Name: PHRMCY_SRVC_ONST_RSDNT_SW COBOL Name: PHRMCY-SRVC-ONST-RSDNT-SW Services: Physician Extender Off-Site Residents 1 779 779 VARCHAR2 Indicator Description: Indicates if physician extender services are provided off-site to residents. SAS Name: PHYSN_EXT_SRVC_OFSITE_RSDNT_SW COBOL Name: PHYSN-EXT-SRVC-OFSITE-RSDNT-SW Services: Physician Extender On-Site Nonresidents 1 780 780 VARCHAR2 Indicator Description: Indicates if physician extender services are provided on-site to nonresidents. SAS Name: PHYSN_EXT_SRVC_ONST_NRSDNT_SW COBOL Name: PHYSN-EXT-SRVC-ONST-NRSDNT-SW Services: Physician Extender On-Site Residents 1 781 781 VARCHAR2 Indicator Description: Indicates if physician extender services are provided on-site to residents. SAS Name: PHYSN_EXT_SRVC_ONST_RSDNT_SW COBOL Name: PHYSN-EXT-SRVC-ONST-RSDNT-SW Services: Physician Off-Site Residents Indicator 1 782 782 VARCHAR2 Description: Indicates if physician services are provided off-site to residents. SAS Name: PHYSN_SRVC_OFSITE_RSDNT_SW COBOL Name: PHYSN-SRVC-OFSITE-RSDNT-SW Services: Physician On-Site Nonresidents Indicator 1 783 783 VARCHAR2 Description: Indicates if physician services are provided on-site to nonresidents. SAS Name: PHYSN_SRVC_ONST_NRSDNT_SW COBOL Name: PHYSN-SRVC-ONST-NRSDNT-SW Services: Physician On-Site Residents Indicator 1 784 784 VARCHAR2 Description: Indicates if physician services are provided on-site to residents. SAS Name: PHYSN_SRVC_ONST_RSDNT_SW COBOL Name: PHYSN-SRVC-ONST-RSDNT-SW Services: Podiatry Off-Site Residents Indicator 1 785 785 VARCHAR2 Description: Indicates if podiatry services are provided off-site to residents. SAS Name: PDTRY_SRVC_OFSITE_RSDNT_SW COBOL Name: PDTRY-SRVC-OFSITE-RSDNT-SW Services: Podiatry On-Site Nonresidents Indicator 1 786 786 VARCHAR2 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 27 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Indicates if podiatry services are provided on-site to nonresidents. SAS Name: PDTRY_SRVC_ONST_NRSDNT_SW COBOL Name: PDTRY-SRVC-ONST-NRSDNT-SW Services: Podiatry On-Site Residents Indicator 1 787 787 VARCHAR2 Description: Indicates if podiatry services are provided on-site to residents. SAS Name: PDTRY_SRVC_ONST_RSDNT_SW COBOL Name: PDTRY-SRVC-ONST-RSDNT-SW Services: PT Off-Site Residents Indicator 1 797 797 VARCHAR2 Description: Indicates if physical therapy services are provided off-site to residents. SAS Name: PT_OFSITE_RSDNT_SW COBOL Name: PT-OFSITE-RSDNT-SW Services: PT On-Site Nonresidents Indicator 1 798 798 VARCHAR2 Description: Indicates if physical therapy services are provided on-site to nonresidents. SAS Name: PT_ONST_NRSDNT_SW COBOL Name: PT-ONST-NRSDNT-SW Services: PT On-Site Residents Indicator 1 799 799 VARCHAR2 Description: Indicates if physical therapy services are provided on-site to residents. SAS Name: PT_ONST_RSDNT_SW COBOL Name: PT-ONST-RSDNT-SW Services: Social Work Off-Site Residents Indicator 1 810 810 VARCHAR2 Description: Indicates if social work services are provided off-site to residents. SAS Name: SCL_WORK_SRVC_OFSITE_RSDNT_SW COBOL Name: SCL-WORK-SRVC-OFSITE-RSDNT-SW Services: Social Work On-Site Nonresidents Indicator 1 811 811 VARCHAR2 Description: Indicates if social work services are provided on-site to nonresidents. SAS Name: SCL_WORK_SRVC_ONST_NRSDNT_SW COBOL Name: SCL-WORK-SRVC-ONST-NRSDNT-SW Services: Social Work On-Site Residents Indicator 1 812 812 VARCHAR2 Description: Indicates if social work services are provided on-site to residents. SAS Name: SCL_WORK_SRVC_ONST_RSDNT_SW COBOL Name: SCL-WORK-SRVC-ONST-RSDNT-SW Services: Speech Pathology Off-Site Residents 1 817 817 VARCHAR2 Indicator Description: Indicates if speech/language pathology services are provided off-site to residents. SAS Name: SPCH_PTHLGY_OFSITE_RSDNT_SW COBOL Name: SPCH-PTHLGY-OFSITE-RSDNT-SW Services: Speech Pathology On-Site Nonresidents 1 818 818 VARCHAR2 Indicator Description: Indicates if speech/language pathology services are provided on-site to nonresidents. SAS Name: SPCH_PTHLGY_ONST_NRSDNT_SW COBOL Name: SPCH-PTHLGY-ONST-NRSDNT-SW Services: Speech Pathology On-Site Residents 1 819 819 VARCHAR2 Indicator DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 28 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Indicates if speech/language pathology services are provided on-site to residents. SAS Name: SPCH_PTHLGY_ONST_RSDNT_SW COBOL Name: SPCH-PTHLGY-ONST-RSDNT-SW Services: Therapeutic - Other Activities Staff - 1 822 822 VARCHAR2 Off-Site Residents Indicator Description: Indicates if therapeutic services are provided off-site to residents by other activities staff. SAS Name: ACTVTY_OTHR_OFSITE_RSDNT_SW COBOL Name: ACTVTY-OTHR-OFSITE-RSDNT-SW Services: Therapeutic - Other Activities Staff - 1 823 823 VARCHAR2 On-Site Nonresidents Indicator Description: Indicates if therapeutic services are provided on-site to nonresidents by other activities staff. SAS Name: ACTVTY_OTHR_ONST_NRSDNT_SW COBOL Name: ACTVTY-OTHR-ONST-NRSDNT-SW Services: Therapeutic - Other Activities Staff - 1 824 824 VARCHAR2 On-Site Residents Indicator Description: Indicates if therapeutic services are provided on-site to residents by other activities staff. SAS Name: ACTVTY_OTHR_ONST_RSDNT_SW COBOL Name: ACTVTY-OTHR-ONST-RSDNT-SW Services: Therapeutic - Other Social Services Staff - 1 825 825 VARCHAR2 Off-Site Residents Indicator Description: Indicates if other therapeutic social services are provided off-site to residents. SAS Name: SCL_SRVC_OTHR_OFSITE_RSDNT_SW COBOL Name: SCL-SRVC-OTHR-OFSITE-RSDNT-SW Services: Therapeutic - Other Social Services Staff - 1 826 826 VARCHAR2 On-Site Nonresidents Indicator Description: Indicates if other therapeutic social services are provided on-site to nonresidents. SAS Name: SCL_SRVC_OTHR_ONST_NRSDNT_SW COBOL Name: SCL-SRVC-OTHR-ONST-NRSDNT-SW Services: Therapeutic - Other Social Services Staff - 1 827 827 VARCHAR2 On-Site Residents Indicator Description: Indicates if other therapeutic social services are provided on-site to residents. SAS Name: SCL_SRVC_OTHR_ONST_RSDNT_SW COBOL Name: SCL-SRVC-OTHR-ONST-RSDNT-SW Services: Therapeutic - Qualified Activities 1 828 828 VARCHAR2 Professional - Off-Site Residents Indicator Description: Indicates if therapeutic services are provided off-site to residents by qualified activities professionals. SAS Name: ACTVTY_OFSITE_RSDNT_SW COBOL Name: ACTVTY-OFSITE-RSDNT-SW Services: Therapeutic - Qualified Activities 1 829 829 VARCHAR2 Professional - On-Site Nonresidents Indicator Description: Indicates if therapeutic services are provided on-site to nonresidents by qualified activities professionals. SAS Name: ACTVTY_ONST_NRSDNT_SW COBOL Name: ACTVTY-ONST-NRSDNT-SW Services: Therapeutic - Qualified Activities 1 830 830 VARCHAR2 Professional - On-Site Residents Indicator DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 29 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Indicates if therapeutic services are provided on-site to residents by qualified activities professionals. SAS Name: ACTVTY_ONST_RSDNT_SW COBOL Name: ACTVTY-ONST-RSDNT-SW Services: Therapeutic Recreational Specialty Off-Site 1 832 832 VARCHAR2 Residents Indicator Description: Indicates if therapeutic recreation specialist services are provided off-site to residents. SAS Name: THRPTC_RCRTNL_OFSITE_RSDNT_SW COBOL Name: THRPTC-RCRTNL-OFSITE-RSDNT-SW Services: Therapeutic Recreational Specialty On-Site 1 833 833 VARCHAR2 Nonresidents Indicator Description: Indicates if therapeutic recreation specialist services are provided on-site to nonresidents. SAS Name: THRPTC_RCRTNL_ONST_NRSDNT_SW COBOL Name: THRPTC-RCRTNL-ONST-NRSDNT-SW Services: Therapeutic Recreational Specialty On-Site 1 834 834 VARCHAR2 Residents Indicator Description: Indicates if therapeutic recreation specialist services are provided on-site to residents. SAS Name: THRPTC_RCRTNL_ONST_RSDNT_SW COBOL Name: THRPTC-RCRTNL-ONST-RSDNT-SW Services: Vocational Off-Site Residents Indicator 1 837 837 VARCHAR2 Description: Indicates if vocational services are provided off-site to residents. SAS Name: VCTNL_SRVC_OFSITE_RSDNT_SW COBOL Name: VCTNL-SRVC-OFSITE-RSDNT-SW Services: Vocational On-Site Nonresidents Indicator 1 838 838 VARCHAR2 Description: Indicates if vocational services are provided on-site to nonresidents. SAS Name: VCTNL_SRVC_ONST_NRSDNT_SW COBOL Name: VCTNL-SRVC-ONST-NRSDNT-SW Services: Vocational On-Site Residents Indicator 1 839 839 VARCHAR2 Description: Indicates if vocational services are provided on-site to residents. SAS Name: VCTNL_SRVC_ONST_RSDNT_SW COBOL Name: VCTNL-SRVC-ONST-RSDNT-SW Services: X-ray Off-Site Residents Indicator 1 840 840 VARCHAR2 Description: Indicates if diagnostic X-ray services are provided off-site to residents. SAS Name: DGNSTC_XRAY_OFSITE_RSDNT_SW COBOL Name: DGNSTC-XRAY-OFSITE-RSDNT-SW Services: X-ray On-Site Nonresidents Indicator 1 841 841 VARCHAR2 Description: Indicates if diagnostic X-ray services are provided on-site to nonresidents. SAS Name: DGNSTC_XRAY_ONST_NRSDNT_SW COBOL Name: DGNSTC-XRAY-ONST-NRSDNT-SW Services: X-ray On-Site Residents Indicator 1 842 842 VARCHAR2 Description: Indicates if diagnostic X-ray services are provided on-site to residents. SAS Name: DGNSTC_XRAY_ONST_RSDNT_SW COBOL Name: DGNSTC-XRAY-ONST-RSDNT-SW Staff Count Override Indicator 1 844 844 CHAR DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 30 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Indicates if the regional office has approved a significant staff count change from the previous certification. SAS Name: OVRRD_STFG_SW COBOL Name: OVRRD-STFG-SW Staff Count: Administrative Staff - Contract 8 845 852 NUMBER Description: Number of full-time equivalent administrative staff under contract to a facility. SAS Name: PROFNL_ADMIN_CNTRCT_CNT COBOL Name: PROFNL-ADMIN-CNTRCT-CNT Staff Count: Administrative Staff - Full-Time 8 853 860 NUMBER Description: Number of full-time equivalent administrative staff employed on a full-time basis by a facility. SAS Name: PROFNL_ADMIN_FLTM_CNT COBOL Name: PROFNL-ADMIN-FLTM-CNT Staff Count: Administrative Staff - Part-Time 8 861 868 NUMBER Description: Number of full-time equivalent administrative staff employed on a part-time basis by a facility. SAS Name: PROFNL_ADMIN_PRTM_CNT COBOL Name: PROFNL-ADMIN-PRTM-CNT Staff Count: Certified Nurse Aide - Contract 8 893 900 NUMBER Description: Number of full-time equivalent certified nurse aides under contract to a facility. SAS Name: NRS_AIDE_CNTRCT_CNT COBOL Name: NRS-AIDE-CNTRCT-CNT Staff Count: Certified Nurse Aide - Full-Time 8 901 908 NUMBER Description: Number of full-time equivalent certified nurse aides employed full-time by a facility. SAS Name: NRS_AIDE_FLTM_CNT COBOL Name: NRS-AIDE-FLTM-CNT Staff Count: Certified Nurse Aide - Part-Time 8 909 916 NUMBER Description: Number of full-time equivalent certified nurse aides employed part-time by a facility. SAS Name: NRS_AIDE_PRTM_CNT COBOL Name: NRS-AIDE-PRTM-CNT Staff Count: Dentist - Contract 8 941 948 NUMBER Description: Number of full-time equivalent dentists under contract to a facility. SAS Name: DNTST_CNTRCT_CNT COBOL Name: DNTST-CNTRCT-CNT Staff Count: Dentist - Full-Time 8 949 956 NUMBER Description: Number of full-time equivalent dentists employed full time by a facility. SAS Name: DNTST_FLTM_CNT COBOL Name: DNTST-FLTM-CNT Staff Count: Dentist - Part-Time 8 957 964 NUMBER Description: Number of full-time equivalent dentists employed part time by a facility. SAS Name: DNTST_PRTM_CNT COBOL Name: DNTST-PRTM-CNT Staff Count: Dietitian - Contract 8 973 980 NUMBER Description: Number of full-time equivalent dietitians under contract to a facility. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 31 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: DIETN_CNTRCT_CNT COBOL Name: DIETN-CNTRCT-CNT Staff Count: Dietitian - Full-Time 8 981 988 NUMBER Description: Number of full-time equivalent dietitians employed full time by a facility. SAS Name: DIETN_FLTM_CNT COBOL Name: DIETN-FLTM-CNT Staff Count: Dietitian - Part-Time 8 989 996 NUMBER Description: Number of full-time equivalent dietitians employed part time by a facility. SAS Name: DIETN_PRTM_CNT COBOL Name: DIETN-PRTM-CNT Staff Count: Food Service Worker - Contract 8 1005 1012 NUMBER Description: Number of full-time equivalent food service personnel under contract to a facility. SAS Name: FOOD_SRVC_CNTRCT_CNT COBOL Name: FOOD-SRVC-CNTRCT-CNT Staff Count: Food Service Worker - Full-Time 8 1013 1020 NUMBER Description: Number of full-time equivalent food service personnel employed full-time by a facility. SAS Name: FOOD_SRVC_FLTM_CNT COBOL Name: FOOD-SRVC-FLTM-CNT Staff Count: Food Service Worker - Part-Time 8 1021 1028 NUMBER Description: Number of full-time equivalent food service personnel employed part-time by a facility. SAS Name: FOOD_SRVC_PRTM_CNT COBOL Name: FOOD-SRVC-PRTM-CNT Staff Count: Housekeeping - Contract 8 1053 1060 NUMBER Description: Number of full-time equivalent housekeeping personnel under contract to a facility. SAS Name: HSEKPNG_CNTRCT_CNT COBOL Name: HSEKPNG-CNTRCT-CNT Staff Count: Housekeeping - Full-Time 8 1061 1068 NUMBER Description: Number of full-time equivalent housekeeping personnel employed full-time by a facility. SAS Name: HSEKPNG_FLTM_CNT COBOL Name: HSEKPNG-FLTM-CNT Staff Count: Housekeeping - Part-Time 8 1069 1076 NUMBER Description: Number of full-time equivalent housekeeping personnel employed part-time by a facility. SAS Name: HSEKPNG_PRTM_CNT COBOL Name: HSEKPNG-PRTM-CNT Staff Count: LPN/LVN - Contract 8 1101 1108 NUMBER Description: Number of full-time equivalent licensed practical/vocational nurses under contract to a facility. SAS Name: LPN_LVN_CNTRCT_CNT COBOL Name: LPN-LVN-CNTRCT-CNT Staff Count: LPN/LVN - Full-Time 8 1109 1116 NUMBER Description: Number of full-time equivalent licensed practical/vocational nurses employed full-time by a facility. SAS Name: LPN_LVN_FLTM_CNT COBOL Name: LPN-LVN-FLTM-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 32 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Staff Count: LPN/LVN - Part-Time 8 1117 1124 NUMBER Description: Number of full-time equivalent licensed practical/vocational nurses employed part-time by a facility. SAS Name: LPN_LVN_PRTM_CNT COBOL Name: LPN-LVN-PRTM-CNT Staff Count: Medical Director - Contract 8 1133 1140 NUMBER Description: Number of full-time equivalent medical directors under contract to a facility. SAS Name: MDCL_DRCTR_CNTRCT_CNT COBOL Name: MDCL-DRCTR-CNTRCT-CNT Staff Count: Medical Director - Full-Time 8 1141 1148 NUMBER Description: Number of full-time equivalent medical directors employed full-time by a facility. SAS Name: MDCL_DRCTR_FLTM_CNT COBOL Name: MDCL-DRCTR-FLTM-CNT Staff Count: Medical Director - Part-Time 8 1149 1156 NUMBER Description: Number of full-time equivalent medical directors employed part-time by a facility. SAS Name: MDCL_DRCTR_PRTM_CNT COBOL Name: MDCL-DRCTR-PRTM-CNT Staff Count: Medication Aide/Technician - Contract 8 1181 1188 NUMBER Description: Number of full-time equivalent medication aides/ technicians under contract to a facility. SAS Name: MDCTN_AIDE_CNTRCT_CNT COBOL Name: MDCTN-AIDE-CNTRCT-CNT Staff Count: Medication Aide/Technician - Full-Time 8 1189 1196 NUMBER Description: Number of full-time equivalent medication aides/ technicians employed full-time by a facility. SAS Name: MDCTN_AIDE_FLTM_CNT COBOL Name: MDCTN-AIDE-FLTM-CNT Staff Count: Medication Aide/Technician - Part-Time 8 1197 1204 NUMBER Description: Number of full-time equivalent medication aides/ technicians employed part-time by a facility. SAS Name: MDCTN_AIDE_PRTM_CNT COBOL Name: MDCTN-AIDE-PRTM-CNT Staff Count: Mental Health Services - Contract 8 1205 1212 NUMBER Description: Number of full-time equivalent mental health services personnel under contract to a facility. SAS Name: MENTL_HLTH_SRVC_CNTRCT_CNT COBOL Name: MENTL-HLTH-SRVC-CNTRCT-CNT Staff Count: Mental Health Services - Full-Time 8 1213 1220 NUMBER Description: Number of full-time equivalent mental health services personnel employed full-time by a facility. SAS Name: MENTL_HLTH_SRVC_FLTM_CNT COBOL Name: MENTL-HLTH-SRVC-FLTM-CNT Staff Count: Mental Health Services - Part-Time 8 1221 1228 NUMBER Description: Number of full-time equivalent mental health services personnel employed part-time by a facility. SAS Name: MENTL_HLTH_SRVC_PRTM_CNT COBOL Name: MENTL-HLTH-SRVC-PRTM-CNT Staff Count: Nurse Aide in Training - Contract 8 1237 1244 NUMBER DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 33 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Number of full-time equivalent nurse aides in training under contract to a facility. SAS Name: NAT_CNTRCT_CNT COBOL Name: NAT-CNTRCT-CNT Staff Count: Nurse Aide in Training - Full-Time 8 1245 1252 NUMBER Description: Number of full-time equivalent nurse aides in training employed full-time by a facility. SAS Name: NAT_FLTM_CNT COBOL Name: NAT-FLTM-CNT Staff Count: Nurse Aide in Training - Part-Time 8 1253 1260 NUMBER Description: Number of full-time equivalent nurse aides in training employed part-time by a facility. SAS Name: NAT_PRTM_CNT COBOL Name: NAT-PRTM-CNT Staff Count: Nurse With Administrative Duties - 8 1269 1276 NUMBER Contract Description: Number of full-time equivalent nurses with administrative duties under contract to a facility. SAS Name: NRS_ADMINV_CNTRCT_CNT COBOL Name: NRS-ADMINV-CNTRCT-CNT Staff Count: Nurse With Administrative Duties - 8 1277 1284 NUMBER Full-Time Description: Number of full-time equivalent nurses with administrative duties employed full-time by a facility. SAS Name: NRS_ADMINV_FLTM_CNT COBOL Name: NRS-ADMINV-FLTM-CNT Staff Count: Nurse With Administrative Duties - 8 1285 1292 NUMBER Part-Time Description: Number of full-time equivalent nurses with administrative duties employed part-time by a facility. SAS Name: NRS_ADMINV_PRTM_CNT COBOL Name: NRS-ADMINV-PRTM-CNT Staff Count: OT - Arrangement 8 1301 1308 NUMBER Description: Number of full-time equivalent occupational therapists under arrangement to the provider SAS Name: OCPTNL_THRPST_CNTRCT_CNT COBOL Name: OCPTNL-THRPST-CNTRCT-CNT Staff Count: OT - Full-Time 8 1309 1316 NUMBER Description: Number of full-time equivalent occupational therapists employed full-time by a facility. SAS Name: OCPTNL_THRPST_FLTM_CNT COBOL Name: OCPTNL-THRPST-FLTM-CNT Staff Count: OT - Part-Time 8 1317 1324 NUMBER Description: Number of full-time equivalent occupational therapists employed part-time by a facility. SAS Name: OCPTNL_THRPST_PRTM_CNT COBOL Name: OCPTNL-THRPST-PRTM-CNT Staff Count: OT Aide - Contract 8 1325 1332 NUMBER Description: Number of full-time equivalent occupational therapy aides under contract to a facility. SAS Name: OT_AIDE_CNTRCT_CNT COBOL Name: OT-AIDE-CNTRCT-CNT Staff Count: OT Aide - Full-Time 8 1333 1340 NUMBER DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 34 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Number of full-time equivalent occupational therapy aides employed full-time by a facility. SAS Name: OT_AIDE_FLTM_CNT COBOL Name: OT-AIDE-FLTM-CNT Staff Count: OT Aide - Part-Time 8 1341 1348 NUMBER Description: Number of full-time equivalent occupational therapy aides employed part-time by a facility. SAS Name: OT_AIDE_PRTM_CNT COBOL Name: OT-AIDE-PRTM-CNT Staff Count: OT Assistant - Contract 8 1349 1356 NUMBER Description: Number of full-time equivalent occupational therapy assistants under contract to a facility. SAS Name: OT_ASTNT_CNTRCT_CNT COBOL Name: OT-ASTNT-CNTRCT-CNT Staff Count: OT Assistant - Full-Time 8 1357 1364 NUMBER Description: Number of full-time equivalent occupational therapy assistants employed full-time by a facility. SAS Name: OT_ASTNT_FLTM_CNT COBOL Name: OT-ASTNT-FLTM-CNT Staff Count: OT Assistant - Part-Time 8 1365 1372 NUMBER Description: Number of full-time equivalent occupational therapy assistants employed part-time by a facility. SAS Name: OT_ASTNT_PRTM_CNT COBOL Name: OT-ASTNT-PRTM-CNT Staff Count: Other Activities - Contract 8 1381 1388 NUMBER Description: Number of full-time equivalent other activities staff providing therapeutic services under contract to a facility. SAS Name: ACTVTY_STF_OTHR_CNTRCT_CNT COBOL Name: ACTVTY-STF-OTHR-CNTRCT-CNT Staff Count: Other Activities - Full-Time 8 1389 1396 NUMBER Description: Number of full-time equivalent other activities staff providing therapeutic services employed full time by a facility. SAS Name: ACTVTY_STF_OTHR_FLTM_CNT COBOL Name: ACTVTY-STF-OTHR-FLTM-CNT Staff Count: Other Activities - Part-Time 8 1397 1404 NUMBER Description: Number of full-time equivalent other activities staff providing therapeutic services employed part time by a facility. SAS Name: ACTVTY_STF_OTHR_PRTM_CNT COBOL Name: ACTVTY-STF-OTHR-PRTM-CNT Staff Count: Other Physician - Contract 8 1405 1412 NUMBER Description: Number of full-time equivalent other physicians under contract to a facility. SAS Name: PHYSN_OTHR_CNTRCT_CNT COBOL Name: PHYSN-OTHR-CNTRCT-CNT Staff Count: Other Physician - Full-Time 8 1413 1420 NUMBER Description: Number of full-time equivalent other physicians employed full-time by a facility. SAS Name: PHYSN_OTHR_FLTM_CNT COBOL Name: PHYSN-OTHR-FLTM-CNT Staff Count: Other Physician - Part-Time 8 1421 1428 NUMBER DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 35 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Number of full-time equivalent other physicians employed part-time by a facility. SAS Name: PHYSN_OTHR_PRTM_CNT COBOL Name: PHYSN-OTHR-PRTM-CNT Staff Count: Other Social Services - Contract 8 1429 1436 NUMBER Description: Number of full-time equivalent other social services staff under contract to a facility. SAS Name: SCL_SRVC_OTHR_STF_CNTRCT_CNT COBOL Name: SCL-SRVC-OTHR-STF-CNTRCT-CNT Staff Count: Other Social Services - Full-Time 8 1437 1444 NUMBER Description: Number of full-time equivalent other social services staff employed full time by a facility. SAS Name: SCL_SRVC_OTHR_STF_FLTM_CNT COBOL Name: SCL-SRVC-OTHR-STF-FLTM-CNT Staff Count: Other Social Services - Part-Time 8 1445 1452 NUMBER Description: Number of full-time equivalent other social services staff employed part time by a facility. SAS Name: SCL_SRVC_OTHR_STF_PRTM_CNT COBOL Name: SCL-SRVC-OTHR-STF-PRTM-CNT Staff Count: Other Staff - Contract 8 1453 1460 NUMBER Description: Number of full-time equivalent staff not included in any other categories under contract to the facility. SAS Name: STF_OTHR_CNTRCT_CNT COBOL Name: STF-OTHR-CNTRCT-CNT Staff Count: Other Staff - Full-Time 8 1461 1468 NUMBER Description: Number of full-time equivalent persons not included in any other categories employed full-time by the facility. SAS Name: STF_OTHR_FLTM_CNT COBOL Name: STF-OTHR-FLTM-CNT Staff Count: Other Staff - Part-Time 8 1469 1476 NUMBER Description: Number of full-time equivalent persons not included in any other categories employed part-time by the facility. SAS Name: STF_OTHR_PRTM_CNT COBOL Name: STF-OTHR-PRTM-CNT Staff Count: Pharmacist - Contract 8 1477 1484 NUMBER Description: Number of full-time equivalent pharmacists under contract to a facility. SAS Name: PHRMCST_CNTRCT_CNT COBOL Name: PHRMCST-CNTRCT-CNT Staff Count: Pharmacist - Full-Time 8 1485 1492 NUMBER Description: Number of full-time equivalent pharmacists employed full-time by a facility. SAS Name: PHRMCST_FLTM_CNT COBOL Name: PHRMCST-FLTM-CNT Staff Count: Pharmacist - Part-Time 8 1493 1500 NUMBER Description: Number of full-time equivalent pharmacists employed part-time by a facility. SAS Name: PHRMCST_PRTM_CNT COBOL Name: PHRMCST-PRTM-CNT Staff Count: Physical Therapist - Contract 8 1501 1508 NUMBER Description: Number of full-time equivalent physical therapists under contract to a facility. SAS Name: PHYS_THRPST_CNTRCT_CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 36 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: PHYS-THRPST-CNTRCT-CNT Staff Count: Physical Therapist - Full-Time 8 1509 1516 NUMBER Description: Number of full-time equivalent physical therapists employed full-time by a facility. SAS Name: PHYS_THRPST_FLTM_CNT COBOL Name: PHYS-THRPST-FLTM-CNT Staff Count: Physical Therapist - Part-Time 8 1517 1524 NUMBER Description: Number of full-time equivalent physical therapists employed part-time by a facility. SAS Name: PHYS_THRPST_PRTM_CNT COBOL Name: PHYS-THRPST-PRTM-CNT Staff Count: Physician Extender - Contract 8 1549 1556 NUMBER Description: Number of full-time equivalent physician extenders under contract to the facility. SAS Name: PHYSN_EXT_CNTRCT_CNT COBOL Name: PHYSN-EXT-CNTRCT-CNT Staff Count: Physician Extender - Full-Time 8 1557 1564 NUMBER Description: Number of full-time equivalent physician extenders employed full-time by the facility. SAS Name: PHYSN_EXT_FLTM_CNT COBOL Name: PHYSN-EXT-FLTM-CNT Staff Count: Physician Extender - Part-Time 8 1565 1572 NUMBER Description: Number of full-time equivalent physician extenders employed part-time by the facility. SAS Name: PHYSN_EXT_PRTM_CNT COBOL Name: PHYSN-EXT-PRTM-CNT Staff Count: Podiatrist - Contract 8 1581 1588 NUMBER Description: Number of full-time equivalent podiatrists under contract to a facility. SAS Name: PDTRST_CNTRCT_CNT COBOL Name: PDTRST-CNTRCT-CNT Staff Count: Podiatrist - Full-Time 8 1589 1596 NUMBER Description: Number of full-time equivalent podiatrists employed full-time by a facility. SAS Name: PDTRST_FLTM_CNT COBOL Name: PDTRST-FLTM-CNT Staff Count: Podiatrist - Part-Time 8 1597 1604 NUMBER Description: Number of full-time equivalent podiatrists employed part-time by a facility. SAS Name: PDTRST_PRTM_CNT COBOL Name: PDTRST-PRTM-CNT Staff Count: PT Aide - Contract 8 1637 1644 NUMBER Description: Number of full-time equivalent physical therapy aides under contract to a facility. SAS Name: PT_AIDE_CNTRCT_CNT COBOL Name: PT-AIDE-CNTRCT-CNT Staff Count: PT Aide - Full-Time 8 1645 1652 NUMBER Description: Number of full-time equivalent physical therapy aides employed full-time by a facility. SAS Name: PT_AIDE_FLTM_CNT COBOL Name: PT-AIDE-FLTM-CNT Staff Count: PT Aide - Part-Time 8 1653 1660 NUMBER DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 37 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Number of full-time equivalent physical therapy aides employed part-time by a facility. SAS Name: PT_AIDE_PRTM_CNT COBOL Name: PT-AIDE-PRTM-CNT Staff Count: PT Assistant - Contract 8 1661 1668 NUMBER Description: Number of full-time equivalent physical therapy assistants under contract to a facility. SAS Name: PT_ASTNT_CNTRCT_CNT COBOL Name: PT-ASTNT-CNTRCT-CNT Staff Count: PT Assistant - Full-Time 8 1669 1676 NUMBER Description: Number of full-time equivalent physical therapy assistants employed full-time by a facility. SAS Name: PT_ASTNT_FLTM_CNT COBOL Name: PT-ASTNT-FLTM-CNT Staff Count: PT Assistant - Part-Time 8 1677 1684 NUMBER Description: Number of full-time equivalent physical therapy assistants employed part-time by a facility. SAS Name: PT_ASTNT_PRTM_CNT COBOL Name: PT-ASTNT-PRTM-CNT Staff Count: Qualified Activities Professional - 8 1685 1692 NUMBER Contract Description: Number of full-time equivalent qualified activities professionals providing therapeutic services under contract to a facility. SAS Name: ACTVTY_PROFNL_CNTRCT_CNT COBOL Name: ACTVTY-PROFNL-CNTRCT-CNT Staff Count: Qualified Activities Professional - 8 1693 1700 NUMBER Full-Time Description: Number of full-time equivalent qualified activities professionals providing therapeutic services employed full time by a facility. SAS Name: ACTVTY_PROFNL_FLTM_CNT COBOL Name: ACTVTY-PROFNL-FLTM-CNT Staff Count: Qualified Activities Professional - 8 1701 1708 NUMBER Part-Time Description: Number of full-time equivalent qualified activities professionals providing therapeutic services employed part time by a facility. SAS Name: ACTVTY_PROFNL_PRTM_CNT COBOL Name: ACTVTY-PROFNL-PRTM-CNT Staff Count: RN - Contract 8 1741 1748 NUMBER Description: Number of full-time equivalent registered nurses under contract to a facility. SAS Name: RN_CNTRCT_CNT COBOL Name: RN-CNTRCT-CNT Staff Count: RN - Full-Time 8 1749 1756 NUMBER Description: Number of full-time equivalent registered nurses employed full-time by a facility. SAS Name: RN_FLTM_CNT COBOL Name: RN-FLTM-CNT Staff Count: RN - Part-Time 8 1757 1764 NUMBER Description: Number of full-time equivalent registered nurses employed part-time by a facility. SAS Name: RN_PRTM_CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 38 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: RN-PRTM-CNT Staff Count: RN Director of Nursing - Contract 8 1773 1780 NUMBER Description: Number of full-time equivalent registered nurse directors of nursing under contract to a facility. SAS Name: RN_DRCTR_CNTRCT_CNT COBOL Name: RN-DRCTR-CNTRCT-CNT Staff Count: RN Director of Nursing - Full-Time 8 1781 1788 NUMBER Description: Number of full-time equivalent registered nurse directors of nursing employed full-time by a facility. SAS Name: RN_DRCTR_FLTM_CNT COBOL Name: RN-DRCTR-FLTM-CNT Staff Count: RN Director of Nursing - Part-Time 8 1789 1796 NUMBER Description: Number of full-time equivalent registered nurse directors of nursing employed part-time by a facility. SAS Name: RN_DRCTR_PRTM_CNT COBOL Name: RN-DRCTR-PRTM-CNT Staff Count: Social Worker - Contract 8 1805 1812 NUMBER Description: Number of full-time equivalent social workers under contract to a facility. SAS Name: SCL_WORKR_CNTRCT_CNT COBOL Name: SCL-WORKR-CNTRCT-CNT Staff Count: Social Worker - Full-Time 8 1813 1820 NUMBER Description: Number of full-time equivalent social workers employed full-time by a facility. SAS Name: SCL_WORKR_FLTM_CNT COBOL Name: SCL-WORKR-FLTM-CNT Staff Count: Social Worker - Part-Time 8 1821 1828 NUMBER Description: Number of full-time equivalent social workers employed part-time by a facility. SAS Name: SCL_WORKR_PRTM_CNT COBOL Name: SCL-WORKR-PRTM-CNT Staff Count: Speech Pathologist - Contract 8 1837 1844 NUMBER Description: Number of full-time equivalent speech pathologists under contract to a facility. SAS Name: SPCH_PTHLGST_CNTRCT_CNT COBOL Name: SPCH-PTHLGST-CNTRCT-CNT Staff Count: Speech Pathologist - Full-Time 8 1845 1852 NUMBER Description: Number of full-time equivalent speech pathologists employed full-time by a facility. SAS Name: SPCH_PTHLGST_FLTM_CNT COBOL Name: SPCH-PTHLGST-FLTM-CNT Staff Count: Speech Pathologist - Part-Time 8 1853 1860 NUMBER Description: Number of full-time equivalent speech pathologists employed part-time by a facility. SAS Name: SPCH_PTHLGST_PRTM_CNT COBOL Name: SPCH-PTHLGST-PRTM-CNT Staff Count: Therapeutic Recreational Specialist - 8 1893 1900 NUMBER Contract Description: Number of full-time equivalent therapeutic recreation specialist staff under contract to a facility. SAS Name: THRPTC_RCRTNL_CNTRCT_CNT COBOL Name: THRPTC-RCRTNL-CNTRCT-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 39 Skilled Nursing Facility/Nursing Facility (Dually Certified), CATEGORY = "02" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Staff Count: Therapeutic Recreational Specialist - 8 1901 1908 NUMBER Full-Time Description: Number of full-time equivalent therapeutic recreation specialist staff employed full-time by a facility. SAS Name: THRPTC_RCRTNL_FLTM_CNT COBOL Name: THRPTC-RCRTNL-FLTM-CNT Staff Count: Therapeutic Recreational Specialist - 8 1909 1916 NUMBER Part-Time Description: Number of full-time equivalent therapeutic recreation specialist staff employed full-time by a facility. SAS Name: THRPTC_RCRTNL_PRTM_CNT COBOL Name: THRPTC-RCRTNL-PRTM-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 1 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Provider Category Subtype Code 2 1 2 VARCHAR2 Description: Identifies the subtype of the provider, within the primary category. Used in reporting to show the breakdown of provider categories, mainly for hospitals and SNFs. SAS Name: PRVDR_CTGRY_SBTYP_CD COBOL Name: PRVDR-CTGRY-SBTYP-CD VALUES: 03=Title 18/19 Provider Category Code 2 3 4 VARCHAR2 Description: Identifies the type of provider participating in the Medicare/Medicaid program. SAS Name: PRVDR_CTGRY_CD COBOL Name: PRVDR-CTGRY-CD VALUES: 03=Skilled Nursing Facility/Nursing Facility (Distinct Part) CHOW Count 2 5 6 NUMBER Description: Number of times this provider has undergone a change of ownership. SAS Name: CHOW_CNT COBOL Name: CHOW-CNT CHOW Date 8 7 14 DATE Description: Effective date of the most recent change of ownership for this provider. SAS Name: CHOW_DT COBOL Name: CHOW-DT Address: City 28 15 42 VARCHAR2 Description: City in which the provider is physically located. SAS Name: CITY_NAME COBOL Name: CITY-NAME Compliance: Acceptable POC 1 43 43 VARCHAR2 Description: Indicates if a provider is in compliance with program requirements based on an acceptable plan for correction of deficiencies. SAS Name: ACPTBL_POC_SW COBOL Name: ACPTBL-POC-SW Compliance: Status 1 44 44 VARCHAR2 Description: Compliance status of a provider at the time of certification survey. SAS Name: CMPLNC_STUS_CD COBOL Name: CMPLNC-STUS-CD VALUES: A=IN COMPLIANCE B=NOT IN COMPLIANCE SSA County Code 3 45 47 VARCHAR2 Description: Social Security Administration geographic code indicating the county where the provider is located. SAS Name: SSA_CNTY_CD COBOL Name: SSA-CNTY-CD Cross Ref Provider Number 10 48 57 CHAR Description: Cross reference provider number SAS Name: CROSS_REF_PROVIDER_NUMBER COBOL Name: CROSS-REF-PROVIDER-NUMBER Certification Date 8 58 65 DATE Description: Equal to the exit date of the initial visit of the Health survey for certifications completed after July 28, 2012. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 2 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE For certifications prior to that date, the certification date is equal to the exit date of the initial visit of the Health survey or LSC survey, whichever is later. SAS Name: CRTFCTN_DT COBOL Name: CRTFCTN-DT Eligibility Indicator 1 66 66 VARCHAR2 Description: Indicates if a facility is eligible to participate in the Medicare and/or Medicaid programs. SAS Name: ELGBLTY_SW COBOL Name: ELGBLTY-SW Facility Name 50 67 116 VARCHAR2 Description: Name of the provider certified to participate in the Medicare and/or Medicaid programs. SAS Name: FAC_NAME COBOL Name: FAC-NAME Medicare Administrative Contractor (MAC) or 5 117 121 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_CD COBOL Name: INTRMDRY-CARR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 3 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 4 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 5 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 6 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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 15 122 136 VARCHAR2 Description: Number which may be assigned to a provider by the state Medicaid agency for external control or billing purposes. SAS Name: MDCD_VNDR_NUM COBOL Name: MDCD-VNDR-NUM Original Participation Date 8 137 144 DATE Description: Date a provider is first approved to provide Medicare and/or Medicaid services. SAS Name: ORGNL_PRTCPTN_DT COBOL Name: ORGNL-PRTCPTN-DT Prior CHOW Date 8 145 152 DATE Description: Effective date of the previous change of ownership for this provider. SAS Name: CHOW_PRIOR_DT COBOL Name: CHOW-PRIOR-DT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 7 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Prior Medicare Administrative Contractor (MAC) or 5 153 157 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the previous Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_PRIOR_CD COBOL Name: INTRMDRY-CARR-PRIOR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 8 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 9 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 10 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 11 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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) CCN 10 158 167 VARCHAR2 Description: Six or ten position identification number that is assigned to a certified provider. This is the CMS Certification Number. SAS Name: PRVDR_NUM COBOL Name: PRVDR-NUM Region Code 2 168 169 VARCHAR2 Description: Indicates the CMS Regional Office responsible for the certification of the provider. SAS Name: RGN_CD COBOL Name: RGN-CD VALUES: 01=Boston 02=New York 03=Philadelphia 04=Atlanta 05=Chicago 06=Dallas 07=Kansas City 08=Denver 09=San Francisco 10=Seattle Skeleton Record Indicator 1 170 170 VARCHAR2 Description: Indicates if the record is a skeleton record. Only a limited set of data is available for this provider; no survey data exists. SAS Name: SKLTN_REC_SW COBOL Name: SKLTN-REC-SW State Abbreviation 2 171 172 VARCHAR2 Description: Two-character state abbreviation. SAS Name: STATE_CD COBOL Name: STATE-CD VALUES: AK=ALASKA AL=ALABAMA DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 12 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE AR=ARKANSAS AS=AMERICAN SAMOA AZ=ARIZONA CA=CALIFORNIA CN=CANADA CO=COLORADO CT=CONNECTICUT DC=DISTRICT OF COLUMBIA DE=DELAWARE FL=FLORIDA FN=INTERNATIONAL GA=GEORGIA GU=GUAM HI=HAWAII IA=IOWA ID=IDAHO IL=ILLINOIS IN=INDIANA KS=KANSAS KY=KENTUCKY LA=LOUISIANA MA=MASSACHUSETTS MD=MARYLAND ME=MAINE MI=MICHIGAN MN=MINNESOTA MO=MISSOURI MP=SAIPAN MS=MISSISSIPPI MT=MONTANA MX=MEXICO NC=NORTH CAROLINA ND=NORTH DAKOTA NE=NEBRASKA NH=NEW HAMPSHIRE NJ=NEW JERSEY NM=NEW MEXICO NV=NEVADA NY=NEW YORK OH=OHIO OK=OKLAHOMA OR=OREGON PA=PENNSYLVANIA PR=PUERTO RICO RI=RHODE ISLAND SC=SOUTH CAROLINA SD=SOUTH DAKOTA TN=TENNESSEE TX=TEXAS UT=UTAH VA=VIRGINIA VI=VIRGIN ISLANDS VT=VERMONT WA=WASHINGTON WI=WISCONSIN WV=WEST VIRGINIA WY=WYOMING SSA State Code 2 173 174 VARCHAR2 Description: Social Security Administration geographic code indicating the state where the provider is located. SAS Name: SSA_STATE_CD COBOL Name: SSA-STATE-CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 13 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 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 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 56=CANADA 57=WEST INDIES 58=EUROPE 59=MEXICO 60=OCEANIA 61=PHILIPPINES 62=SOUTH AMERICA 63=UNITED STATES POSSESSIONS 64=AMERICAN SAMOA DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 14 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 65=GUAM 66=SAIPAN 99=INTERNATIONAL State Region Code 3 175 177 VARCHAR2 Description: Identifies the region within a state where the provider is located. SAS Name: STATE_RGN_CD COBOL Name: STATE-RGN-CD VALUES: AK/001=ALASKA AK/LAB=LABORATORIES AL/001=ALABAMA AL/LAB=LABORATORIES AR/001=ARKANSAS AR/LAB=LABORATORIES AS/001=AMERICAN SAMOA AS/LAB=LABORATORY AZ/AZ=PHOENIX AZ/LAB=ARIZONA LAB AZ/TUC=TUCSON CA/BAK=BAKERSFIELD CA/BER=SAN BERNARDINO CA/BK=BERKELEY CA/BK1=CONTRA COSTA CA/FR=FRESNO CA/L1=L.A. WEST CA/L2=L.A. NORTH CA/L3=L.A. CENTRAL CA/L4=L.A. EAST CA/L5=SAN GABRIEL CA/LAB=LABORATORIES CA/M1=LAB. SOUTH CA/M2=LAB. NORTH CA/ORG=ORANGE CO CA/RIV=RIVERSIDE CA/RWC=REDWOOD COAST CA/S1=SACRAMENTO CA/S2=SACTO SOUTH CA/S3=CHICO CA/SD=SAN DIEGO CA/SDS=SAN DIEGO SOUTH CA/SF=SAN FRANCISCO CA/SJ=SAN JOSE CA/SR=SANTA ROSA CA/VEN=VENTURA CN/001=CANADA CN/LAB=LABORATORY CO/001=COLORADO CO/LAB=LABORATORIES CT/001=CONNECTICUT CT/LAB=LABORATORIES DC/001=DISTRICT OF COLUMBIA DC/LAB=LABORATORIES DE/001=DELAWARE DE/LAB=LABORATORIES FL/FTM=FT. MYERS FL/GAI=GAINESVILLE FL/JAX=JACKSONVILLE FL/LAB=LABORATORIES FL/LAN=LANTANA FL/LAU=LAUDERHILL FL/MIA=MIAMI FL/ORL=ORLANDO DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 15 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE FL/PEN=PENSACOLA FL/STP=ST. PETERSBURG FL/TAL=TALLAHASSEE FL/TAM=TAMPA FM/001=FEDERATED STATES OF MICRO FN/001=INTERNATIONAL FN/LAB=LABORATORIES GA/001=GEORGIA GA/GAA=GEORGIA ALL GA/GAC=GEORGIA CENTRAL GA/GAE=GEORGIA EASTERN GA/GAN=GEORGIA NORTH GA/GAS=GEORGIA SOUTH GA/GAW=GEORGIA WESTERN GA/LAB=LABORATORIES GU/001=GUAM GU/LAB=LABORATORIES HI/001=HAWAII HI/LAB=LABORATORIES IA/001=IOWA IA/LAB=LABORATORIES ID/001=IDAHO ID/LAB=LABORATORIES IL/001=ILLINOIS IL/LAB=LABORATORIES IN/001=INDIANA IN/LAB=LABORATORIES KS/KCK=KANSAS CITY KS/KDH=KDHE KS/LAB=LABORATORIES KS/LAW=LAWRENCE KS/NC=NORTH CENTRAL KANSAS KS/NE=NORTH EAST KANSAS KS/NW=NORTH WEST KANSAS KS/SC=SOUTH CENTRAL KANSAS KS/SE=SOUTH EAST KANSAS KS/SW=SOUTH WEST KANSAS KS/WST=WEST KY/2C1=HOPKINSVILLE KY/2C2=LOUISVILLE KY/2C3=LONDON KY/2C4=LEXINGTON KY/LAB=LABORATORIES LA/001=LOUISIANA LA/LA1=NEW ORLEANS LA/LA2=MANDEVILLE LA/LA3=LAFAYETTE LA/LA4=MONROE LA/LA5=SHREVEPORT LA/LA6=ALEXANDRIA LA/LAB=LABORATORIES LA/LB1=CLIA NEW ORLEANS LA/LB5=CLIA SHREVEPORT LA/LB6=CLIA ALEXANDRIA MA/001=MASSACHUSETTS MA/LAB=LABORATORIES MD/001=MARYLAND MD/LAB=LABORATORIES ME/001=MAINE ME/LAB=LABORATORIES MH/001=MARSHALL ISLANDS MI/001=MICHIGAN MI/LAB=LABORATORIES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 16 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE MN/001=MINNESOTA MN/LAB=LABORATORIES MO/01=REGION01 MO/02=REGION02 MO/03=REGION 03 MO/04=REGION 04 MO/05=REGION 05 MO/06=REGION 06 MO/07=REGION 07 MO/1NH=REGION 1 NH MO/2NH=REGION 2 NH MO/3NH=REGION 3 NH MO/4NH=REGION 4 NH MO/5NH=REGION 5 NH MO/6NH=REGION 6 NH MO/7NH=REGION 7 NH MO/LAB=LABORATORIES MO/MO=STATEWIDE MP/001=NORTHERN MARIANA ISLANDS MP/LAB=LABORATORIES MS/001=MISSISSIPPI MS/LAB=LABORATORIES MT/001=MONTANA MT/LAB=LABORATORIES MX/001=MEXICO MX/LAB=LABORATORY NC/LAB=LABORATORIES NC/NCC=NORTH CAROLINA CENTRAL NC/NCE=NORTH CAROLINA EAST NC/NCN=NORTH CAROLINA NORTH NC/NCS=NORTH CAROLINA SOUTH NC/NCW=NORTH CAROLINA WEST ND/001=NORTH DAKOTA ND/LAB=LABORATORIES NE/1=NORTH CENTRAL NE/2=CENTRAL NE/3=NORTHEAST NE/4=SOUTHEAST NE/5=WESTERN NE/LAB=LABORATORIES NH/001=NEW HAMPSHIRE NH/LAB=LABORATORIES NJ/001=NEW JERSEY NJ/LAB=LABORATORIES NM/001=NEW MEXICO NM/LAB=LABORATORIES NV/CC=CARSON CITY NV/LAB=LABORATORIES NV/LV=LAS VEGAS NY/001=BUFFALO NY/002=ROCHESTER NY/003=SYRACUSE NY/004=ALBANY NY/005=NEW ROCHELLE NY/006=NEW YORK CITY NY/007=SUFFOLK/NASSAU COUNTY NY/LAB=LABORATORIES OH/001=OHIO OH/LAB=LABORATORIES OK/001=OKLAHOMA OK/LAB=LABORATORIES OR/001=OFFICE #1 OR/002=OFFICE #2 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 17 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE OR/003=OFFICE #3 OR/LAB=LABORATORIES PA/001=PENNSYLVANIA PA/LAB=LABORATORIES PR/001=PUERTO RICO PR/LAB=LABORATORIES PW/001=PALAU RI/001=RHODE ISLAND RI/LAB=LABORATORIES SC/001=SOUTH CAROLINA SC/LAB=LABORATORIES SD/001=SOUTH DAKOTA SD/LAB=LABORATORIES TN/LAB=LABORATORIES TN/TNC=TENNESSEE COOKEVILLE TN/TNE=TENNESSEE EASTERN TN/TNM=TENNESSEE MIDDLE TN/TNW=TENNESSEE WESTERN TX/001=TEXAS TX/L01=AMARILLO-LTC TX/L02=ABILENE-LTC TX/L03=ARLINGTON-LTC TX/L04=TYLER-LTC TX/L05=BEAUMONT-LTC TX/L06=HOUSTON-LTC TX/L07=TEMPLE-LTC TX/L08=SAN ANTONIO-LTC TX/L09=SAN ANGELO-LTC TX/L10=EL PASO-LTC TX/L11=CORPUS CHRISTI-LTC TX/LAB=LABORATORIES TX/TX1=LUBBOCK TX/TX2=ARLINGTON TX/TX3=SAN ANTONIO TX/TX4=HOUSTON TX/TX5=TYLER TX/TX6=AUSTIN UT/001=UTAH UT/LAB=LABORATORIES VA/001=VIRGINIA VA/LAB=LABORATORIES VI/001=VIRGIN ISLANDS VI/LAB=LABORATORIES VT/001=VERMONT VT/LAB=LABORATORIES WA/001=ALL OTHERS (NON-LTC FAC) WA/D1=SPOKANE & YAKIMA AREAS WA/D1A=District 1, Unit A WA/D1B=District 1, Unit B WA/D1C=District 1, Unit C WA/D1D=District 1, Unit D WA/D2=SPOKANE & SE WA/D2A=District 2, Unit A WA/D2B=District 2, Unit B WA/D2C=District 2, Unit C WA/D2D=District 2, Unit D WA/D2E=District 2, Unit E WA/D2F=District 2, Unit F WA/D2G=District 2, Unit G WA/D3=NW WASHINGTON WA/D3A=District 3, Unit A WA/D3B=District 3, Unit B WA/D3C=District 3, Unit C DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 18 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE WA/D3D=District 3, Unit D WA/D3E=District 3, Unit E WA/D4A=GREATER SEATTLE AREA WA/D4B=S KING COUNTY WA/D5A=PIERCE CTY & PENINSULA WA/D5B=PIERCE CTY & GRAYS HARBOR WA/D6=OLYMPIA AREA WA/LAB=LABORATORIES WI/001=WISCONSIN WI/LAB=LABORATORIES WV/001=WEST VIRGINIA WV/LAB=LABORATORIES WY/001=WYOMING WY/LAB=LABORATORIES Address: Street 50 178 227 VARCHAR2 Description: Street address where the provider is located. SAS Name: ST_ADR COBOL Name: ST-ADR Telephone Number 10 228 237 VARCHAR2 Description: Telephone number of the provider. SAS Name: PHNE_NUM COBOL Name: PHNE-NUM Termination Code 2 238 239 VARCHAR2 Description: Indicates the current termination status for the provider. SAS Name: PGM_TRMNTN_CD COBOL Name: PGM-TRMNTN-CD VALUES: 00=ACTIVE PROVIDER 01=VOLUNTARY-MERGER, CLOSURE 02=VOLUNTARY-DISSATISFACTION WITH REIMBURSEMENT 03=VOLUNTARY-RISK OF INVOLUNTARY TERMINATION 04=VOLUNTARY-OTHER REASON FOR WITHDRAWAL 05=INVOLUNTARY-FAILURE TO MEET HEALTH/SAFETY REQ 06=INVOLUNTARY-FAILURE TO MEET AGREEMENT 07=OTHER-PROVIDER STATUS CHANGE 08=NONPAYMENT OF FEES - CLIA Only 09=REV/UNSUCCESSFUL PARTICIPATION IN PT - CLIA Only 10=REV/OTHER REASON - CLIA Only 11=INCOMPLETE CLIA APPLICATION INFORMATION - CLIA Only 12=NO LONGER PERFORMING TESTS - CLIA Only 13=MULTIPLE TO SINGLE SITE CERTIFICATE - CLIA Only 14=SHARED LABORATORY - CLIA Only 15=FAILURE TO RENEW WAIVER PPM CERTIFICATE - CLIA Only 16=DUPLICATE CLIA NUMBER - CLIA Only 17=MAIL RETURNED NO FORWARD ADDRESS CERT ENDED - CLIA Only 20=NOTIFICATION BANKRUPTCY - CLIA Only 33=ACCREDITATION NOT CONFIRMED - CLIA Only 80=AWAITING STATE APPROVAL 99=OIG ACTION - DO NOT ACTIVATE - CLIA Only Termination or Expiration Date 8 240 247 DATE Description: Date the provider was terminated. For CLIA providers, date the laboratory's certificate was terminated or the expiration date of the current CLIA certificate. SAS Name: TRMNTN_EXPRTN_DT COBOL Name: TRMNTN-EXPRTN-DT Type of Action Code 1 248 248 VARCHAR2 Description: Identifies the reason for the certification. Type of action from the official survey record, CMS 1539 form. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 19 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: CRTFCTN_ACTN_TYPE_CD COBOL Name: CRTFCTN-ACTN-TYPE-CD VALUES: 1=INITIAL 2=RECERTIFICATION 3=TERMINATION 4=CHANGE OF OWNERSHIP 5=VALIDATION 8=FULL SURVEY AFTER COMPLAINT Ownership Type Code 2 249 250 VARCHAR2 Description: Indicates the ownership type of the provider. SAS Name: GNRL_CNTL_TYPE_CD COBOL Name: GNRL-CNTL-TYPE-CD 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 13=FOR PROFIT - LIMITED LIABILITY CORPORATION Address: ZIP Code 5 251 255 VARCHAR2 Description: Five-digit ZIP code for a provider's physical address. SAS Name: ZIP_CD COBOL Name: ZIP-CD FIPS State Code 2 256 257 VARCHAR2 Description: FIPS State Code SAS Name: FIPS_STATE_CD COBOL Name: FIPS-STATE-CD VALUES: 01=ALABAMA 02=ALASKA 04=ARIZONA 05=ARKANSAS 06=CALIFORNIA 08=COLORADO 09=CONNECTICUT 10=DELAWARE 11=DISTRICT OF COLUMBIA 12=FLORIDA 13=GEORGIA 15=HAWAII 16=IDAHO 17=ILLINOIS 18=INDIANA 19=IOWA 20=KANSAS 21=KENTUCKY 22=LOUISIANA 23=MAINE 24=MARYLAND 25=MASSACHUSETTS 26=MICHIGAN 27=MINNESOTA 28=MISSISSIPPI 29=MISSOURI 30=MONTANA DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 20 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 31=NEBRASKA 32=NEVADA 33=NEW HAMPSHIRE 34=NEW JERSEY 35=NEW MEXICO 36=NEW YORK 37=NORTH CAROLINA 38=NORTH DAKOTA 39=OHIO 40=OKLAHOMA 41=OREGON 42=PENNSYLVANIA 43=PUERTO RICO 44=RHODE ISLAND 45=SOUTH CAROLINA 46=SOUTH DAKOTA 47=TENNESSEE 48=TEXAS 49=UTAH 50=VERMONT 51=VIRGINIA 53=WASHINGTON 54=WEST VIRGINIA 55=WISCONSIN 56=WYOMING 64=AMERICAN SAMOA 65=GUAM 66=SAIPAN/MARIANA IS. 78=VIRGIN ISLANDS FIPS County Code 3 258 260 VARCHAR2 Description: FIPS County Code SAS Name: FIPS_CNTY_CD COBOL Name: FIPS-CNTY-CD CBSA Urban Rural Indicator 1 261 261 VARCHAR2 Description: CBSA (Core Based Statistical Area) indicates whether the county is defined as Urban or Rural. SAS Name: CBSA_URBN_RRL_IND COBOL Name: CBSA-URBN-RRL-IND CBSA Code 5 262 266 VARCHAR2 Description: CBSA (Core Based Statistical Area) geographic entities defined by the U.S. Office of Management and Budget (OMB) on June 6, 2003 for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics. CBSA collectively refers to MSA. SAS Name: CBSA_CD COBOL Name: CBSA-CD Bed Count Override Indicator 1 325 325 CHAR Description: Indicates if the regional office has approved a significant bed count change from the previous certification. SAS Name: OVRRD_BED_CNT_SW COBOL Name: OVRRD-BED-CNT-SW Bed Count: Certified 4 326 329 NUMBER Description: Number of beds in Medicare and/or Medicaid certified areas within a facility. SAS Name: CRTFD_BED_CNT COBOL Name: CRTFD-BED-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 21 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Bed Count: Medicaid NF 4 334 337 NUMBER Description: Number of Medicaid-certified Nursing Facility beds. SAS Name: MDCD_NF_BED_CNT COBOL Name: MDCD-NF-BED-CNT Bed Count: Medicare SNF 4 338 341 NUMBER Description: Number of Medicare-certified Skilled Nursing Facility beds. SAS Name: MDCR_SNF_BED_CNT COBOL Name: MDCR-SNF-BED-CNT Bed Count: Medicare/Medicaid SNF 4 342 345 NUMBER Description: Number of dually certified (Medicare/Medicaid) beds in a Skilled Nursing Facility. SAS Name: MDCR_MDCD_SNF_BED_CNT COBOL Name: MDCR-MDCD-SNF-BED-CNT Bed Count: Special Care - AIDS 3 346 348 NUMBER Description: Number of beds in a special care unit dedicated for residents with AIDS. SAS Name: AIDS_BED_CNT COBOL Name: AIDS-BED-CNT Bed Count: Special Care - Alzheimers 3 349 351 NUMBER Description: Number of beds in a special care unit dedicated for residents with Alzheimer's disease. SAS Name: ALZHMR_BED_CNT COBOL Name: ALZHMR-BED-CNT Bed Count: Special Care - Dialysis 3 352 354 NUMBER Description: Number of beds in a special care unit dedicated for residents who require dialysis. SAS Name: DLYS_BED_CNT COBOL Name: DLYS-BED-CNT Bed Count: Special Care - Disabled Children 3 355 357 NUMBER Description: Number of beds in a special care unit dedicated for disabled children. SAS Name: DSBL_CHLDRN_BED_CNT COBOL Name: DSBL-CHLDRN-BED-CNT Bed Count: Special Care - Head Trauma 3 358 360 NUMBER Description: Number of beds in a special care unit dedicated for residents with head trauma. SAS Name: HEAD_TRMA_BED_CNT COBOL Name: HEAD-TRMA-BED-CNT Bed Count: Special Care - Hospice 3 361 363 NUMBER Description: Number of beds in a special care unit dedicated for residents who require hospice care. SAS Name: HOSPC_BED_CNT COBOL Name: HOSPC-BED-CNT Bed Count: Special Care - Huntingtons Disease 3 364 366 NUMBER Description: Number of beds in a special care unit dedicated for residents with Huntington's disease. SAS Name: HNTGTN_DEASE_BED_CNT COBOL Name: HNTGTN-DEASE-BED-CNT Bed Count: Special Care - Specialized Rehab 3 367 369 NUMBER Description: Number of beds in a special care unit dedicated for residents with specialized rehab needs. SAS Name: REHAB_BED_CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 22 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: REHAB-BED-CNT Bed Count: Special Care - Ventilator 3 370 372 NUMBER Description: Number of beds in a special care unit dedicated for residents requiring a ventilator and/or respiratory care. SAS Name: VNTLTR_BED_CNT COBOL Name: VNTLTR-BED-CNT Bed Count: Total 4 373 376 NUMBER Description: Total number of beds in a provider, including those in non-participating or non-licensed areas. SAS Name: BED_CNT COBOL Name: BED-CNT Compliance: 24-Hour RN Waiver Indicator 1 442 442 CHAR Description: Indicates if a waiver of the 24-hour registered nurse staffing requirements has been recommended for a Skilled Nursing Facility or Nursing Facility. SAS Name: RN_24_HR_WVR_SW COBOL Name: RN-24-HR-WVR-SW Compliance: 7-Day RN Waiver Indicator 1 443 443 VARCHAR2 Description: Indicates if a waiver of the 7-day registered nurse staffing requirements has been recommended for a Skilled Nursing Facility. SAS Name: RN_7_DAY_WVR_SW COBOL Name: RN-7-DAY-WVR-SW Compliance: Beds Per Room Waiver Indicator 1 444 444 CHAR Description: Indicates if a waiver of the beds per room requirement has been recommended for a facility. SAS Name: BED_PER_ROOM_WVR_SW COBOL Name: BED-PER-ROOM-WVR-SW Compliance: LSC Waiver Indicator 1 445 445 CHAR Description: Indicates if a waiver of any life safety code provision has been recommended for a provider. SAS Name: LSC_WVR_SW COBOL Name: LSC-WVR-SW Compliance: Patient Room Size Waiver Indicator 1 446 446 CHAR Description: Indicates if a waiver of the patient room size provision has been recommended for a provider. SAS Name: ROOM_SIZE_WVR_SW COBOL Name: ROOM-SIZE-WVR-SW Experimental Research Conducted Indicator 1 453 453 VARCHAR2 Description: Indicates if a facility conducts experimental research. SAS Name: EXPRMT_RSRCH_CNDCTD_SW COBOL Name: EXPRMT-RSRCH-CNDCTD-SW Fiscal Year End Date (MMDD) 4 464 467 VARCHAR2 Description: End date, consisting of the month and day, of the provider's fiscal year. SAS Name: FY_END_MO_DAY_CD COBOL Name: FY-END-MO-DAY-CD LTC Cross Ref Provider Number 10 485 494 CHAR Description: LTC cross ref provider number SAS Name: LTC_CROSS_REF_PROVIDER_NUMBER COBOL Name: LTC-CROSS-REF-PROVIDER-NUMBER Multiple Facility Organization Name 38 513 550 CHAR DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 23 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Name of the multi-facility organization that owns the facility. SAS Name: MLT_FAC_ORG_NAME COBOL Name: MLT-FAC-ORG-NAME Multiple Facility Organization Owned Indicator 1 551 551 CHAR Description: Indicates if a facility is owned by an organization that owns (or leases) two or more long term care facilities. SAS Name: MLT_OWND_FAC_ORG_SW COBOL Name: MLT-OWND-FAC-ORG-SW Organized Family Group Indicator 1 609 609 VARCHAR2 Description: Indicates if the facility has an organized group of family members of residents. SAS Name: ORGNZ_FMLY_MBR_GRP_SW COBOL Name: ORGNZ-FMLY-MBR-GRP-SW Organized Resident Group Indicator 1 610 610 VARCHAR2 Description: Indicates if the facility has an organized residents group. SAS Name: ORGNZ_RSDNT_GRP_SW COBOL Name: ORGNZ-RSDNT-GRP-SW Program Participation Code 1 623 623 CHAR Description: Indicates if the provider participates in Medicare, Medicaid, or both programs. SAS Name: PGM_PRTCPTN_CD COBOL Name: PGM-PRTCPTN-CD VALUES: 1=MEDICARE ONLY 2=MEDICAID ONLY 3=MEDICARE AND MEDICAID Related Provider Number 10 669 678 CHAR Description: Related provider number SAS Name: RELATED_PROVIDER_NUMBER COBOL Name: RELATED-PROVIDER-NUMBER Services: Blood Administration Off-Site Residents 1 686 686 VARCHAR2 Indicator Description: Indicates if blood administration and storage services are provided off-site to residents. SAS Name: BLOOD_SRVC_OFSITE_RSDNT_SW COBOL Name: BLOOD-SRVC-OFSITE-RSDNT-SW Services: Blood Administration On-Site Nonresidents 1 687 687 VARCHAR2 Indicator Description: Indicates if blood administration and storage services are provided on-site to nonresidents. SAS Name: BLOOD_SRVC_ONST_NRSDNT_SW COBOL Name: BLOOD-SRVC-ONST-NRSDNT-SW Services: Blood Administration On-Site Residents 1 688 688 VARCHAR2 Indicator Description: Indicates if blood administration and storage services are provided on-site to residents. SAS Name: BLOOD_SRVC_ONST_RSDNT_SW COBOL Name: BLOOD-SRVC-ONST-RSDNT-SW Services: Clinical Laboratory - Off-Site Residents 1 695 695 VARCHAR2 Indicator Description: Indicates if clinical laboratory services are provided off-site to residents. SAS Name: CL_SRVC_OFSITE_RSDNT_SW DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 24 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: CL-SRVC-OFSITE-RSDNT-SW Services: Clinical Laboratory - On-Site Nonresidents 1 696 696 VARCHAR2 Indicator Description: Indicates if clinical laboratory services are provided on-site to nonresidents. SAS Name: CL_SRVC_ONST_NRSDNT_SW COBOL Name: CL-SRVC-ONST-NRSDNT-SW Services: Clinical Laboratory - On-Site Residents 1 697 697 VARCHAR2 Indicator Description: Indicates if clinical laboratory services are provided on-site to residents. SAS Name: CL_SRVC_ONST_RSDNT_SW COBOL Name: CL-SRVC-ONST-RSDNT-SW Services: Dental Off-Site Residents Indicator 1 703 703 VARCHAR2 Description: Indicates if dental services are provided off-site to residents. SAS Name: DNTL_SRVC_OFSITE_RSDNT_SW COBOL Name: DNTL-SRVC-OFSITE-RSDNT-SW Services: Dental On-Site Nonresidents Indicator 1 704 704 VARCHAR2 Description: Indicates if dental services are provided on-site to nonresidents. SAS Name: DNTL_SRVC_ONST_NRSDNT_SW COBOL Name: DNTL-SRVC-ONST-NRSDNT-SW Services: Dental On-Site Residents Indicator 1 705 705 VARCHAR2 Description: Indicates if dental services are provided on-site to residents. SAS Name: DNTL_SRVC_ONST_RSDNT_SW COBOL Name: DNTL-SRVC-ONST-RSDNT-SW Services: Dietary Off-Site Residents Indicator 1 709 709 VARCHAR2 Description: Indicates if dietary services are provided off-site to residents. SAS Name: DTRY_OFSITE_RSDNT_SW COBOL Name: DTRY-OFSITE-RSDNT-SW Services: Dietary On-Site Nonresidents Indicator 1 710 710 VARCHAR2 Description: Indicates if dietary services are provided on-site to nonresidents. SAS Name: DTRY_ONST_NRSDNT_SW COBOL Name: DTRY-ONST-NRSDNT-SW Services: Dietary On-Site Residents Indicator 1 711 711 VARCHAR2 Description: Indicates if dietary services are provided on-site to residents. SAS Name: DTRY_ONST_RSDNT_SW COBOL Name: DTRY-ONST-RSDNT-SW Services: Housekeeping Off-Site Residents Indicator 1 721 721 VARCHAR2 Description: Indicates if housekeeping services are provided off-site to residents. SAS Name: HSEKPNG_SRVC_OFSITE_RSDNT_SW COBOL Name: HSEKPNG-SRVC-OFSITE-RSDNT-SW Services: Housekeeping On-Site Nonresidents Indicator 1 722 722 VARCHAR2 Description: Indicates if housekeeping services are provided on-site to nonresidents. SAS Name: HSEKPNG_SRVC_ONST_NRSDNT_SW COBOL Name: HSEKPNG-SRVC-ONST-NRSDNT-SW DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 25 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Services: Housekeeping On-Site Residents Indicator 1 723 723 VARCHAR2 Description: Indicates if housekeeping services are provided on-site to residents. SAS Name: HSEKPNG_SRVC_ONST_RSDNT_SW COBOL Name: HSEKPNG-SRVC-ONST-RSDNT-SW Services: Mental Health Off-Site Residents Indicator 1 730 730 VARCHAR2 Description: Indicates if mental health services are provided off-site to residents. SAS Name: MENTL_HLTH_OFSITE_RSDNT_SW COBOL Name: MENTL-HLTH-OFSITE-RSDNT-SW Services: Mental Health On-Site Nonresidents 1 731 731 VARCHAR2 Indicator Description: Indicates if mental health services are provided on-site to nonresidents. SAS Name: MENTL_HLTH_ONST_NRSDNT_SW COBOL Name: MENTL-HLTH-ONST-NRSDNT-SW Services: Mental Health On-Site Residents Indicator 1 732 732 VARCHAR2 Description: Indicates if mental health services are provided on-site to residents. SAS Name: MENTL_HLTH_ONST_RSDNT_SW COBOL Name: MENTL-HLTH-ONST-RSDNT-SW Services: Nursing Off-Site Residents Indicator 1 743 743 VARCHAR2 Description: Indicates if nursing services are provided off-site to residents. SAS Name: NRSNG_SRVC_OFSITE_RSDNT_SW COBOL Name: NRSNG-SRVC-OFSITE-RSDNT-SW Services: Nursing On-Site Nonresidents Indicator 1 744 744 VARCHAR2 Description: Indicates if nursing services are provided on-site to nonresidents. SAS Name: NRSNG_SRVC_ONST_NRSDNT_SW COBOL Name: NRSNG-SRVC-ONST-NRSDNT-SW Services: Nursing On-Site Residents Indicator 1 745 745 VARCHAR2 Description: Indicates if nursing services are provided on-site to residents. SAS Name: NRSNG_SRVC_ONST_RSDNT_SW COBOL Name: NRSNG-SRVC-ONST-RSDNT-SW Services: OT Off-Site Residents Indicator 1 759 759 VARCHAR2 Description: Indicates if occupational therapy services are provided off-site to residents. SAS Name: OT_SRVC_OFSITE_RSDNT_SW COBOL Name: OT-SRVC-OFSITE-RSDNT-SW Services: OT On-Site Nonresidents Indicator 1 760 760 VARCHAR2 Description: Indicates if occupational therapy services are provided on-site to nonresidents. SAS Name: OT_SRVC_ONST_NRSDNT_SW COBOL Name: OT-SRVC-ONST-NRSDNT-SW Services: OT On-Site Residents Indicator 1 761 761 VARCHAR2 Description: Indicates if occupational therapy services are provided on-site to residents. SAS Name: OT_SRVC_ONST_RSDNT_SW COBOL Name: OT-SRVC-ONST-RSDNT-SW Services: Pharmacy Off-Site Residents Indicator 1 772 772 VARCHAR2 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 26 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Indicates if pharmacy services are provided off-site to residents. SAS Name: PHRMCY_SRVC_OFSITE_RSDNT_SW COBOL Name: PHRMCY-SRVC-OFSITE-RSDNT-SW Services: Pharmacy On-Site Nonresidents Indicator 1 773 773 VARCHAR2 Description: Indicates if pharmacy services are provided on-site to nonresidents. SAS Name: PHRMCY_SRVC_ONST_NRSDNT_SW COBOL Name: PHRMCY-SRVC-ONST-NRSDNT-SW Services: Pharmacy On-Site Residents Indicator 1 774 774 VARCHAR2 Description: Indicates if pharmacy services are provided on-site to residents. SAS Name: PHRMCY_SRVC_ONST_RSDNT_SW COBOL Name: PHRMCY-SRVC-ONST-RSDNT-SW Services: Physician Extender Off-Site Residents 1 779 779 VARCHAR2 Indicator Description: Indicates if physician extender services are provided off-site to residents. SAS Name: PHYSN_EXT_SRVC_OFSITE_RSDNT_SW COBOL Name: PHYSN-EXT-SRVC-OFSITE-RSDNT-SW Services: Physician Extender On-Site Nonresidents 1 780 780 VARCHAR2 Indicator Description: Indicates if physician extender services are provided on-site to nonresidents. SAS Name: PHYSN_EXT_SRVC_ONST_NRSDNT_SW COBOL Name: PHYSN-EXT-SRVC-ONST-NRSDNT-SW Services: Physician Extender On-Site Residents 1 781 781 VARCHAR2 Indicator Description: Indicates if physician extender services are provided on-site to residents. SAS Name: PHYSN_EXT_SRVC_ONST_RSDNT_SW COBOL Name: PHYSN-EXT-SRVC-ONST-RSDNT-SW Services: Physician Off-Site Residents Indicator 1 782 782 VARCHAR2 Description: Indicates if physician services are provided off-site to residents. SAS Name: PHYSN_SRVC_OFSITE_RSDNT_SW COBOL Name: PHYSN-SRVC-OFSITE-RSDNT-SW Services: Physician On-Site Nonresidents Indicator 1 783 783 VARCHAR2 Description: Indicates if physician services are provided on-site to nonresidents. SAS Name: PHYSN_SRVC_ONST_NRSDNT_SW COBOL Name: PHYSN-SRVC-ONST-NRSDNT-SW Services: Physician On-Site Residents Indicator 1 784 784 VARCHAR2 Description: Indicates if physician services are provided on-site to residents. SAS Name: PHYSN_SRVC_ONST_RSDNT_SW COBOL Name: PHYSN-SRVC-ONST-RSDNT-SW Services: Podiatry Off-Site Residents Indicator 1 785 785 VARCHAR2 Description: Indicates if podiatry services are provided off-site to residents. SAS Name: PDTRY_SRVC_OFSITE_RSDNT_SW COBOL Name: PDTRY-SRVC-OFSITE-RSDNT-SW Services: Podiatry On-Site Nonresidents Indicator 1 786 786 VARCHAR2 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 27 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Indicates if podiatry services are provided on-site to nonresidents. SAS Name: PDTRY_SRVC_ONST_NRSDNT_SW COBOL Name: PDTRY-SRVC-ONST-NRSDNT-SW Services: Podiatry On-Site Residents Indicator 1 787 787 VARCHAR2 Description: Indicates if podiatry services are provided on-site to residents. SAS Name: PDTRY_SRVC_ONST_RSDNT_SW COBOL Name: PDTRY-SRVC-ONST-RSDNT-SW Services: PT Off-Site Residents Indicator 1 797 797 VARCHAR2 Description: Indicates if physical therapy services are provided off-site to residents. SAS Name: PT_OFSITE_RSDNT_SW COBOL Name: PT-OFSITE-RSDNT-SW Services: PT On-Site Nonresidents Indicator 1 798 798 VARCHAR2 Description: Indicates if physical therapy services are provided on-site to nonresidents. SAS Name: PT_ONST_NRSDNT_SW COBOL Name: PT-ONST-NRSDNT-SW Services: PT On-Site Residents Indicator 1 799 799 VARCHAR2 Description: Indicates if physical therapy services are provided on-site to residents. SAS Name: PT_ONST_RSDNT_SW COBOL Name: PT-ONST-RSDNT-SW Services: Social Work Off-Site Residents Indicator 1 810 810 VARCHAR2 Description: Indicates if social work services are provided off-site to residents. SAS Name: SCL_WORK_SRVC_OFSITE_RSDNT_SW COBOL Name: SCL-WORK-SRVC-OFSITE-RSDNT-SW Services: Social Work On-Site Nonresidents Indicator 1 811 811 VARCHAR2 Description: Indicates if social work services are provided on-site to nonresidents. SAS Name: SCL_WORK_SRVC_ONST_NRSDNT_SW COBOL Name: SCL-WORK-SRVC-ONST-NRSDNT-SW Services: Social Work On-Site Residents Indicator 1 812 812 VARCHAR2 Description: Indicates if social work services are provided on-site to residents. SAS Name: SCL_WORK_SRVC_ONST_RSDNT_SW COBOL Name: SCL-WORK-SRVC-ONST-RSDNT-SW Services: Speech Pathology Off-Site Residents 1 817 817 VARCHAR2 Indicator Description: Indicates if speech/language pathology services are provided off-site to residents. SAS Name: SPCH_PTHLGY_OFSITE_RSDNT_SW COBOL Name: SPCH-PTHLGY-OFSITE-RSDNT-SW Services: Speech Pathology On-Site Nonresidents 1 818 818 VARCHAR2 Indicator Description: Indicates if speech/language pathology services are provided on-site to nonresidents. SAS Name: SPCH_PTHLGY_ONST_NRSDNT_SW COBOL Name: SPCH-PTHLGY-ONST-NRSDNT-SW Services: Speech Pathology On-Site Residents 1 819 819 VARCHAR2 Indicator DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 28 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Indicates if speech/language pathology services are provided on-site to residents. SAS Name: SPCH_PTHLGY_ONST_RSDNT_SW COBOL Name: SPCH-PTHLGY-ONST-RSDNT-SW Services: Therapeutic - Other Activities Staff - 1 822 822 VARCHAR2 Off-Site Residents Indicator Description: Indicates if therapeutic services are provided off-site to residents by other activities staff. SAS Name: ACTVTY_OTHR_OFSITE_RSDNT_SW COBOL Name: ACTVTY-OTHR-OFSITE-RSDNT-SW Services: Therapeutic - Other Activities Staff - 1 823 823 VARCHAR2 On-Site Nonresidents Indicator Description: Indicates if therapeutic services are provided on-site to nonresidents by other activities staff. SAS Name: ACTVTY_OTHR_ONST_NRSDNT_SW COBOL Name: ACTVTY-OTHR-ONST-NRSDNT-SW Services: Therapeutic - Other Activities Staff - 1 824 824 VARCHAR2 On-Site Residents Indicator Description: Indicates if therapeutic services are provided on-site to residents by other activities staff. SAS Name: ACTVTY_OTHR_ONST_RSDNT_SW COBOL Name: ACTVTY-OTHR-ONST-RSDNT-SW Services: Therapeutic - Other Social Services Staff - 1 825 825 VARCHAR2 Off-Site Residents Indicator Description: Indicates if other therapeutic social services are provided off-site to residents. SAS Name: SCL_SRVC_OTHR_OFSITE_RSDNT_SW COBOL Name: SCL-SRVC-OTHR-OFSITE-RSDNT-SW Services: Therapeutic - Other Social Services Staff - 1 826 826 VARCHAR2 On-Site Nonresidents Indicator Description: Indicates if other therapeutic social services are provided on-site to nonresidents. SAS Name: SCL_SRVC_OTHR_ONST_NRSDNT_SW COBOL Name: SCL-SRVC-OTHR-ONST-NRSDNT-SW Services: Therapeutic - Other Social Services Staff - 1 827 827 VARCHAR2 On-Site Residents Indicator Description: Indicates if other therapeutic social services are provided on-site to residents. SAS Name: SCL_SRVC_OTHR_ONST_RSDNT_SW COBOL Name: SCL-SRVC-OTHR-ONST-RSDNT-SW Services: Therapeutic - Qualified Activities 1 828 828 VARCHAR2 Professional - Off-Site Residents Indicator Description: Indicates if therapeutic services are provided off-site to residents by qualified activities professionals. SAS Name: ACTVTY_OFSITE_RSDNT_SW COBOL Name: ACTVTY-OFSITE-RSDNT-SW Services: Therapeutic - Qualified Activities 1 829 829 VARCHAR2 Professional - On-Site Nonresidents Indicator Description: Indicates if therapeutic services are provided on-site to nonresidents by qualified activities professionals. SAS Name: ACTVTY_ONST_NRSDNT_SW COBOL Name: ACTVTY-ONST-NRSDNT-SW Services: Therapeutic - Qualified Activities 1 830 830 VARCHAR2 Professional - On-Site Residents Indicator DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 29 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Indicates if therapeutic services are provided on-site to residents by qualified activities professionals. SAS Name: ACTVTY_ONST_RSDNT_SW COBOL Name: ACTVTY-ONST-RSDNT-SW Services: Therapeutic Recreational Specialty Off-Site 1 832 832 VARCHAR2 Residents Indicator Description: Indicates if therapeutic recreation specialist services are provided off-site to residents. SAS Name: THRPTC_RCRTNL_OFSITE_RSDNT_SW COBOL Name: THRPTC-RCRTNL-OFSITE-RSDNT-SW Services: Therapeutic Recreational Specialty On-Site 1 833 833 VARCHAR2 Nonresidents Indicator Description: Indicates if therapeutic recreation specialist services are provided on-site to nonresidents. SAS Name: THRPTC_RCRTNL_ONST_NRSDNT_SW COBOL Name: THRPTC-RCRTNL-ONST-NRSDNT-SW Services: Therapeutic Recreational Specialty On-Site 1 834 834 VARCHAR2 Residents Indicator Description: Indicates if therapeutic recreation specialist services are provided on-site to residents. SAS Name: THRPTC_RCRTNL_ONST_RSDNT_SW COBOL Name: THRPTC-RCRTNL-ONST-RSDNT-SW Services: Vocational Off-Site Residents Indicator 1 837 837 VARCHAR2 Description: Indicates if vocational services are provided off-site to residents. SAS Name: VCTNL_SRVC_OFSITE_RSDNT_SW COBOL Name: VCTNL-SRVC-OFSITE-RSDNT-SW Services: Vocational On-Site Nonresidents Indicator 1 838 838 VARCHAR2 Description: Indicates if vocational services are provided on-site to nonresidents. SAS Name: VCTNL_SRVC_ONST_NRSDNT_SW COBOL Name: VCTNL-SRVC-ONST-NRSDNT-SW Services: Vocational On-Site Residents Indicator 1 839 839 VARCHAR2 Description: Indicates if vocational services are provided on-site to residents. SAS Name: VCTNL_SRVC_ONST_RSDNT_SW COBOL Name: VCTNL-SRVC-ONST-RSDNT-SW Services: X-ray Off-Site Residents Indicator 1 840 840 VARCHAR2 Description: Indicates if diagnostic X-ray services are provided off-site to residents. SAS Name: DGNSTC_XRAY_OFSITE_RSDNT_SW COBOL Name: DGNSTC-XRAY-OFSITE-RSDNT-SW Services: X-ray On-Site Nonresidents Indicator 1 841 841 VARCHAR2 Description: Indicates if diagnostic X-ray services are provided on-site to nonresidents. SAS Name: DGNSTC_XRAY_ONST_NRSDNT_SW COBOL Name: DGNSTC-XRAY-ONST-NRSDNT-SW Services: X-ray On-Site Residents Indicator 1 842 842 VARCHAR2 Description: Indicates if diagnostic X-ray services are provided on-site to residents. SAS Name: DGNSTC_XRAY_ONST_RSDNT_SW COBOL Name: DGNSTC-XRAY-ONST-RSDNT-SW Staff Count Override Indicator 1 844 844 CHAR DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 30 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Indicates if the regional office has approved a significant staff count change from the previous certification. SAS Name: OVRRD_STFG_SW COBOL Name: OVRRD-STFG-SW Staff Count: Administrative Staff - Contract 8 845 852 NUMBER Description: Number of full-time equivalent administrative staff under contract to a facility. SAS Name: PROFNL_ADMIN_CNTRCT_CNT COBOL Name: PROFNL-ADMIN-CNTRCT-CNT Staff Count: Administrative Staff - Full-Time 8 853 860 NUMBER Description: Number of full-time equivalent administrative staff employed on a full-time basis by a facility. SAS Name: PROFNL_ADMIN_FLTM_CNT COBOL Name: PROFNL-ADMIN-FLTM-CNT Staff Count: Administrative Staff - Part-Time 8 861 868 NUMBER Description: Number of full-time equivalent administrative staff employed on a part-time basis by a facility. SAS Name: PROFNL_ADMIN_PRTM_CNT COBOL Name: PROFNL-ADMIN-PRTM-CNT Staff Count: Certified Nurse Aide - Contract 8 893 900 NUMBER Description: Number of full-time equivalent certified nurse aides under contract to a facility. SAS Name: NRS_AIDE_CNTRCT_CNT COBOL Name: NRS-AIDE-CNTRCT-CNT Staff Count: Certified Nurse Aide - Full-Time 8 901 908 NUMBER Description: Number of full-time equivalent certified nurse aides employed full-time by a facility. SAS Name: NRS_AIDE_FLTM_CNT COBOL Name: NRS-AIDE-FLTM-CNT Staff Count: Certified Nurse Aide - Part-Time 8 909 916 NUMBER Description: Number of full-time equivalent certified nurse aides employed part-time by a facility. SAS Name: NRS_AIDE_PRTM_CNT COBOL Name: NRS-AIDE-PRTM-CNT Staff Count: Dentist - Contract 8 941 948 NUMBER Description: Number of full-time equivalent dentists under contract to a facility. SAS Name: DNTST_CNTRCT_CNT COBOL Name: DNTST-CNTRCT-CNT Staff Count: Dentist - Full-Time 8 949 956 NUMBER Description: Number of full-time equivalent dentists employed full time by a facility. SAS Name: DNTST_FLTM_CNT COBOL Name: DNTST-FLTM-CNT Staff Count: Dentist - Part-Time 8 957 964 NUMBER Description: Number of full-time equivalent dentists employed part time by a facility. SAS Name: DNTST_PRTM_CNT COBOL Name: DNTST-PRTM-CNT Staff Count: Dietitian - Contract 8 973 980 NUMBER Description: Number of full-time equivalent dietitians under contract to a facility. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 31 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: DIETN_CNTRCT_CNT COBOL Name: DIETN-CNTRCT-CNT Staff Count: Dietitian - Full-Time 8 981 988 NUMBER Description: Number of full-time equivalent dietitians employed full time by a facility. SAS Name: DIETN_FLTM_CNT COBOL Name: DIETN-FLTM-CNT Staff Count: Dietitian - Part-Time 8 989 996 NUMBER Description: Number of full-time equivalent dietitians employed part time by a facility. SAS Name: DIETN_PRTM_CNT COBOL Name: DIETN-PRTM-CNT Staff Count: Food Service Worker - Contract 8 1005 1012 NUMBER Description: Number of full-time equivalent food service personnel under contract to a facility. SAS Name: FOOD_SRVC_CNTRCT_CNT COBOL Name: FOOD-SRVC-CNTRCT-CNT Staff Count: Food Service Worker - Full-Time 8 1013 1020 NUMBER Description: Number of full-time equivalent food service personnel employed full-time by a facility. SAS Name: FOOD_SRVC_FLTM_CNT COBOL Name: FOOD-SRVC-FLTM-CNT Staff Count: Food Service Worker - Part-Time 8 1021 1028 NUMBER Description: Number of full-time equivalent food service personnel employed part-time by a facility. SAS Name: FOOD_SRVC_PRTM_CNT COBOL Name: FOOD-SRVC-PRTM-CNT Staff Count: Housekeeping - Contract 8 1053 1060 NUMBER Description: Number of full-time equivalent housekeeping personnel under contract to a facility. SAS Name: HSEKPNG_CNTRCT_CNT COBOL Name: HSEKPNG-CNTRCT-CNT Staff Count: Housekeeping - Full-Time 8 1061 1068 NUMBER Description: Number of full-time equivalent housekeeping personnel employed full-time by a facility. SAS Name: HSEKPNG_FLTM_CNT COBOL Name: HSEKPNG-FLTM-CNT Staff Count: Housekeeping - Part-Time 8 1069 1076 NUMBER Description: Number of full-time equivalent housekeeping personnel employed part-time by a facility. SAS Name: HSEKPNG_PRTM_CNT COBOL Name: HSEKPNG-PRTM-CNT Staff Count: LPN/LVN - Contract 8 1101 1108 NUMBER Description: Number of full-time equivalent licensed practical/vocational nurses under contract to a facility. SAS Name: LPN_LVN_CNTRCT_CNT COBOL Name: LPN-LVN-CNTRCT-CNT Staff Count: LPN/LVN - Full-Time 8 1109 1116 NUMBER Description: Number of full-time equivalent licensed practical/vocational nurses employed full-time by a facility. SAS Name: LPN_LVN_FLTM_CNT COBOL Name: LPN-LVN-FLTM-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 32 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Staff Count: LPN/LVN - Part-Time 8 1117 1124 NUMBER Description: Number of full-time equivalent licensed practical/vocational nurses employed part-time by a facility. SAS Name: LPN_LVN_PRTM_CNT COBOL Name: LPN-LVN-PRTM-CNT Staff Count: Medical Director - Contract 8 1133 1140 NUMBER Description: Number of full-time equivalent medical directors under contract to a facility. SAS Name: MDCL_DRCTR_CNTRCT_CNT COBOL Name: MDCL-DRCTR-CNTRCT-CNT Staff Count: Medical Director - Full-Time 8 1141 1148 NUMBER Description: Number of full-time equivalent medical directors employed full-time by a facility. SAS Name: MDCL_DRCTR_FLTM_CNT COBOL Name: MDCL-DRCTR-FLTM-CNT Staff Count: Medical Director - Part-Time 8 1149 1156 NUMBER Description: Number of full-time equivalent medical directors employed part-time by a facility. SAS Name: MDCL_DRCTR_PRTM_CNT COBOL Name: MDCL-DRCTR-PRTM-CNT Staff Count: Medication Aide/Technician - Contract 8 1181 1188 NUMBER Description: Number of full-time equivalent medication aides/ technicians under contract to a facility. SAS Name: MDCTN_AIDE_CNTRCT_CNT COBOL Name: MDCTN-AIDE-CNTRCT-CNT Staff Count: Medication Aide/Technician - Full-Time 8 1189 1196 NUMBER Description: Number of full-time equivalent medication aides/ technicians employed full-time by a facility. SAS Name: MDCTN_AIDE_FLTM_CNT COBOL Name: MDCTN-AIDE-FLTM-CNT Staff Count: Medication Aide/Technician - Part-Time 8 1197 1204 NUMBER Description: Number of full-time equivalent medication aides/ technicians employed part-time by a facility. SAS Name: MDCTN_AIDE_PRTM_CNT COBOL Name: MDCTN-AIDE-PRTM-CNT Staff Count: Mental Health Services - Contract 8 1205 1212 NUMBER Description: Number of full-time equivalent mental health services personnel under contract to a facility. SAS Name: MENTL_HLTH_SRVC_CNTRCT_CNT COBOL Name: MENTL-HLTH-SRVC-CNTRCT-CNT Staff Count: Mental Health Services - Full-Time 8 1213 1220 NUMBER Description: Number of full-time equivalent mental health services personnel employed full-time by a facility. SAS Name: MENTL_HLTH_SRVC_FLTM_CNT COBOL Name: MENTL-HLTH-SRVC-FLTM-CNT Staff Count: Mental Health Services - Part-Time 8 1221 1228 NUMBER Description: Number of full-time equivalent mental health services personnel employed part-time by a facility. SAS Name: MENTL_HLTH_SRVC_PRTM_CNT COBOL Name: MENTL-HLTH-SRVC-PRTM-CNT Staff Count: Nurse Aide in Training - Contract 8 1237 1244 NUMBER DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 33 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Number of full-time equivalent nurse aides in training under contract to a facility. SAS Name: NAT_CNTRCT_CNT COBOL Name: NAT-CNTRCT-CNT Staff Count: Nurse Aide in Training - Full-Time 8 1245 1252 NUMBER Description: Number of full-time equivalent nurse aides in training employed full-time by a facility. SAS Name: NAT_FLTM_CNT COBOL Name: NAT-FLTM-CNT Staff Count: Nurse Aide in Training - Part-Time 8 1253 1260 NUMBER Description: Number of full-time equivalent nurse aides in training employed part-time by a facility. SAS Name: NAT_PRTM_CNT COBOL Name: NAT-PRTM-CNT Staff Count: Nurse With Administrative Duties - 8 1269 1276 NUMBER Contract Description: Number of full-time equivalent nurses with administrative duties under contract to a facility. SAS Name: NRS_ADMINV_CNTRCT_CNT COBOL Name: NRS-ADMINV-CNTRCT-CNT Staff Count: Nurse With Administrative Duties - 8 1277 1284 NUMBER Full-Time Description: Number of full-time equivalent nurses with administrative duties employed full-time by a facility. SAS Name: NRS_ADMINV_FLTM_CNT COBOL Name: NRS-ADMINV-FLTM-CNT Staff Count: Nurse With Administrative Duties - 8 1285 1292 NUMBER Part-Time Description: Number of full-time equivalent nurses with administrative duties employed part-time by a facility. SAS Name: NRS_ADMINV_PRTM_CNT COBOL Name: NRS-ADMINV-PRTM-CNT Staff Count: OT - Arrangement 8 1301 1308 NUMBER Description: Number of full-time equivalent occupational therapists under arrangement to the provider SAS Name: OCPTNL_THRPST_CNTRCT_CNT COBOL Name: OCPTNL-THRPST-CNTRCT-CNT Staff Count: OT - Full-Time 8 1309 1316 NUMBER Description: Number of full-time equivalent occupational therapists employed full-time by a facility. SAS Name: OCPTNL_THRPST_FLTM_CNT COBOL Name: OCPTNL-THRPST-FLTM-CNT Staff Count: OT - Part-Time 8 1317 1324 NUMBER Description: Number of full-time equivalent occupational therapists employed part-time by a facility. SAS Name: OCPTNL_THRPST_PRTM_CNT COBOL Name: OCPTNL-THRPST-PRTM-CNT Staff Count: OT Aide - Contract 8 1325 1332 NUMBER Description: Number of full-time equivalent occupational therapy aides under contract to a facility. SAS Name: OT_AIDE_CNTRCT_CNT COBOL Name: OT-AIDE-CNTRCT-CNT Staff Count: OT Aide - Full-Time 8 1333 1340 NUMBER DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 34 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Number of full-time equivalent occupational therapy aides employed full-time by a facility. SAS Name: OT_AIDE_FLTM_CNT COBOL Name: OT-AIDE-FLTM-CNT Staff Count: OT Aide - Part-Time 8 1341 1348 NUMBER Description: Number of full-time equivalent occupational therapy aides employed part-time by a facility. SAS Name: OT_AIDE_PRTM_CNT COBOL Name: OT-AIDE-PRTM-CNT Staff Count: OT Assistant - Contract 8 1349 1356 NUMBER Description: Number of full-time equivalent occupational therapy assistants under contract to a facility. SAS Name: OT_ASTNT_CNTRCT_CNT COBOL Name: OT-ASTNT-CNTRCT-CNT Staff Count: OT Assistant - Full-Time 8 1357 1364 NUMBER Description: Number of full-time equivalent occupational therapy assistants employed full-time by a facility. SAS Name: OT_ASTNT_FLTM_CNT COBOL Name: OT-ASTNT-FLTM-CNT Staff Count: OT Assistant - Part-Time 8 1365 1372 NUMBER Description: Number of full-time equivalent occupational therapy assistants employed part-time by a facility. SAS Name: OT_ASTNT_PRTM_CNT COBOL Name: OT-ASTNT-PRTM-CNT Staff Count: Other Activities - Contract 8 1381 1388 NUMBER Description: Number of full-time equivalent other activities staff providing therapeutic services under contract to a facility. SAS Name: ACTVTY_STF_OTHR_CNTRCT_CNT COBOL Name: ACTVTY-STF-OTHR-CNTRCT-CNT Staff Count: Other Activities - Full-Time 8 1389 1396 NUMBER Description: Number of full-time equivalent other activities staff providing therapeutic services employed full time by a facility. SAS Name: ACTVTY_STF_OTHR_FLTM_CNT COBOL Name: ACTVTY-STF-OTHR-FLTM-CNT Staff Count: Other Activities - Part-Time 8 1397 1404 NUMBER Description: Number of full-time equivalent other activities staff providing therapeutic services employed part time by a facility. SAS Name: ACTVTY_STF_OTHR_PRTM_CNT COBOL Name: ACTVTY-STF-OTHR-PRTM-CNT Staff Count: Other Physician - Contract 8 1405 1412 NUMBER Description: Number of full-time equivalent other physicians under contract to a facility. SAS Name: PHYSN_OTHR_CNTRCT_CNT COBOL Name: PHYSN-OTHR-CNTRCT-CNT Staff Count: Other Physician - Full-Time 8 1413 1420 NUMBER Description: Number of full-time equivalent other physicians employed full-time by a facility. SAS Name: PHYSN_OTHR_FLTM_CNT COBOL Name: PHYSN-OTHR-FLTM-CNT Staff Count: Other Physician - Part-Time 8 1421 1428 NUMBER DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 35 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Number of full-time equivalent other physicians employed part-time by a facility. SAS Name: PHYSN_OTHR_PRTM_CNT COBOL Name: PHYSN-OTHR-PRTM-CNT Staff Count: Other Social Services - Contract 8 1429 1436 NUMBER Description: Number of full-time equivalent other social services staff under contract to a facility. SAS Name: SCL_SRVC_OTHR_STF_CNTRCT_CNT COBOL Name: SCL-SRVC-OTHR-STF-CNTRCT-CNT Staff Count: Other Social Services - Full-Time 8 1437 1444 NUMBER Description: Number of full-time equivalent other social services staff employed full time by a facility. SAS Name: SCL_SRVC_OTHR_STF_FLTM_CNT COBOL Name: SCL-SRVC-OTHR-STF-FLTM-CNT Staff Count: Other Social Services - Part-Time 8 1445 1452 NUMBER Description: Number of full-time equivalent other social services staff employed part time by a facility. SAS Name: SCL_SRVC_OTHR_STF_PRTM_CNT COBOL Name: SCL-SRVC-OTHR-STF-PRTM-CNT Staff Count: Other Staff - Contract 8 1453 1460 NUMBER Description: Number of full-time equivalent staff not included in any other categories under contract to the facility. SAS Name: STF_OTHR_CNTRCT_CNT COBOL Name: STF-OTHR-CNTRCT-CNT Staff Count: Other Staff - Full-Time 8 1461 1468 NUMBER Description: Number of full-time equivalent persons not included in any other categories employed full-time by the facility. SAS Name: STF_OTHR_FLTM_CNT COBOL Name: STF-OTHR-FLTM-CNT Staff Count: Other Staff - Part-Time 8 1469 1476 NUMBER Description: Number of full-time equivalent persons not included in any other categories employed part-time by the facility. SAS Name: STF_OTHR_PRTM_CNT COBOL Name: STF-OTHR-PRTM-CNT Staff Count: Pharmacist - Contract 8 1477 1484 NUMBER Description: Number of full-time equivalent pharmacists under contract to a facility. SAS Name: PHRMCST_CNTRCT_CNT COBOL Name: PHRMCST-CNTRCT-CNT Staff Count: Pharmacist - Full-Time 8 1485 1492 NUMBER Description: Number of full-time equivalent pharmacists employed full-time by a facility. SAS Name: PHRMCST_FLTM_CNT COBOL Name: PHRMCST-FLTM-CNT Staff Count: Pharmacist - Part-Time 8 1493 1500 NUMBER Description: Number of full-time equivalent pharmacists employed part-time by a facility. SAS Name: PHRMCST_PRTM_CNT COBOL Name: PHRMCST-PRTM-CNT Staff Count: Physical Therapist - Contract 8 1501 1508 NUMBER Description: Number of full-time equivalent physical therapists under contract to a facility. SAS Name: PHYS_THRPST_CNTRCT_CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 36 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: PHYS-THRPST-CNTRCT-CNT Staff Count: Physical Therapist - Full-Time 8 1509 1516 NUMBER Description: Number of full-time equivalent physical therapists employed full-time by a facility. SAS Name: PHYS_THRPST_FLTM_CNT COBOL Name: PHYS-THRPST-FLTM-CNT Staff Count: Physical Therapist - Part-Time 8 1517 1524 NUMBER Description: Number of full-time equivalent physical therapists employed part-time by a facility. SAS Name: PHYS_THRPST_PRTM_CNT COBOL Name: PHYS-THRPST-PRTM-CNT Staff Count: Physician Extender - Contract 8 1549 1556 NUMBER Description: Number of full-time equivalent physician extenders under contract to the facility. SAS Name: PHYSN_EXT_CNTRCT_CNT COBOL Name: PHYSN-EXT-CNTRCT-CNT Staff Count: Physician Extender - Full-Time 8 1557 1564 NUMBER Description: Number of full-time equivalent physician extenders employed full-time by the facility. SAS Name: PHYSN_EXT_FLTM_CNT COBOL Name: PHYSN-EXT-FLTM-CNT Staff Count: Physician Extender - Part-Time 8 1565 1572 NUMBER Description: Number of full-time equivalent physician extenders employed part-time by the facility. SAS Name: PHYSN_EXT_PRTM_CNT COBOL Name: PHYSN-EXT-PRTM-CNT Staff Count: Podiatrist - Contract 8 1581 1588 NUMBER Description: Number of full-time equivalent podiatrists under contract to a facility. SAS Name: PDTRST_CNTRCT_CNT COBOL Name: PDTRST-CNTRCT-CNT Staff Count: Podiatrist - Full-Time 8 1589 1596 NUMBER Description: Number of full-time equivalent podiatrists employed full-time by a facility. SAS Name: PDTRST_FLTM_CNT COBOL Name: PDTRST-FLTM-CNT Staff Count: Podiatrist - Part-Time 8 1597 1604 NUMBER Description: Number of full-time equivalent podiatrists employed part-time by a facility. SAS Name: PDTRST_PRTM_CNT COBOL Name: PDTRST-PRTM-CNT Staff Count: PT Aide - Contract 8 1637 1644 NUMBER Description: Number of full-time equivalent physical therapy aides under contract to a facility. SAS Name: PT_AIDE_CNTRCT_CNT COBOL Name: PT-AIDE-CNTRCT-CNT Staff Count: PT Aide - Full-Time 8 1645 1652 NUMBER Description: Number of full-time equivalent physical therapy aides employed full-time by a facility. SAS Name: PT_AIDE_FLTM_CNT COBOL Name: PT-AIDE-FLTM-CNT Staff Count: PT Aide - Part-Time 8 1653 1660 NUMBER DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 37 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Number of full-time equivalent physical therapy aides employed part-time by a facility. SAS Name: PT_AIDE_PRTM_CNT COBOL Name: PT-AIDE-PRTM-CNT Staff Count: PT Assistant - Contract 8 1661 1668 NUMBER Description: Number of full-time equivalent physical therapy assistants under contract to a facility. SAS Name: PT_ASTNT_CNTRCT_CNT COBOL Name: PT-ASTNT-CNTRCT-CNT Staff Count: PT Assistant - Full-Time 8 1669 1676 NUMBER Description: Number of full-time equivalent physical therapy assistants employed full-time by a facility. SAS Name: PT_ASTNT_FLTM_CNT COBOL Name: PT-ASTNT-FLTM-CNT Staff Count: PT Assistant - Part-Time 8 1677 1684 NUMBER Description: Number of full-time equivalent physical therapy assistants employed part-time by a facility. SAS Name: PT_ASTNT_PRTM_CNT COBOL Name: PT-ASTNT-PRTM-CNT Staff Count: Qualified Activities Professional - 8 1685 1692 NUMBER Contract Description: Number of full-time equivalent qualified activities professionals providing therapeutic services under contract to a facility. SAS Name: ACTVTY_PROFNL_CNTRCT_CNT COBOL Name: ACTVTY-PROFNL-CNTRCT-CNT Staff Count: Qualified Activities Professional - 8 1693 1700 NUMBER Full-Time Description: Number of full-time equivalent qualified activities professionals providing therapeutic services employed full time by a facility. SAS Name: ACTVTY_PROFNL_FLTM_CNT COBOL Name: ACTVTY-PROFNL-FLTM-CNT Staff Count: Qualified Activities Professional - 8 1701 1708 NUMBER Part-Time Description: Number of full-time equivalent qualified activities professionals providing therapeutic services employed part time by a facility. SAS Name: ACTVTY_PROFNL_PRTM_CNT COBOL Name: ACTVTY-PROFNL-PRTM-CNT Staff Count: RN - Contract 8 1741 1748 NUMBER Description: Number of full-time equivalent registered nurses under contract to a facility. SAS Name: RN_CNTRCT_CNT COBOL Name: RN-CNTRCT-CNT Staff Count: RN - Full-Time 8 1749 1756 NUMBER Description: Number of full-time equivalent registered nurses employed full-time by a facility. SAS Name: RN_FLTM_CNT COBOL Name: RN-FLTM-CNT Staff Count: RN - Part-Time 8 1757 1764 NUMBER Description: Number of full-time equivalent registered nurses employed part-time by a facility. SAS Name: RN_PRTM_CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 38 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: RN-PRTM-CNT Staff Count: RN Director of Nursing - Contract 8 1773 1780 NUMBER Description: Number of full-time equivalent registered nurse directors of nursing under contract to a facility. SAS Name: RN_DRCTR_CNTRCT_CNT COBOL Name: RN-DRCTR-CNTRCT-CNT Staff Count: RN Director of Nursing - Full-Time 8 1781 1788 NUMBER Description: Number of full-time equivalent registered nurse directors of nursing employed full-time by a facility. SAS Name: RN_DRCTR_FLTM_CNT COBOL Name: RN-DRCTR-FLTM-CNT Staff Count: RN Director of Nursing - Part-Time 8 1789 1796 NUMBER Description: Number of full-time equivalent registered nurse directors of nursing employed part-time by a facility. SAS Name: RN_DRCTR_PRTM_CNT COBOL Name: RN-DRCTR-PRTM-CNT Staff Count: Social Worker - Contract 8 1805 1812 NUMBER Description: Number of full-time equivalent social workers under contract to a facility. SAS Name: SCL_WORKR_CNTRCT_CNT COBOL Name: SCL-WORKR-CNTRCT-CNT Staff Count: Social Worker - Full-Time 8 1813 1820 NUMBER Description: Number of full-time equivalent social workers employed full-time by a facility. SAS Name: SCL_WORKR_FLTM_CNT COBOL Name: SCL-WORKR-FLTM-CNT Staff Count: Social Worker - Part-Time 8 1821 1828 NUMBER Description: Number of full-time equivalent social workers employed part-time by a facility. SAS Name: SCL_WORKR_PRTM_CNT COBOL Name: SCL-WORKR-PRTM-CNT Staff Count: Speech Pathologist - Contract 8 1837 1844 NUMBER Description: Number of full-time equivalent speech pathologists under contract to a facility. SAS Name: SPCH_PTHLGST_CNTRCT_CNT COBOL Name: SPCH-PTHLGST-CNTRCT-CNT Staff Count: Speech Pathologist - Full-Time 8 1845 1852 NUMBER Description: Number of full-time equivalent speech pathologists employed full-time by a facility. SAS Name: SPCH_PTHLGST_FLTM_CNT COBOL Name: SPCH-PTHLGST-FLTM-CNT Staff Count: Speech Pathologist - Part-Time 8 1853 1860 NUMBER Description: Number of full-time equivalent speech pathologists employed part-time by a facility. SAS Name: SPCH_PTHLGST_PRTM_CNT COBOL Name: SPCH-PTHLGST-PRTM-CNT Staff Count: Therapeutic Recreational Specialist - 8 1893 1900 NUMBER Contract Description: Number of full-time equivalent therapeutic recreation specialist staff under contract to a facility. SAS Name: THRPTC_RCRTNL_CNTRCT_CNT COBOL Name: THRPTC-RCRTNL-CNTRCT-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 39 Skilled Nursing Facility/Nursing Facility (Distinct Part), CATEGORY = "03" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Staff Count: Therapeutic Recreational Specialist - 8 1901 1908 NUMBER Full-Time Description: Number of full-time equivalent therapeutic recreation specialist staff employed full-time by a facility. SAS Name: THRPTC_RCRTNL_FLTM_CNT COBOL Name: THRPTC-RCRTNL-FLTM-CNT Staff Count: Therapeutic Recreational Specialist - 8 1909 1916 NUMBER Part-Time Description: Number of full-time equivalent therapeutic recreation specialist staff employed full-time by a facility. SAS Name: THRPTC_RCRTNL_PRTM_CNT COBOL Name: THRPTC-RCRTNL-PRTM-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 1 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Provider Category Subtype Code 2 1 2 VARCHAR2 Description: Identifies the subtype of the provider, within the primary category. Used in reporting to show the breakdown of provider categories, mainly for hospitals and SNFs. SAS Name: PRVDR_CTGRY_SBTYP_CD COBOL Name: PRVDR-CTGRY-SBTYP-CD VALUES: 01=Title 18 Only Provider Category Code 2 3 4 VARCHAR2 Description: Identifies the type of provider participating in the Medicare/Medicaid program. SAS Name: PRVDR_CTGRY_CD COBOL Name: PRVDR-CTGRY-CD VALUES: 04=Skilled Nursing Facility CHOW Count 2 5 6 NUMBER Description: Number of times this provider has undergone a change of ownership. SAS Name: CHOW_CNT COBOL Name: CHOW-CNT CHOW Date 8 7 14 DATE Description: Effective date of the most recent change of ownership for this provider. SAS Name: CHOW_DT COBOL Name: CHOW-DT Address: City 28 15 42 VARCHAR2 Description: City in which the provider is physically located. SAS Name: CITY_NAME COBOL Name: CITY-NAME Compliance: Acceptable POC 1 43 43 VARCHAR2 Description: Indicates if a provider is in compliance with program requirements based on an acceptable plan for correction of deficiencies. SAS Name: ACPTBL_POC_SW COBOL Name: ACPTBL-POC-SW Compliance: Status 1 44 44 VARCHAR2 Description: Compliance status of a provider at the time of certification survey. SAS Name: CMPLNC_STUS_CD COBOL Name: CMPLNC-STUS-CD VALUES: A=IN COMPLIANCE B=NOT IN COMPLIANCE SSA County Code 3 45 47 VARCHAR2 Description: Social Security Administration geographic code indicating the county where the provider is located. SAS Name: SSA_CNTY_CD COBOL Name: SSA-CNTY-CD Cross Ref Provider Number 10 48 57 CHAR Description: Cross reference provider number SAS Name: CROSS_REF_PROVIDER_NUMBER COBOL Name: CROSS-REF-PROVIDER-NUMBER Certification Date 8 58 65 DATE Description: Equal to the exit date of the initial visit of the Health survey for certifications completed after July 28, 2012. For certifications prior to that date, the certification DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 2 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE date is equal to the exit date of the initial visit of the Health survey or LSC survey, whichever is later. SAS Name: CRTFCTN_DT COBOL Name: CRTFCTN-DT Eligibility Indicator 1 66 66 VARCHAR2 Description: Indicates if a facility is eligible to participate in the Medicare and/or Medicaid programs. SAS Name: ELGBLTY_SW COBOL Name: ELGBLTY-SW Facility Name 50 67 116 VARCHAR2 Description: Name of the provider certified to participate in the Medicare and/or Medicaid programs. SAS Name: FAC_NAME COBOL Name: FAC-NAME Medicare Administrative Contractor (MAC) or 5 117 121 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_CD COBOL Name: INTRMDRY-CARR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 3 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 4 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 5 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 6 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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 15 122 136 VARCHAR2 Description: Number which may be assigned to a provider by the state Medicaid agency for external control or billing purposes. SAS Name: MDCD_VNDR_NUM COBOL Name: MDCD-VNDR-NUM Original Participation Date 8 137 144 DATE Description: Date a provider is first approved to provide Medicare and/or Medicaid services. SAS Name: ORGNL_PRTCPTN_DT COBOL Name: ORGNL-PRTCPTN-DT Prior CHOW Date 8 145 152 DATE Description: Effective date of the previous change of ownership for this provider. SAS Name: CHOW_PRIOR_DT COBOL Name: CHOW-PRIOR-DT Prior Medicare Administrative Contractor (MAC) or 5 153 157 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the previous Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_PRIOR_CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 7 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: INTRMDRY-CARR-PRIOR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 00520=BLUE SHIELD (ARKANSAS) 00528=BLUE SHIELD (ARKANSAS/LOUISIANA) 00542=BLUE SHIELD (CALIFORNIA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 8 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00550=BLUE SHIELD (COLORADO) 00570=BLUE SHIELD (DELAWARE) 00580=BLUE SHIELD (DISTRICT OF COLUMBIA) 00590=BLUE SHIELD (FLORIDA) 00621=BLUE SHIELD (ILLINOIS) 00630=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 9 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 10 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 11 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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) CCN 10 158 167 VARCHAR2 Description: Six or ten position identification number that is assigned to a certified provider. This is the CMS Certification Number. SAS Name: PRVDR_NUM COBOL Name: PRVDR-NUM Region Code 2 168 169 VARCHAR2 Description: Indicates the CMS Regional Office responsible for the certification of the provider. SAS Name: RGN_CD COBOL Name: RGN-CD VALUES: 01=Boston 02=New York 03=Philadelphia 04=Atlanta 05=Chicago 06=Dallas 07=Kansas City 08=Denver 09=San Francisco 10=Seattle Skeleton Record Indicator 1 170 170 VARCHAR2 Description: Indicates if the record is a skeleton record. Only a limited set of data is available for this provider; no survey data exists. SAS Name: SKLTN_REC_SW COBOL Name: SKLTN-REC-SW State Abbreviation 2 171 172 VARCHAR2 Description: Two-character state abbreviation. SAS Name: STATE_CD COBOL Name: STATE-CD VALUES: AK=ALASKA AL=ALABAMA AR=ARKANSAS AS=AMERICAN SAMOA AZ=ARIZONA CA=CALIFORNIA CN=CANADA CO=COLORADO CT=CONNECTICUT DC=DISTRICT OF COLUMBIA DE=DELAWARE FL=FLORIDA FN=INTERNATIONAL DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 12 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA=GEORGIA GU=GUAM HI=HAWAII IA=IOWA ID=IDAHO IL=ILLINOIS IN=INDIANA KS=KANSAS KY=KENTUCKY LA=LOUISIANA MA=MASSACHUSETTS MD=MARYLAND ME=MAINE MI=MICHIGAN MN=MINNESOTA MO=MISSOURI MP=SAIPAN MS=MISSISSIPPI MT=MONTANA MX=MEXICO NC=NORTH CAROLINA ND=NORTH DAKOTA NE=NEBRASKA NH=NEW HAMPSHIRE NJ=NEW JERSEY NM=NEW MEXICO NV=NEVADA NY=NEW YORK OH=OHIO OK=OKLAHOMA OR=OREGON PA=PENNSYLVANIA PR=PUERTO RICO RI=RHODE ISLAND SC=SOUTH CAROLINA SD=SOUTH DAKOTA TN=TENNESSEE TX=TEXAS UT=UTAH VA=VIRGINIA VI=VIRGIN ISLANDS VT=VERMONT WA=WASHINGTON WI=WISCONSIN WV=WEST VIRGINIA WY=WYOMING SSA State Code 2 173 174 VARCHAR2 Description: Social Security Administration geographic code indicating the state where the provider is located. SAS Name: SSA_STATE_CD COBOL Name: SSA-STATE-CD 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 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 13 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 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 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 99=INTERNATIONAL State Region Code 3 175 177 VARCHAR2 Description: Identifies the region within a state where the provider is located. SAS Name: STATE_RGN_CD COBOL Name: STATE-RGN-CD VALUES: AK/001=ALASKA AK/LAB=LABORATORIES AL/001=ALABAMA AL/LAB=LABORATORIES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 14 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE AR/001=ARKANSAS AR/LAB=LABORATORIES AS/001=AMERICAN SAMOA AS/LAB=LABORATORY AZ/AZ=PHOENIX AZ/LAB=ARIZONA LAB AZ/TUC=TUCSON CA/BAK=BAKERSFIELD CA/BER=SAN BERNARDINO CA/BK=BERKELEY CA/BK1=CONTRA COSTA CA/FR=FRESNO CA/L1=L.A. WEST CA/L2=L.A. NORTH CA/L3=L.A. CENTRAL CA/L4=L.A. EAST CA/L5=SAN GABRIEL CA/LAB=LABORATORIES CA/M1=LAB. SOUTH CA/M2=LAB. NORTH CA/ORG=ORANGE CO CA/RIV=RIVERSIDE CA/RWC=REDWOOD COAST CA/S1=SACRAMENTO CA/S2=SACTO SOUTH CA/S3=CHICO CA/SD=SAN DIEGO CA/SDS=SAN DIEGO SOUTH CA/SF=SAN FRANCISCO CA/SJ=SAN JOSE CA/SR=SANTA ROSA CA/VEN=VENTURA CN/001=CANADA CN/LAB=LABORATORY CO/001=COLORADO CO/LAB=LABORATORIES CT/001=CONNECTICUT CT/LAB=LABORATORIES DC/001=DISTRICT OF COLUMBIA DC/LAB=LABORATORIES DE/001=DELAWARE DE/LAB=LABORATORIES FL/FTM=FT. MYERS FL/GAI=GAINESVILLE FL/JAX=JACKSONVILLE FL/LAB=LABORATORIES FL/LAN=LANTANA FL/LAU=LAUDERHILL FL/MIA=MIAMI FL/ORL=ORLANDO FL/PEN=PENSACOLA FL/STP=ST. PETERSBURG FL/TAL=TALLAHASSEE FL/TAM=TAMPA FM/001=FEDERATED STATES OF MICRO FN/001=INTERNATIONAL FN/LAB=LABORATORIES GA/001=GEORGIA GA/GAA=GEORGIA ALL GA/GAC=GEORGIA CENTRAL GA/GAE=GEORGIA EASTERN GA/GAN=GEORGIA NORTH GA/GAS=GEORGIA SOUTH GA/GAW=GEORGIA WESTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 15 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA/LAB=LABORATORIES GU/001=GUAM GU/LAB=LABORATORIES HI/001=HAWAII HI/LAB=LABORATORIES IA/001=IOWA IA/LAB=LABORATORIES ID/001=IDAHO ID/LAB=LABORATORIES IL/001=ILLINOIS IL/LAB=LABORATORIES IN/001=INDIANA IN/LAB=LABORATORIES KS/KCK=KANSAS CITY KS/KDH=KDHE KS/LAB=LABORATORIES KS/LAW=LAWRENCE KS/NC=NORTH CENTRAL KANSAS KS/NE=NORTH EAST KANSAS KS/NW=NORTH WEST KANSAS KS/SC=SOUTH CENTRAL KANSAS KS/SE=SOUTH EAST KANSAS KS/SW=SOUTH WEST KANSAS KS/WST=WEST KY/2C1=HOPKINSVILLE KY/2C2=LOUISVILLE KY/2C3=LONDON KY/2C4=LEXINGTON KY/LAB=LABORATORIES LA/001=LOUISIANA LA/LA1=NEW ORLEANS LA/LA2=MANDEVILLE LA/LA3=LAFAYETTE LA/LA4=MONROE LA/LA5=SHREVEPORT LA/LA6=ALEXANDRIA LA/LAB=LABORATORIES LA/LB1=CLIA NEW ORLEANS LA/LB5=CLIA SHREVEPORT LA/LB6=CLIA ALEXANDRIA MA/001=MASSACHUSETTS MA/LAB=LABORATORIES MD/001=MARYLAND MD/LAB=LABORATORIES ME/001=MAINE ME/LAB=LABORATORIES MH/001=MARSHALL ISLANDS MI/001=MICHIGAN MI/LAB=LABORATORIES MN/001=MINNESOTA MN/LAB=LABORATORIES MO/01=REGION01 MO/02=REGION02 MO/03=REGION 03 MO/04=REGION 04 MO/05=REGION 05 MO/06=REGION 06 MO/07=REGION 07 MO/1NH=REGION 1 NH MO/2NH=REGION 2 NH MO/3NH=REGION 3 NH MO/4NH=REGION 4 NH MO/5NH=REGION 5 NH MO/6NH=REGION 6 NH DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 16 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE MO/7NH=REGION 7 NH MO/LAB=LABORATORIES MO/MO=STATEWIDE MP/001=NORTHERN MARIANA ISLANDS MP/LAB=LABORATORIES MS/001=MISSISSIPPI MS/LAB=LABORATORIES MT/001=MONTANA MT/LAB=LABORATORIES MX/001=MEXICO MX/LAB=LABORATORY NC/LAB=LABORATORIES NC/NCC=NORTH CAROLINA CENTRAL NC/NCE=NORTH CAROLINA EAST NC/NCN=NORTH CAROLINA NORTH NC/NCS=NORTH CAROLINA SOUTH NC/NCW=NORTH CAROLINA WEST ND/001=NORTH DAKOTA ND/LAB=LABORATORIES NE/1=NORTH CENTRAL NE/2=CENTRAL NE/3=NORTHEAST NE/4=SOUTHEAST NE/5=WESTERN NE/LAB=LABORATORIES NH/001=NEW HAMPSHIRE NH/LAB=LABORATORIES NJ/001=NEW JERSEY NJ/LAB=LABORATORIES NM/001=NEW MEXICO NM/LAB=LABORATORIES NV/CC=CARSON CITY NV/LAB=LABORATORIES NV/LV=LAS VEGAS NY/001=BUFFALO NY/002=ROCHESTER NY/003=SYRACUSE NY/004=ALBANY NY/005=NEW ROCHELLE NY/006=NEW YORK CITY NY/007=SUFFOLK/NASSAU COUNTY NY/LAB=LABORATORIES OH/001=OHIO OH/LAB=LABORATORIES OK/001=OKLAHOMA OK/LAB=LABORATORIES OR/001=OFFICE #1 OR/002=OFFICE #2 OR/003=OFFICE #3 OR/LAB=LABORATORIES PA/001=PENNSYLVANIA PA/LAB=LABORATORIES PR/001=PUERTO RICO PR/LAB=LABORATORIES PW/001=PALAU RI/001=RHODE ISLAND RI/LAB=LABORATORIES SC/001=SOUTH CAROLINA SC/LAB=LABORATORIES SD/001=SOUTH DAKOTA SD/LAB=LABORATORIES TN/LAB=LABORATORIES TN/TNC=TENNESSEE COOKEVILLE TN/TNE=TENNESSEE EASTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 17 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE TN/TNM=TENNESSEE MIDDLE TN/TNW=TENNESSEE WESTERN TX/001=TEXAS TX/L01=AMARILLO-LTC TX/L02=ABILENE-LTC TX/L03=ARLINGTON-LTC TX/L04=TYLER-LTC TX/L05=BEAUMONT-LTC TX/L06=HOUSTON-LTC TX/L07=TEMPLE-LTC TX/L08=SAN ANTONIO-LTC TX/L09=SAN ANGELO-LTC TX/L10=EL PASO-LTC TX/L11=CORPUS CHRISTI-LTC TX/LAB=LABORATORIES TX/TX1=LUBBOCK TX/TX2=ARLINGTON TX/TX3=SAN ANTONIO TX/TX4=HOUSTON TX/TX5=TYLER TX/TX6=AUSTIN UT/001=UTAH UT/LAB=LABORATORIES VA/001=VIRGINIA VA/LAB=LABORATORIES VI/001=VIRGIN ISLANDS VI/LAB=LABORATORIES VT/001=VERMONT VT/LAB=LABORATORIES WA/001=ALL OTHERS (NON-LTC FAC) WA/D1=SPOKANE & YAKIMA AREAS WA/D1A=District 1, Unit A WA/D1B=District 1, Unit B WA/D1C=District 1, Unit C WA/D1D=District 1, Unit D WA/D2=SPOKANE & SE WA/D2A=District 2, Unit A WA/D2B=District 2, Unit B WA/D2C=District 2, Unit C WA/D2D=District 2, Unit D WA/D2E=District 2, Unit E WA/D2F=District 2, Unit F WA/D2G=District 2, Unit G WA/D3=NW WASHINGTON WA/D3A=District 3, Unit A WA/D3B=District 3, Unit B WA/D3C=District 3, Unit C WA/D3D=District 3, Unit D WA/D3E=District 3, Unit E WA/D4A=GREATER SEATTLE AREA WA/D4B=S KING COUNTY WA/D5A=PIERCE CTY & PENINSULA WA/D5B=PIERCE CTY & GRAYS HARBOR WA/D6=OLYMPIA AREA WA/LAB=LABORATORIES WI/001=WISCONSIN WI/LAB=LABORATORIES WV/001=WEST VIRGINIA WV/LAB=LABORATORIES WY/001=WYOMING WY/LAB=LABORATORIES Address: Street 50 178 227 VARCHAR2 Description: Street address where the provider is located. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 18 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: ST_ADR COBOL Name: ST-ADR Telephone Number 10 228 237 VARCHAR2 Description: Telephone number of the provider. SAS Name: PHNE_NUM COBOL Name: PHNE-NUM Termination Code 2 238 239 VARCHAR2 Description: Indicates the current termination status for the provider. SAS Name: PGM_TRMNTN_CD COBOL Name: PGM-TRMNTN-CD VALUES: 00=ACTIVE PROVIDER 01=VOLUNTARY-MERGER, CLOSURE 02=VOLUNTARY-DISSATISFACTION WITH REIMBURSEMENT 03=VOLUNTARY-RISK OF INVOLUNTARY TERMINATION 04=VOLUNTARY-OTHER REASON FOR WITHDRAWAL 05=INVOLUNTARY-FAILURE TO MEET HEALTH/SAFETY REQ 06=INVOLUNTARY-FAILURE TO MEET AGREEMENT 07=OTHER-PROVIDER STATUS CHANGE 08=NONPAYMENT OF FEES - CLIA Only 09=REV/UNSUCCESSFUL PARTICIPATION IN PT - CLIA Only 10=REV/OTHER REASON - CLIA Only 11=INCOMPLETE CLIA APPLICATION INFORMATION - CLIA Only 12=NO LONGER PERFORMING TESTS - CLIA Only 13=MULTIPLE TO SINGLE SITE CERTIFICATE - CLIA Only 14=SHARED LABORATORY - CLIA Only 15=FAILURE TO RENEW WAIVER PPM CERTIFICATE - CLIA Only 16=DUPLICATE CLIA NUMBER - CLIA Only 17=MAIL RETURNED NO FORWARD ADDRESS CERT ENDED - CLIA Only 20=NOTIFICATION BANKRUPTCY - CLIA Only 33=ACCREDITATION NOT CONFIRMED - CLIA Only 80=AWAITING STATE APPROVAL 99=OIG ACTION - DO NOT ACTIVATE - CLIA Only Termination or Expiration Date 8 240 247 DATE Description: Date the provider was terminated. For CLIA providers, date the laboratory's certificate was terminated or the expiration date of the current CLIA certificate. SAS Name: TRMNTN_EXPRTN_DT COBOL Name: TRMNTN-EXPRTN-DT Type of Action Code 1 248 248 VARCHAR2 Description: Identifies the reason for the certification. Type of action from the official survey record, CMS 1539 form. SAS Name: CRTFCTN_ACTN_TYPE_CD COBOL Name: CRTFCTN-ACTN-TYPE-CD VALUES: 1=INITIAL 2=RECERTIFICATION 3=TERMINATION 4=CHANGE OF OWNERSHIP 5=VALIDATION 8=FULL SURVEY AFTER COMPLAINT Ownership Type Code 2 249 250 VARCHAR2 Description: Indicates the ownership type of the provider. SAS Name: GNRL_CNTL_TYPE_CD COBOL Name: GNRL-CNTL-TYPE-CD VALUES: 01=FOR PROFIT - INDIVIDUAL 02=FOR PROFIT - PARTNERSHIP 03=FOR PROFIT - CORPORATION 04=NONPROFIT - CHURCH RELATED 05=NONPROFIT - CORPORATION DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 19 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 06=NONPROFIT - OTHER 07=GOVERNMENT - STATE 08=GOVERNMENT - COUNTY 09=GOVERNMENT - CITY 10=GOVERNMENT - CITY/COUNTY 11=GOVERNMENT - HOSPITAL DISTRICT 12=GOVERNMENT - FEDERAL 13=FOR PROFIT - LIMITED LIABILITY CORPORATION Address: ZIP Code 5 251 255 VARCHAR2 Description: Five-digit ZIP code for a provider's physical address. SAS Name: ZIP_CD COBOL Name: ZIP-CD FIPS State Code 2 256 257 VARCHAR2 Description: FIPS State Code SAS Name: FIPS_STATE_CD COBOL Name: FIPS-STATE-CD VALUES: 01=ALABAMA 02=ALASKA 04=ARIZONA 05=ARKANSAS 06=CALIFORNIA 08=COLORADO 09=CONNECTICUT 10=DELAWARE 11=DISTRICT OF COLUMBIA 12=FLORIDA 13=GEORGIA 15=HAWAII 16=IDAHO 17=ILLINOIS 18=INDIANA 19=IOWA 20=KANSAS 21=KENTUCKY 22=LOUISIANA 23=MAINE 24=MARYLAND 25=MASSACHUSETTS 26=MICHIGAN 27=MINNESOTA 28=MISSISSIPPI 29=MISSOURI 30=MONTANA 31=NEBRASKA 32=NEVADA 33=NEW HAMPSHIRE 34=NEW JERSEY 35=NEW MEXICO 36=NEW YORK 37=NORTH CAROLINA 38=NORTH DAKOTA 39=OHIO 40=OKLAHOMA 41=OREGON 42=PENNSYLVANIA 43=PUERTO RICO 44=RHODE ISLAND 45=SOUTH CAROLINA 46=SOUTH DAKOTA 47=TENNESSEE 48=TEXAS 49=UTAH DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 20 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 50=VERMONT 51=VIRGINIA 53=WASHINGTON 54=WEST VIRGINIA 55=WISCONSIN 56=WYOMING 64=AMERICAN SAMOA 65=GUAM 66=SAIPAN/MARIANA IS. 78=VIRGIN ISLANDS FIPS County Code 3 258 260 VARCHAR2 Description: FIPS County Code SAS Name: FIPS_CNTY_CD COBOL Name: FIPS-CNTY-CD CBSA Urban Rural Indicator 1 261 261 VARCHAR2 Description: CBSA (Core Based Statistical Area) indicates whether the county is defined as Urban or Rural. SAS Name: CBSA_URBN_RRL_IND COBOL Name: CBSA-URBN-RRL-IND CBSA Code 5 262 266 VARCHAR2 Description: CBSA (Core Based Statistical Area) geographic entities defined by the U.S. Office of Management and Budget (OMB) on June 6, 2003 for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics. CBSA collectively refers to MSA. SAS Name: CBSA_CD COBOL Name: CBSA-CD Bed Count Override Indicator 1 325 325 CHAR Description: Indicates if the regional office has approved a significant bed count change from the previous certification. SAS Name: OVRRD_BED_CNT_SW COBOL Name: OVRRD-BED-CNT-SW Bed Count: Certified 4 326 329 NUMBER Description: Number of beds in Medicare and/or Medicaid certified areas within a facility. SAS Name: CRTFD_BED_CNT COBOL Name: CRTFD-BED-CNT Bed Count: Medicaid NF 4 334 337 NUMBER Description: Number of Medicaid-certified Nursing Facility beds. SAS Name: MDCD_NF_BED_CNT COBOL Name: MDCD-NF-BED-CNT Bed Count: Medicare SNF 4 338 341 NUMBER Description: Number of Medicare-certified Skilled Nursing Facility beds. SAS Name: MDCR_SNF_BED_CNT COBOL Name: MDCR-SNF-BED-CNT Bed Count: Medicare/Medicaid SNF 4 342 345 NUMBER Description: Number of dually certified (Medicare/Medicaid) beds in a Skilled Nursing Facility. SAS Name: MDCR_MDCD_SNF_BED_CNT COBOL Name: MDCR-MDCD-SNF-BED-CNT Bed Count: Special Care - AIDS 3 346 348 NUMBER Description: Number of beds in a special care unit dedicated for residents with AIDS. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 21 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: AIDS_BED_CNT COBOL Name: AIDS-BED-CNT Bed Count: Special Care - Alzheimers 3 349 351 NUMBER Description: Number of beds in a special care unit dedicated for residents with Alzheimer's disease. SAS Name: ALZHMR_BED_CNT COBOL Name: ALZHMR-BED-CNT Bed Count: Special Care - Dialysis 3 352 354 NUMBER Description: Number of beds in a special care unit dedicated for residents who require dialysis. SAS Name: DLYS_BED_CNT COBOL Name: DLYS-BED-CNT Bed Count: Special Care - Disabled Children 3 355 357 NUMBER Description: Number of beds in a special care unit dedicated for disabled children. SAS Name: DSBL_CHLDRN_BED_CNT COBOL Name: DSBL-CHLDRN-BED-CNT Bed Count: Special Care - Head Trauma 3 358 360 NUMBER Description: Number of beds in a special care unit dedicated for residents with head trauma. SAS Name: HEAD_TRMA_BED_CNT COBOL Name: HEAD-TRMA-BED-CNT Bed Count: Special Care - Hospice 3 361 363 NUMBER Description: Number of beds in a special care unit dedicated for residents who require hospice care. SAS Name: HOSPC_BED_CNT COBOL Name: HOSPC-BED-CNT Bed Count: Special Care - Huntingtons Disease 3 364 366 NUMBER Description: Number of beds in a special care unit dedicated for residents with Huntington's disease. SAS Name: HNTGTN_DEASE_BED_CNT COBOL Name: HNTGTN-DEASE-BED-CNT Bed Count: Special Care - Specialized Rehab 3 367 369 NUMBER Description: Number of beds in a special care unit dedicated for residents with specialized rehab needs. SAS Name: REHAB_BED_CNT COBOL Name: REHAB-BED-CNT Bed Count: Special Care - Ventilator 3 370 372 NUMBER Description: Number of beds in a special care unit dedicated for residents requiring a ventilator and/or respiratory care. SAS Name: VNTLTR_BED_CNT COBOL Name: VNTLTR-BED-CNT Bed Count: Total 4 373 376 NUMBER Description: Total number of beds in a provider, including those in non-participating or non-licensed areas. SAS Name: BED_CNT COBOL Name: BED-CNT Compliance: 24-Hour RN Waiver Indicator 1 442 442 CHAR Description: Indicates if a waiver of the 24-hour registered nurse staffing requirements has been recommended for a Skilled Nursing Facility or Nursing Facility. SAS Name: RN_24_HR_WVR_SW COBOL Name: RN-24-HR-WVR-SW DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 22 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Compliance: 7-Day RN Waiver Indicator 1 443 443 VARCHAR2 Description: Indicates if a waiver of the 7-day registered nurse staffing requirements has been recommended for a Skilled Nursing Facility. SAS Name: RN_7_DAY_WVR_SW COBOL Name: RN-7-DAY-WVR-SW Compliance: Beds Per Room Waiver Indicator 1 444 444 CHAR Description: Indicates if a waiver of the beds per room requirement has been recommended for a facility. SAS Name: BED_PER_ROOM_WVR_SW COBOL Name: BED-PER-ROOM-WVR-SW Compliance: LSC Waiver Indicator 1 445 445 CHAR Description: Indicates if a waiver of any life safety code provision has been recommended for a provider. SAS Name: LSC_WVR_SW COBOL Name: LSC-WVR-SW Compliance: Patient Room Size Waiver Indicator 1 446 446 CHAR Description: Indicates if a waiver of the patient room size provision has been recommended for a provider. SAS Name: ROOM_SIZE_WVR_SW COBOL Name: ROOM-SIZE-WVR-SW Experimental Research Conducted Indicator 1 453 453 VARCHAR2 Description: Indicates if a facility conducts experimental research. SAS Name: EXPRMT_RSRCH_CNDCTD_SW COBOL Name: EXPRMT-RSRCH-CNDCTD-SW Fiscal Year End Date (MMDD) 4 464 467 VARCHAR2 Description: End date, consisting of the month and day, of the provider's fiscal year. SAS Name: FY_END_MO_DAY_CD COBOL Name: FY-END-MO-DAY-CD LTC Cross Ref Provider Number 10 485 494 CHAR Description: LTC cross ref provider number SAS Name: LTC_CROSS_REF_PROVIDER_NUMBER COBOL Name: LTC-CROSS-REF-PROVIDER-NUMBER Multiple Facility Organization Name 38 513 550 CHAR Description: Name of the multi-facility organization that owns the facility. SAS Name: MLT_FAC_ORG_NAME COBOL Name: MLT-FAC-ORG-NAME Multiple Facility Organization Owned Indicator 1 551 551 CHAR Description: Indicates if a facility is owned by an organization that owns (or leases) two or more long term care facilities. SAS Name: MLT_OWND_FAC_ORG_SW COBOL Name: MLT-OWND-FAC-ORG-SW Organized Family Group Indicator 1 609 609 VARCHAR2 Description: Indicates if the facility has an organized group of family members of residents. SAS Name: ORGNZ_FMLY_MBR_GRP_SW COBOL Name: ORGNZ-FMLY-MBR-GRP-SW Organized Resident Group Indicator 1 610 610 VARCHAR2 Description: Indicates if the facility has an organized residents group. SAS Name: ORGNZ_RSDNT_GRP_SW COBOL Name: ORGNZ-RSDNT-GRP-SW DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 23 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Program Participation Code 1 623 623 CHAR Description: Indicates if the provider participates in Medicare, Medicaid, or both programs. SAS Name: PGM_PRTCPTN_CD COBOL Name: PGM-PRTCPTN-CD VALUES: 1=MEDICARE ONLY 2=MEDICAID ONLY 3=MEDICARE AND MEDICAID Related Provider Number 10 669 678 CHAR Description: Related provider number SAS Name: RELATED_PROVIDER_NUMBER COBOL Name: RELATED-PROVIDER-NUMBER Services: Blood Administration Off-Site Residents 1 686 686 VARCHAR2 Indicator Description: Indicates if blood administration and storage services are provided off-site to residents. SAS Name: BLOOD_SRVC_OFSITE_RSDNT_SW COBOL Name: BLOOD-SRVC-OFSITE-RSDNT-SW Services: Blood Administration On-Site Nonresidents 1 687 687 VARCHAR2 Indicator Description: Indicates if blood administration and storage services are provided on-site to nonresidents. SAS Name: BLOOD_SRVC_ONST_NRSDNT_SW COBOL Name: BLOOD-SRVC-ONST-NRSDNT-SW Services: Blood Administration On-Site Residents 1 688 688 VARCHAR2 Indicator Description: Indicates if blood administration and storage services are provided on-site to residents. SAS Name: BLOOD_SRVC_ONST_RSDNT_SW COBOL Name: BLOOD-SRVC-ONST-RSDNT-SW Services: Clinical Laboratory - Off-Site Residents 1 695 695 VARCHAR2 Indicator Description: Indicates if clinical laboratory services are provided off-site to residents. SAS Name: CL_SRVC_OFSITE_RSDNT_SW COBOL Name: CL-SRVC-OFSITE-RSDNT-SW Services: Clinical Laboratory - On-Site Nonresidents 1 696 696 VARCHAR2 Indicator Description: Indicates if clinical laboratory services are provided on-site to nonresidents. SAS Name: CL_SRVC_ONST_NRSDNT_SW COBOL Name: CL-SRVC-ONST-NRSDNT-SW Services: Clinical Laboratory - On-Site Residents 1 697 697 VARCHAR2 Indicator Description: Indicates if clinical laboratory services are provided on-site to residents. SAS Name: CL_SRVC_ONST_RSDNT_SW COBOL Name: CL-SRVC-ONST-RSDNT-SW Services: Dental Off-Site Residents Indicator 1 703 703 VARCHAR2 Description: Indicates if dental services are provided off-site to residents. SAS Name: DNTL_SRVC_OFSITE_RSDNT_SW COBOL Name: DNTL-SRVC-OFSITE-RSDNT-SW Services: Dental On-Site Nonresidents Indicator 1 704 704 VARCHAR2 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 24 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Indicates if dental services are provided on-site to nonresidents. SAS Name: DNTL_SRVC_ONST_NRSDNT_SW COBOL Name: DNTL-SRVC-ONST-NRSDNT-SW Services: Dental On-Site Residents Indicator 1 705 705 VARCHAR2 Description: Indicates if dental services are provided on-site to residents. SAS Name: DNTL_SRVC_ONST_RSDNT_SW COBOL Name: DNTL-SRVC-ONST-RSDNT-SW Services: Dietary Off-Site Residents Indicator 1 709 709 VARCHAR2 Description: Indicates if dietary services are provided off-site to residents. SAS Name: DTRY_OFSITE_RSDNT_SW COBOL Name: DTRY-OFSITE-RSDNT-SW Services: Dietary On-Site Nonresidents Indicator 1 710 710 VARCHAR2 Description: Indicates if dietary services are provided on-site to nonresidents. SAS Name: DTRY_ONST_NRSDNT_SW COBOL Name: DTRY-ONST-NRSDNT-SW Services: Dietary On-Site Residents Indicator 1 711 711 VARCHAR2 Description: Indicates if dietary services are provided on-site to residents. SAS Name: DTRY_ONST_RSDNT_SW COBOL Name: DTRY-ONST-RSDNT-SW Services: Housekeeping Off-Site Residents Indicator 1 721 721 VARCHAR2 Description: Indicates if housekeeping services are provided off-site to residents. SAS Name: HSEKPNG_SRVC_OFSITE_RSDNT_SW COBOL Name: HSEKPNG-SRVC-OFSITE-RSDNT-SW Services: Housekeeping On-Site Nonresidents Indicator 1 722 722 VARCHAR2 Description: Indicates if housekeeping services are provided on-site to nonresidents. SAS Name: HSEKPNG_SRVC_ONST_NRSDNT_SW COBOL Name: HSEKPNG-SRVC-ONST-NRSDNT-SW Services: Housekeeping On-Site Residents Indicator 1 723 723 VARCHAR2 Description: Indicates if housekeeping services are provided on-site to residents. SAS Name: HSEKPNG_SRVC_ONST_RSDNT_SW COBOL Name: HSEKPNG-SRVC-ONST-RSDNT-SW Services: Mental Health Off-Site Residents Indicator 1 730 730 VARCHAR2 Description: Indicates if mental health services are provided off-site to residents. SAS Name: MENTL_HLTH_OFSITE_RSDNT_SW COBOL Name: MENTL-HLTH-OFSITE-RSDNT-SW Services: Mental Health On-Site Nonresidents 1 731 731 VARCHAR2 Indicator Description: Indicates if mental health services are provided on-site to nonresidents. SAS Name: MENTL_HLTH_ONST_NRSDNT_SW COBOL Name: MENTL-HLTH-ONST-NRSDNT-SW Services: Mental Health On-Site Residents Indicator 1 732 732 VARCHAR2 Description: Indicates if mental health services are provided on-site to residents. SAS Name: MENTL_HLTH_ONST_RSDNT_SW DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 25 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: MENTL-HLTH-ONST-RSDNT-SW Services: Nursing Off-Site Residents Indicator 1 743 743 VARCHAR2 Description: Indicates if nursing services are provided off-site to residents. SAS Name: NRSNG_SRVC_OFSITE_RSDNT_SW COBOL Name: NRSNG-SRVC-OFSITE-RSDNT-SW Services: Nursing On-Site Nonresidents Indicator 1 744 744 VARCHAR2 Description: Indicates if nursing services are provided on-site to nonresidents. SAS Name: NRSNG_SRVC_ONST_NRSDNT_SW COBOL Name: NRSNG-SRVC-ONST-NRSDNT-SW Services: Nursing On-Site Residents Indicator 1 745 745 VARCHAR2 Description: Indicates if nursing services are provided on-site to residents. SAS Name: NRSNG_SRVC_ONST_RSDNT_SW COBOL Name: NRSNG-SRVC-ONST-RSDNT-SW Services: OT Off-Site Residents Indicator 1 759 759 VARCHAR2 Description: Indicates if occupational therapy services are provided off-site to residents. SAS Name: OT_SRVC_OFSITE_RSDNT_SW COBOL Name: OT-SRVC-OFSITE-RSDNT-SW Services: OT On-Site Nonresidents Indicator 1 760 760 VARCHAR2 Description: Indicates if occupational therapy services are provided on-site to nonresidents. SAS Name: OT_SRVC_ONST_NRSDNT_SW COBOL Name: OT-SRVC-ONST-NRSDNT-SW Services: OT On-Site Residents Indicator 1 761 761 VARCHAR2 Description: Indicates if occupational therapy services are provided on-site to residents. SAS Name: OT_SRVC_ONST_RSDNT_SW COBOL Name: OT-SRVC-ONST-RSDNT-SW Services: Pharmacy Off-Site Residents Indicator 1 772 772 VARCHAR2 Description: Indicates if pharmacy services are provided off-site to residents. SAS Name: PHRMCY_SRVC_OFSITE_RSDNT_SW COBOL Name: PHRMCY-SRVC-OFSITE-RSDNT-SW Services: Pharmacy On-Site Nonresidents Indicator 1 773 773 VARCHAR2 Description: Indicates if pharmacy services are provided on-site to nonresidents. SAS Name: PHRMCY_SRVC_ONST_NRSDNT_SW COBOL Name: PHRMCY-SRVC-ONST-NRSDNT-SW Services: Pharmacy On-Site Residents Indicator 1 774 774 VARCHAR2 Description: Indicates if pharmacy services are provided on-site to residents. SAS Name: PHRMCY_SRVC_ONST_RSDNT_SW COBOL Name: PHRMCY-SRVC-ONST-RSDNT-SW Services: Physician Extender Off-Site Residents 1 779 779 VARCHAR2 Indicator Description: Indicates if physician extender services are provided off-site to residents. SAS Name: PHYSN_EXT_SRVC_OFSITE_RSDNT_SW COBOL Name: PHYSN-EXT-SRVC-OFSITE-RSDNT-SW Services: Physician Extender On-Site Nonresidents 1 780 780 VARCHAR2 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 26 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Indicator Description: Indicates if physician extender services are provided on-site to nonresidents. SAS Name: PHYSN_EXT_SRVC_ONST_NRSDNT_SW COBOL Name: PHYSN-EXT-SRVC-ONST-NRSDNT-SW Services: Physician Extender On-Site Residents 1 781 781 VARCHAR2 Indicator Description: Indicates if physician extender services are provided on-site to residents. SAS Name: PHYSN_EXT_SRVC_ONST_RSDNT_SW COBOL Name: PHYSN-EXT-SRVC-ONST-RSDNT-SW Services: Physician Off-Site Residents Indicator 1 782 782 VARCHAR2 Description: Indicates if physician services are provided off-site to residents. SAS Name: PHYSN_SRVC_OFSITE_RSDNT_SW COBOL Name: PHYSN-SRVC-OFSITE-RSDNT-SW Services: Physician On-Site Nonresidents Indicator 1 783 783 VARCHAR2 Description: Indicates if physician services are provided on-site to nonresidents. SAS Name: PHYSN_SRVC_ONST_NRSDNT_SW COBOL Name: PHYSN-SRVC-ONST-NRSDNT-SW Services: Physician On-Site Residents Indicator 1 784 784 VARCHAR2 Description: Indicates if physician services are provided on-site to residents. SAS Name: PHYSN_SRVC_ONST_RSDNT_SW COBOL Name: PHYSN-SRVC-ONST-RSDNT-SW Services: Podiatry Off-Site Residents Indicator 1 785 785 VARCHAR2 Description: Indicates if podiatry services are provided off-site to residents. SAS Name: PDTRY_SRVC_OFSITE_RSDNT_SW COBOL Name: PDTRY-SRVC-OFSITE-RSDNT-SW Services: Podiatry On-Site Nonresidents Indicator 1 786 786 VARCHAR2 Description: Indicates if podiatry services are provided on-site to nonresidents. SAS Name: PDTRY_SRVC_ONST_NRSDNT_SW COBOL Name: PDTRY-SRVC-ONST-NRSDNT-SW Services: Podiatry On-Site Residents Indicator 1 787 787 VARCHAR2 Description: Indicates if podiatry services are provided on-site to residents. SAS Name: PDTRY_SRVC_ONST_RSDNT_SW COBOL Name: PDTRY-SRVC-ONST-RSDNT-SW Services: PT Off-Site Residents Indicator 1 797 797 VARCHAR2 Description: Indicates if physical therapy services are provided off-site to residents. SAS Name: PT_OFSITE_RSDNT_SW COBOL Name: PT-OFSITE-RSDNT-SW Services: PT On-Site Nonresidents Indicator 1 798 798 VARCHAR2 Description: Indicates if physical therapy services are provided on-site to nonresidents. SAS Name: PT_ONST_NRSDNT_SW COBOL Name: PT-ONST-NRSDNT-SW Services: PT On-Site Residents Indicator 1 799 799 VARCHAR2 Description: Indicates if physical therapy services are provided on-site to residents. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 27 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: PT_ONST_RSDNT_SW COBOL Name: PT-ONST-RSDNT-SW Services: Social Work Off-Site Residents Indicator 1 810 810 VARCHAR2 Description: Indicates if social work services are provided off-site to residents. SAS Name: SCL_WORK_SRVC_OFSITE_RSDNT_SW COBOL Name: SCL-WORK-SRVC-OFSITE-RSDNT-SW Services: Social Work On-Site Nonresidents Indicator 1 811 811 VARCHAR2 Description: Indicates if social work services are provided on-site to nonresidents. SAS Name: SCL_WORK_SRVC_ONST_NRSDNT_SW COBOL Name: SCL-WORK-SRVC-ONST-NRSDNT-SW Services: Social Work On-Site Residents Indicator 1 812 812 VARCHAR2 Description: Indicates if social work services are provided on-site to residents. SAS Name: SCL_WORK_SRVC_ONST_RSDNT_SW COBOL Name: SCL-WORK-SRVC-ONST-RSDNT-SW Services: Speech Pathology Off-Site Residents 1 817 817 VARCHAR2 Indicator Description: Indicates if speech/language pathology services are provided off-site to residents. SAS Name: SPCH_PTHLGY_OFSITE_RSDNT_SW COBOL Name: SPCH-PTHLGY-OFSITE-RSDNT-SW Services: Speech Pathology On-Site Nonresidents 1 818 818 VARCHAR2 Indicator Description: Indicates if speech/language pathology services are provided on-site to nonresidents. SAS Name: SPCH_PTHLGY_ONST_NRSDNT_SW COBOL Name: SPCH-PTHLGY-ONST-NRSDNT-SW Services: Speech Pathology On-Site Residents 1 819 819 VARCHAR2 Indicator Description: Indicates if speech/language pathology services are provided on-site to residents. SAS Name: SPCH_PTHLGY_ONST_RSDNT_SW COBOL Name: SPCH-PTHLGY-ONST-RSDNT-SW Services: Therapeutic - Other Activities Staff - 1 822 822 VARCHAR2 Off-Site Residents Indicator Description: Indicates if therapeutic services are provided off-site to residents by other activities staff. SAS Name: ACTVTY_OTHR_OFSITE_RSDNT_SW COBOL Name: ACTVTY-OTHR-OFSITE-RSDNT-SW Services: Therapeutic - Other Activities Staff - 1 823 823 VARCHAR2 On-Site Nonresidents Indicator Description: Indicates if therapeutic services are provided on-site to nonresidents by other activities staff. SAS Name: ACTVTY_OTHR_ONST_NRSDNT_SW COBOL Name: ACTVTY-OTHR-ONST-NRSDNT-SW Services: Therapeutic - Other Activities Staff - 1 824 824 VARCHAR2 On-Site Residents Indicator Description: Indicates if therapeutic services are provided on-site to residents by other activities staff. SAS Name: ACTVTY_OTHR_ONST_RSDNT_SW COBOL Name: ACTVTY-OTHR-ONST-RSDNT-SW Services: Therapeutic - Other Social Services Staff - 1 825 825 VARCHAR2 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 28 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Off-Site Residents Indicator Description: Indicates if other therapeutic social services are provided off-site to residents. SAS Name: SCL_SRVC_OTHR_OFSITE_RSDNT_SW COBOL Name: SCL-SRVC-OTHR-OFSITE-RSDNT-SW Services: Therapeutic - Other Social Services Staff - 1 826 826 VARCHAR2 On-Site Nonresidents Indicator Description: Indicates if other therapeutic social services are provided on-site to nonresidents. SAS Name: SCL_SRVC_OTHR_ONST_NRSDNT_SW COBOL Name: SCL-SRVC-OTHR-ONST-NRSDNT-SW Services: Therapeutic - Other Social Services Staff - 1 827 827 VARCHAR2 On-Site Residents Indicator Description: Indicates if other therapeutic social services are provided on-site to residents. SAS Name: SCL_SRVC_OTHR_ONST_RSDNT_SW COBOL Name: SCL-SRVC-OTHR-ONST-RSDNT-SW Services: Therapeutic - Qualified Activities 1 828 828 VARCHAR2 Professional - Off-Site Residents Indicator Description: Indicates if therapeutic services are provided off-site to residents by qualified activities professionals. SAS Name: ACTVTY_OFSITE_RSDNT_SW COBOL Name: ACTVTY-OFSITE-RSDNT-SW Services: Therapeutic - Qualified Activities 1 829 829 VARCHAR2 Professional - On-Site Nonresidents Indicator Description: Indicates if therapeutic services are provided on-site to nonresidents by qualified activities professionals. SAS Name: ACTVTY_ONST_NRSDNT_SW COBOL Name: ACTVTY-ONST-NRSDNT-SW Services: Therapeutic - Qualified Activities 1 830 830 VARCHAR2 Professional - On-Site Residents Indicator Description: Indicates if therapeutic services are provided on-site to residents by qualified activities professionals. SAS Name: ACTVTY_ONST_RSDNT_SW COBOL Name: ACTVTY-ONST-RSDNT-SW Services: Therapeutic Recreational Specialty Off-Site 1 832 832 VARCHAR2 Residents Indicator Description: Indicates if therapeutic recreation specialist services are provided off-site to residents. SAS Name: THRPTC_RCRTNL_OFSITE_RSDNT_SW COBOL Name: THRPTC-RCRTNL-OFSITE-RSDNT-SW Services: Therapeutic Recreational Specialty On-Site 1 833 833 VARCHAR2 Nonresidents Indicator Description: Indicates if therapeutic recreation specialist services are provided on-site to nonresidents. SAS Name: THRPTC_RCRTNL_ONST_NRSDNT_SW COBOL Name: THRPTC-RCRTNL-ONST-NRSDNT-SW Services: Therapeutic Recreational Specialty On-Site 1 834 834 VARCHAR2 Residents Indicator Description: Indicates if therapeutic recreation specialist services are provided on-site to residents. SAS Name: THRPTC_RCRTNL_ONST_RSDNT_SW COBOL Name: THRPTC-RCRTNL-ONST-RSDNT-SW Services: Vocational Off-Site Residents Indicator 1 837 837 VARCHAR2 Description: Indicates if vocational services are provided off-site to DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 29 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE residents. SAS Name: VCTNL_SRVC_OFSITE_RSDNT_SW COBOL Name: VCTNL-SRVC-OFSITE-RSDNT-SW Services: Vocational On-Site Nonresidents Indicator 1 838 838 VARCHAR2 Description: Indicates if vocational services are provided on-site to nonresidents. SAS Name: VCTNL_SRVC_ONST_NRSDNT_SW COBOL Name: VCTNL-SRVC-ONST-NRSDNT-SW Services: Vocational On-Site Residents Indicator 1 839 839 VARCHAR2 Description: Indicates if vocational services are provided on-site to residents. SAS Name: VCTNL_SRVC_ONST_RSDNT_SW COBOL Name: VCTNL-SRVC-ONST-RSDNT-SW Services: X-ray Off-Site Residents Indicator 1 840 840 VARCHAR2 Description: Indicates if diagnostic X-ray services are provided off-site to residents. SAS Name: DGNSTC_XRAY_OFSITE_RSDNT_SW COBOL Name: DGNSTC-XRAY-OFSITE-RSDNT-SW Services: X-ray On-Site Nonresidents Indicator 1 841 841 VARCHAR2 Description: Indicates if diagnostic X-ray services are provided on-site to nonresidents. SAS Name: DGNSTC_XRAY_ONST_NRSDNT_SW COBOL Name: DGNSTC-XRAY-ONST-NRSDNT-SW Services: X-ray On-Site Residents Indicator 1 842 842 VARCHAR2 Description: Indicates if diagnostic X-ray services are provided on-site to residents. SAS Name: DGNSTC_XRAY_ONST_RSDNT_SW COBOL Name: DGNSTC-XRAY-ONST-RSDNT-SW Staff Count Override Indicator 1 844 844 CHAR Description: Indicates if the regional office has approved a significant staff count change from the previous certification. SAS Name: OVRRD_STFG_SW COBOL Name: OVRRD-STFG-SW Staff Count: Administrative Staff - Contract 8 845 852 NUMBER Description: Number of full-time equivalent administrative staff under contract to a facility. SAS Name: PROFNL_ADMIN_CNTRCT_CNT COBOL Name: PROFNL-ADMIN-CNTRCT-CNT Staff Count: Administrative Staff - Full-Time 8 853 860 NUMBER Description: Number of full-time equivalent administrative staff employed on a full-time basis by a facility. SAS Name: PROFNL_ADMIN_FLTM_CNT COBOL Name: PROFNL-ADMIN-FLTM-CNT Staff Count: Administrative Staff - Part-Time 8 861 868 NUMBER Description: Number of full-time equivalent administrative staff employed on a part-time basis by a facility. SAS Name: PROFNL_ADMIN_PRTM_CNT COBOL Name: PROFNL-ADMIN-PRTM-CNT Staff Count: Certified Nurse Aide - Contract 8 893 900 NUMBER Description: Number of full-time equivalent certified nurse aides under contract to a facility. SAS Name: NRS_AIDE_CNTRCT_CNT COBOL Name: NRS-AIDE-CNTRCT-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 30 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Staff Count: Certified Nurse Aide - Full-Time 8 901 908 NUMBER Description: Number of full-time equivalent certified nurse aides employed full-time by a facility. SAS Name: NRS_AIDE_FLTM_CNT COBOL Name: NRS-AIDE-FLTM-CNT Staff Count: Certified Nurse Aide - Part-Time 8 909 916 NUMBER Description: Number of full-time equivalent certified nurse aides employed part-time by a facility. SAS Name: NRS_AIDE_PRTM_CNT COBOL Name: NRS-AIDE-PRTM-CNT Staff Count: Dentist - Contract 8 941 948 NUMBER Description: Number of full-time equivalent dentists under contract to a facility. SAS Name: DNTST_CNTRCT_CNT COBOL Name: DNTST-CNTRCT-CNT Staff Count: Dentist - Full-Time 8 949 956 NUMBER Description: Number of full-time equivalent dentists employed full time by a facility. SAS Name: DNTST_FLTM_CNT COBOL Name: DNTST-FLTM-CNT Staff Count: Dentist - Part-Time 8 957 964 NUMBER Description: Number of full-time equivalent dentists employed part time by a facility. SAS Name: DNTST_PRTM_CNT COBOL Name: DNTST-PRTM-CNT Staff Count: Dietitian - Contract 8 973 980 NUMBER Description: Number of full-time equivalent dietitians under contract to a facility. SAS Name: DIETN_CNTRCT_CNT COBOL Name: DIETN-CNTRCT-CNT Staff Count: Dietitian - Full-Time 8 981 988 NUMBER Description: Number of full-time equivalent dietitians employed full time by a facility. SAS Name: DIETN_FLTM_CNT COBOL Name: DIETN-FLTM-CNT Staff Count: Dietitian - Part-Time 8 989 996 NUMBER Description: Number of full-time equivalent dietitians employed part time by a facility. SAS Name: DIETN_PRTM_CNT COBOL Name: DIETN-PRTM-CNT Staff Count: Food Service Worker - Contract 8 1005 1012 NUMBER Description: Number of full-time equivalent food service personnel under contract to a facility. SAS Name: FOOD_SRVC_CNTRCT_CNT COBOL Name: FOOD-SRVC-CNTRCT-CNT Staff Count: Food Service Worker - Full-Time 8 1013 1020 NUMBER Description: Number of full-time equivalent food service personnel employed full-time by a facility. SAS Name: FOOD_SRVC_FLTM_CNT COBOL Name: FOOD-SRVC-FLTM-CNT Staff Count: Food Service Worker - Part-Time 8 1021 1028 NUMBER Description: Number of full-time equivalent food service personnel employed part-time by a facility. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 31 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: FOOD_SRVC_PRTM_CNT COBOL Name: FOOD-SRVC-PRTM-CNT Staff Count: Housekeeping - Contract 8 1053 1060 NUMBER Description: Number of full-time equivalent housekeeping personnel under contract to a facility. SAS Name: HSEKPNG_CNTRCT_CNT COBOL Name: HSEKPNG-CNTRCT-CNT Staff Count: Housekeeping - Full-Time 8 1061 1068 NUMBER Description: Number of full-time equivalent housekeeping personnel employed full-time by a facility. SAS Name: HSEKPNG_FLTM_CNT COBOL Name: HSEKPNG-FLTM-CNT Staff Count: Housekeeping - Part-Time 8 1069 1076 NUMBER Description: Number of full-time equivalent housekeeping personnel employed part-time by a facility. SAS Name: HSEKPNG_PRTM_CNT COBOL Name: HSEKPNG-PRTM-CNT Staff Count: LPN/LVN - Contract 8 1101 1108 NUMBER Description: Number of full-time equivalent licensed practical/vocational nurses under contract to a facility. SAS Name: LPN_LVN_CNTRCT_CNT COBOL Name: LPN-LVN-CNTRCT-CNT Staff Count: LPN/LVN - Full-Time 8 1109 1116 NUMBER Description: Number of full-time equivalent licensed practical/vocational nurses employed full-time by a facility. SAS Name: LPN_LVN_FLTM_CNT COBOL Name: LPN-LVN-FLTM-CNT Staff Count: LPN/LVN - Part-Time 8 1117 1124 NUMBER Description: Number of full-time equivalent licensed practical/vocational nurses employed part-time by a facility. SAS Name: LPN_LVN_PRTM_CNT COBOL Name: LPN-LVN-PRTM-CNT Staff Count: Medical Director - Contract 8 1133 1140 NUMBER Description: Number of full-time equivalent medical directors under contract to a facility. SAS Name: MDCL_DRCTR_CNTRCT_CNT COBOL Name: MDCL-DRCTR-CNTRCT-CNT Staff Count: Medical Director - Full-Time 8 1141 1148 NUMBER Description: Number of full-time equivalent medical directors employed full-time by a facility. SAS Name: MDCL_DRCTR_FLTM_CNT COBOL Name: MDCL-DRCTR-FLTM-CNT Staff Count: Medical Director - Part-Time 8 1149 1156 NUMBER Description: Number of full-time equivalent medical directors employed part-time by a facility. SAS Name: MDCL_DRCTR_PRTM_CNT COBOL Name: MDCL-DRCTR-PRTM-CNT Staff Count: Medication Aide/Technician - Contract 8 1181 1188 NUMBER Description: Number of full-time equivalent medication aides/ technicians under contract to a facility. SAS Name: MDCTN_AIDE_CNTRCT_CNT COBOL Name: MDCTN-AIDE-CNTRCT-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 32 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Staff Count: Medication Aide/Technician - Full-Time 8 1189 1196 NUMBER Description: Number of full-time equivalent medication aides/ technicians employed full-time by a facility. SAS Name: MDCTN_AIDE_FLTM_CNT COBOL Name: MDCTN-AIDE-FLTM-CNT Staff Count: Medication Aide/Technician - Part-Time 8 1197 1204 NUMBER Description: Number of full-time equivalent medication aides/ technicians employed part-time by a facility. SAS Name: MDCTN_AIDE_PRTM_CNT COBOL Name: MDCTN-AIDE-PRTM-CNT Staff Count: Mental Health Services - Contract 8 1205 1212 NUMBER Description: Number of full-time equivalent mental health services personnel under contract to a facility. SAS Name: MENTL_HLTH_SRVC_CNTRCT_CNT COBOL Name: MENTL-HLTH-SRVC-CNTRCT-CNT Staff Count: Mental Health Services - Full-Time 8 1213 1220 NUMBER Description: Number of full-time equivalent mental health services personnel employed full-time by a facility. SAS Name: MENTL_HLTH_SRVC_FLTM_CNT COBOL Name: MENTL-HLTH-SRVC-FLTM-CNT Staff Count: Mental Health Services - Part-Time 8 1221 1228 NUMBER Description: Number of full-time equivalent mental health services personnel employed part-time by a facility. SAS Name: MENTL_HLTH_SRVC_PRTM_CNT COBOL Name: MENTL-HLTH-SRVC-PRTM-CNT Staff Count: Nurse Aide in Training - Contract 8 1237 1244 NUMBER Description: Number of full-time equivalent nurse aides in training under contract to a facility. SAS Name: NAT_CNTRCT_CNT COBOL Name: NAT-CNTRCT-CNT Staff Count: Nurse Aide in Training - Full-Time 8 1245 1252 NUMBER Description: Number of full-time equivalent nurse aides in training employed full-time by a facility. SAS Name: NAT_FLTM_CNT COBOL Name: NAT-FLTM-CNT Staff Count: Nurse Aide in Training - Part-Time 8 1253 1260 NUMBER Description: Number of full-time equivalent nurse aides in training employed part-time by a facility. SAS Name: NAT_PRTM_CNT COBOL Name: NAT-PRTM-CNT Staff Count: Nurse With Administrative Duties - 8 1269 1276 NUMBER Contract Description: Number of full-time equivalent nurses with administrative duties under contract to a facility. SAS Name: NRS_ADMINV_CNTRCT_CNT COBOL Name: NRS-ADMINV-CNTRCT-CNT Staff Count: Nurse With Administrative Duties - 8 1277 1284 NUMBER Full-Time Description: Number of full-time equivalent nurses with administrative duties employed full-time by a facility. SAS Name: NRS_ADMINV_FLTM_CNT COBOL Name: NRS-ADMINV-FLTM-CNT Staff Count: Nurse With Administrative Duties - 8 1285 1292 NUMBER DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 33 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Part-Time Description: Number of full-time equivalent nurses with administrative duties employed part-time by a facility. SAS Name: NRS_ADMINV_PRTM_CNT COBOL Name: NRS-ADMINV-PRTM-CNT Staff Count: OT - Arrangement 8 1301 1308 NUMBER Description: Number of full-time equivalent occupational therapists under arrangement to the provider SAS Name: OCPTNL_THRPST_CNTRCT_CNT COBOL Name: OCPTNL-THRPST-CNTRCT-CNT Staff Count: OT - Full-Time 8 1309 1316 NUMBER Description: Number of full-time equivalent occupational therapists employed full-time by a facility. SAS Name: OCPTNL_THRPST_FLTM_CNT COBOL Name: OCPTNL-THRPST-FLTM-CNT Staff Count: OT - Part-Time 8 1317 1324 NUMBER Description: Number of full-time equivalent occupational therapists employed part-time by a facility. SAS Name: OCPTNL_THRPST_PRTM_CNT COBOL Name: OCPTNL-THRPST-PRTM-CNT Staff Count: OT Aide - Contract 8 1325 1332 NUMBER Description: Number of full-time equivalent occupational therapy aides under contract to a facility. SAS Name: OT_AIDE_CNTRCT_CNT COBOL Name: OT-AIDE-CNTRCT-CNT Staff Count: OT Aide - Full-Time 8 1333 1340 NUMBER Description: Number of full-time equivalent occupational therapy aides employed full-time by a facility. SAS Name: OT_AIDE_FLTM_CNT COBOL Name: OT-AIDE-FLTM-CNT Staff Count: OT Aide - Part-Time 8 1341 1348 NUMBER Description: Number of full-time equivalent occupational therapy aides employed part-time by a facility. SAS Name: OT_AIDE_PRTM_CNT COBOL Name: OT-AIDE-PRTM-CNT Staff Count: OT Assistant - Contract 8 1349 1356 NUMBER Description: Number of full-time equivalent occupational therapy assistants under contract to a facility. SAS Name: OT_ASTNT_CNTRCT_CNT COBOL Name: OT-ASTNT-CNTRCT-CNT Staff Count: OT Assistant - Full-Time 8 1357 1364 NUMBER Description: Number of full-time equivalent occupational therapy assistants employed full-time by a facility. SAS Name: OT_ASTNT_FLTM_CNT COBOL Name: OT-ASTNT-FLTM-CNT Staff Count: OT Assistant - Part-Time 8 1365 1372 NUMBER Description: Number of full-time equivalent occupational therapy assistants employed part-time by a facility. SAS Name: OT_ASTNT_PRTM_CNT COBOL Name: OT-ASTNT-PRTM-CNT Staff Count: Other Activities - Contract 8 1381 1388 NUMBER Description: Number of full-time equivalent other activities staff providing therapeutic services under contract to a facility. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 34 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: ACTVTY_STF_OTHR_CNTRCT_CNT COBOL Name: ACTVTY-STF-OTHR-CNTRCT-CNT Staff Count: Other Activities - Full-Time 8 1389 1396 NUMBER Description: Number of full-time equivalent other activities staff providing therapeutic services employed full time by a facility. SAS Name: ACTVTY_STF_OTHR_FLTM_CNT COBOL Name: ACTVTY-STF-OTHR-FLTM-CNT Staff Count: Other Activities - Part-Time 8 1397 1404 NUMBER Description: Number of full-time equivalent other activities staff providing therapeutic services employed part time by a facility. SAS Name: ACTVTY_STF_OTHR_PRTM_CNT COBOL Name: ACTVTY-STF-OTHR-PRTM-CNT Staff Count: Other Physician - Contract 8 1405 1412 NUMBER Description: Number of full-time equivalent other physicians under contract to a facility. SAS Name: PHYSN_OTHR_CNTRCT_CNT COBOL Name: PHYSN-OTHR-CNTRCT-CNT Staff Count: Other Physician - Full-Time 8 1413 1420 NUMBER Description: Number of full-time equivalent other physicians employed full-time by a facility. SAS Name: PHYSN_OTHR_FLTM_CNT COBOL Name: PHYSN-OTHR-FLTM-CNT Staff Count: Other Physician - Part-Time 8 1421 1428 NUMBER Description: Number of full-time equivalent other physicians employed part-time by a facility. SAS Name: PHYSN_OTHR_PRTM_CNT COBOL Name: PHYSN-OTHR-PRTM-CNT Staff Count: Other Social Services - Contract 8 1429 1436 NUMBER Description: Number of full-time equivalent other social services staff under contract to a facility. SAS Name: SCL_SRVC_OTHR_STF_CNTRCT_CNT COBOL Name: SCL-SRVC-OTHR-STF-CNTRCT-CNT Staff Count: Other Social Services - Full-Time 8 1437 1444 NUMBER Description: Number of full-time equivalent other social services staff employed full time by a facility. SAS Name: SCL_SRVC_OTHR_STF_FLTM_CNT COBOL Name: SCL-SRVC-OTHR-STF-FLTM-CNT Staff Count: Other Social Services - Part-Time 8 1445 1452 NUMBER Description: Number of full-time equivalent other social services staff employed part time by a facility. SAS Name: SCL_SRVC_OTHR_STF_PRTM_CNT COBOL Name: SCL-SRVC-OTHR-STF-PRTM-CNT Staff Count: Other Staff - Contract 8 1453 1460 NUMBER Description: Number of full-time equivalent staff not included in any other categories under contract to the facility. SAS Name: STF_OTHR_CNTRCT_CNT COBOL Name: STF-OTHR-CNTRCT-CNT Staff Count: Other Staff - Full-Time 8 1461 1468 NUMBER Description: Number of full-time equivalent persons not included in any other categories employed full-time by the facility. SAS Name: STF_OTHR_FLTM_CNT COBOL Name: STF-OTHR-FLTM-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 35 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Staff Count: Other Staff - Part-Time 8 1469 1476 NUMBER Description: Number of full-time equivalent persons not included in any other categories employed part-time by the facility. SAS Name: STF_OTHR_PRTM_CNT COBOL Name: STF-OTHR-PRTM-CNT Staff Count: Pharmacist - Contract 8 1477 1484 NUMBER Description: Number of full-time equivalent pharmacists under contract to a facility. SAS Name: PHRMCST_CNTRCT_CNT COBOL Name: PHRMCST-CNTRCT-CNT Staff Count: Pharmacist - Full-Time 8 1485 1492 NUMBER Description: Number of full-time equivalent pharmacists employed full-time by a facility. SAS Name: PHRMCST_FLTM_CNT COBOL Name: PHRMCST-FLTM-CNT Staff Count: Pharmacist - Part-Time 8 1493 1500 NUMBER Description: Number of full-time equivalent pharmacists employed part-time by a facility. SAS Name: PHRMCST_PRTM_CNT COBOL Name: PHRMCST-PRTM-CNT Staff Count: Physical Therapist - Contract 8 1501 1508 NUMBER Description: Number of full-time equivalent physical therapists under contract to a facility. SAS Name: PHYS_THRPST_CNTRCT_CNT COBOL Name: PHYS-THRPST-CNTRCT-CNT Staff Count: Physical Therapist - Full-Time 8 1509 1516 NUMBER Description: Number of full-time equivalent physical therapists employed full-time by a facility. SAS Name: PHYS_THRPST_FLTM_CNT COBOL Name: PHYS-THRPST-FLTM-CNT Staff Count: Physical Therapist - Part-Time 8 1517 1524 NUMBER Description: Number of full-time equivalent physical therapists employed part-time by a facility. SAS Name: PHYS_THRPST_PRTM_CNT COBOL Name: PHYS-THRPST-PRTM-CNT Staff Count: Physician Extender - Contract 8 1549 1556 NUMBER Description: Number of full-time equivalent physician extenders under contract to the facility. SAS Name: PHYSN_EXT_CNTRCT_CNT COBOL Name: PHYSN-EXT-CNTRCT-CNT Staff Count: Physician Extender - Full-Time 8 1557 1564 NUMBER Description: Number of full-time equivalent physician extenders employed full-time by the facility. SAS Name: PHYSN_EXT_FLTM_CNT COBOL Name: PHYSN-EXT-FLTM-CNT Staff Count: Physician Extender - Part-Time 8 1565 1572 NUMBER Description: Number of full-time equivalent physician extenders employed part-time by the facility. SAS Name: PHYSN_EXT_PRTM_CNT COBOL Name: PHYSN-EXT-PRTM-CNT Staff Count: Podiatrist - Contract 8 1581 1588 NUMBER Description: Number of full-time equivalent podiatrists under contract to a facility. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 36 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: PDTRST_CNTRCT_CNT COBOL Name: PDTRST-CNTRCT-CNT Staff Count: Podiatrist - Full-Time 8 1589 1596 NUMBER Description: Number of full-time equivalent podiatrists employed full-time by a facility. SAS Name: PDTRST_FLTM_CNT COBOL Name: PDTRST-FLTM-CNT Staff Count: Podiatrist - Part-Time 8 1597 1604 NUMBER Description: Number of full-time equivalent podiatrists employed part-time by a facility. SAS Name: PDTRST_PRTM_CNT COBOL Name: PDTRST-PRTM-CNT Staff Count: PT Aide - Contract 8 1637 1644 NUMBER Description: Number of full-time equivalent physical therapy aides under contract to a facility. SAS Name: PT_AIDE_CNTRCT_CNT COBOL Name: PT-AIDE-CNTRCT-CNT Staff Count: PT Aide - Full-Time 8 1645 1652 NUMBER Description: Number of full-time equivalent physical therapy aides employed full-time by a facility. SAS Name: PT_AIDE_FLTM_CNT COBOL Name: PT-AIDE-FLTM-CNT Staff Count: PT Aide - Part-Time 8 1653 1660 NUMBER Description: Number of full-time equivalent physical therapy aides employed part-time by a facility. SAS Name: PT_AIDE_PRTM_CNT COBOL Name: PT-AIDE-PRTM-CNT Staff Count: PT Assistant - Contract 8 1661 1668 NUMBER Description: Number of full-time equivalent physical therapy assistants under contract to a facility. SAS Name: PT_ASTNT_CNTRCT_CNT COBOL Name: PT-ASTNT-CNTRCT-CNT Staff Count: PT Assistant - Full-Time 8 1669 1676 NUMBER Description: Number of full-time equivalent physical therapy assistants employed full-time by a facility. SAS Name: PT_ASTNT_FLTM_CNT COBOL Name: PT-ASTNT-FLTM-CNT Staff Count: PT Assistant - Part-Time 8 1677 1684 NUMBER Description: Number of full-time equivalent physical therapy assistants employed part-time by a facility. SAS Name: PT_ASTNT_PRTM_CNT COBOL Name: PT-ASTNT-PRTM-CNT Staff Count: Qualified Activities Professional - 8 1685 1692 NUMBER Contract Description: Number of full-time equivalent qualified activities professionals providing therapeutic services under contract to a facility. SAS Name: ACTVTY_PROFNL_CNTRCT_CNT COBOL Name: ACTVTY-PROFNL-CNTRCT-CNT Staff Count: Qualified Activities Professional - 8 1693 1700 NUMBER Full-Time Description: Number of full-time equivalent qualified activities professionals providing therapeutic services employed full time by a facility. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 37 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: ACTVTY_PROFNL_FLTM_CNT COBOL Name: ACTVTY-PROFNL-FLTM-CNT Staff Count: Qualified Activities Professional - 8 1701 1708 NUMBER Part-Time Description: Number of full-time equivalent qualified activities professionals providing therapeutic services employed part time by a facility. SAS Name: ACTVTY_PROFNL_PRTM_CNT COBOL Name: ACTVTY-PROFNL-PRTM-CNT Staff Count: RN - Contract 8 1741 1748 NUMBER Description: Number of full-time equivalent registered nurses under contract to a facility. SAS Name: RN_CNTRCT_CNT COBOL Name: RN-CNTRCT-CNT Staff Count: RN - Full-Time 8 1749 1756 NUMBER Description: Number of full-time equivalent registered nurses employed full-time by a facility. SAS Name: RN_FLTM_CNT COBOL Name: RN-FLTM-CNT Staff Count: RN - Part-Time 8 1757 1764 NUMBER Description: Number of full-time equivalent registered nurses employed part-time by a facility. SAS Name: RN_PRTM_CNT COBOL Name: RN-PRTM-CNT Staff Count: RN Director of Nursing - Contract 8 1773 1780 NUMBER Description: Number of full-time equivalent registered nurse directors of nursing under contract to a facility. SAS Name: RN_DRCTR_CNTRCT_CNT COBOL Name: RN-DRCTR-CNTRCT-CNT Staff Count: RN Director of Nursing - Full-Time 8 1781 1788 NUMBER Description: Number of full-time equivalent registered nurse directors of nursing employed full-time by a facility. SAS Name: RN_DRCTR_FLTM_CNT COBOL Name: RN-DRCTR-FLTM-CNT Staff Count: RN Director of Nursing - Part-Time 8 1789 1796 NUMBER Description: Number of full-time equivalent registered nurse directors of nursing employed part-time by a facility. SAS Name: RN_DRCTR_PRTM_CNT COBOL Name: RN-DRCTR-PRTM-CNT Staff Count: Social Worker - Contract 8 1805 1812 NUMBER Description: Number of full-time equivalent social workers under contract to a facility. SAS Name: SCL_WORKR_CNTRCT_CNT COBOL Name: SCL-WORKR-CNTRCT-CNT Staff Count: Social Worker - Full-Time 8 1813 1820 NUMBER Description: Number of full-time equivalent social workers employed full-time by a facility. SAS Name: SCL_WORKR_FLTM_CNT COBOL Name: SCL-WORKR-FLTM-CNT Staff Count: Social Worker - Part-Time 8 1821 1828 NUMBER Description: Number of full-time equivalent social workers employed part-time by a facility. SAS Name: SCL_WORKR_PRTM_CNT COBOL Name: SCL-WORKR-PRTM-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 38 Skilled Nursing Facility, CATEGORY = "04" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Staff Count: Speech Pathologist - Contract 8 1837 1844 NUMBER Description: Number of full-time equivalent speech pathologists under contract to a facility. SAS Name: SPCH_PTHLGST_CNTRCT_CNT COBOL Name: SPCH-PTHLGST-CNTRCT-CNT Staff Count: Speech Pathologist - Full-Time 8 1845 1852 NUMBER Description: Number of full-time equivalent speech pathologists employed full-time by a facility. SAS Name: SPCH_PTHLGST_FLTM_CNT COBOL Name: SPCH-PTHLGST-FLTM-CNT Staff Count: Speech Pathologist - Part-Time 8 1853 1860 NUMBER Description: Number of full-time equivalent speech pathologists employed part-time by a facility. SAS Name: SPCH_PTHLGST_PRTM_CNT COBOL Name: SPCH-PTHLGST-PRTM-CNT Staff Count: Therapeutic Recreational Specialist - 8 1893 1900 NUMBER Contract Description: Number of full-time equivalent therapeutic recreation specialist staff under contract to a facility. SAS Name: THRPTC_RCRTNL_CNTRCT_CNT COBOL Name: THRPTC-RCRTNL-CNTRCT-CNT Staff Count: Therapeutic Recreational Specialist - 8 1901 1908 NUMBER Full-Time Description: Number of full-time equivalent therapeutic recreation specialist staff employed full-time by a facility. SAS Name: THRPTC_RCRTNL_FLTM_CNT COBOL Name: THRPTC-RCRTNL-FLTM-CNT Staff Count: Therapeutic Recreational Specialist - 8 1909 1916 NUMBER Part-Time Description: Number of full-time equivalent therapeutic recreation specialist staff employed full-time by a facility. SAS Name: THRPTC_RCRTNL_PRTM_CNT COBOL Name: THRPTC-RCRTNL-PRTM-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 1 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Provider Category Subtype Code 2 1 2 VARCHAR2 Description: Identifies the subtype of the provider, within the primary category. Used in reporting to show the breakdown of provider categories, mainly for hospitals and SNFs. SAS Name: PRVDR_CTGRY_SBTYP_CD COBOL Name: PRVDR-CTGRY-SBTYP-CD VALUES: 01=Home Health Agency Provider Category Code 2 3 4 VARCHAR2 Description: Identifies the type of provider participating in the Medicare/Medicaid program. SAS Name: PRVDR_CTGRY_CD COBOL Name: PRVDR-CTGRY-CD VALUES: 05=Home Health Agency CHOW Count 2 5 6 NUMBER Description: Number of times this provider has undergone a change of ownership. SAS Name: CHOW_CNT COBOL Name: CHOW-CNT CHOW Date 8 7 14 DATE Description: Effective date of the most recent change of ownership for this provider. SAS Name: CHOW_DT COBOL Name: CHOW-DT Address: City 28 15 42 VARCHAR2 Description: City in which the provider is physically located. SAS Name: CITY_NAME COBOL Name: CITY-NAME Compliance: Acceptable POC 1 43 43 VARCHAR2 Description: Indicates if a provider is in compliance with program requirements based on an acceptable plan for correction of deficiencies. SAS Name: ACPTBL_POC_SW COBOL Name: ACPTBL-POC-SW Compliance: Status 1 44 44 VARCHAR2 Description: Compliance status of a provider at the time of certification survey. SAS Name: CMPLNC_STUS_CD COBOL Name: CMPLNC-STUS-CD VALUES: A=IN COMPLIANCE B=NOT IN COMPLIANCE SSA County Code 3 45 47 VARCHAR2 Description: Social Security Administration geographic code indicating the county where the provider is located. SAS Name: SSA_CNTY_CD COBOL Name: SSA-CNTY-CD Cross Ref Provider Number 10 48 57 CHAR Description: Cross reference provider number SAS Name: CROSS_REF_PROVIDER_NUMBER COBOL Name: CROSS-REF-PROVIDER-NUMBER Certification Date 8 58 65 DATE Description: Equal to the exit date of the initial visit of the Health survey for certifications completed after July 28, 2012. For certifications prior to that date, the certification DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 2 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE date is equal to the exit date of the initial visit of the Health survey or LSC survey, whichever is later. SAS Name: CRTFCTN_DT COBOL Name: CRTFCTN-DT Eligibility Indicator 1 66 66 VARCHAR2 Description: Indicates if a facility is eligible to participate in the Medicare and/or Medicaid programs. SAS Name: ELGBLTY_SW COBOL Name: ELGBLTY-SW Facility Name 50 67 116 VARCHAR2 Description: Name of the provider certified to participate in the Medicare and/or Medicaid programs. SAS Name: FAC_NAME COBOL Name: FAC-NAME Medicare Administrative Contractor (MAC) or 5 117 121 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_CD COBOL Name: INTRMDRY-CARR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 3 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 4 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 5 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 6 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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 15 122 136 VARCHAR2 Description: Number which may be assigned to a provider by the state Medicaid agency for external control or billing purposes. SAS Name: MDCD_VNDR_NUM COBOL Name: MDCD-VNDR-NUM Original Participation Date 8 137 144 DATE Description: Date a provider is first approved to provide Medicare and/or Medicaid services. SAS Name: ORGNL_PRTCPTN_DT COBOL Name: ORGNL-PRTCPTN-DT Prior CHOW Date 8 145 152 DATE Description: Effective date of the previous change of ownership for this provider. SAS Name: CHOW_PRIOR_DT COBOL Name: CHOW-PRIOR-DT Prior Medicare Administrative Contractor (MAC) or 5 153 157 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the previous Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_PRIOR_CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 7 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: INTRMDRY-CARR-PRIOR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 00520=BLUE SHIELD (ARKANSAS) 00528=BLUE SHIELD (ARKANSAS/LOUISIANA) 00542=BLUE SHIELD (CALIFORNIA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 8 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00550=BLUE SHIELD (COLORADO) 00570=BLUE SHIELD (DELAWARE) 00580=BLUE SHIELD (DISTRICT OF COLUMBIA) 00590=BLUE SHIELD (FLORIDA) 00621=BLUE SHIELD (ILLINOIS) 00630=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 9 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 10 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 11 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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) CCN 10 158 167 VARCHAR2 Description: Six or ten position identification number that is assigned to a certified provider. This is the CMS Certification Number. SAS Name: PRVDR_NUM COBOL Name: PRVDR-NUM Region Code 2 168 169 VARCHAR2 Description: Indicates the CMS Regional Office responsible for the certification of the provider. SAS Name: RGN_CD COBOL Name: RGN-CD VALUES: 01=Boston 02=New York 03=Philadelphia 04=Atlanta 05=Chicago 06=Dallas 07=Kansas City 08=Denver 09=San Francisco 10=Seattle Skeleton Record Indicator 1 170 170 VARCHAR2 Description: Indicates if the record is a skeleton record. Only a limited set of data is available for this provider; no survey data exists. SAS Name: SKLTN_REC_SW COBOL Name: SKLTN-REC-SW State Abbreviation 2 171 172 VARCHAR2 Description: Two-character state abbreviation. SAS Name: STATE_CD COBOL Name: STATE-CD VALUES: AK=ALASKA AL=ALABAMA AR=ARKANSAS AS=AMERICAN SAMOA AZ=ARIZONA CA=CALIFORNIA CN=CANADA CO=COLORADO CT=CONNECTICUT DC=DISTRICT OF COLUMBIA DE=DELAWARE FL=FLORIDA FN=INTERNATIONAL DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 12 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA=GEORGIA GU=GUAM HI=HAWAII IA=IOWA ID=IDAHO IL=ILLINOIS IN=INDIANA KS=KANSAS KY=KENTUCKY LA=LOUISIANA MA=MASSACHUSETTS MD=MARYLAND ME=MAINE MI=MICHIGAN MN=MINNESOTA MO=MISSOURI MP=SAIPAN MS=MISSISSIPPI MT=MONTANA MX=MEXICO NC=NORTH CAROLINA ND=NORTH DAKOTA NE=NEBRASKA NH=NEW HAMPSHIRE NJ=NEW JERSEY NM=NEW MEXICO NV=NEVADA NY=NEW YORK OH=OHIO OK=OKLAHOMA OR=OREGON PA=PENNSYLVANIA PR=PUERTO RICO RI=RHODE ISLAND SC=SOUTH CAROLINA SD=SOUTH DAKOTA TN=TENNESSEE TX=TEXAS UT=UTAH VA=VIRGINIA VI=VIRGIN ISLANDS VT=VERMONT WA=WASHINGTON WI=WISCONSIN WV=WEST VIRGINIA WY=WYOMING SSA State Code 2 173 174 VARCHAR2 Description: Social Security Administration geographic code indicating the state where the provider is located. SAS Name: SSA_STATE_CD COBOL Name: SSA-STATE-CD 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 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 13 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 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 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 99=INTERNATIONAL State Region Code 3 175 177 VARCHAR2 Description: Identifies the region within a state where the provider is located. SAS Name: STATE_RGN_CD COBOL Name: STATE-RGN-CD VALUES: AK/001=ALASKA AK/LAB=LABORATORIES AL/001=ALABAMA AL/LAB=LABORATORIES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 14 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE AR/001=ARKANSAS AR/LAB=LABORATORIES AS/001=AMERICAN SAMOA AS/LAB=LABORATORY AZ/AZ=PHOENIX AZ/LAB=ARIZONA LAB AZ/TUC=TUCSON CA/BAK=BAKERSFIELD CA/BER=SAN BERNARDINO CA/BK=BERKELEY CA/BK1=CONTRA COSTA CA/FR=FRESNO CA/L1=L.A. WEST CA/L2=L.A. NORTH CA/L3=L.A. CENTRAL CA/L4=L.A. EAST CA/L5=SAN GABRIEL CA/LAB=LABORATORIES CA/M1=LAB. SOUTH CA/M2=LAB. NORTH CA/ORG=ORANGE CO CA/RIV=RIVERSIDE CA/RWC=REDWOOD COAST CA/S1=SACRAMENTO CA/S2=SACTO SOUTH CA/S3=CHICO CA/SD=SAN DIEGO CA/SDS=SAN DIEGO SOUTH CA/SF=SAN FRANCISCO CA/SJ=SAN JOSE CA/SR=SANTA ROSA CA/VEN=VENTURA CN/001=CANADA CN/LAB=LABORATORY CO/001=COLORADO CO/LAB=LABORATORIES CT/001=CONNECTICUT CT/LAB=LABORATORIES DC/001=DISTRICT OF COLUMBIA DC/LAB=LABORATORIES DE/001=DELAWARE DE/LAB=LABORATORIES FL/FTM=FT. MYERS FL/GAI=GAINESVILLE FL/JAX=JACKSONVILLE FL/LAB=LABORATORIES FL/LAN=LANTANA FL/LAU=LAUDERHILL FL/MIA=MIAMI FL/ORL=ORLANDO FL/PEN=PENSACOLA FL/STP=ST. PETERSBURG FL/TAL=TALLAHASSEE FL/TAM=TAMPA FM/001=FEDERATED STATES OF MICRO FN/001=INTERNATIONAL FN/LAB=LABORATORIES GA/001=GEORGIA GA/GAA=GEORGIA ALL GA/GAC=GEORGIA CENTRAL GA/GAE=GEORGIA EASTERN GA/GAN=GEORGIA NORTH GA/GAS=GEORGIA SOUTH GA/GAW=GEORGIA WESTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 15 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA/LAB=LABORATORIES GU/001=GUAM GU/LAB=LABORATORIES HI/001=HAWAII HI/LAB=LABORATORIES IA/001=IOWA IA/LAB=LABORATORIES ID/001=IDAHO ID/LAB=LABORATORIES IL/001=ILLINOIS IL/LAB=LABORATORIES IN/001=INDIANA IN/LAB=LABORATORIES KS/KCK=KANSAS CITY KS/KDH=KDHE KS/LAB=LABORATORIES KS/LAW=LAWRENCE KS/NC=NORTH CENTRAL KANSAS KS/NE=NORTH EAST KANSAS KS/NW=NORTH WEST KANSAS KS/SC=SOUTH CENTRAL KANSAS KS/SE=SOUTH EAST KANSAS KS/SW=SOUTH WEST KANSAS KS/WST=WEST KY/2C1=HOPKINSVILLE KY/2C2=LOUISVILLE KY/2C3=LONDON KY/2C4=LEXINGTON KY/LAB=LABORATORIES LA/001=LOUISIANA LA/LA1=NEW ORLEANS LA/LA2=MANDEVILLE LA/LA3=LAFAYETTE LA/LA4=MONROE LA/LA5=SHREVEPORT LA/LA6=ALEXANDRIA LA/LAB=LABORATORIES LA/LB1=CLIA NEW ORLEANS LA/LB5=CLIA SHREVEPORT LA/LB6=CLIA ALEXANDRIA MA/001=MASSACHUSETTS MA/LAB=LABORATORIES MD/001=MARYLAND MD/LAB=LABORATORIES ME/001=MAINE ME/LAB=LABORATORIES MH/001=MARSHALL ISLANDS MI/001=MICHIGAN MI/LAB=LABORATORIES MN/001=MINNESOTA MN/LAB=LABORATORIES MO/01=REGION01 MO/02=REGION02 MO/03=REGION 03 MO/04=REGION 04 MO/05=REGION 05 MO/06=REGION 06 MO/07=REGION 07 MO/1NH=REGION 1 NH MO/2NH=REGION 2 NH MO/3NH=REGION 3 NH MO/4NH=REGION 4 NH MO/5NH=REGION 5 NH MO/6NH=REGION 6 NH DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 16 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE MO/7NH=REGION 7 NH MO/LAB=LABORATORIES MO/MO=STATEWIDE MP/001=NORTHERN MARIANA ISLANDS MP/LAB=LABORATORIES MS/001=MISSISSIPPI MS/LAB=LABORATORIES MT/001=MONTANA MT/LAB=LABORATORIES MX/001=MEXICO MX/LAB=LABORATORY NC/LAB=LABORATORIES NC/NCC=NORTH CAROLINA CENTRAL NC/NCE=NORTH CAROLINA EAST NC/NCN=NORTH CAROLINA NORTH NC/NCS=NORTH CAROLINA SOUTH NC/NCW=NORTH CAROLINA WEST ND/001=NORTH DAKOTA ND/LAB=LABORATORIES NE/1=NORTH CENTRAL NE/2=CENTRAL NE/3=NORTHEAST NE/4=SOUTHEAST NE/5=WESTERN NE/LAB=LABORATORIES NH/001=NEW HAMPSHIRE NH/LAB=LABORATORIES NJ/001=NEW JERSEY NJ/LAB=LABORATORIES NM/001=NEW MEXICO NM/LAB=LABORATORIES NV/CC=CARSON CITY NV/LAB=LABORATORIES NV/LV=LAS VEGAS NY/001=BUFFALO NY/002=ROCHESTER NY/003=SYRACUSE NY/004=ALBANY NY/005=NEW ROCHELLE NY/006=NEW YORK CITY NY/007=SUFFOLK/NASSAU COUNTY NY/LAB=LABORATORIES OH/001=OHIO OH/LAB=LABORATORIES OK/001=OKLAHOMA OK/LAB=LABORATORIES OR/001=OFFICE #1 OR/002=OFFICE #2 OR/003=OFFICE #3 OR/LAB=LABORATORIES PA/001=PENNSYLVANIA PA/LAB=LABORATORIES PR/001=PUERTO RICO PR/LAB=LABORATORIES PW/001=PALAU RI/001=RHODE ISLAND RI/LAB=LABORATORIES SC/001=SOUTH CAROLINA SC/LAB=LABORATORIES SD/001=SOUTH DAKOTA SD/LAB=LABORATORIES TN/LAB=LABORATORIES TN/TNC=TENNESSEE COOKEVILLE TN/TNE=TENNESSEE EASTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 17 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE TN/TNM=TENNESSEE MIDDLE TN/TNW=TENNESSEE WESTERN TX/001=TEXAS TX/L01=AMARILLO-LTC TX/L02=ABILENE-LTC TX/L03=ARLINGTON-LTC TX/L04=TYLER-LTC TX/L05=BEAUMONT-LTC TX/L06=HOUSTON-LTC TX/L07=TEMPLE-LTC TX/L08=SAN ANTONIO-LTC TX/L09=SAN ANGELO-LTC TX/L10=EL PASO-LTC TX/L11=CORPUS CHRISTI-LTC TX/LAB=LABORATORIES TX/TX1=LUBBOCK TX/TX2=ARLINGTON TX/TX3=SAN ANTONIO TX/TX4=HOUSTON TX/TX5=TYLER TX/TX6=AUSTIN UT/001=UTAH UT/LAB=LABORATORIES VA/001=VIRGINIA VA/LAB=LABORATORIES VI/001=VIRGIN ISLANDS VI/LAB=LABORATORIES VT/001=VERMONT VT/LAB=LABORATORIES WA/001=ALL OTHERS (NON-LTC FAC) WA/D1=SPOKANE & YAKIMA AREAS WA/D1A=District 1, Unit A WA/D1B=District 1, Unit B WA/D1C=District 1, Unit C WA/D1D=District 1, Unit D WA/D2=SPOKANE & SE WA/D2A=District 2, Unit A WA/D2B=District 2, Unit B WA/D2C=District 2, Unit C WA/D2D=District 2, Unit D WA/D2E=District 2, Unit E WA/D2F=District 2, Unit F WA/D2G=District 2, Unit G WA/D3=NW WASHINGTON WA/D3A=District 3, Unit A WA/D3B=District 3, Unit B WA/D3C=District 3, Unit C WA/D3D=District 3, Unit D WA/D3E=District 3, Unit E WA/D4A=GREATER SEATTLE AREA WA/D4B=S KING COUNTY WA/D5A=PIERCE CTY & PENINSULA WA/D5B=PIERCE CTY & GRAYS HARBOR WA/D6=OLYMPIA AREA WA/LAB=LABORATORIES WI/001=WISCONSIN WI/LAB=LABORATORIES WV/001=WEST VIRGINIA WV/LAB=LABORATORIES WY/001=WYOMING WY/LAB=LABORATORIES Address: Street 50 178 227 VARCHAR2 Description: Street address where the provider is located. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 18 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: ST_ADR COBOL Name: ST-ADR Telephone Number 10 228 237 VARCHAR2 Description: Telephone number of the provider. SAS Name: PHNE_NUM COBOL Name: PHNE-NUM Termination Code 2 238 239 VARCHAR2 Description: Indicates the current termination status for the provider. SAS Name: PGM_TRMNTN_CD COBOL Name: PGM-TRMNTN-CD VALUES: 00=ACTIVE PROVIDER 01=VOLUNTARY-MERGER, CLOSURE 02=VOLUNTARY-DISSATISFACTION WITH REIMBURSEMENT 03=VOLUNTARY-RISK OF INVOLUNTARY TERMINATION 04=VOLUNTARY-OTHER REASON FOR WITHDRAWAL 05=INVOLUNTARY-FAILURE TO MEET HEALTH/SAFETY REQ 06=INVOLUNTARY-FAILURE TO MEET AGREEMENT 07=OTHER-PROVIDER STATUS CHANGE 08=NONPAYMENT OF FEES - CLIA Only 09=REV/UNSUCCESSFUL PARTICIPATION IN PT - CLIA Only 10=REV/OTHER REASON - CLIA Only 11=INCOMPLETE CLIA APPLICATION INFORMATION - CLIA Only 12=NO LONGER PERFORMING TESTS - CLIA Only 13=MULTIPLE TO SINGLE SITE CERTIFICATE - CLIA Only 14=SHARED LABORATORY - CLIA Only 15=FAILURE TO RENEW WAIVER PPM CERTIFICATE - CLIA Only 16=DUPLICATE CLIA NUMBER - CLIA Only 17=MAIL RETURNED NO FORWARD ADDRESS CERT ENDED - CLIA Only 20=NOTIFICATION BANKRUPTCY - CLIA Only 33=ACCREDITATION NOT CONFIRMED - CLIA Only 80=AWAITING STATE APPROVAL 99=OIG ACTION - DO NOT ACTIVATE - CLIA Only Termination or Expiration Date 8 240 247 DATE Description: Date the provider was terminated. For CLIA providers, date the laboratory's certificate was terminated or the expiration date of the current CLIA certificate. SAS Name: TRMNTN_EXPRTN_DT COBOL Name: TRMNTN-EXPRTN-DT Type of Action Code 1 248 248 VARCHAR2 Description: Identifies the reason for the certification. Type of action from the official survey record, CMS 1539 form. SAS Name: CRTFCTN_ACTN_TYPE_CD COBOL Name: CRTFCTN-ACTN-TYPE-CD VALUES: 1=INITIAL 2=RECERTIFICATION 3=TERMINATION 4=CHANGE OF OWNERSHIP 5=VALIDATION 8=FULL SURVEY AFTER COMPLAINT Ownership Type Code 2 249 250 VARCHAR2 Description: Indicates the ownership type of the provider. SAS Name: GNRL_CNTL_TYPE_CD COBOL Name: GNRL-CNTL-TYPE-CD VALUES: 01=VOLUNTARY NON PROFIT - RELIGIOUS AFFILIATION 02=VOLUNTARY NON-PROFIT - PRIVATE 03=VOLUNTARY NON-PROFIT - OTHER 04=PROPRIETARY 05=GOVERNMENT - STATE/COUNTY DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 19 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 06=GOVERNMENT - COMBINATION GOVT & VOLUNTARY 07=GOVERNMENT - LOCAL Address: ZIP Code 5 251 255 VARCHAR2 Description: Five-digit ZIP code for a provider's physical address. SAS Name: ZIP_CD COBOL Name: ZIP-CD FIPS State Code 2 256 257 VARCHAR2 Description: FIPS State Code SAS Name: FIPS_STATE_CD COBOL Name: FIPS-STATE-CD VALUES: 01=ALABAMA 02=ALASKA 04=ARIZONA 05=ARKANSAS 06=CALIFORNIA 08=COLORADO 09=CONNECTICUT 10=DELAWARE 11=DISTRICT OF COLUMBIA 12=FLORIDA 13=GEORGIA 15=HAWAII 16=IDAHO 17=ILLINOIS 18=INDIANA 19=IOWA 20=KANSAS 21=KENTUCKY 22=LOUISIANA 23=MAINE 24=MARYLAND 25=MASSACHUSETTS 26=MICHIGAN 27=MINNESOTA 28=MISSISSIPPI 29=MISSOURI 30=MONTANA 31=NEBRASKA 32=NEVADA 33=NEW HAMPSHIRE 34=NEW JERSEY 35=NEW MEXICO 36=NEW YORK 37=NORTH CAROLINA 38=NORTH DAKOTA 39=OHIO 40=OKLAHOMA 41=OREGON 42=PENNSYLVANIA 43=PUERTO RICO 44=RHODE ISLAND 45=SOUTH CAROLINA 46=SOUTH DAKOTA 47=TENNESSEE 48=TEXAS 49=UTAH 50=VERMONT 51=VIRGINIA 53=WASHINGTON 54=WEST VIRGINIA 55=WISCONSIN 56=WYOMING DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 20 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 64=AMERICAN SAMOA 65=GUAM 66=SAIPAN/MARIANA IS. 78=VIRGIN ISLANDS FIPS County Code 3 258 260 VARCHAR2 Description: FIPS County Code SAS Name: FIPS_CNTY_CD COBOL Name: FIPS-CNTY-CD CBSA Urban Rural Indicator 1 261 261 VARCHAR2 Description: CBSA (Core Based Statistical Area) indicates whether the county is defined as Urban or Rural. SAS Name: CBSA_URBN_RRL_IND COBOL Name: CBSA-URBN-RRL-IND CBSA Code 5 262 266 VARCHAR2 Description: CBSA (Core Based Statistical Area) geographic entities defined by the U.S. Office of Management and Budget (OMB) on June 6, 2003 for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics. CBSA collectively refers to MSA. SAS Name: CBSA_CD COBOL Name: CBSA-CD Accreditation Type Code 1 283 283 VARCHAR2 Description: Indicates an accrediting organization deeming the provider. If a provider is deemed by multiple accrediting organizations then the accrediting organization with the earliest active deeming effective date is displayed in this field. SAS Name: ACRDTN_TYPE_CD COBOL Name: ACRDTN-TYPE-CD VALUES: 0=UNACCREDITED 1=JC 2=CHAP 3=ACHC Services: Laboratory Code 1 313 313 CHAR Description: Indicates how laboratory services are provided. SAS Name: LAB_SRVC_CD COBOL Name: LAB-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: Pharmacy Code 1 314 314 CHAR Description: Indicates how pharmaceutical services are provided. SAS Name: PHRMCY_SRVC_CD COBOL Name: PHRMCY-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Branch Count 3 377 379 NUMBER Description: Number of branches operated by the home health agency. SAS Name: BRNCH_CNT COBOL Name: BRNCH-CNT Branch Operation Indicator 1 380 380 VARCHAR2 Description: Indicates if the home health agency operates any branches. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 21 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: BRNCH_OPRTN_SW COBOL Name: BRNCH-OPRTN-SW Category-specific Facility Type Code 2 388 389 VARCHAR2 Description: Indicates the category-specific facility type code, for certain provider categories only. SAS Name: GNRL_FAC_TYPE_CD COBOL Name: GNRL-FAC-TYPE-CD 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 07=Other CHOW Indicator 1 390 390 VARCHAR2 Description: Indicates if the home health agency has undergone a change of ownership since the last survey. SAS Name: CHOW_SW COBOL Name: CHOW-SW Fiscal Year End Date (MMDD) 4 464 467 VARCHAR2 Description: End date, consisting of the month and day, of the provider's fiscal year. SAS Name: FY_END_MO_DAY_CD COBOL Name: FY-END-MO-DAY-CD HHA Qualified For OPT Indicator 1 479 479 VARCHAR2 Description: Indicates if a home health agency is qualified to provide outpatient physical therapy/speech services. SAS Name: HHA_QLFYD_OPT_SPCH_SW COBOL Name: HHA-QLFYD-OPT-SPCH-SW Home Health Aide Training Program Code 1 480 480 VARCHAR2 Description: Indicates how the agency provides home health aide training and competency evaluation programs. SAS Name: HH_AIDE_TRNG_PGM_CD COBOL Name: HH-AIDE-TRNG-PGM-CD VALUES: 1=HOME HEALTH AIDE TRAINING 2=HOME HEALTH AIDE COMPETENCY EVALUATION PROG. 3=HOME HEALTH AIDE TRAINING/COMPETENCY PROGRAMS 4=NEITHER Hospice Indicator 1 482 482 VARCHAR2 Description: Indicates if the home health agency also participates in the Medicare program as a hospice. SAS Name: MDCR_HOSPC_SW COBOL Name: MDCR-HOSPC-SW Medicare Hospice Provider Num 10 496 505 CHAR Description: Medicare hospice provider number SAS Name: MEDICARE_HOSPICE_PROVIDER_NUM COBOL Name: MEDICARE-HOSPICE-PROVIDER-NUM Medicare Medicaid Prvdr Number 6 507 512 CHAR Description: Medicare/Medicaid provider number SAS Name: MEDICARE_MEDICAID_PRVDR_NUMBER COBOL Name: MEDICARE-MEDICAID-PRVDR-NUMBER Program Participation Code 1 623 623 CHAR Description: Indicates if the provider participates in Medicare, Medicaid, or both programs. SAS Name: PGM_PRTCPTN_CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 22 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: PGM-PRTCPTN-CD VALUES: 1=MEDICARE ONLY 2=MEDICAID ONLY 3=MEDICARE AND MEDICAID Related Provider Number 10 669 678 CHAR Description: Related provider number SAS Name: RELATED_PROVIDER_NUMBER COBOL Name: RELATED-PROVIDER-NUMBER Services: Home Health Aide Code 1 681 681 CHAR Description: Indicates how home health aide services are provided. SAS Name: HH_AIDE_SRVC_CD COBOL Name: HH-AIDE-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: Appliance and Equipment Code 1 684 684 VARCHAR2 Description: Indicates how appliance and equipment services are provided by a home health agency. SAS Name: APLNC_EQUIP_SRVC_CD COBOL Name: APLNC-EQUIP-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: Interns and Residents Code 1 725 725 VARCHAR2 Description: Indicates how intern and resident services are provided by a home health agency. SAS Name: INTRN_RSDNT_SRVC_CD COBOL Name: INTRN-RSDNT-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: Medical Social Code 1 726 726 CHAR Description: Indicates how medical social services are provided. SAS Name: MDCL_SCL_SRVC_CD COBOL Name: MDCL-SCL-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: Nursing Code 1 742 742 CHAR Description: Indicates how nursing services are provided. SAS Name: NRSNG_SRVC_CD COBOL Name: NRSNG-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: Nutritional Guidance Code 1 746 746 VARCHAR2 Description: Indicates how nutritional guidance services are provided by a home health agency. SAS Name: NTRTNL_GDNC_SRVC_CD COBOL Name: NTRTNL-GDNC-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 23 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: OT Code 1 758 758 CHAR Description: Indicates how occupational therapy services are provided. SAS Name: OT_SRVC_CD COBOL Name: OT-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: Other Code 1 762 762 CHAR Description: Indicates how other services are provided. SAS Name: OTHR_SRVC_CD COBOL Name: OTHR-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: PT Code 1 796 796 CHAR Description: Indicates how physical therapy services are provided. SAS Name: PT_SRVC_CD COBOL Name: PT-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: Speech Therapy Code 1 820 820 VARCHAR2 Description: Indicates how speech therapy services are provided by the home health agency. SAS Name: SPCH_THRPY_SRVC_CD COBOL Name: SPCH-THRPY-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: Vocational Guidance Code 1 836 836 VARCHAR2 Description: Indicates how vocational guidance services are provided by the home health agency. SAS Name: VCTNL_GDNC_SRVC_CD COBOL Name: VCTNL-GDNC-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Staff Count Override Indicator 1 844 844 CHAR Description: Indicates if the regional office has approved a significant staff count change from the previous certification. SAS Name: OVRRD_STFG_SW COBOL Name: OVRRD-STFG-SW Staff Count: Other Personnel 8 885 892 NUMBER Description: Number of full-time equivalent other personnel employed by a provider SAS Name: PRSNEL_OTHR_CNT COBOL Name: PRSNEL-OTHR-CNT Staff Count: Dietitian 8 965 972 NUMBER DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 24 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Number of full-time equivalent dietitians employed by a provider. SAS Name: DIETN_CNT COBOL Name: DIETN-CNT Staff Count: Home Health Aide 8 1029 1036 NUMBER Description: Number of full-time equivalent home health aides employed by a home health agency. SAS Name: HH_AIDE_CNT COBOL Name: HH-AIDE-CNT Staff Count: LPN/LVN - Employee 8 1093 1100 NUMBER Description: Number of full-time equivalent licensed practical or vocational nurses employed by a provider. SAS Name: LPN_LVN_CNT COBOL Name: LPN-LVN-CNT Staff Count: OT - Total 8 1293 1300 NUMBER Description: Total number of full-time equivalent occupational therapists employed by a provider. SAS Name: OCPTNL_THRPST_CNT COBOL Name: OCPTNL-THRPST-CNT Staff Count: PT 8 1613 1620 NUMBER Description: Number of full-time equivalent physical therapists employed by a provider. SAS Name: PHYS_THRPST_STF_CNT COBOL Name: PHYS-THRPST-STF-CNT Staff Count: Registered Pharmacist 8 1717 1724 NUMBER Description: Number of full-time equivalent registered pharmacists employed by the provider. SAS Name: REG_PHRMCST_CNT COBOL Name: REG-PHRMCST-CNT Staff Count: RN 8 1733 1740 NUMBER Description: Number of full-time equivalent registered nurses employed by a provider. SAS Name: RN_CNT COBOL Name: RN-CNT Staff Count: Social Worker 8 1797 1804 NUMBER Description: Number of full-time equivalent social workers employed by the provider. SAS Name: SCL_WORKR_CNT COBOL Name: SCL-WORKR-CNT Staff Count: Speech Pathologist/Audiologist 8 1869 1876 NUMBER Description: Number of full-time equivalent speech pathologists or audiologists employed by the provider. SAS Name: SPCH_PTHLGST_AUDLGST_CNT COBOL Name: SPCH-PTHLGST-AUDLGST-CNT Subunit Count 3 1935 1937 NUMBER Description: Number of subunits operated by the home health agency. SAS Name: SBUNIT_CNT COBOL Name: SBUNIT-CNT Subunit Indicator 1 1938 1938 VARCHAR2 Description: Indicates if the home health agency is a subunit of another agency. SAS Name: SBUNIT_SW COBOL Name: SBUNIT-SW DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 25 Home Health Agency, CATEGORY = "05" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Subunit Operation Indicator 1 1939 1939 VARCHAR2 Description: Indicates if the home health agency operates any subunits. SAS Name: SBUNIT_OPRTN_SW COBOL Name: SBUNIT-OPRTN-SW DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 1 Psychiatric Residential Treatment Facility, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Provider Category Subtype Code 2 1 2 VARCHAR2 Description: Identifies the subtype of the provider, within the primary category. Used in reporting to show the breakdown of provider categories, mainly for hospitals and SNFs. SAS Name: PRVDR_CTGRY_SBTYP_CD COBOL Name: PRVDR-CTGRY-SBTYP-CD VALUES: 01=Psychiatric Residential Treatment Provider Category Code 2 3 4 VARCHAR2 Description: Identifies the type of provider participating in the Medicare/Medicaid program. SAS Name: PRVDR_CTGRY_CD COBOL Name: PRVDR-CTGRY-CD VALUES: 06=Psychiatric Residential Treatment Facility CHOW Count 2 5 6 NUMBER Description: Number of times this provider has undergone a change of ownership. SAS Name: CHOW_CNT COBOL Name: CHOW-CNT CHOW Date 8 7 14 DATE Description: Effective date of the most recent change of ownership for this provider. SAS Name: CHOW_DT COBOL Name: CHOW-DT Address: City 28 15 42 VARCHAR2 Description: City in which the provider is physically located. SAS Name: CITY_NAME COBOL Name: CITY-NAME Compliance: Acceptable POC 1 43 43 VARCHAR2 Description: Indicates if a provider is in compliance with program requirements based on an acceptable plan for correction of deficiencies. SAS Name: ACPTBL_POC_SW COBOL Name: ACPTBL-POC-SW Compliance: Status 1 44 44 VARCHAR2 Description: Compliance status of a provider at the time of certification survey. SAS Name: CMPLNC_STUS_CD COBOL Name: CMPLNC-STUS-CD VALUES: A=IN COMPLIANCE B=NOT IN COMPLIANCE SSA County Code 3 45 47 VARCHAR2 Description: Social Security Administration geographic code indicating the county where the provider is located. SAS Name: SSA_CNTY_CD COBOL Name: SSA-CNTY-CD Cross Ref Provider Number 10 48 57 CHAR Description: Cross reference provider number SAS Name: CROSS_REF_PROVIDER_NUMBER COBOL Name: CROSS-REF-PROVIDER-NUMBER Certification Date 8 58 65 DATE Description: Equal to the exit date of the initial visit of the Health survey for certifications completed after July 28, 2012. For certifications prior to that date, the certification DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 2 Psychiatric Residential Treatment Facility, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE date is equal to the exit date of the initial visit of the Health survey or LSC survey, whichever is later. SAS Name: CRTFCTN_DT COBOL Name: CRTFCTN-DT Eligibility Indicator 1 66 66 VARCHAR2 Description: Indicates if a facility is eligible to participate in the Medicare and/or Medicaid programs. SAS Name: ELGBLTY_SW COBOL Name: ELGBLTY-SW Facility Name 50 67 116 VARCHAR2 Description: Name of the provider certified to participate in the Medicare and/or Medicaid programs. SAS Name: FAC_NAME COBOL Name: FAC-NAME Medicare Administrative Contractor (MAC) or 5 117 121 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_CD COBOL Name: INTRMDRY-CARR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 3 Psychiatric Residential Treatment Facility, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 4 Psychiatric Residential Treatment Facility, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 5 Psychiatric Residential Treatment Facility, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 6 Psychiatric Residential Treatment Facility, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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 15 122 136 VARCHAR2 Description: Number which may be assigned to a provider by the state Medicaid agency for external control or billing purposes. SAS Name: MDCD_VNDR_NUM COBOL Name: MDCD-VNDR-NUM Original Participation Date 8 137 144 DATE Description: Date a provider is first approved to provide Medicare and/or Medicaid services. SAS Name: ORGNL_PRTCPTN_DT COBOL Name: ORGNL-PRTCPTN-DT Prior CHOW Date 8 145 152 DATE Description: Effective date of the previous change of ownership for this provider. SAS Name: CHOW_PRIOR_DT COBOL Name: CHOW-PRIOR-DT Prior Medicare Administrative Contractor (MAC) or 5 153 157 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the previous Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_PRIOR_CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 7 Psychiatric Residential Treatment Facility, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: INTRMDRY-CARR-PRIOR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 00520=BLUE SHIELD (ARKANSAS) 00528=BLUE SHIELD (ARKANSAS/LOUISIANA) 00542=BLUE SHIELD (CALIFORNIA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 8 Psychiatric Residential Treatment Facility, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00550=BLUE SHIELD (COLORADO) 00570=BLUE SHIELD (DELAWARE) 00580=BLUE SHIELD (DISTRICT OF COLUMBIA) 00590=BLUE SHIELD (FLORIDA) 00621=BLUE SHIELD (ILLINOIS) 00630=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 9 Psychiatric Residential Treatment Facility, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 10 Psychiatric Residential Treatment Facility, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 11 Psychiatric Residential Treatment Facility, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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) CCN 10 158 167 VARCHAR2 Description: Six or ten position identification number that is assigned to a certified provider. This is the CMS Certification Number. SAS Name: PRVDR_NUM COBOL Name: PRVDR-NUM Region Code 2 168 169 VARCHAR2 Description: Indicates the CMS Regional Office responsible for the certification of the provider. SAS Name: RGN_CD COBOL Name: RGN-CD VALUES: 01=Boston 02=New York 03=Philadelphia 04=Atlanta 05=Chicago 06=Dallas 07=Kansas City 08=Denver 09=San Francisco 10=Seattle Skeleton Record Indicator 1 170 170 VARCHAR2 Description: Indicates if the record is a skeleton record. Only a limited set of data is available for this provider; no survey data exists. SAS Name: SKLTN_REC_SW COBOL Name: SKLTN-REC-SW State Abbreviation 2 171 172 VARCHAR2 Description: Two-character state abbreviation. SAS Name: STATE_CD COBOL Name: STATE-CD VALUES: AK=ALASKA AL=ALABAMA AR=ARKANSAS AS=AMERICAN SAMOA AZ=ARIZONA CA=CALIFORNIA CN=CANADA CO=COLORADO CT=CONNECTICUT DC=DISTRICT OF COLUMBIA DE=DELAWARE FL=FLORIDA FN=INTERNATIONAL DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 12 Psychiatric Residential Treatment Facility, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA=GEORGIA GU=GUAM HI=HAWAII IA=IOWA ID=IDAHO IL=ILLINOIS IN=INDIANA KS=KANSAS KY=KENTUCKY LA=LOUISIANA MA=MASSACHUSETTS MD=MARYLAND ME=MAINE MI=MICHIGAN MN=MINNESOTA MO=MISSOURI MP=SAIPAN MS=MISSISSIPPI MT=MONTANA MX=MEXICO NC=NORTH CAROLINA ND=NORTH DAKOTA NE=NEBRASKA NH=NEW HAMPSHIRE NJ=NEW JERSEY NM=NEW MEXICO NV=NEVADA NY=NEW YORK OH=OHIO OK=OKLAHOMA OR=OREGON PA=PENNSYLVANIA PR=PUERTO RICO RI=RHODE ISLAND SC=SOUTH CAROLINA SD=SOUTH DAKOTA TN=TENNESSEE TX=TEXAS UT=UTAH VA=VIRGINIA VI=VIRGIN ISLANDS VT=VERMONT WA=WASHINGTON WI=WISCONSIN WV=WEST VIRGINIA WY=WYOMING SSA State Code 2 173 174 VARCHAR2 Description: Social Security Administration geographic code indicating the state where the provider is located. SAS Name: SSA_STATE_CD COBOL Name: SSA-STATE-CD 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 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 13 Psychiatric Residential Treatment Facility, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 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 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 99=INTERNATIONAL State Region Code 3 175 177 VARCHAR2 Description: Identifies the region within a state where the provider is located. SAS Name: STATE_RGN_CD COBOL Name: STATE-RGN-CD VALUES: AK/001=ALASKA AK/LAB=LABORATORIES AL/001=ALABAMA AL/LAB=LABORATORIES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 14 Psychiatric Residential Treatment Facility, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE AR/001=ARKANSAS AR/LAB=LABORATORIES AS/001=AMERICAN SAMOA AS/LAB=LABORATORY AZ/AZ=PHOENIX AZ/LAB=ARIZONA LAB AZ/TUC=TUCSON CA/BAK=BAKERSFIELD CA/BER=SAN BERNARDINO CA/BK=BERKELEY CA/BK1=CONTRA COSTA CA/FR=FRESNO CA/L1=L.A. WEST CA/L2=L.A. NORTH CA/L3=L.A. CENTRAL CA/L4=L.A. EAST CA/L5=SAN GABRIEL CA/LAB=LABORATORIES CA/M1=LAB. SOUTH CA/M2=LAB. NORTH CA/ORG=ORANGE CO CA/RIV=RIVERSIDE CA/RWC=REDWOOD COAST CA/S1=SACRAMENTO CA/S2=SACTO SOUTH CA/S3=CHICO CA/SD=SAN DIEGO CA/SDS=SAN DIEGO SOUTH CA/SF=SAN FRANCISCO CA/SJ=SAN JOSE CA/SR=SANTA ROSA CA/VEN=VENTURA CN/001=CANADA CN/LAB=LABORATORY CO/001=COLORADO CO/LAB=LABORATORIES CT/001=CONNECTICUT CT/LAB=LABORATORIES DC/001=DISTRICT OF COLUMBIA DC/LAB=LABORATORIES DE/001=DELAWARE DE/LAB=LABORATORIES FL/FTM=FT. MYERS FL/GAI=GAINESVILLE FL/JAX=JACKSONVILLE FL/LAB=LABORATORIES FL/LAN=LANTANA FL/LAU=LAUDERHILL FL/MIA=MIAMI FL/ORL=ORLANDO FL/PEN=PENSACOLA FL/STP=ST. PETERSBURG FL/TAL=TALLAHASSEE FL/TAM=TAMPA FM/001=FEDERATED STATES OF MICRO FN/001=INTERNATIONAL FN/LAB=LABORATORIES GA/001=GEORGIA GA/GAA=GEORGIA ALL GA/GAC=GEORGIA CENTRAL GA/GAE=GEORGIA EASTERN GA/GAN=GEORGIA NORTH GA/GAS=GEORGIA SOUTH GA/GAW=GEORGIA WESTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 15 Psychiatric Residential Treatment Facility, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA/LAB=LABORATORIES GU/001=GUAM GU/LAB=LABORATORIES HI/001=HAWAII HI/LAB=LABORATORIES IA/001=IOWA IA/LAB=LABORATORIES ID/001=IDAHO ID/LAB=LABORATORIES IL/001=ILLINOIS IL/LAB=LABORATORIES IN/001=INDIANA IN/LAB=LABORATORIES KS/KCK=KANSAS CITY KS/KDH=KDHE KS/LAB=LABORATORIES KS/LAW=LAWRENCE KS/NC=NORTH CENTRAL KANSAS KS/NE=NORTH EAST KANSAS KS/NW=NORTH WEST KANSAS KS/SC=SOUTH CENTRAL KANSAS KS/SE=SOUTH EAST KANSAS KS/SW=SOUTH WEST KANSAS KS/WST=WEST KY/2C1=HOPKINSVILLE KY/2C2=LOUISVILLE KY/2C3=LONDON KY/2C4=LEXINGTON KY/LAB=LABORATORIES LA/001=LOUISIANA LA/LA1=NEW ORLEANS LA/LA2=MANDEVILLE LA/LA3=LAFAYETTE LA/LA4=MONROE LA/LA5=SHREVEPORT LA/LA6=ALEXANDRIA LA/LAB=LABORATORIES LA/LB1=CLIA NEW ORLEANS LA/LB5=CLIA SHREVEPORT LA/LB6=CLIA ALEXANDRIA MA/001=MASSACHUSETTS MA/LAB=LABORATORIES MD/001=MARYLAND MD/LAB=LABORATORIES ME/001=MAINE ME/LAB=LABORATORIES MH/001=MARSHALL ISLANDS MI/001=MICHIGAN MI/LAB=LABORATORIES MN/001=MINNESOTA MN/LAB=LABORATORIES MO/01=REGION01 MO/02=REGION02 MO/03=REGION 03 MO/04=REGION 04 MO/05=REGION 05 MO/06=REGION 06 MO/07=REGION 07 MO/1NH=REGION 1 NH MO/2NH=REGION 2 NH MO/3NH=REGION 3 NH MO/4NH=REGION 4 NH MO/5NH=REGION 5 NH MO/6NH=REGION 6 NH DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 16 Psychiatric Residential Treatment Facility, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE MO/7NH=REGION 7 NH MO/LAB=LABORATORIES MO/MO=STATEWIDE MP/001=NORTHERN MARIANA ISLANDS MP/LAB=LABORATORIES MS/001=MISSISSIPPI MS/LAB=LABORATORIES MT/001=MONTANA MT/LAB=LABORATORIES MX/001=MEXICO MX/LAB=LABORATORY NC/LAB=LABORATORIES NC/NCC=NORTH CAROLINA CENTRAL NC/NCE=NORTH CAROLINA EAST NC/NCN=NORTH CAROLINA NORTH NC/NCS=NORTH CAROLINA SOUTH NC/NCW=NORTH CAROLINA WEST ND/001=NORTH DAKOTA ND/LAB=LABORATORIES NE/1=NORTH CENTRAL NE/2=CENTRAL NE/3=NORTHEAST NE/4=SOUTHEAST NE/5=WESTERN NE/LAB=LABORATORIES NH/001=NEW HAMPSHIRE NH/LAB=LABORATORIES NJ/001=NEW JERSEY NJ/LAB=LABORATORIES NM/001=NEW MEXICO NM/LAB=LABORATORIES NV/CC=CARSON CITY NV/LAB=LABORATORIES NV/LV=LAS VEGAS NY/001=BUFFALO NY/002=ROCHESTER NY/003=SYRACUSE NY/004=ALBANY NY/005=NEW ROCHELLE NY/006=NEW YORK CITY NY/007=SUFFOLK/NASSAU COUNTY NY/LAB=LABORATORIES OH/001=OHIO OH/LAB=LABORATORIES OK/001=OKLAHOMA OK/LAB=LABORATORIES OR/001=OFFICE #1 OR/002=OFFICE #2 OR/003=OFFICE #3 OR/LAB=LABORATORIES PA/001=PENNSYLVANIA PA/LAB=LABORATORIES PR/001=PUERTO RICO PR/LAB=LABORATORIES PW/001=PALAU RI/001=RHODE ISLAND RI/LAB=LABORATORIES SC/001=SOUTH CAROLINA SC/LAB=LABORATORIES SD/001=SOUTH DAKOTA SD/LAB=LABORATORIES TN/LAB=LABORATORIES TN/TNC=TENNESSEE COOKEVILLE TN/TNE=TENNESSEE EASTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 17 Psychiatric Residential Treatment Facility, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE TN/TNM=TENNESSEE MIDDLE TN/TNW=TENNESSEE WESTERN TX/001=TEXAS TX/L01=AMARILLO-LTC TX/L02=ABILENE-LTC TX/L03=ARLINGTON-LTC TX/L04=TYLER-LTC TX/L05=BEAUMONT-LTC TX/L06=HOUSTON-LTC TX/L07=TEMPLE-LTC TX/L08=SAN ANTONIO-LTC TX/L09=SAN ANGELO-LTC TX/L10=EL PASO-LTC TX/L11=CORPUS CHRISTI-LTC TX/LAB=LABORATORIES TX/TX1=LUBBOCK TX/TX2=ARLINGTON TX/TX3=SAN ANTONIO TX/TX4=HOUSTON TX/TX5=TYLER TX/TX6=AUSTIN UT/001=UTAH UT/LAB=LABORATORIES VA/001=VIRGINIA VA/LAB=LABORATORIES VI/001=VIRGIN ISLANDS VI/LAB=LABORATORIES VT/001=VERMONT VT/LAB=LABORATORIES WA/001=ALL OTHERS (NON-LTC FAC) WA/D1=SPOKANE & YAKIMA AREAS WA/D1A=District 1, Unit A WA/D1B=District 1, Unit B WA/D1C=District 1, Unit C WA/D1D=District 1, Unit D WA/D2=SPOKANE & SE WA/D2A=District 2, Unit A WA/D2B=District 2, Unit B WA/D2C=District 2, Unit C WA/D2D=District 2, Unit D WA/D2E=District 2, Unit E WA/D2F=District 2, Unit F WA/D2G=District 2, Unit G WA/D3=NW WASHINGTON WA/D3A=District 3, Unit A WA/D3B=District 3, Unit B WA/D3C=District 3, Unit C WA/D3D=District 3, Unit D WA/D3E=District 3, Unit E WA/D4A=GREATER SEATTLE AREA WA/D4B=S KING COUNTY WA/D5A=PIERCE CTY & PENINSULA WA/D5B=PIERCE CTY & GRAYS HARBOR WA/D6=OLYMPIA AREA WA/LAB=LABORATORIES WI/001=WISCONSIN WI/LAB=LABORATORIES WV/001=WEST VIRGINIA WV/LAB=LABORATORIES WY/001=WYOMING WY/LAB=LABORATORIES Address: Street 50 178 227 VARCHAR2 Description: Street address where the provider is located. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 18 Psychiatric Residential Treatment Facility, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: ST_ADR COBOL Name: ST-ADR Telephone Number 10 228 237 VARCHAR2 Description: Telephone number of the provider. SAS Name: PHNE_NUM COBOL Name: PHNE-NUM Termination Code 2 238 239 VARCHAR2 Description: Indicates the current termination status for the provider. SAS Name: PGM_TRMNTN_CD COBOL Name: PGM-TRMNTN-CD VALUES: 00=ACTIVE PROVIDER 01=VOLUNTARY-MERGER, CLOSURE 02=VOLUNTARY-DISSATISFACTION WITH REIMBURSEMENT 03=VOLUNTARY-RISK OF INVOLUNTARY TERMINATION 04=VOLUNTARY-OTHER REASON FOR WITHDRAWAL 05=INVOLUNTARY-FAILURE TO MEET HEALTH/SAFETY REQ 06=INVOLUNTARY-FAILURE TO MEET AGREEMENT 07=OTHER-PROVIDER STATUS CHANGE 08=NONPAYMENT OF FEES - CLIA Only 09=REV/UNSUCCESSFUL PARTICIPATION IN PT - CLIA Only 10=REV/OTHER REASON - CLIA Only 11=INCOMPLETE CLIA APPLICATION INFORMATION - CLIA Only 12=NO LONGER PERFORMING TESTS - CLIA Only 13=MULTIPLE TO SINGLE SITE CERTIFICATE - CLIA Only 14=SHARED LABORATORY - CLIA Only 15=FAILURE TO RENEW WAIVER PPM CERTIFICATE - CLIA Only 16=DUPLICATE CLIA NUMBER - CLIA Only 17=MAIL RETURNED NO FORWARD ADDRESS CERT ENDED - CLIA Only 20=NOTIFICATION BANKRUPTCY - CLIA Only 33=ACCREDITATION NOT CONFIRMED - CLIA Only 80=AWAITING STATE APPROVAL 99=OIG ACTION - DO NOT ACTIVATE - CLIA Only Termination or Expiration Date 8 240 247 DATE Description: Date the provider was terminated. For CLIA providers, date the laboratory's certificate was terminated or the expiration date of the current CLIA certificate. SAS Name: TRMNTN_EXPRTN_DT COBOL Name: TRMNTN-EXPRTN-DT Type of Action Code 1 248 248 VARCHAR2 Description: Identifies the reason for the certification. Type of action from the official survey record, CMS 1539 form. SAS Name: CRTFCTN_ACTN_TYPE_CD COBOL Name: CRTFCTN-ACTN-TYPE-CD VALUES: 1=INITIAL 2=RECERTIFICATION 3=TERMINATION 4=CHANGE OF OWNERSHIP 5=VALIDATION 8=FULL SURVEY AFTER COMPLAINT Ownership Type Code 2 249 250 VARCHAR2 Description: Indicates the ownership type of the provider. SAS Name: GNRL_CNTL_TYPE_CD COBOL Name: GNRL-CNTL-TYPE-CD VALUES: 01=PRIVATE NON PROFIT 02=PROPRIETARY 03=RELIGIOUS AFFILIATION 04=VOL. NON-PROF. - RELIGIOUS AFF. 05=FOR PROFIT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 19 Psychiatric Residential Treatment Facility, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 06=NOT FOR PROFIT 07=CORPORATION 08=STATE 09=LOCAL GOVERNMENT Address: ZIP Code 5 251 255 VARCHAR2 Description: Five-digit ZIP code for a provider's physical address. SAS Name: ZIP_CD COBOL Name: ZIP-CD FIPS State Code 2 256 257 VARCHAR2 Description: FIPS State Code SAS Name: FIPS_STATE_CD COBOL Name: FIPS-STATE-CD VALUES: 01=ALABAMA 02=ALASKA 04=ARIZONA 05=ARKANSAS 06=CALIFORNIA 08=COLORADO 09=CONNECTICUT 10=DELAWARE 11=DISTRICT OF COLUMBIA 12=FLORIDA 13=GEORGIA 15=HAWAII 16=IDAHO 17=ILLINOIS 18=INDIANA 19=IOWA 20=KANSAS 21=KENTUCKY 22=LOUISIANA 23=MAINE 24=MARYLAND 25=MASSACHUSETTS 26=MICHIGAN 27=MINNESOTA 28=MISSISSIPPI 29=MISSOURI 30=MONTANA 31=NEBRASKA 32=NEVADA 33=NEW HAMPSHIRE 34=NEW JERSEY 35=NEW MEXICO 36=NEW YORK 37=NORTH CAROLINA 38=NORTH DAKOTA 39=OHIO 40=OKLAHOMA 41=OREGON 42=PENNSYLVANIA 43=PUERTO RICO 44=RHODE ISLAND 45=SOUTH CAROLINA 46=SOUTH DAKOTA 47=TENNESSEE 48=TEXAS 49=UTAH 50=VERMONT 51=VIRGINIA 53=WASHINGTON 54=WEST VIRGINIA DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 20 Psychiatric Residential Treatment Facility, CATEGORY = "06" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 55=WISCONSIN 56=WYOMING 64=AMERICAN SAMOA 65=GUAM 66=SAIPAN/MARIANA IS. 78=VIRGIN ISLANDS FIPS County Code 3 258 260 VARCHAR2 Description: FIPS County Code SAS Name: FIPS_CNTY_CD COBOL Name: FIPS-CNTY-CD CBSA Urban Rural Indicator 1 261 261 VARCHAR2 Description: CBSA (Core Based Statistical Area) indicates whether the county is defined as Urban or Rural. SAS Name: CBSA_URBN_RRL_IND COBOL Name: CBSA-URBN-RRL-IND CBSA Code 5 262 266 VARCHAR2 Description: CBSA (Core Based Statistical Area) geographic entities defined by the U.S. Office of Management and Budget (OMB) on June 6, 2003 for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics. CBSA collectively refers to MSA. SAS Name: CBSA_CD COBOL Name: CBSA-CD Bed Count: Total 4 373 376 NUMBER Description: Total number of beds in a provider, including those in non-participating or non-licensed areas. SAS Name: BED_CNT COBOL Name: BED-CNT Fiscal Year End Date (MMDD) 4 464 467 VARCHAR2 Description: End date, consisting of the month and day, of the provider's fiscal year. SAS Name: FY_END_MO_DAY_CD COBOL Name: FY-END-MO-DAY-CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 1 Portable X-Ray Supplier, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Provider Category Subtype Code 2 1 2 VARCHAR2 Description: Identifies the subtype of the provider, within the primary category. Used in reporting to show the breakdown of provider categories, mainly for hospitals and SNFs. SAS Name: PRVDR_CTGRY_SBTYP_CD COBOL Name: PRVDR-CTGRY-SBTYP-CD VALUES: 01=X-Ray Provider Category Code 2 3 4 VARCHAR2 Description: Identifies the type of provider participating in the Medicare/Medicaid program. SAS Name: PRVDR_CTGRY_CD COBOL Name: PRVDR-CTGRY-CD VALUES: 07=Portable X-Ray Supplier CHOW Count 2 5 6 NUMBER Description: Number of times this provider has undergone a change of ownership. SAS Name: CHOW_CNT COBOL Name: CHOW-CNT CHOW Date 8 7 14 DATE Description: Effective date of the most recent change of ownership for this provider. SAS Name: CHOW_DT COBOL Name: CHOW-DT Address: City 28 15 42 VARCHAR2 Description: City in which the provider is physically located. SAS Name: CITY_NAME COBOL Name: CITY-NAME Compliance: Acceptable POC 1 43 43 VARCHAR2 Description: Indicates if a provider is in compliance with program requirements based on an acceptable plan for correction of deficiencies. SAS Name: ACPTBL_POC_SW COBOL Name: ACPTBL-POC-SW Compliance: Status 1 44 44 VARCHAR2 Description: Compliance status of a provider at the time of certification survey. SAS Name: CMPLNC_STUS_CD COBOL Name: CMPLNC-STUS-CD VALUES: A=IN COMPLIANCE B=NOT IN COMPLIANCE SSA County Code 3 45 47 VARCHAR2 Description: Social Security Administration geographic code indicating the county where the provider is located. SAS Name: SSA_CNTY_CD COBOL Name: SSA-CNTY-CD Cross Ref Provider Number 10 48 57 CHAR Description: Cross reference provider number SAS Name: CROSS_REF_PROVIDER_NUMBER COBOL Name: CROSS-REF-PROVIDER-NUMBER Certification Date 8 58 65 DATE Description: Equal to the exit date of the initial visit of the Health survey for certifications completed after July 28, 2012. For certifications prior to that date, the certification DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 2 Portable X-Ray Supplier, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE date is equal to the exit date of the initial visit of the Health survey or LSC survey, whichever is later. SAS Name: CRTFCTN_DT COBOL Name: CRTFCTN-DT Eligibility Indicator 1 66 66 VARCHAR2 Description: Indicates if a facility is eligible to participate in the Medicare and/or Medicaid programs. SAS Name: ELGBLTY_SW COBOL Name: ELGBLTY-SW Facility Name 50 67 116 VARCHAR2 Description: Name of the provider certified to participate in the Medicare and/or Medicaid programs. SAS Name: FAC_NAME COBOL Name: FAC-NAME Medicare Administrative Contractor (MAC) or 5 117 121 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_CD COBOL Name: INTRMDRY-CARR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 3 Portable X-Ray Supplier, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 4 Portable X-Ray Supplier, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 5 Portable X-Ray Supplier, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 6 Portable X-Ray Supplier, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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 15 122 136 VARCHAR2 Description: Number which may be assigned to a provider by the state Medicaid agency for external control or billing purposes. SAS Name: MDCD_VNDR_NUM COBOL Name: MDCD-VNDR-NUM Original Participation Date 8 137 144 DATE Description: Date a provider is first approved to provide Medicare and/or Medicaid services. SAS Name: ORGNL_PRTCPTN_DT COBOL Name: ORGNL-PRTCPTN-DT Prior CHOW Date 8 145 152 DATE Description: Effective date of the previous change of ownership for this provider. SAS Name: CHOW_PRIOR_DT COBOL Name: CHOW-PRIOR-DT Prior Medicare Administrative Contractor (MAC) or 5 153 157 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the previous Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_PRIOR_CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 7 Portable X-Ray Supplier, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: INTRMDRY-CARR-PRIOR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 00520=BLUE SHIELD (ARKANSAS) 00528=BLUE SHIELD (ARKANSAS/LOUISIANA) 00542=BLUE SHIELD (CALIFORNIA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 8 Portable X-Ray Supplier, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00550=BLUE SHIELD (COLORADO) 00570=BLUE SHIELD (DELAWARE) 00580=BLUE SHIELD (DISTRICT OF COLUMBIA) 00590=BLUE SHIELD (FLORIDA) 00621=BLUE SHIELD (ILLINOIS) 00630=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 9 Portable X-Ray Supplier, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 10 Portable X-Ray Supplier, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 11 Portable X-Ray Supplier, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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) CCN 10 158 167 VARCHAR2 Description: Six or ten position identification number that is assigned to a certified provider. This is the CMS Certification Number. SAS Name: PRVDR_NUM COBOL Name: PRVDR-NUM Region Code 2 168 169 VARCHAR2 Description: Indicates the CMS Regional Office responsible for the certification of the provider. SAS Name: RGN_CD COBOL Name: RGN-CD VALUES: 01=Boston 02=New York 03=Philadelphia 04=Atlanta 05=Chicago 06=Dallas 07=Kansas City 08=Denver 09=San Francisco 10=Seattle Skeleton Record Indicator 1 170 170 VARCHAR2 Description: Indicates if the record is a skeleton record. Only a limited set of data is available for this provider; no survey data exists. SAS Name: SKLTN_REC_SW COBOL Name: SKLTN-REC-SW State Abbreviation 2 171 172 VARCHAR2 Description: Two-character state abbreviation. SAS Name: STATE_CD COBOL Name: STATE-CD VALUES: AK=ALASKA AL=ALABAMA AR=ARKANSAS AS=AMERICAN SAMOA AZ=ARIZONA CA=CALIFORNIA CN=CANADA CO=COLORADO CT=CONNECTICUT DC=DISTRICT OF COLUMBIA DE=DELAWARE FL=FLORIDA FN=INTERNATIONAL DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 12 Portable X-Ray Supplier, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA=GEORGIA GU=GUAM HI=HAWAII IA=IOWA ID=IDAHO IL=ILLINOIS IN=INDIANA KS=KANSAS KY=KENTUCKY LA=LOUISIANA MA=MASSACHUSETTS MD=MARYLAND ME=MAINE MI=MICHIGAN MN=MINNESOTA MO=MISSOURI MP=SAIPAN MS=MISSISSIPPI MT=MONTANA MX=MEXICO NC=NORTH CAROLINA ND=NORTH DAKOTA NE=NEBRASKA NH=NEW HAMPSHIRE NJ=NEW JERSEY NM=NEW MEXICO NV=NEVADA NY=NEW YORK OH=OHIO OK=OKLAHOMA OR=OREGON PA=PENNSYLVANIA PR=PUERTO RICO RI=RHODE ISLAND SC=SOUTH CAROLINA SD=SOUTH DAKOTA TN=TENNESSEE TX=TEXAS UT=UTAH VA=VIRGINIA VI=VIRGIN ISLANDS VT=VERMONT WA=WASHINGTON WI=WISCONSIN WV=WEST VIRGINIA WY=WYOMING SSA State Code 2 173 174 VARCHAR2 Description: Social Security Administration geographic code indicating the state where the provider is located. SAS Name: SSA_STATE_CD COBOL Name: SSA-STATE-CD 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 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 13 Portable X-Ray Supplier, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 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 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 99=INTERNATIONAL State Region Code 3 175 177 VARCHAR2 Description: Identifies the region within a state where the provider is located. SAS Name: STATE_RGN_CD COBOL Name: STATE-RGN-CD VALUES: AK/001=ALASKA AK/LAB=LABORATORIES AL/001=ALABAMA AL/LAB=LABORATORIES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 14 Portable X-Ray Supplier, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE AR/001=ARKANSAS AR/LAB=LABORATORIES AS/001=AMERICAN SAMOA AS/LAB=LABORATORY AZ/AZ=PHOENIX AZ/LAB=ARIZONA LAB AZ/TUC=TUCSON CA/BAK=BAKERSFIELD CA/BER=SAN BERNARDINO CA/BK=BERKELEY CA/BK1=CONTRA COSTA CA/FR=FRESNO CA/L1=L.A. WEST CA/L2=L.A. NORTH CA/L3=L.A. CENTRAL CA/L4=L.A. EAST CA/L5=SAN GABRIEL CA/LAB=LABORATORIES CA/M1=LAB. SOUTH CA/M2=LAB. NORTH CA/ORG=ORANGE CO CA/RIV=RIVERSIDE CA/RWC=REDWOOD COAST CA/S1=SACRAMENTO CA/S2=SACTO SOUTH CA/S3=CHICO CA/SD=SAN DIEGO CA/SDS=SAN DIEGO SOUTH CA/SF=SAN FRANCISCO CA/SJ=SAN JOSE CA/SR=SANTA ROSA CA/VEN=VENTURA CN/001=CANADA CN/LAB=LABORATORY CO/001=COLORADO CO/LAB=LABORATORIES CT/001=CONNECTICUT CT/LAB=LABORATORIES DC/001=DISTRICT OF COLUMBIA DC/LAB=LABORATORIES DE/001=DELAWARE DE/LAB=LABORATORIES FL/FTM=FT. MYERS FL/GAI=GAINESVILLE FL/JAX=JACKSONVILLE FL/LAB=LABORATORIES FL/LAN=LANTANA FL/LAU=LAUDERHILL FL/MIA=MIAMI FL/ORL=ORLANDO FL/PEN=PENSACOLA FL/STP=ST. PETERSBURG FL/TAL=TALLAHASSEE FL/TAM=TAMPA FM/001=FEDERATED STATES OF MICRO FN/001=INTERNATIONAL FN/LAB=LABORATORIES GA/001=GEORGIA GA/GAA=GEORGIA ALL GA/GAC=GEORGIA CENTRAL GA/GAE=GEORGIA EASTERN GA/GAN=GEORGIA NORTH GA/GAS=GEORGIA SOUTH GA/GAW=GEORGIA WESTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 15 Portable X-Ray Supplier, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA/LAB=LABORATORIES GU/001=GUAM GU/LAB=LABORATORIES HI/001=HAWAII HI/LAB=LABORATORIES IA/001=IOWA IA/LAB=LABORATORIES ID/001=IDAHO ID/LAB=LABORATORIES IL/001=ILLINOIS IL/LAB=LABORATORIES IN/001=INDIANA IN/LAB=LABORATORIES KS/KCK=KANSAS CITY KS/KDH=KDHE KS/LAB=LABORATORIES KS/LAW=LAWRENCE KS/NC=NORTH CENTRAL KANSAS KS/NE=NORTH EAST KANSAS KS/NW=NORTH WEST KANSAS KS/SC=SOUTH CENTRAL KANSAS KS/SE=SOUTH EAST KANSAS KS/SW=SOUTH WEST KANSAS KS/WST=WEST KY/2C1=HOPKINSVILLE KY/2C2=LOUISVILLE KY/2C3=LONDON KY/2C4=LEXINGTON KY/LAB=LABORATORIES LA/001=LOUISIANA LA/LA1=NEW ORLEANS LA/LA2=MANDEVILLE LA/LA3=LAFAYETTE LA/LA4=MONROE LA/LA5=SHREVEPORT LA/LA6=ALEXANDRIA LA/LAB=LABORATORIES LA/LB1=CLIA NEW ORLEANS LA/LB5=CLIA SHREVEPORT LA/LB6=CLIA ALEXANDRIA MA/001=MASSACHUSETTS MA/LAB=LABORATORIES MD/001=MARYLAND MD/LAB=LABORATORIES ME/001=MAINE ME/LAB=LABORATORIES MH/001=MARSHALL ISLANDS MI/001=MICHIGAN MI/LAB=LABORATORIES MN/001=MINNESOTA MN/LAB=LABORATORIES MO/01=REGION01 MO/02=REGION02 MO/03=REGION 03 MO/04=REGION 04 MO/05=REGION 05 MO/06=REGION 06 MO/07=REGION 07 MO/1NH=REGION 1 NH MO/2NH=REGION 2 NH MO/3NH=REGION 3 NH MO/4NH=REGION 4 NH MO/5NH=REGION 5 NH MO/6NH=REGION 6 NH DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 16 Portable X-Ray Supplier, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE MO/7NH=REGION 7 NH MO/LAB=LABORATORIES MO/MO=STATEWIDE MP/001=NORTHERN MARIANA ISLANDS MP/LAB=LABORATORIES MS/001=MISSISSIPPI MS/LAB=LABORATORIES MT/001=MONTANA MT/LAB=LABORATORIES MX/001=MEXICO MX/LAB=LABORATORY NC/LAB=LABORATORIES NC/NCC=NORTH CAROLINA CENTRAL NC/NCE=NORTH CAROLINA EAST NC/NCN=NORTH CAROLINA NORTH NC/NCS=NORTH CAROLINA SOUTH NC/NCW=NORTH CAROLINA WEST ND/001=NORTH DAKOTA ND/LAB=LABORATORIES NE/1=NORTH CENTRAL NE/2=CENTRAL NE/3=NORTHEAST NE/4=SOUTHEAST NE/5=WESTERN NE/LAB=LABORATORIES NH/001=NEW HAMPSHIRE NH/LAB=LABORATORIES NJ/001=NEW JERSEY NJ/LAB=LABORATORIES NM/001=NEW MEXICO NM/LAB=LABORATORIES NV/CC=CARSON CITY NV/LAB=LABORATORIES NV/LV=LAS VEGAS NY/001=BUFFALO NY/002=ROCHESTER NY/003=SYRACUSE NY/004=ALBANY NY/005=NEW ROCHELLE NY/006=NEW YORK CITY NY/007=SUFFOLK/NASSAU COUNTY NY/LAB=LABORATORIES OH/001=OHIO OH/LAB=LABORATORIES OK/001=OKLAHOMA OK/LAB=LABORATORIES OR/001=OFFICE #1 OR/002=OFFICE #2 OR/003=OFFICE #3 OR/LAB=LABORATORIES PA/001=PENNSYLVANIA PA/LAB=LABORATORIES PR/001=PUERTO RICO PR/LAB=LABORATORIES PW/001=PALAU RI/001=RHODE ISLAND RI/LAB=LABORATORIES SC/001=SOUTH CAROLINA SC/LAB=LABORATORIES SD/001=SOUTH DAKOTA SD/LAB=LABORATORIES TN/LAB=LABORATORIES TN/TNC=TENNESSEE COOKEVILLE TN/TNE=TENNESSEE EASTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 17 Portable X-Ray Supplier, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE TN/TNM=TENNESSEE MIDDLE TN/TNW=TENNESSEE WESTERN TX/001=TEXAS TX/L01=AMARILLO-LTC TX/L02=ABILENE-LTC TX/L03=ARLINGTON-LTC TX/L04=TYLER-LTC TX/L05=BEAUMONT-LTC TX/L06=HOUSTON-LTC TX/L07=TEMPLE-LTC TX/L08=SAN ANTONIO-LTC TX/L09=SAN ANGELO-LTC TX/L10=EL PASO-LTC TX/L11=CORPUS CHRISTI-LTC TX/LAB=LABORATORIES TX/TX1=LUBBOCK TX/TX2=ARLINGTON TX/TX3=SAN ANTONIO TX/TX4=HOUSTON TX/TX5=TYLER TX/TX6=AUSTIN UT/001=UTAH UT/LAB=LABORATORIES VA/001=VIRGINIA VA/LAB=LABORATORIES VI/001=VIRGIN ISLANDS VI/LAB=LABORATORIES VT/001=VERMONT VT/LAB=LABORATORIES WA/001=ALL OTHERS (NON-LTC FAC) WA/D1=SPOKANE & YAKIMA AREAS WA/D1A=District 1, Unit A WA/D1B=District 1, Unit B WA/D1C=District 1, Unit C WA/D1D=District 1, Unit D WA/D2=SPOKANE & SE WA/D2A=District 2, Unit A WA/D2B=District 2, Unit B WA/D2C=District 2, Unit C WA/D2D=District 2, Unit D WA/D2E=District 2, Unit E WA/D2F=District 2, Unit F WA/D2G=District 2, Unit G WA/D3=NW WASHINGTON WA/D3A=District 3, Unit A WA/D3B=District 3, Unit B WA/D3C=District 3, Unit C WA/D3D=District 3, Unit D WA/D3E=District 3, Unit E WA/D4A=GREATER SEATTLE AREA WA/D4B=S KING COUNTY WA/D5A=PIERCE CTY & PENINSULA WA/D5B=PIERCE CTY & GRAYS HARBOR WA/D6=OLYMPIA AREA WA/LAB=LABORATORIES WI/001=WISCONSIN WI/LAB=LABORATORIES WV/001=WEST VIRGINIA WV/LAB=LABORATORIES WY/001=WYOMING WY/LAB=LABORATORIES Address: Street 50 178 227 VARCHAR2 Description: Street address where the provider is located. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 18 Portable X-Ray Supplier, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: ST_ADR COBOL Name: ST-ADR Telephone Number 10 228 237 VARCHAR2 Description: Telephone number of the provider. SAS Name: PHNE_NUM COBOL Name: PHNE-NUM Termination Code 2 238 239 VARCHAR2 Description: Indicates the current termination status for the provider. SAS Name: PGM_TRMNTN_CD COBOL Name: PGM-TRMNTN-CD VALUES: 00=ACTIVE PROVIDER 01=VOLUNTARY-MERGER, CLOSURE 02=VOLUNTARY-DISSATISFACTION WITH REIMBURSEMENT 03=VOLUNTARY-RISK OF INVOLUNTARY TERMINATION 04=VOLUNTARY-OTHER REASON FOR WITHDRAWAL 05=INVOLUNTARY-FAILURE TO MEET HEALTH/SAFETY REQ 06=INVOLUNTARY-FAILURE TO MEET AGREEMENT 07=OTHER-PROVIDER STATUS CHANGE 08=NONPAYMENT OF FEES - CLIA Only 09=REV/UNSUCCESSFUL PARTICIPATION IN PT - CLIA Only 10=REV/OTHER REASON - CLIA Only 11=INCOMPLETE CLIA APPLICATION INFORMATION - CLIA Only 12=NO LONGER PERFORMING TESTS - CLIA Only 13=MULTIPLE TO SINGLE SITE CERTIFICATE - CLIA Only 14=SHARED LABORATORY - CLIA Only 15=FAILURE TO RENEW WAIVER PPM CERTIFICATE - CLIA Only 16=DUPLICATE CLIA NUMBER - CLIA Only 17=MAIL RETURNED NO FORWARD ADDRESS CERT ENDED - CLIA Only 20=NOTIFICATION BANKRUPTCY - CLIA Only 33=ACCREDITATION NOT CONFIRMED - CLIA Only 80=AWAITING STATE APPROVAL 99=OIG ACTION - DO NOT ACTIVATE - CLIA Only Termination or Expiration Date 8 240 247 DATE Description: Date the provider was terminated. For CLIA providers, date the laboratory's certificate was terminated or the expiration date of the current CLIA certificate. SAS Name: TRMNTN_EXPRTN_DT COBOL Name: TRMNTN-EXPRTN-DT Type of Action Code 1 248 248 VARCHAR2 Description: Identifies the reason for the certification. Type of action from the official survey record, CMS 1539 form. SAS Name: CRTFCTN_ACTN_TYPE_CD COBOL Name: CRTFCTN-ACTN-TYPE-CD VALUES: 1=INITIAL 2=RECERTIFICATION 3=TERMINATION 4=CHANGE OF OWNERSHIP 5=VALIDATION 8=FULL SURVEY AFTER COMPLAINT Ownership Type Code 2 249 250 VARCHAR2 Description: Indicates the ownership type of the provider. SAS Name: GNRL_CNTL_TYPE_CD COBOL Name: GNRL-CNTL-TYPE-CD VALUES: 01=INDIVIDUAL 02=PARTNERSHIP 03=CORPORATION 04=OTHER THAN PRIVATE DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 19 Portable X-Ray Supplier, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Address: ZIP Code 5 251 255 VARCHAR2 Description: Five-digit ZIP code for a provider's physical address. SAS Name: ZIP_CD COBOL Name: ZIP-CD FIPS State Code 2 256 257 VARCHAR2 Description: FIPS State Code SAS Name: FIPS_STATE_CD COBOL Name: FIPS-STATE-CD VALUES: 01=ALABAMA 02=ALASKA 04=ARIZONA 05=ARKANSAS 06=CALIFORNIA 08=COLORADO 09=CONNECTICUT 10=DELAWARE 11=DISTRICT OF COLUMBIA 12=FLORIDA 13=GEORGIA 15=HAWAII 16=IDAHO 17=ILLINOIS 18=INDIANA 19=IOWA 20=KANSAS 21=KENTUCKY 22=LOUISIANA 23=MAINE 24=MARYLAND 25=MASSACHUSETTS 26=MICHIGAN 27=MINNESOTA 28=MISSISSIPPI 29=MISSOURI 30=MONTANA 31=NEBRASKA 32=NEVADA 33=NEW HAMPSHIRE 34=NEW JERSEY 35=NEW MEXICO 36=NEW YORK 37=NORTH CAROLINA 38=NORTH DAKOTA 39=OHIO 40=OKLAHOMA 41=OREGON 42=PENNSYLVANIA 43=PUERTO RICO 44=RHODE ISLAND 45=SOUTH CAROLINA 46=SOUTH DAKOTA 47=TENNESSEE 48=TEXAS 49=UTAH 50=VERMONT 51=VIRGINIA 53=WASHINGTON 54=WEST VIRGINIA 55=WISCONSIN 56=WYOMING 64=AMERICAN SAMOA 65=GUAM 66=SAIPAN/MARIANA IS. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 20 Portable X-Ray Supplier, CATEGORY = "07" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 78=VIRGIN ISLANDS FIPS County Code 3 258 260 VARCHAR2 Description: FIPS County Code SAS Name: FIPS_CNTY_CD COBOL Name: FIPS-CNTY-CD CBSA Urban Rural Indicator 1 261 261 VARCHAR2 Description: CBSA (Core Based Statistical Area) indicates whether the county is defined as Urban or Rural. SAS Name: CBSA_URBN_RRL_IND COBOL Name: CBSA-URBN-RRL-IND CBSA Code 5 262 266 VARCHAR2 Description: CBSA (Core Based Statistical Area) geographic entities defined by the U.S. Office of Management and Budget (OMB) on June 6, 2003 for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics. CBSA collectively refers to MSA. SAS Name: CBSA_CD COBOL Name: CBSA-CD Fiscal Year End Date (MMDD) 4 464 467 VARCHAR2 Description: End date, consisting of the month and day, of the provider's fiscal year. SAS Name: FY_END_MO_DAY_CD COBOL Name: FY-END-MO-DAY-CD Staff Count: Other Personnel 8 885 892 NUMBER Description: Number of full-time equivalent other personnel employed by a provider SAS Name: PRSNEL_OTHR_CNT COBOL Name: PRSNEL-OTHR-CNT Technologist Count: 24-Month Radiologic School 8 1952 1959 NUMBER Description: Number of full-time equivalent technologists who are graduates of a 24-month approved school of radiologic technology. SAS Name: TCHNLGST_2_YR_RDLGC_CNT COBOL Name: TCHNLGST-2-YR-RDLGC-CNT Technologist Count: Associate Degree 8 1960 1967 NUMBER Description: Number of full-time equivalent technologists with an Associate degree in radiologic technology. SAS Name: TCHNLGST_ASCT_DGR_CNT COBOL Name: TCHNLGST-ASCT-DGR-CNT Technologist Count: BS or BA Degree 8 1968 1975 NUMBER Description: Number of full-time equivalent technologists with a Bachelor of Science or Bachelor of Arts degree in radiologic technology. SAS Name: TCHNLGST_BS_BA_DGR_CNT COBOL Name: TCHNLGST-BS-BA-DGR-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 1 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Provider Category Subtype Code 2 1 2 VARCHAR2 Description: Identifies the subtype of the provider, within the primary category. Used in reporting to show the breakdown of provider categories, mainly for hospitals and SNFs. SAS Name: PRVDR_CTGRY_SBTYP_CD COBOL Name: PRVDR-CTGRY-SBTYP-CD VALUES: 01=OPT or Speech Pathology Provider Category Code 2 3 4 VARCHAR2 Description: Identifies the type of provider participating in the Medicare/Medicaid program. SAS Name: PRVDR_CTGRY_CD COBOL Name: PRVDR-CTGRY-CD VALUES: 08=Outpatient Physical Therapy/Speech Pathology CHOW Count 2 5 6 NUMBER Description: Number of times this provider has undergone a change of ownership. SAS Name: CHOW_CNT COBOL Name: CHOW-CNT CHOW Date 8 7 14 DATE Description: Effective date of the most recent change of ownership for this provider. SAS Name: CHOW_DT COBOL Name: CHOW-DT Address: City 28 15 42 VARCHAR2 Description: City in which the provider is physically located. SAS Name: CITY_NAME COBOL Name: CITY-NAME Compliance: Acceptable POC 1 43 43 VARCHAR2 Description: Indicates if a provider is in compliance with program requirements based on an acceptable plan for correction of deficiencies. SAS Name: ACPTBL_POC_SW COBOL Name: ACPTBL-POC-SW Compliance: Status 1 44 44 VARCHAR2 Description: Compliance status of a provider at the time of certification survey. SAS Name: CMPLNC_STUS_CD COBOL Name: CMPLNC-STUS-CD VALUES: A=IN COMPLIANCE B=NOT IN COMPLIANCE SSA County Code 3 45 47 VARCHAR2 Description: Social Security Administration geographic code indicating the county where the provider is located. SAS Name: SSA_CNTY_CD COBOL Name: SSA-CNTY-CD Cross Ref Provider Number 10 48 57 CHAR Description: Cross reference provider number SAS Name: CROSS_REF_PROVIDER_NUMBER COBOL Name: CROSS-REF-PROVIDER-NUMBER Certification Date 8 58 65 DATE Description: Equal to the exit date of the initial visit of the Health survey for certifications completed after July 28, 2012. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 2 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE For certifications prior to that date, the certification date is equal to the exit date of the initial visit of the Health survey or LSC survey, whichever is later. SAS Name: CRTFCTN_DT COBOL Name: CRTFCTN-DT Eligibility Indicator 1 66 66 VARCHAR2 Description: Indicates if a facility is eligible to participate in the Medicare and/or Medicaid programs. SAS Name: ELGBLTY_SW COBOL Name: ELGBLTY-SW Facility Name 50 67 116 VARCHAR2 Description: Name of the provider certified to participate in the Medicare and/or Medicaid programs. SAS Name: FAC_NAME COBOL Name: FAC-NAME Medicare Administrative Contractor (MAC) or 5 117 121 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_CD COBOL Name: INTRMDRY-CARR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 3 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 4 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 5 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 6 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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 15 122 136 VARCHAR2 Description: Number which may be assigned to a provider by the state Medicaid agency for external control or billing purposes. SAS Name: MDCD_VNDR_NUM COBOL Name: MDCD-VNDR-NUM Original Participation Date 8 137 144 DATE Description: Date a provider is first approved to provide Medicare and/or Medicaid services. SAS Name: ORGNL_PRTCPTN_DT COBOL Name: ORGNL-PRTCPTN-DT Prior CHOW Date 8 145 152 DATE Description: Effective date of the previous change of ownership for this provider. SAS Name: CHOW_PRIOR_DT COBOL Name: CHOW-PRIOR-DT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 7 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Prior Medicare Administrative Contractor (MAC) or 5 153 157 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the previous Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_PRIOR_CD COBOL Name: INTRMDRY-CARR-PRIOR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 8 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 9 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 10 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 11 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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) CCN 10 158 167 VARCHAR2 Description: Six or ten position identification number that is assigned to a certified provider. This is the CMS Certification Number. SAS Name: PRVDR_NUM COBOL Name: PRVDR-NUM Region Code 2 168 169 VARCHAR2 Description: Indicates the CMS Regional Office responsible for the certification of the provider. SAS Name: RGN_CD COBOL Name: RGN-CD VALUES: 01=Boston 02=New York 03=Philadelphia 04=Atlanta 05=Chicago 06=Dallas 07=Kansas City 08=Denver 09=San Francisco 10=Seattle Skeleton Record Indicator 1 170 170 VARCHAR2 Description: Indicates if the record is a skeleton record. Only a limited set of data is available for this provider; no survey data exists. SAS Name: SKLTN_REC_SW COBOL Name: SKLTN-REC-SW State Abbreviation 2 171 172 VARCHAR2 Description: Two-character state abbreviation. SAS Name: STATE_CD COBOL Name: STATE-CD VALUES: AK=ALASKA AL=ALABAMA DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 12 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE AR=ARKANSAS AS=AMERICAN SAMOA AZ=ARIZONA CA=CALIFORNIA CN=CANADA CO=COLORADO CT=CONNECTICUT DC=DISTRICT OF COLUMBIA DE=DELAWARE FL=FLORIDA FN=INTERNATIONAL GA=GEORGIA GU=GUAM HI=HAWAII IA=IOWA ID=IDAHO IL=ILLINOIS IN=INDIANA KS=KANSAS KY=KENTUCKY LA=LOUISIANA MA=MASSACHUSETTS MD=MARYLAND ME=MAINE MI=MICHIGAN MN=MINNESOTA MO=MISSOURI MP=SAIPAN MS=MISSISSIPPI MT=MONTANA MX=MEXICO NC=NORTH CAROLINA ND=NORTH DAKOTA NE=NEBRASKA NH=NEW HAMPSHIRE NJ=NEW JERSEY NM=NEW MEXICO NV=NEVADA NY=NEW YORK OH=OHIO OK=OKLAHOMA OR=OREGON PA=PENNSYLVANIA PR=PUERTO RICO RI=RHODE ISLAND SC=SOUTH CAROLINA SD=SOUTH DAKOTA TN=TENNESSEE TX=TEXAS UT=UTAH VA=VIRGINIA VI=VIRGIN ISLANDS VT=VERMONT WA=WASHINGTON WI=WISCONSIN WV=WEST VIRGINIA WY=WYOMING SSA State Code 2 173 174 VARCHAR2 Description: Social Security Administration geographic code indicating the state where the provider is located. SAS Name: SSA_STATE_CD COBOL Name: SSA-STATE-CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 13 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 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 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 56=CANADA 57=WEST INDIES 58=EUROPE 59=MEXICO 60=OCEANIA 61=PHILIPPINES 62=SOUTH AMERICA 63=UNITED STATES POSSESSIONS 64=AMERICAN SAMOA DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 14 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 65=GUAM 66=SAIPAN 99=INTERNATIONAL State Region Code 3 175 177 VARCHAR2 Description: Identifies the region within a state where the provider is located. SAS Name: STATE_RGN_CD COBOL Name: STATE-RGN-CD VALUES: AK/001=ALASKA AK/LAB=LABORATORIES AL/001=ALABAMA AL/LAB=LABORATORIES AR/001=ARKANSAS AR/LAB=LABORATORIES AS/001=AMERICAN SAMOA AS/LAB=LABORATORY AZ/AZ=PHOENIX AZ/LAB=ARIZONA LAB AZ/TUC=TUCSON CA/BAK=BAKERSFIELD CA/BER=SAN BERNARDINO CA/BK=BERKELEY CA/BK1=CONTRA COSTA CA/FR=FRESNO CA/L1=L.A. WEST CA/L2=L.A. NORTH CA/L3=L.A. CENTRAL CA/L4=L.A. EAST CA/L5=SAN GABRIEL CA/LAB=LABORATORIES CA/M1=LAB. SOUTH CA/M2=LAB. NORTH CA/ORG=ORANGE CO CA/RIV=RIVERSIDE CA/RWC=REDWOOD COAST CA/S1=SACRAMENTO CA/S2=SACTO SOUTH CA/S3=CHICO CA/SD=SAN DIEGO CA/SDS=SAN DIEGO SOUTH CA/SF=SAN FRANCISCO CA/SJ=SAN JOSE CA/SR=SANTA ROSA CA/VEN=VENTURA CN/001=CANADA CN/LAB=LABORATORY CO/001=COLORADO CO/LAB=LABORATORIES CT/001=CONNECTICUT CT/LAB=LABORATORIES DC/001=DISTRICT OF COLUMBIA DC/LAB=LABORATORIES DE/001=DELAWARE DE/LAB=LABORATORIES FL/FTM=FT. MYERS FL/GAI=GAINESVILLE FL/JAX=JACKSONVILLE FL/LAB=LABORATORIES FL/LAN=LANTANA FL/LAU=LAUDERHILL FL/MIA=MIAMI FL/ORL=ORLANDO DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 15 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE FL/PEN=PENSACOLA FL/STP=ST. PETERSBURG FL/TAL=TALLAHASSEE FL/TAM=TAMPA FM/001=FEDERATED STATES OF MICRO FN/001=INTERNATIONAL FN/LAB=LABORATORIES GA/001=GEORGIA GA/GAA=GEORGIA ALL GA/GAC=GEORGIA CENTRAL GA/GAE=GEORGIA EASTERN GA/GAN=GEORGIA NORTH GA/GAS=GEORGIA SOUTH GA/GAW=GEORGIA WESTERN GA/LAB=LABORATORIES GU/001=GUAM GU/LAB=LABORATORIES HI/001=HAWAII HI/LAB=LABORATORIES IA/001=IOWA IA/LAB=LABORATORIES ID/001=IDAHO ID/LAB=LABORATORIES IL/001=ILLINOIS IL/LAB=LABORATORIES IN/001=INDIANA IN/LAB=LABORATORIES KS/KCK=KANSAS CITY KS/KDH=KDHE KS/LAB=LABORATORIES KS/LAW=LAWRENCE KS/NC=NORTH CENTRAL KANSAS KS/NE=NORTH EAST KANSAS KS/NW=NORTH WEST KANSAS KS/SC=SOUTH CENTRAL KANSAS KS/SE=SOUTH EAST KANSAS KS/SW=SOUTH WEST KANSAS KS/WST=WEST KY/2C1=HOPKINSVILLE KY/2C2=LOUISVILLE KY/2C3=LONDON KY/2C4=LEXINGTON KY/LAB=LABORATORIES LA/001=LOUISIANA LA/LA1=NEW ORLEANS LA/LA2=MANDEVILLE LA/LA3=LAFAYETTE LA/LA4=MONROE LA/LA5=SHREVEPORT LA/LA6=ALEXANDRIA LA/LAB=LABORATORIES LA/LB1=CLIA NEW ORLEANS LA/LB5=CLIA SHREVEPORT LA/LB6=CLIA ALEXANDRIA MA/001=MASSACHUSETTS MA/LAB=LABORATORIES MD/001=MARYLAND MD/LAB=LABORATORIES ME/001=MAINE ME/LAB=LABORATORIES MH/001=MARSHALL ISLANDS MI/001=MICHIGAN MI/LAB=LABORATORIES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 16 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE MN/001=MINNESOTA MN/LAB=LABORATORIES MO/01=REGION01 MO/02=REGION02 MO/03=REGION 03 MO/04=REGION 04 MO/05=REGION 05 MO/06=REGION 06 MO/07=REGION 07 MO/1NH=REGION 1 NH MO/2NH=REGION 2 NH MO/3NH=REGION 3 NH MO/4NH=REGION 4 NH MO/5NH=REGION 5 NH MO/6NH=REGION 6 NH MO/7NH=REGION 7 NH MO/LAB=LABORATORIES MO/MO=STATEWIDE MP/001=NORTHERN MARIANA ISLANDS MP/LAB=LABORATORIES MS/001=MISSISSIPPI MS/LAB=LABORATORIES MT/001=MONTANA MT/LAB=LABORATORIES MX/001=MEXICO MX/LAB=LABORATORY NC/LAB=LABORATORIES NC/NCC=NORTH CAROLINA CENTRAL NC/NCE=NORTH CAROLINA EAST NC/NCN=NORTH CAROLINA NORTH NC/NCS=NORTH CAROLINA SOUTH NC/NCW=NORTH CAROLINA WEST ND/001=NORTH DAKOTA ND/LAB=LABORATORIES NE/1=NORTH CENTRAL NE/2=CENTRAL NE/3=NORTHEAST NE/4=SOUTHEAST NE/5=WESTERN NE/LAB=LABORATORIES NH/001=NEW HAMPSHIRE NH/LAB=LABORATORIES NJ/001=NEW JERSEY NJ/LAB=LABORATORIES NM/001=NEW MEXICO NM/LAB=LABORATORIES NV/CC=CARSON CITY NV/LAB=LABORATORIES NV/LV=LAS VEGAS NY/001=BUFFALO NY/002=ROCHESTER NY/003=SYRACUSE NY/004=ALBANY NY/005=NEW ROCHELLE NY/006=NEW YORK CITY NY/007=SUFFOLK/NASSAU COUNTY NY/LAB=LABORATORIES OH/001=OHIO OH/LAB=LABORATORIES OK/001=OKLAHOMA OK/LAB=LABORATORIES OR/001=OFFICE #1 OR/002=OFFICE #2 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 17 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE OR/003=OFFICE #3 OR/LAB=LABORATORIES PA/001=PENNSYLVANIA PA/LAB=LABORATORIES PR/001=PUERTO RICO PR/LAB=LABORATORIES PW/001=PALAU RI/001=RHODE ISLAND RI/LAB=LABORATORIES SC/001=SOUTH CAROLINA SC/LAB=LABORATORIES SD/001=SOUTH DAKOTA SD/LAB=LABORATORIES TN/LAB=LABORATORIES TN/TNC=TENNESSEE COOKEVILLE TN/TNE=TENNESSEE EASTERN TN/TNM=TENNESSEE MIDDLE TN/TNW=TENNESSEE WESTERN TX/001=TEXAS TX/L01=AMARILLO-LTC TX/L02=ABILENE-LTC TX/L03=ARLINGTON-LTC TX/L04=TYLER-LTC TX/L05=BEAUMONT-LTC TX/L06=HOUSTON-LTC TX/L07=TEMPLE-LTC TX/L08=SAN ANTONIO-LTC TX/L09=SAN ANGELO-LTC TX/L10=EL PASO-LTC TX/L11=CORPUS CHRISTI-LTC TX/LAB=LABORATORIES TX/TX1=LUBBOCK TX/TX2=ARLINGTON TX/TX3=SAN ANTONIO TX/TX4=HOUSTON TX/TX5=TYLER TX/TX6=AUSTIN UT/001=UTAH UT/LAB=LABORATORIES VA/001=VIRGINIA VA/LAB=LABORATORIES VI/001=VIRGIN ISLANDS VI/LAB=LABORATORIES VT/001=VERMONT VT/LAB=LABORATORIES WA/001=ALL OTHERS (NON-LTC FAC) WA/D1=SPOKANE & YAKIMA AREAS WA/D1A=District 1, Unit A WA/D1B=District 1, Unit B WA/D1C=District 1, Unit C WA/D1D=District 1, Unit D WA/D2=SPOKANE & SE WA/D2A=District 2, Unit A WA/D2B=District 2, Unit B WA/D2C=District 2, Unit C WA/D2D=District 2, Unit D WA/D2E=District 2, Unit E WA/D2F=District 2, Unit F WA/D2G=District 2, Unit G WA/D3=NW WASHINGTON WA/D3A=District 3, Unit A WA/D3B=District 3, Unit B WA/D3C=District 3, Unit C DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 18 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE WA/D3D=District 3, Unit D WA/D3E=District 3, Unit E WA/D4A=GREATER SEATTLE AREA WA/D4B=S KING COUNTY WA/D5A=PIERCE CTY & PENINSULA WA/D5B=PIERCE CTY & GRAYS HARBOR WA/D6=OLYMPIA AREA WA/LAB=LABORATORIES WI/001=WISCONSIN WI/LAB=LABORATORIES WV/001=WEST VIRGINIA WV/LAB=LABORATORIES WY/001=WYOMING WY/LAB=LABORATORIES Address: Street 50 178 227 VARCHAR2 Description: Street address where the provider is located. SAS Name: ST_ADR COBOL Name: ST-ADR Telephone Number 10 228 237 VARCHAR2 Description: Telephone number of the provider. SAS Name: PHNE_NUM COBOL Name: PHNE-NUM Termination Code 2 238 239 VARCHAR2 Description: Indicates the current termination status for the provider. SAS Name: PGM_TRMNTN_CD COBOL Name: PGM-TRMNTN-CD VALUES: 00=ACTIVE PROVIDER 01=VOLUNTARY-MERGER, CLOSURE 02=VOLUNTARY-DISSATISFACTION WITH REIMBURSEMENT 03=VOLUNTARY-RISK OF INVOLUNTARY TERMINATION 04=VOLUNTARY-OTHER REASON FOR WITHDRAWAL 05=INVOLUNTARY-FAILURE TO MEET HEALTH/SAFETY REQ 06=INVOLUNTARY-FAILURE TO MEET AGREEMENT 07=OTHER-PROVIDER STATUS CHANGE 08=NONPAYMENT OF FEES - CLIA Only 09=REV/UNSUCCESSFUL PARTICIPATION IN PT - CLIA Only 10=REV/OTHER REASON - CLIA Only 11=INCOMPLETE CLIA APPLICATION INFORMATION - CLIA Only 12=NO LONGER PERFORMING TESTS - CLIA Only 13=MULTIPLE TO SINGLE SITE CERTIFICATE - CLIA Only 14=SHARED LABORATORY - CLIA Only 15=FAILURE TO RENEW WAIVER PPM CERTIFICATE - CLIA Only 16=DUPLICATE CLIA NUMBER - CLIA Only 17=MAIL RETURNED NO FORWARD ADDRESS CERT ENDED - CLIA Only 20=NOTIFICATION BANKRUPTCY - CLIA Only 33=ACCREDITATION NOT CONFIRMED - CLIA Only 80=AWAITING STATE APPROVAL 99=OIG ACTION - DO NOT ACTIVATE - CLIA Only Termination or Expiration Date 8 240 247 DATE Description: Date the provider was terminated. For CLIA providers, date the laboratory's certificate was terminated or the expiration date of the current CLIA certificate. SAS Name: TRMNTN_EXPRTN_DT COBOL Name: TRMNTN-EXPRTN-DT Type of Action Code 1 248 248 VARCHAR2 Description: Identifies the reason for the certification. Type of action from the official survey record, CMS 1539 form. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 19 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: CRTFCTN_ACTN_TYPE_CD COBOL Name: CRTFCTN-ACTN-TYPE-CD VALUES: 1=INITIAL 2=RECERTIFICATION 3=TERMINATION 4=CHANGE OF OWNERSHIP 5=VALIDATION 8=FULL SURVEY AFTER COMPLAINT Ownership Type Code 2 249 250 VARCHAR2 Description: Indicates the ownership type of the provider. SAS Name: GNRL_CNTL_TYPE_CD COBOL Name: GNRL-CNTL-TYPE-CD VALUES: 01=VOLUNTARY NON PROFIT OTHER THAN CHURCH 02=VOLUNTARY NON PROFIT CHURCH 03=STATE GOVERNMENT 04=LOCAL GOVERNMENT 05=COMBINATION GOVERNMENT & VOLUNTARY 06=PROPRIETARY Address: ZIP Code 5 251 255 VARCHAR2 Description: Five-digit ZIP code for a provider's physical address. SAS Name: ZIP_CD COBOL Name: ZIP-CD FIPS State Code 2 256 257 VARCHAR2 Description: FIPS State Code SAS Name: FIPS_STATE_CD COBOL Name: FIPS-STATE-CD VALUES: 01=ALABAMA 02=ALASKA 04=ARIZONA 05=ARKANSAS 06=CALIFORNIA 08=COLORADO 09=CONNECTICUT 10=DELAWARE 11=DISTRICT OF COLUMBIA 12=FLORIDA 13=GEORGIA 15=HAWAII 16=IDAHO 17=ILLINOIS 18=INDIANA 19=IOWA 20=KANSAS 21=KENTUCKY 22=LOUISIANA 23=MAINE 24=MARYLAND 25=MASSACHUSETTS 26=MICHIGAN 27=MINNESOTA 28=MISSISSIPPI 29=MISSOURI 30=MONTANA 31=NEBRASKA 32=NEVADA 33=NEW HAMPSHIRE 34=NEW JERSEY 35=NEW MEXICO 36=NEW YORK 37=NORTH CAROLINA DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 20 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 38=NORTH DAKOTA 39=OHIO 40=OKLAHOMA 41=OREGON 42=PENNSYLVANIA 43=PUERTO RICO 44=RHODE ISLAND 45=SOUTH CAROLINA 46=SOUTH DAKOTA 47=TENNESSEE 48=TEXAS 49=UTAH 50=VERMONT 51=VIRGINIA 53=WASHINGTON 54=WEST VIRGINIA 55=WISCONSIN 56=WYOMING 64=AMERICAN SAMOA 65=GUAM 66=SAIPAN/MARIANA IS. 78=VIRGIN ISLANDS FIPS County Code 3 258 260 VARCHAR2 Description: FIPS County Code SAS Name: FIPS_CNTY_CD COBOL Name: FIPS-CNTY-CD CBSA Urban Rural Indicator 1 261 261 VARCHAR2 Description: CBSA (Core Based Statistical Area) indicates whether the county is defined as Urban or Rural. SAS Name: CBSA_URBN_RRL_IND COBOL Name: CBSA-URBN-RRL-IND CBSA Code 5 262 266 VARCHAR2 Description: CBSA (Core Based Statistical Area) geographic entities defined by the U.S. Office of Management and Budget (OMB) on June 6, 2003 for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics. CBSA collectively refers to MSA. SAS Name: CBSA_CD COBOL Name: CBSA-CD Accreditation Type Code 1 283 283 VARCHAR2 Description: Indicates an accrediting organization deeming the provider. If a provider is deemed by multiple accrediting organizations then the accrediting organization with the earliest active deeming effective date is displayed in this field. SAS Name: ACRDTN_TYPE_CD COBOL Name: ACRDTN-TYPE-CD VALUES: 0=UNACCREDITED 1=AAAASF Category-specific Facility Type Code 2 388 389 VARCHAR2 Description: Indicates the category-specific facility type code, for certain provider categories only. SAS Name: GNRL_FAC_TYPE_CD COBOL Name: GNRL-FAC-TYPE-CD VALUES: 01=Hospital 02=Skilled Nursing Facility 03=Home Health Agency 04=Rehabilitation Agency DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 21 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 05=Public Clinic 06=Private Clinic 07=Public Health Agency Fiscal Year End Date (MMDD) 4 464 467 VARCHAR2 Description: End date, consisting of the month and day, of the provider's fiscal year. SAS Name: FY_END_MO_DAY_CD COBOL Name: FY-END-MO-DAY-CD Related Provider Number 10 669 678 CHAR Description: Related provider number SAS Name: RELATED_PROVIDER_NUMBER COBOL Name: RELATED-PROVIDER-NUMBER Services: OT Code 1 758 758 CHAR Description: Indicates how occupational therapy services are provided. SAS Name: OT_SRVC_CD COBOL Name: OT-SRVC-CD VALUES: 0=Not Provided 1=Provided Services: PT Code 1 796 796 CHAR Description: Indicates how physical therapy services are provided. SAS Name: PT_SRVC_CD COBOL Name: PT-SRVC-CD VALUES: 0=Not Provided 1=Provided Services: Speech Pathology Code 1 816 816 CHAR Description: Indicates how speech pathology services are provided. SAS Name: SPCH_PTHLGY_SRVC_CD COBOL Name: SPCH-PTHLGY-SRVC-CD VALUES: 0=Not Provided 1=Provided Staff Count: OT - Total 8 1293 1300 NUMBER Description: Total number of full-time equivalent occupational therapists employed by a provider. SAS Name: OCPTNL_THRPST_CNT COBOL Name: OCPTNL-THRPST-CNT Staff Count: OT - Arrangement 8 1301 1308 NUMBER Description: Number of full-time equivalent occupational therapists under arrangement to the provider SAS Name: OCPTNL_THRPST_CNTRCT_CNT COBOL Name: OCPTNL-THRPST-CNTRCT-CNT Staff Count: OT - Full-Time 8 1309 1316 NUMBER Description: Number of full-time equivalent occupational therapists employed full-time by a facility. SAS Name: OCPTNL_THRPST_FLTM_CNT COBOL Name: OCPTNL-THRPST-FLTM-CNT Staff Count: PT 8 1613 1620 NUMBER Description: Number of full-time equivalent physical therapists employed by a provider. SAS Name: PHYS_THRPST_STF_CNT COBOL Name: PHYS-THRPST-STF-CNT Staff Count: PT 8 1621 1628 NUMBER Description: Number of full-time equivalent physical therapists employed by a provider. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 22 Outpatient Physical Therapy/Speech Pathology, CATEGORY = "08" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: PHYS_THRPST_CNT COBOL Name: PHYS-THRPST-CNT Staff Count: PT - Arrangement 8 1629 1636 NUMBER Description: Total number of full-time equivalent physical therapists at the outpatient physical therapy facility. SAS Name: PHYS_THRPST_ARNGMT_CNT COBOL Name: PHYS-THRPST-ARNGMT-CNT Staff Count: Speech Pathologist - Arrangement 8 1829 1836 NUMBER Description: Number of full-time equivalent speech pathologists under arrangement to the outpatient physical therapy facility. SAS Name: SPCH_PTHLGST_ARNGMT_CNT COBOL Name: SPCH-PTHLGST-ARNGMT-CNT Staff Count: Speech Pathologist - Full-Time 8 1845 1852 NUMBER Description: Number of full-time equivalent speech pathologists employed full-time by a facility. SAS Name: SPCH_PTHLGST_FLTM_CNT COBOL Name: SPCH-PTHLGST-FLTM-CNT Staff Count: Speech Pathologist - Total 8 1861 1868 NUMBER Description: Total number of full-time equivalent speech pathologists at the outpatient physical therapy facility. SAS Name: SPCH_PTHLGST_CNT COBOL Name: SPCH-PTHLGST-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 1 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Provider Category Subtype Code 2 1 2 VARCHAR2 Description: Identifies the subtype of the provider, within the primary category. Used in reporting to show the breakdown of provider categories, mainly for hospitals and SNFs. SAS Name: PRVDR_CTGRY_SBTYP_CD COBOL Name: PRVDR-CTGRY-SBTYP-CD VALUES: 01=End Stage Renal Disease Provider Category Code 2 3 4 VARCHAR2 Description: Identifies the type of provider participating in the Medicare/Medicaid program. SAS Name: PRVDR_CTGRY_CD COBOL Name: PRVDR-CTGRY-CD VALUES: 09=End Stage Renal Disease Facility CHOW Count 2 5 6 NUMBER Description: Number of times this provider has undergone a change of ownership. SAS Name: CHOW_CNT COBOL Name: CHOW-CNT CHOW Date 8 7 14 DATE Description: Effective date of the most recent change of ownership for this provider. SAS Name: CHOW_DT COBOL Name: CHOW-DT Address: City 28 15 42 VARCHAR2 Description: City in which the provider is physically located. SAS Name: CITY_NAME COBOL Name: CITY-NAME Compliance: Acceptable POC 1 43 43 VARCHAR2 Description: Indicates if a provider is in compliance with program requirements based on an acceptable plan for correction of deficiencies. SAS Name: ACPTBL_POC_SW COBOL Name: ACPTBL-POC-SW Compliance: Status 1 44 44 VARCHAR2 Description: Compliance status of a provider at the time of certification survey. SAS Name: CMPLNC_STUS_CD COBOL Name: CMPLNC-STUS-CD VALUES: A=IN COMPLIANCE B=NOT IN COMPLIANCE SSA County Code 3 45 47 VARCHAR2 Description: Social Security Administration geographic code indicating the county where the provider is located. SAS Name: SSA_CNTY_CD COBOL Name: SSA-CNTY-CD Cross Ref Provider Number 10 48 57 CHAR Description: Cross reference provider number SAS Name: CROSS_REF_PROVIDER_NUMBER COBOL Name: CROSS-REF-PROVIDER-NUMBER Certification Date 8 58 65 DATE Description: Equal to the exit date of the initial visit of the Health survey for certifications completed after July 28, 2012. For certifications prior to that date, the certification DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 2 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE date is equal to the exit date of the initial visit of the Health survey or LSC survey, whichever is later. SAS Name: CRTFCTN_DT COBOL Name: CRTFCTN-DT Eligibility Indicator 1 66 66 VARCHAR2 Description: Indicates if a facility is eligible to participate in the Medicare and/or Medicaid programs. SAS Name: ELGBLTY_SW COBOL Name: ELGBLTY-SW Facility Name 50 67 116 VARCHAR2 Description: Name of the provider certified to participate in the Medicare and/or Medicaid programs. SAS Name: FAC_NAME COBOL Name: FAC-NAME Medicare Administrative Contractor (MAC) or 5 117 121 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_CD COBOL Name: INTRMDRY-CARR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 3 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 4 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 5 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 6 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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 15 122 136 VARCHAR2 Description: Number which may be assigned to a provider by the state Medicaid agency for external control or billing purposes. SAS Name: MDCD_VNDR_NUM COBOL Name: MDCD-VNDR-NUM Original Participation Date 8 137 144 DATE Description: Date a provider is first approved to provide Medicare and/or Medicaid services. SAS Name: ORGNL_PRTCPTN_DT COBOL Name: ORGNL-PRTCPTN-DT Prior CHOW Date 8 145 152 DATE Description: Effective date of the previous change of ownership for this provider. SAS Name: CHOW_PRIOR_DT COBOL Name: CHOW-PRIOR-DT Prior Medicare Administrative Contractor (MAC) or 5 153 157 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the previous Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_PRIOR_CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 7 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: INTRMDRY-CARR-PRIOR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 00520=BLUE SHIELD (ARKANSAS) 00528=BLUE SHIELD (ARKANSAS/LOUISIANA) 00542=BLUE SHIELD (CALIFORNIA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 8 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00550=BLUE SHIELD (COLORADO) 00570=BLUE SHIELD (DELAWARE) 00580=BLUE SHIELD (DISTRICT OF COLUMBIA) 00590=BLUE SHIELD (FLORIDA) 00621=BLUE SHIELD (ILLINOIS) 00630=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 9 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 10 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 11 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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) CCN 10 158 167 VARCHAR2 Description: Six or ten position identification number that is assigned to a certified provider. This is the CMS Certification Number. SAS Name: PRVDR_NUM COBOL Name: PRVDR-NUM Region Code 2 168 169 VARCHAR2 Description: Indicates the CMS Regional Office responsible for the certification of the provider. SAS Name: RGN_CD COBOL Name: RGN-CD VALUES: 01=Boston 02=New York 03=Philadelphia 04=Atlanta 05=Chicago 06=Dallas 07=Kansas City 08=Denver 09=San Francisco 10=Seattle Skeleton Record Indicator 1 170 170 VARCHAR2 Description: Indicates if the record is a skeleton record. Only a limited set of data is available for this provider; no survey data exists. SAS Name: SKLTN_REC_SW COBOL Name: SKLTN-REC-SW State Abbreviation 2 171 172 VARCHAR2 Description: Two-character state abbreviation. SAS Name: STATE_CD COBOL Name: STATE-CD VALUES: AK=ALASKA AL=ALABAMA AR=ARKANSAS AS=AMERICAN SAMOA AZ=ARIZONA CA=CALIFORNIA CN=CANADA CO=COLORADO CT=CONNECTICUT DC=DISTRICT OF COLUMBIA DE=DELAWARE FL=FLORIDA FN=INTERNATIONAL DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 12 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA=GEORGIA GU=GUAM HI=HAWAII IA=IOWA ID=IDAHO IL=ILLINOIS IN=INDIANA KS=KANSAS KY=KENTUCKY LA=LOUISIANA MA=MASSACHUSETTS MD=MARYLAND ME=MAINE MI=MICHIGAN MN=MINNESOTA MO=MISSOURI MP=SAIPAN MS=MISSISSIPPI MT=MONTANA MX=MEXICO NC=NORTH CAROLINA ND=NORTH DAKOTA NE=NEBRASKA NH=NEW HAMPSHIRE NJ=NEW JERSEY NM=NEW MEXICO NV=NEVADA NY=NEW YORK OH=OHIO OK=OKLAHOMA OR=OREGON PA=PENNSYLVANIA PR=PUERTO RICO RI=RHODE ISLAND SC=SOUTH CAROLINA SD=SOUTH DAKOTA TN=TENNESSEE TX=TEXAS UT=UTAH VA=VIRGINIA VI=VIRGIN ISLANDS VT=VERMONT WA=WASHINGTON WI=WISCONSIN WV=WEST VIRGINIA WY=WYOMING SSA State Code 2 173 174 VARCHAR2 Description: Social Security Administration geographic code indicating the state where the provider is located. SAS Name: SSA_STATE_CD COBOL Name: SSA-STATE-CD 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 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 13 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 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 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 99=INTERNATIONAL State Region Code 3 175 177 VARCHAR2 Description: Identifies the region within a state where the provider is located. SAS Name: STATE_RGN_CD COBOL Name: STATE-RGN-CD VALUES: AK/001=ALASKA AK/LAB=LABORATORIES AL/001=ALABAMA AL/LAB=LABORATORIES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 14 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE AR/001=ARKANSAS AR/LAB=LABORATORIES AS/001=AMERICAN SAMOA AS/LAB=LABORATORY AZ/AZ=PHOENIX AZ/LAB=ARIZONA LAB AZ/TUC=TUCSON CA/BAK=BAKERSFIELD CA/BER=SAN BERNARDINO CA/BK=BERKELEY CA/BK1=CONTRA COSTA CA/FR=FRESNO CA/L1=L.A. WEST CA/L2=L.A. NORTH CA/L3=L.A. CENTRAL CA/L4=L.A. EAST CA/L5=SAN GABRIEL CA/LAB=LABORATORIES CA/M1=LAB. SOUTH CA/M2=LAB. NORTH CA/ORG=ORANGE CO CA/RIV=RIVERSIDE CA/RWC=REDWOOD COAST CA/S1=SACRAMENTO CA/S2=SACTO SOUTH CA/S3=CHICO CA/SD=SAN DIEGO CA/SDS=SAN DIEGO SOUTH CA/SF=SAN FRANCISCO CA/SJ=SAN JOSE CA/SR=SANTA ROSA CA/VEN=VENTURA CN/001=CANADA CN/LAB=LABORATORY CO/001=COLORADO CO/LAB=LABORATORIES CT/001=CONNECTICUT CT/LAB=LABORATORIES DC/001=DISTRICT OF COLUMBIA DC/LAB=LABORATORIES DE/001=DELAWARE DE/LAB=LABORATORIES FL/FTM=FT. MYERS FL/GAI=GAINESVILLE FL/JAX=JACKSONVILLE FL/LAB=LABORATORIES FL/LAN=LANTANA FL/LAU=LAUDERHILL FL/MIA=MIAMI FL/ORL=ORLANDO FL/PEN=PENSACOLA FL/STP=ST. PETERSBURG FL/TAL=TALLAHASSEE FL/TAM=TAMPA FM/001=FEDERATED STATES OF MICRO FN/001=INTERNATIONAL FN/LAB=LABORATORIES GA/001=GEORGIA GA/GAA=GEORGIA ALL GA/GAC=GEORGIA CENTRAL GA/GAE=GEORGIA EASTERN GA/GAN=GEORGIA NORTH GA/GAS=GEORGIA SOUTH GA/GAW=GEORGIA WESTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 15 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA/LAB=LABORATORIES GU/001=GUAM GU/LAB=LABORATORIES HI/001=HAWAII HI/LAB=LABORATORIES IA/001=IOWA IA/LAB=LABORATORIES ID/001=IDAHO ID/LAB=LABORATORIES IL/001=ILLINOIS IL/LAB=LABORATORIES IN/001=INDIANA IN/LAB=LABORATORIES KS/KCK=KANSAS CITY KS/KDH=KDHE KS/LAB=LABORATORIES KS/LAW=LAWRENCE KS/NC=NORTH CENTRAL KANSAS KS/NE=NORTH EAST KANSAS KS/NW=NORTH WEST KANSAS KS/SC=SOUTH CENTRAL KANSAS KS/SE=SOUTH EAST KANSAS KS/SW=SOUTH WEST KANSAS KS/WST=WEST KY/2C1=HOPKINSVILLE KY/2C2=LOUISVILLE KY/2C3=LONDON KY/2C4=LEXINGTON KY/LAB=LABORATORIES LA/001=LOUISIANA LA/LA1=NEW ORLEANS LA/LA2=MANDEVILLE LA/LA3=LAFAYETTE LA/LA4=MONROE LA/LA5=SHREVEPORT LA/LA6=ALEXANDRIA LA/LAB=LABORATORIES LA/LB1=CLIA NEW ORLEANS LA/LB5=CLIA SHREVEPORT LA/LB6=CLIA ALEXANDRIA MA/001=MASSACHUSETTS MA/LAB=LABORATORIES MD/001=MARYLAND MD/LAB=LABORATORIES ME/001=MAINE ME/LAB=LABORATORIES MH/001=MARSHALL ISLANDS MI/001=MICHIGAN MI/LAB=LABORATORIES MN/001=MINNESOTA MN/LAB=LABORATORIES MO/01=REGION01 MO/02=REGION02 MO/03=REGION 03 MO/04=REGION 04 MO/05=REGION 05 MO/06=REGION 06 MO/07=REGION 07 MO/1NH=REGION 1 NH MO/2NH=REGION 2 NH MO/3NH=REGION 3 NH MO/4NH=REGION 4 NH MO/5NH=REGION 5 NH MO/6NH=REGION 6 NH DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 16 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE MO/7NH=REGION 7 NH MO/LAB=LABORATORIES MO/MO=STATEWIDE MP/001=NORTHERN MARIANA ISLANDS MP/LAB=LABORATORIES MS/001=MISSISSIPPI MS/LAB=LABORATORIES MT/001=MONTANA MT/LAB=LABORATORIES MX/001=MEXICO MX/LAB=LABORATORY NC/LAB=LABORATORIES NC/NCC=NORTH CAROLINA CENTRAL NC/NCE=NORTH CAROLINA EAST NC/NCN=NORTH CAROLINA NORTH NC/NCS=NORTH CAROLINA SOUTH NC/NCW=NORTH CAROLINA WEST ND/001=NORTH DAKOTA ND/LAB=LABORATORIES NE/1=NORTH CENTRAL NE/2=CENTRAL NE/3=NORTHEAST NE/4=SOUTHEAST NE/5=WESTERN NE/LAB=LABORATORIES NH/001=NEW HAMPSHIRE NH/LAB=LABORATORIES NJ/001=NEW JERSEY NJ/LAB=LABORATORIES NM/001=NEW MEXICO NM/LAB=LABORATORIES NV/CC=CARSON CITY NV/LAB=LABORATORIES NV/LV=LAS VEGAS NY/001=BUFFALO NY/002=ROCHESTER NY/003=SYRACUSE NY/004=ALBANY NY/005=NEW ROCHELLE NY/006=NEW YORK CITY NY/007=SUFFOLK/NASSAU COUNTY NY/LAB=LABORATORIES OH/001=OHIO OH/LAB=LABORATORIES OK/001=OKLAHOMA OK/LAB=LABORATORIES OR/001=OFFICE #1 OR/002=OFFICE #2 OR/003=OFFICE #3 OR/LAB=LABORATORIES PA/001=PENNSYLVANIA PA/LAB=LABORATORIES PR/001=PUERTO RICO PR/LAB=LABORATORIES PW/001=PALAU RI/001=RHODE ISLAND RI/LAB=LABORATORIES SC/001=SOUTH CAROLINA SC/LAB=LABORATORIES SD/001=SOUTH DAKOTA SD/LAB=LABORATORIES TN/LAB=LABORATORIES TN/TNC=TENNESSEE COOKEVILLE TN/TNE=TENNESSEE EASTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 17 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE TN/TNM=TENNESSEE MIDDLE TN/TNW=TENNESSEE WESTERN TX/001=TEXAS TX/L01=AMARILLO-LTC TX/L02=ABILENE-LTC TX/L03=ARLINGTON-LTC TX/L04=TYLER-LTC TX/L05=BEAUMONT-LTC TX/L06=HOUSTON-LTC TX/L07=TEMPLE-LTC TX/L08=SAN ANTONIO-LTC TX/L09=SAN ANGELO-LTC TX/L10=EL PASO-LTC TX/L11=CORPUS CHRISTI-LTC TX/LAB=LABORATORIES TX/TX1=LUBBOCK TX/TX2=ARLINGTON TX/TX3=SAN ANTONIO TX/TX4=HOUSTON TX/TX5=TYLER TX/TX6=AUSTIN UT/001=UTAH UT/LAB=LABORATORIES VA/001=VIRGINIA VA/LAB=LABORATORIES VI/001=VIRGIN ISLANDS VI/LAB=LABORATORIES VT/001=VERMONT VT/LAB=LABORATORIES WA/001=ALL OTHERS (NON-LTC FAC) WA/D1=SPOKANE & YAKIMA AREAS WA/D1A=District 1, Unit A WA/D1B=District 1, Unit B WA/D1C=District 1, Unit C WA/D1D=District 1, Unit D WA/D2=SPOKANE & SE WA/D2A=District 2, Unit A WA/D2B=District 2, Unit B WA/D2C=District 2, Unit C WA/D2D=District 2, Unit D WA/D2E=District 2, Unit E WA/D2F=District 2, Unit F WA/D2G=District 2, Unit G WA/D3=NW WASHINGTON WA/D3A=District 3, Unit A WA/D3B=District 3, Unit B WA/D3C=District 3, Unit C WA/D3D=District 3, Unit D WA/D3E=District 3, Unit E WA/D4A=GREATER SEATTLE AREA WA/D4B=S KING COUNTY WA/D5A=PIERCE CTY & PENINSULA WA/D5B=PIERCE CTY & GRAYS HARBOR WA/D6=OLYMPIA AREA WA/LAB=LABORATORIES WI/001=WISCONSIN WI/LAB=LABORATORIES WV/001=WEST VIRGINIA WV/LAB=LABORATORIES WY/001=WYOMING WY/LAB=LABORATORIES Address: Street 50 178 227 VARCHAR2 Description: Street address where the provider is located. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 18 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: ST_ADR COBOL Name: ST-ADR Telephone Number 10 228 237 VARCHAR2 Description: Telephone number of the provider. SAS Name: PHNE_NUM COBOL Name: PHNE-NUM Termination Code 2 238 239 VARCHAR2 Description: Indicates the current termination status for the provider. SAS Name: PGM_TRMNTN_CD COBOL Name: PGM-TRMNTN-CD VALUES: 00=ACTIVE PROVIDER 01=VOLUNTARY-MERGER, CLOSURE 02=VOLUNTARY-DISSATISFACTION WITH REIMBURSEMENT 03=VOLUNTARY-RISK OF INVOLUNTARY TERMINATION 04=VOLUNTARY-OTHER REASON FOR WITHDRAWAL 05=INVOLUNTARY-FAILURE TO MEET HEALTH/SAFETY REQ 06=INVOLUNTARY-FAILURE TO MEET AGREEMENT 07=OTHER-PROVIDER STATUS CHANGE 08=NONPAYMENT OF FEES - CLIA Only 09=REV/UNSUCCESSFUL PARTICIPATION IN PT - CLIA Only 10=REV/OTHER REASON - CLIA Only 11=INCOMPLETE CLIA APPLICATION INFORMATION - CLIA Only 12=NO LONGER PERFORMING TESTS - CLIA Only 13=MULTIPLE TO SINGLE SITE CERTIFICATE - CLIA Only 14=SHARED LABORATORY - CLIA Only 15=FAILURE TO RENEW WAIVER PPM CERTIFICATE - CLIA Only 16=DUPLICATE CLIA NUMBER - CLIA Only 17=MAIL RETURNED NO FORWARD ADDRESS CERT ENDED - CLIA Only 20=NOTIFICATION BANKRUPTCY - CLIA Only 33=ACCREDITATION NOT CONFIRMED - CLIA Only 80=AWAITING STATE APPROVAL 99=OIG ACTION - DO NOT ACTIVATE - CLIA Only Termination or Expiration Date 8 240 247 DATE Description: Date the provider was terminated. For CLIA providers, date the laboratory's certificate was terminated or the expiration date of the current CLIA certificate. SAS Name: TRMNTN_EXPRTN_DT COBOL Name: TRMNTN-EXPRTN-DT Type of Action Code 1 248 248 VARCHAR2 Description: Identifies the reason for the certification. Type of action from the official survey record, CMS 1539 form. SAS Name: CRTFCTN_ACTN_TYPE_CD COBOL Name: CRTFCTN-ACTN-TYPE-CD VALUES: 1=INITIAL 2=RECERTIFICATION 3=TERMINATION 4=CHANGE OF OWNERSHIP 5=VALIDATION 8=FULL SURVEY AFTER COMPLAINT Ownership Type Code 2 249 250 VARCHAR2 Description: Indicates the ownership type of the provider. SAS Name: GNRL_CNTL_TYPE_CD COBOL Name: GNRL-CNTL-TYPE-CD VALUES: 01=FOR PROFIT 02=NOT FOR PROFIT 03=PUBLIC Address: ZIP Code 5 251 255 VARCHAR2 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 19 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Five-digit ZIP code for a provider's physical address. SAS Name: ZIP_CD COBOL Name: ZIP-CD FIPS State Code 2 256 257 VARCHAR2 Description: FIPS State Code SAS Name: FIPS_STATE_CD COBOL Name: FIPS-STATE-CD VALUES: 01=ALABAMA 02=ALASKA 04=ARIZONA 05=ARKANSAS 06=CALIFORNIA 08=COLORADO 09=CONNECTICUT 10=DELAWARE 11=DISTRICT OF COLUMBIA 12=FLORIDA 13=GEORGIA 15=HAWAII 16=IDAHO 17=ILLINOIS 18=INDIANA 19=IOWA 20=KANSAS 21=KENTUCKY 22=LOUISIANA 23=MAINE 24=MARYLAND 25=MASSACHUSETTS 26=MICHIGAN 27=MINNESOTA 28=MISSISSIPPI 29=MISSOURI 30=MONTANA 31=NEBRASKA 32=NEVADA 33=NEW HAMPSHIRE 34=NEW JERSEY 35=NEW MEXICO 36=NEW YORK 37=NORTH CAROLINA 38=NORTH DAKOTA 39=OHIO 40=OKLAHOMA 41=OREGON 42=PENNSYLVANIA 43=PUERTO RICO 44=RHODE ISLAND 45=SOUTH CAROLINA 46=SOUTH DAKOTA 47=TENNESSEE 48=TEXAS 49=UTAH 50=VERMONT 51=VIRGINIA 53=WASHINGTON 54=WEST VIRGINIA 55=WISCONSIN 56=WYOMING 64=AMERICAN SAMOA 65=GUAM 66=SAIPAN/MARIANA IS. 78=VIRGIN ISLANDS DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 20 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE FIPS County Code 3 258 260 VARCHAR2 Description: FIPS County Code SAS Name: FIPS_CNTY_CD COBOL Name: FIPS-CNTY-CD CBSA Urban Rural Indicator 1 261 261 VARCHAR2 Description: CBSA (Core Based Statistical Area) indicates whether the county is defined as Urban or Rural. SAS Name: CBSA_URBN_RRL_IND COBOL Name: CBSA-URBN-RRL-IND CBSA Code 5 262 266 VARCHAR2 Description: CBSA (Core Based Statistical Area) geographic entities defined by the U.S. Office of Management and Budget (OMB) on June 6, 2003 for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics. CBSA collectively refers to MSA. SAS Name: CBSA_CD COBOL Name: CBSA-CD ESRD Network Number 2 451 452 VARCHAR2 Description: Number of the network to which the end-stage renal disease facility is assigned. SAS Name: ESRD_NTWRK_NUM COBOL Name: ESRD-NTWRK-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 Fiscal Year End Date (MMDD) 4 464 467 VARCHAR2 Description: End date, consisting of the month and day, of the provider's fiscal year. SAS Name: FY_END_MO_DAY_CD COBOL Name: FY-END-MO-DAY-CD Home Training & Support Services Only HD & PD 1 481 481 VARCHAR2 Indicator Description: Indicates if home training and support services only for hemodialysis and peritoneal dialysis are provided. SAS Name: HOME_TRNG_SPRT_ONLY_SRVC_SW COBOL Name: HOME-TRNG-SPRT-ONLY-SRVC-SW In-Center Nocturnal Hemodialysis Services Indicator 1 484 484 VARCHAR2 Description: Indicates if in-center nocturnal hemodialysis services are provided. SAS Name: INCNTR_NCTRNL_SRVC_SW COBOL Name: INCNTR-NCTRNL-SRVC-SW DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 21 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Multiple Facility Organization Name 38 513 550 CHAR Description: Name of the multi-facility organization that owns the facility. SAS Name: MLT_FAC_ORG_NAME COBOL Name: MLT-FAC-ORG-NAME Multiple Facility Organization Owned Indicator 1 551 551 CHAR Description: Indicates if a facility is owned by an organization that owns (or leases) two or more long term care facilities. SAS Name: MLT_OWND_FAC_ORG_SW COBOL Name: MLT-OWND-FAC-ORG-SW Related Provider Number 10 669 678 CHAR Description: Related provider number SAS Name: RELATED_PROVIDER_NUMBER COBOL Name: RELATED-PROVIDER-NUMBER Services: Hemodialysis Home Training/Support 1 718 718 VARCHAR2 Indicator Description: Indicates if the facility provides home training and support for hemodialysis. SAS Name: SP_HOME_TRNG_SPRT_HD_SW COBOL Name: SP-HOME-TRNG-SPRT-HD-SW Services: Hemodialysis Indicator 1 719 719 VARCHAR2 Description: Indicates if hemodialysis service is provided. SAS Name: HMDLYS_SRVC_SW COBOL Name: HMDLYS-SRVC-SW Services: Peritoneal Dialysis Home Training/Support 1 769 769 VARCHAR2 Indicator Description: Indicates if the facility provides home training and support for peritoneal dialysis. SAS Name: SP_HOME_TRNG_SPRT_PD_SW COBOL Name: SP-HOME-TRNG-SPRT-PD-SW Services: Peritoneal Dialysis Indicator 1 770 770 VARCHAR2 Description: Indicates if peritoneal dialysis service is provided. SAS Name: PRTNL_DLYS_SRVC_SW COBOL Name: PRTNL-DLYS-SRVC-SW Staff Count: Other Personnel 8 885 892 NUMBER Description: Number of full-time equivalent other personnel employed by a provider SAS Name: PRSNEL_OTHR_CNT COBOL Name: PRSNEL-OTHR-CNT Staff Count: Dietitian 8 965 972 NUMBER Description: Number of full-time equivalent dietitians employed by a provider. SAS Name: DIETN_CNT COBOL Name: DIETN-CNT Staff Count: LPN 8 1085 1092 NUMBER Description: Number of licensed practical nurses. SAS Name: LPN_CNT COBOL Name: LPN-CNT Staff Count: RN 8 1733 1740 NUMBER Description: Number of full-time equivalent registered nurses employed by a provider. SAS Name: RN_CNT COBOL Name: RN-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 22 End Stage Renal Disease Facility, CATEGORY = "09" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Staff Count: Social Worker 8 1797 1804 NUMBER Description: Number of full-time equivalent social workers employed by the provider. SAS Name: SCL_WORKR_CNT COBOL Name: SCL-WORKR-CNT Staff Count: Technical Staff 8 1877 1884 NUMBER Description: Number of full-time equivalent technical staff (water, machine) employed by a facility. SAS Name: TCHNCL_STF_NUM COBOL Name: TCHNCL-STF-NUM Staff Count: Technician 8 1885 1892 NUMBER Description: Number of full-time equivalent technicians employed by a facility. SAS Name: TCHNCN_CNT COBOL Name: TCHNCN-CNT Total Approved Stations 3 1976 1978 NUMBER Description: Total number of approved dialysis stations in an end-stage renal disease facility. SAS Name: DLYS_STN_CNT COBOL Name: DLYS-STN-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 1 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Provider Category Subtype Code 2 1 2 VARCHAR2 Description: Identifies the subtype of the provider, within the primary category. Used in reporting to show the breakdown of provider categories, mainly for hospitals and SNFs. SAS Name: PRVDR_CTGRY_SBTYP_CD COBOL Name: PRVDR-CTGRY-SBTYP-CD VALUES: 02=Title 19 Only Provider Category Code 2 3 4 VARCHAR2 Description: Identifies the type of provider participating in the Medicare/Medicaid program. SAS Name: PRVDR_CTGRY_CD COBOL Name: PRVDR-CTGRY-CD VALUES: 10=Nursing Facility CHOW Count 2 5 6 NUMBER Description: Number of times this provider has undergone a change of ownership. SAS Name: CHOW_CNT COBOL Name: CHOW-CNT CHOW Date 8 7 14 DATE Description: Effective date of the most recent change of ownership for this provider. SAS Name: CHOW_DT COBOL Name: CHOW-DT Address: City 28 15 42 VARCHAR2 Description: City in which the provider is physically located. SAS Name: CITY_NAME COBOL Name: CITY-NAME Compliance: Acceptable POC 1 43 43 VARCHAR2 Description: Indicates if a provider is in compliance with program requirements based on an acceptable plan for correction of deficiencies. SAS Name: ACPTBL_POC_SW COBOL Name: ACPTBL-POC-SW Compliance: Status 1 44 44 VARCHAR2 Description: Compliance status of a provider at the time of certification survey. SAS Name: CMPLNC_STUS_CD COBOL Name: CMPLNC-STUS-CD VALUES: A=IN COMPLIANCE B=NOT IN COMPLIANCE SSA County Code 3 45 47 VARCHAR2 Description: Social Security Administration geographic code indicating the county where the provider is located. SAS Name: SSA_CNTY_CD COBOL Name: SSA-CNTY-CD Cross Ref Provider Number 10 48 57 CHAR Description: Cross reference provider number SAS Name: CROSS_REF_PROVIDER_NUMBER COBOL Name: CROSS-REF-PROVIDER-NUMBER Certification Date 8 58 65 DATE Description: Equal to the exit date of the initial visit of the Health survey for certifications completed after July 28, 2012. For certifications prior to that date, the certification DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 2 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE date is equal to the exit date of the initial visit of the Health survey or LSC survey, whichever is later. SAS Name: CRTFCTN_DT COBOL Name: CRTFCTN-DT Eligibility Indicator 1 66 66 VARCHAR2 Description: Indicates if a facility is eligible to participate in the Medicare and/or Medicaid programs. SAS Name: ELGBLTY_SW COBOL Name: ELGBLTY-SW Facility Name 50 67 116 VARCHAR2 Description: Name of the provider certified to participate in the Medicare and/or Medicaid programs. SAS Name: FAC_NAME COBOL Name: FAC-NAME Medicare Administrative Contractor (MAC) or 5 117 121 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_CD COBOL Name: INTRMDRY-CARR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 3 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 4 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 5 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 6 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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 15 122 136 VARCHAR2 Description: Number which may be assigned to a provider by the state Medicaid agency for external control or billing purposes. SAS Name: MDCD_VNDR_NUM COBOL Name: MDCD-VNDR-NUM Original Participation Date 8 137 144 DATE Description: Date a provider is first approved to provide Medicare and/or Medicaid services. SAS Name: ORGNL_PRTCPTN_DT COBOL Name: ORGNL-PRTCPTN-DT Prior CHOW Date 8 145 152 DATE Description: Effective date of the previous change of ownership for this provider. SAS Name: CHOW_PRIOR_DT COBOL Name: CHOW-PRIOR-DT Prior Medicare Administrative Contractor (MAC) or 5 153 157 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the previous Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_PRIOR_CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 7 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: INTRMDRY-CARR-PRIOR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 00520=BLUE SHIELD (ARKANSAS) 00528=BLUE SHIELD (ARKANSAS/LOUISIANA) 00542=BLUE SHIELD (CALIFORNIA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 8 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00550=BLUE SHIELD (COLORADO) 00570=BLUE SHIELD (DELAWARE) 00580=BLUE SHIELD (DISTRICT OF COLUMBIA) 00590=BLUE SHIELD (FLORIDA) 00621=BLUE SHIELD (ILLINOIS) 00630=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 9 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 10 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 11 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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) CCN 10 158 167 VARCHAR2 Description: Six or ten position identification number that is assigned to a certified provider. This is the CMS Certification Number. SAS Name: PRVDR_NUM COBOL Name: PRVDR-NUM Region Code 2 168 169 VARCHAR2 Description: Indicates the CMS Regional Office responsible for the certification of the provider. SAS Name: RGN_CD COBOL Name: RGN-CD VALUES: 01=Boston 02=New York 03=Philadelphia 04=Atlanta 05=Chicago 06=Dallas 07=Kansas City 08=Denver 09=San Francisco 10=Seattle Skeleton Record Indicator 1 170 170 VARCHAR2 Description: Indicates if the record is a skeleton record. Only a limited set of data is available for this provider; no survey data exists. SAS Name: SKLTN_REC_SW COBOL Name: SKLTN-REC-SW State Abbreviation 2 171 172 VARCHAR2 Description: Two-character state abbreviation. SAS Name: STATE_CD COBOL Name: STATE-CD VALUES: AK=ALASKA AL=ALABAMA AR=ARKANSAS AS=AMERICAN SAMOA AZ=ARIZONA CA=CALIFORNIA CN=CANADA CO=COLORADO CT=CONNECTICUT DC=DISTRICT OF COLUMBIA DE=DELAWARE FL=FLORIDA FN=INTERNATIONAL DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 12 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA=GEORGIA GU=GUAM HI=HAWAII IA=IOWA ID=IDAHO IL=ILLINOIS IN=INDIANA KS=KANSAS KY=KENTUCKY LA=LOUISIANA MA=MASSACHUSETTS MD=MARYLAND ME=MAINE MI=MICHIGAN MN=MINNESOTA MO=MISSOURI MP=SAIPAN MS=MISSISSIPPI MT=MONTANA MX=MEXICO NC=NORTH CAROLINA ND=NORTH DAKOTA NE=NEBRASKA NH=NEW HAMPSHIRE NJ=NEW JERSEY NM=NEW MEXICO NV=NEVADA NY=NEW YORK OH=OHIO OK=OKLAHOMA OR=OREGON PA=PENNSYLVANIA PR=PUERTO RICO RI=RHODE ISLAND SC=SOUTH CAROLINA SD=SOUTH DAKOTA TN=TENNESSEE TX=TEXAS UT=UTAH VA=VIRGINIA VI=VIRGIN ISLANDS VT=VERMONT WA=WASHINGTON WI=WISCONSIN WV=WEST VIRGINIA WY=WYOMING SSA State Code 2 173 174 VARCHAR2 Description: Social Security Administration geographic code indicating the state where the provider is located. SAS Name: SSA_STATE_CD COBOL Name: SSA-STATE-CD 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 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 13 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 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 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 99=INTERNATIONAL State Region Code 3 175 177 VARCHAR2 Description: Identifies the region within a state where the provider is located. SAS Name: STATE_RGN_CD COBOL Name: STATE-RGN-CD VALUES: AK/001=ALASKA AK/LAB=LABORATORIES AL/001=ALABAMA AL/LAB=LABORATORIES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 14 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE AR/001=ARKANSAS AR/LAB=LABORATORIES AS/001=AMERICAN SAMOA AS/LAB=LABORATORY AZ/AZ=PHOENIX AZ/LAB=ARIZONA LAB AZ/TUC=TUCSON CA/BAK=BAKERSFIELD CA/BER=SAN BERNARDINO CA/BK=BERKELEY CA/BK1=CONTRA COSTA CA/FR=FRESNO CA/L1=L.A. WEST CA/L2=L.A. NORTH CA/L3=L.A. CENTRAL CA/L4=L.A. EAST CA/L5=SAN GABRIEL CA/LAB=LABORATORIES CA/M1=LAB. SOUTH CA/M2=LAB. NORTH CA/ORG=ORANGE CO CA/RIV=RIVERSIDE CA/RWC=REDWOOD COAST CA/S1=SACRAMENTO CA/S2=SACTO SOUTH CA/S3=CHICO CA/SD=SAN DIEGO CA/SDS=SAN DIEGO SOUTH CA/SF=SAN FRANCISCO CA/SJ=SAN JOSE CA/SR=SANTA ROSA CA/VEN=VENTURA CN/001=CANADA CN/LAB=LABORATORY CO/001=COLORADO CO/LAB=LABORATORIES CT/001=CONNECTICUT CT/LAB=LABORATORIES DC/001=DISTRICT OF COLUMBIA DC/LAB=LABORATORIES DE/001=DELAWARE DE/LAB=LABORATORIES FL/FTM=FT. MYERS FL/GAI=GAINESVILLE FL/JAX=JACKSONVILLE FL/LAB=LABORATORIES FL/LAN=LANTANA FL/LAU=LAUDERHILL FL/MIA=MIAMI FL/ORL=ORLANDO FL/PEN=PENSACOLA FL/STP=ST. PETERSBURG FL/TAL=TALLAHASSEE FL/TAM=TAMPA FM/001=FEDERATED STATES OF MICRO FN/001=INTERNATIONAL FN/LAB=LABORATORIES GA/001=GEORGIA GA/GAA=GEORGIA ALL GA/GAC=GEORGIA CENTRAL GA/GAE=GEORGIA EASTERN GA/GAN=GEORGIA NORTH GA/GAS=GEORGIA SOUTH GA/GAW=GEORGIA WESTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 15 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA/LAB=LABORATORIES GU/001=GUAM GU/LAB=LABORATORIES HI/001=HAWAII HI/LAB=LABORATORIES IA/001=IOWA IA/LAB=LABORATORIES ID/001=IDAHO ID/LAB=LABORATORIES IL/001=ILLINOIS IL/LAB=LABORATORIES IN/001=INDIANA IN/LAB=LABORATORIES KS/KCK=KANSAS CITY KS/KDH=KDHE KS/LAB=LABORATORIES KS/LAW=LAWRENCE KS/NC=NORTH CENTRAL KANSAS KS/NE=NORTH EAST KANSAS KS/NW=NORTH WEST KANSAS KS/SC=SOUTH CENTRAL KANSAS KS/SE=SOUTH EAST KANSAS KS/SW=SOUTH WEST KANSAS KS/WST=WEST KY/2C1=HOPKINSVILLE KY/2C2=LOUISVILLE KY/2C3=LONDON KY/2C4=LEXINGTON KY/LAB=LABORATORIES LA/001=LOUISIANA LA/LA1=NEW ORLEANS LA/LA2=MANDEVILLE LA/LA3=LAFAYETTE LA/LA4=MONROE LA/LA5=SHREVEPORT LA/LA6=ALEXANDRIA LA/LAB=LABORATORIES LA/LB1=CLIA NEW ORLEANS LA/LB5=CLIA SHREVEPORT LA/LB6=CLIA ALEXANDRIA MA/001=MASSACHUSETTS MA/LAB=LABORATORIES MD/001=MARYLAND MD/LAB=LABORATORIES ME/001=MAINE ME/LAB=LABORATORIES MH/001=MARSHALL ISLANDS MI/001=MICHIGAN MI/LAB=LABORATORIES MN/001=MINNESOTA MN/LAB=LABORATORIES MO/01=REGION01 MO/02=REGION02 MO/03=REGION 03 MO/04=REGION 04 MO/05=REGION 05 MO/06=REGION 06 MO/07=REGION 07 MO/1NH=REGION 1 NH MO/2NH=REGION 2 NH MO/3NH=REGION 3 NH MO/4NH=REGION 4 NH MO/5NH=REGION 5 NH MO/6NH=REGION 6 NH DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 16 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE MO/7NH=REGION 7 NH MO/LAB=LABORATORIES MO/MO=STATEWIDE MP/001=NORTHERN MARIANA ISLANDS MP/LAB=LABORATORIES MS/001=MISSISSIPPI MS/LAB=LABORATORIES MT/001=MONTANA MT/LAB=LABORATORIES MX/001=MEXICO MX/LAB=LABORATORY NC/LAB=LABORATORIES NC/NCC=NORTH CAROLINA CENTRAL NC/NCE=NORTH CAROLINA EAST NC/NCN=NORTH CAROLINA NORTH NC/NCS=NORTH CAROLINA SOUTH NC/NCW=NORTH CAROLINA WEST ND/001=NORTH DAKOTA ND/LAB=LABORATORIES NE/1=NORTH CENTRAL NE/2=CENTRAL NE/3=NORTHEAST NE/4=SOUTHEAST NE/5=WESTERN NE/LAB=LABORATORIES NH/001=NEW HAMPSHIRE NH/LAB=LABORATORIES NJ/001=NEW JERSEY NJ/LAB=LABORATORIES NM/001=NEW MEXICO NM/LAB=LABORATORIES NV/CC=CARSON CITY NV/LAB=LABORATORIES NV/LV=LAS VEGAS NY/001=BUFFALO NY/002=ROCHESTER NY/003=SYRACUSE NY/004=ALBANY NY/005=NEW ROCHELLE NY/006=NEW YORK CITY NY/007=SUFFOLK/NASSAU COUNTY NY/LAB=LABORATORIES OH/001=OHIO OH/LAB=LABORATORIES OK/001=OKLAHOMA OK/LAB=LABORATORIES OR/001=OFFICE #1 OR/002=OFFICE #2 OR/003=OFFICE #3 OR/LAB=LABORATORIES PA/001=PENNSYLVANIA PA/LAB=LABORATORIES PR/001=PUERTO RICO PR/LAB=LABORATORIES PW/001=PALAU RI/001=RHODE ISLAND RI/LAB=LABORATORIES SC/001=SOUTH CAROLINA SC/LAB=LABORATORIES SD/001=SOUTH DAKOTA SD/LAB=LABORATORIES TN/LAB=LABORATORIES TN/TNC=TENNESSEE COOKEVILLE TN/TNE=TENNESSEE EASTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 17 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE TN/TNM=TENNESSEE MIDDLE TN/TNW=TENNESSEE WESTERN TX/001=TEXAS TX/L01=AMARILLO-LTC TX/L02=ABILENE-LTC TX/L03=ARLINGTON-LTC TX/L04=TYLER-LTC TX/L05=BEAUMONT-LTC TX/L06=HOUSTON-LTC TX/L07=TEMPLE-LTC TX/L08=SAN ANTONIO-LTC TX/L09=SAN ANGELO-LTC TX/L10=EL PASO-LTC TX/L11=CORPUS CHRISTI-LTC TX/LAB=LABORATORIES TX/TX1=LUBBOCK TX/TX2=ARLINGTON TX/TX3=SAN ANTONIO TX/TX4=HOUSTON TX/TX5=TYLER TX/TX6=AUSTIN UT/001=UTAH UT/LAB=LABORATORIES VA/001=VIRGINIA VA/LAB=LABORATORIES VI/001=VIRGIN ISLANDS VI/LAB=LABORATORIES VT/001=VERMONT VT/LAB=LABORATORIES WA/001=ALL OTHERS (NON-LTC FAC) WA/D1=SPOKANE & YAKIMA AREAS WA/D1A=District 1, Unit A WA/D1B=District 1, Unit B WA/D1C=District 1, Unit C WA/D1D=District 1, Unit D WA/D2=SPOKANE & SE WA/D2A=District 2, Unit A WA/D2B=District 2, Unit B WA/D2C=District 2, Unit C WA/D2D=District 2, Unit D WA/D2E=District 2, Unit E WA/D2F=District 2, Unit F WA/D2G=District 2, Unit G WA/D3=NW WASHINGTON WA/D3A=District 3, Unit A WA/D3B=District 3, Unit B WA/D3C=District 3, Unit C WA/D3D=District 3, Unit D WA/D3E=District 3, Unit E WA/D4A=GREATER SEATTLE AREA WA/D4B=S KING COUNTY WA/D5A=PIERCE CTY & PENINSULA WA/D5B=PIERCE CTY & GRAYS HARBOR WA/D6=OLYMPIA AREA WA/LAB=LABORATORIES WI/001=WISCONSIN WI/LAB=LABORATORIES WV/001=WEST VIRGINIA WV/LAB=LABORATORIES WY/001=WYOMING WY/LAB=LABORATORIES Address: Street 50 178 227 VARCHAR2 Description: Street address where the provider is located. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 18 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: ST_ADR COBOL Name: ST-ADR Telephone Number 10 228 237 VARCHAR2 Description: Telephone number of the provider. SAS Name: PHNE_NUM COBOL Name: PHNE-NUM Termination Code 2 238 239 VARCHAR2 Description: Indicates the current termination status for the provider. SAS Name: PGM_TRMNTN_CD COBOL Name: PGM-TRMNTN-CD VALUES: 00=ACTIVE PROVIDER 01=VOLUNTARY-MERGER, CLOSURE 02=VOLUNTARY-DISSATISFACTION WITH REIMBURSEMENT 03=VOLUNTARY-RISK OF INVOLUNTARY TERMINATION 04=VOLUNTARY-OTHER REASON FOR WITHDRAWAL 05=INVOLUNTARY-FAILURE TO MEET HEALTH/SAFETY REQ 06=INVOLUNTARY-FAILURE TO MEET AGREEMENT 07=OTHER-PROVIDER STATUS CHANGE 08=NONPAYMENT OF FEES - CLIA Only 09=REV/UNSUCCESSFUL PARTICIPATION IN PT - CLIA Only 10=REV/OTHER REASON - CLIA Only 11=INCOMPLETE CLIA APPLICATION INFORMATION - CLIA Only 12=NO LONGER PERFORMING TESTS - CLIA Only 13=MULTIPLE TO SINGLE SITE CERTIFICATE - CLIA Only 14=SHARED LABORATORY - CLIA Only 15=FAILURE TO RENEW WAIVER PPM CERTIFICATE - CLIA Only 16=DUPLICATE CLIA NUMBER - CLIA Only 17=MAIL RETURNED NO FORWARD ADDRESS CERT ENDED - CLIA Only 20=NOTIFICATION BANKRUPTCY - CLIA Only 33=ACCREDITATION NOT CONFIRMED - CLIA Only 80=AWAITING STATE APPROVAL 99=OIG ACTION - DO NOT ACTIVATE - CLIA Only Termination or Expiration Date 8 240 247 DATE Description: Date the provider was terminated. For CLIA providers, date the laboratory's certificate was terminated or the expiration date of the current CLIA certificate. SAS Name: TRMNTN_EXPRTN_DT COBOL Name: TRMNTN-EXPRTN-DT Type of Action Code 1 248 248 VARCHAR2 Description: Identifies the reason for the certification. Type of action from the official survey record, CMS 1539 form. SAS Name: CRTFCTN_ACTN_TYPE_CD COBOL Name: CRTFCTN-ACTN-TYPE-CD VALUES: 1=INITIAL 2=RECERTIFICATION 3=TERMINATION 4=CHANGE OF OWNERSHIP 5=VALIDATION 8=FULL SURVEY AFTER COMPLAINT Ownership Type Code 2 249 250 VARCHAR2 Description: Indicates the ownership type of the provider. SAS Name: GNRL_CNTL_TYPE_CD COBOL Name: GNRL-CNTL-TYPE-CD VALUES: 01=FOR PROFIT - INDIVIDUAL 02=FOR PROFIT - PARTNERSHIP 03=FOR PROFIT - CORPORATION 04=NONPROFIT - CHURCH RELATED 05=NONPROFIT - CORPORATION DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 19 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 06=NONPROFIT - OTHER 07=GOVERNMENT - STATE 08=GOVERNMENT - COUNTY 09=GOVERNMENT - CITY 10=GOVERNMENT - CITY/COUNTY 11=GOVERNMENT - HOSPITAL DISTRICT 12=GOVERNMENT - FEDERAL 13=FOR PROFIT - LIMITED LIABILITY CORPORATION Address: ZIP Code 5 251 255 VARCHAR2 Description: Five-digit ZIP code for a provider's physical address. SAS Name: ZIP_CD COBOL Name: ZIP-CD FIPS State Code 2 256 257 VARCHAR2 Description: FIPS State Code SAS Name: FIPS_STATE_CD COBOL Name: FIPS-STATE-CD VALUES: 01=ALABAMA 02=ALASKA 04=ARIZONA 05=ARKANSAS 06=CALIFORNIA 08=COLORADO 09=CONNECTICUT 10=DELAWARE 11=DISTRICT OF COLUMBIA 12=FLORIDA 13=GEORGIA 15=HAWAII 16=IDAHO 17=ILLINOIS 18=INDIANA 19=IOWA 20=KANSAS 21=KENTUCKY 22=LOUISIANA 23=MAINE 24=MARYLAND 25=MASSACHUSETTS 26=MICHIGAN 27=MINNESOTA 28=MISSISSIPPI 29=MISSOURI 30=MONTANA 31=NEBRASKA 32=NEVADA 33=NEW HAMPSHIRE 34=NEW JERSEY 35=NEW MEXICO 36=NEW YORK 37=NORTH CAROLINA 38=NORTH DAKOTA 39=OHIO 40=OKLAHOMA 41=OREGON 42=PENNSYLVANIA 43=PUERTO RICO 44=RHODE ISLAND 45=SOUTH CAROLINA 46=SOUTH DAKOTA 47=TENNESSEE 48=TEXAS 49=UTAH DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 20 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 50=VERMONT 51=VIRGINIA 53=WASHINGTON 54=WEST VIRGINIA 55=WISCONSIN 56=WYOMING 64=AMERICAN SAMOA 65=GUAM 66=SAIPAN/MARIANA IS. 78=VIRGIN ISLANDS FIPS County Code 3 258 260 VARCHAR2 Description: FIPS County Code SAS Name: FIPS_CNTY_CD COBOL Name: FIPS-CNTY-CD CBSA Urban Rural Indicator 1 261 261 VARCHAR2 Description: CBSA (Core Based Statistical Area) indicates whether the county is defined as Urban or Rural. SAS Name: CBSA_URBN_RRL_IND COBOL Name: CBSA-URBN-RRL-IND CBSA Code 5 262 266 VARCHAR2 Description: CBSA (Core Based Statistical Area) geographic entities defined by the U.S. Office of Management and Budget (OMB) on June 6, 2003 for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics. CBSA collectively refers to MSA. SAS Name: CBSA_CD COBOL Name: CBSA-CD Bed Count Override Indicator 1 325 325 CHAR Description: Indicates if the regional office has approved a significant bed count change from the previous certification. SAS Name: OVRRD_BED_CNT_SW COBOL Name: OVRRD-BED-CNT-SW Bed Count: Certified 4 326 329 NUMBER Description: Number of beds in Medicare and/or Medicaid certified areas within a facility. SAS Name: CRTFD_BED_CNT COBOL Name: CRTFD-BED-CNT Bed Count: Medicaid NF 4 334 337 NUMBER Description: Number of Medicaid-certified Nursing Facility beds. SAS Name: MDCD_NF_BED_CNT COBOL Name: MDCD-NF-BED-CNT Bed Count: Medicare SNF 4 338 341 NUMBER Description: Number of Medicare-certified Skilled Nursing Facility beds. SAS Name: MDCR_SNF_BED_CNT COBOL Name: MDCR-SNF-BED-CNT Bed Count: Medicare/Medicaid SNF 4 342 345 NUMBER Description: Number of dually certified (Medicare/Medicaid) beds in a Skilled Nursing Facility. SAS Name: MDCR_MDCD_SNF_BED_CNT COBOL Name: MDCR-MDCD-SNF-BED-CNT Bed Count: Special Care - AIDS 3 346 348 NUMBER Description: Number of beds in a special care unit dedicated for residents with AIDS. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 21 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: AIDS_BED_CNT COBOL Name: AIDS-BED-CNT Bed Count: Special Care - Alzheimers 3 349 351 NUMBER Description: Number of beds in a special care unit dedicated for residents with Alzheimer's disease. SAS Name: ALZHMR_BED_CNT COBOL Name: ALZHMR-BED-CNT Bed Count: Special Care - Dialysis 3 352 354 NUMBER Description: Number of beds in a special care unit dedicated for residents who require dialysis. SAS Name: DLYS_BED_CNT COBOL Name: DLYS-BED-CNT Bed Count: Special Care - Disabled Children 3 355 357 NUMBER Description: Number of beds in a special care unit dedicated for disabled children. SAS Name: DSBL_CHLDRN_BED_CNT COBOL Name: DSBL-CHLDRN-BED-CNT Bed Count: Special Care - Head Trauma 3 358 360 NUMBER Description: Number of beds in a special care unit dedicated for residents with head trauma. SAS Name: HEAD_TRMA_BED_CNT COBOL Name: HEAD-TRMA-BED-CNT Bed Count: Special Care - Hospice 3 361 363 NUMBER Description: Number of beds in a special care unit dedicated for residents who require hospice care. SAS Name: HOSPC_BED_CNT COBOL Name: HOSPC-BED-CNT Bed Count: Special Care - Huntingtons Disease 3 364 366 NUMBER Description: Number of beds in a special care unit dedicated for residents with Huntington's disease. SAS Name: HNTGTN_DEASE_BED_CNT COBOL Name: HNTGTN-DEASE-BED-CNT Bed Count: Special Care - Specialized Rehab 3 367 369 NUMBER Description: Number of beds in a special care unit dedicated for residents with specialized rehab needs. SAS Name: REHAB_BED_CNT COBOL Name: REHAB-BED-CNT Bed Count: Special Care - Ventilator 3 370 372 NUMBER Description: Number of beds in a special care unit dedicated for residents requiring a ventilator and/or respiratory care. SAS Name: VNTLTR_BED_CNT COBOL Name: VNTLTR-BED-CNT Bed Count: Total 4 373 376 NUMBER Description: Total number of beds in a provider, including those in non-participating or non-licensed areas. SAS Name: BED_CNT COBOL Name: BED-CNT Compliance: 24-Hour RN Waiver Indicator 1 442 442 CHAR Description: Indicates if a waiver of the 24-hour registered nurse staffing requirements has been recommended for a Skilled Nursing Facility or Nursing Facility. SAS Name: RN_24_HR_WVR_SW COBOL Name: RN-24-HR-WVR-SW DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 22 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Compliance: 7-Day RN Waiver Indicator 1 443 443 VARCHAR2 Description: Indicates if a waiver of the 7-day registered nurse staffing requirements has been recommended for a Skilled Nursing Facility. SAS Name: RN_7_DAY_WVR_SW COBOL Name: RN-7-DAY-WVR-SW Compliance: Beds Per Room Waiver Indicator 1 444 444 CHAR Description: Indicates if a waiver of the beds per room requirement has been recommended for a facility. SAS Name: BED_PER_ROOM_WVR_SW COBOL Name: BED-PER-ROOM-WVR-SW Compliance: LSC Waiver Indicator 1 445 445 CHAR Description: Indicates if a waiver of any life safety code provision has been recommended for a provider. SAS Name: LSC_WVR_SW COBOL Name: LSC-WVR-SW Compliance: Patient Room Size Waiver Indicator 1 446 446 CHAR Description: Indicates if a waiver of the patient room size provision has been recommended for a provider. SAS Name: ROOM_SIZE_WVR_SW COBOL Name: ROOM-SIZE-WVR-SW Experimental Research Conducted Indicator 1 453 453 VARCHAR2 Description: Indicates if a facility conducts experimental research. SAS Name: EXPRMT_RSRCH_CNDCTD_SW COBOL Name: EXPRMT-RSRCH-CNDCTD-SW Fiscal Year End Date (MMDD) 4 464 467 VARCHAR2 Description: End date, consisting of the month and day, of the provider's fiscal year. SAS Name: FY_END_MO_DAY_CD COBOL Name: FY-END-MO-DAY-CD LTC Cross Ref Provider Number 10 485 494 CHAR Description: LTC cross ref provider number SAS Name: LTC_CROSS_REF_PROVIDER_NUMBER COBOL Name: LTC-CROSS-REF-PROVIDER-NUMBER Multiple Facility Organization Name 38 513 550 CHAR Description: Name of the multi-facility organization that owns the facility. SAS Name: MLT_FAC_ORG_NAME COBOL Name: MLT-FAC-ORG-NAME Multiple Facility Organization Owned Indicator 1 551 551 CHAR Description: Indicates if a facility is owned by an organization that owns (or leases) two or more long term care facilities. SAS Name: MLT_OWND_FAC_ORG_SW COBOL Name: MLT-OWND-FAC-ORG-SW Organized Family Group Indicator 1 609 609 VARCHAR2 Description: Indicates if the facility has an organized group of family members of residents. SAS Name: ORGNZ_FMLY_MBR_GRP_SW COBOL Name: ORGNZ-FMLY-MBR-GRP-SW Organized Resident Group Indicator 1 610 610 VARCHAR2 Description: Indicates if the facility has an organized residents group. SAS Name: ORGNZ_RSDNT_GRP_SW COBOL Name: ORGNZ-RSDNT-GRP-SW DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 23 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Program Participation Code 1 623 623 CHAR Description: Indicates if the provider participates in Medicare, Medicaid, or both programs. SAS Name: PGM_PRTCPTN_CD COBOL Name: PGM-PRTCPTN-CD VALUES: 1=MEDICARE ONLY 2=MEDICAID ONLY 3=MEDICARE AND MEDICAID Related Provider Number 10 669 678 CHAR Description: Related provider number SAS Name: RELATED_PROVIDER_NUMBER COBOL Name: RELATED-PROVIDER-NUMBER Services: Blood Administration Off-Site Residents 1 686 686 VARCHAR2 Indicator Description: Indicates if blood administration and storage services are provided off-site to residents. SAS Name: BLOOD_SRVC_OFSITE_RSDNT_SW COBOL Name: BLOOD-SRVC-OFSITE-RSDNT-SW Services: Blood Administration On-Site Nonresidents 1 687 687 VARCHAR2 Indicator Description: Indicates if blood administration and storage services are provided on-site to nonresidents. SAS Name: BLOOD_SRVC_ONST_NRSDNT_SW COBOL Name: BLOOD-SRVC-ONST-NRSDNT-SW Services: Blood Administration On-Site Residents 1 688 688 VARCHAR2 Indicator Description: Indicates if blood administration and storage services are provided on-site to residents. SAS Name: BLOOD_SRVC_ONST_RSDNT_SW COBOL Name: BLOOD-SRVC-ONST-RSDNT-SW Services: Clinical Laboratory - Off-Site Residents 1 695 695 VARCHAR2 Indicator Description: Indicates if clinical laboratory services are provided off-site to residents. SAS Name: CL_SRVC_OFSITE_RSDNT_SW COBOL Name: CL-SRVC-OFSITE-RSDNT-SW Services: Clinical Laboratory - On-Site Nonresidents 1 696 696 VARCHAR2 Indicator Description: Indicates if clinical laboratory services are provided on-site to nonresidents. SAS Name: CL_SRVC_ONST_NRSDNT_SW COBOL Name: CL-SRVC-ONST-NRSDNT-SW Services: Clinical Laboratory - On-Site Residents 1 697 697 VARCHAR2 Indicator Description: Indicates if clinical laboratory services are provided on-site to residents. SAS Name: CL_SRVC_ONST_RSDNT_SW COBOL Name: CL-SRVC-ONST-RSDNT-SW Services: Dental Off-Site Residents Indicator 1 703 703 VARCHAR2 Description: Indicates if dental services are provided off-site to residents. SAS Name: DNTL_SRVC_OFSITE_RSDNT_SW COBOL Name: DNTL-SRVC-OFSITE-RSDNT-SW Services: Dental On-Site Nonresidents Indicator 1 704 704 VARCHAR2 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 24 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Indicates if dental services are provided on-site to nonresidents. SAS Name: DNTL_SRVC_ONST_NRSDNT_SW COBOL Name: DNTL-SRVC-ONST-NRSDNT-SW Services: Dental On-Site Residents Indicator 1 705 705 VARCHAR2 Description: Indicates if dental services are provided on-site to residents. SAS Name: DNTL_SRVC_ONST_RSDNT_SW COBOL Name: DNTL-SRVC-ONST-RSDNT-SW Services: Dietary Off-Site Residents Indicator 1 709 709 VARCHAR2 Description: Indicates if dietary services are provided off-site to residents. SAS Name: DTRY_OFSITE_RSDNT_SW COBOL Name: DTRY-OFSITE-RSDNT-SW Services: Dietary On-Site Nonresidents Indicator 1 710 710 VARCHAR2 Description: Indicates if dietary services are provided on-site to nonresidents. SAS Name: DTRY_ONST_NRSDNT_SW COBOL Name: DTRY-ONST-NRSDNT-SW Services: Dietary On-Site Residents Indicator 1 711 711 VARCHAR2 Description: Indicates if dietary services are provided on-site to residents. SAS Name: DTRY_ONST_RSDNT_SW COBOL Name: DTRY-ONST-RSDNT-SW Services: Housekeeping Off-Site Residents Indicator 1 721 721 VARCHAR2 Description: Indicates if housekeeping services are provided off-site to residents. SAS Name: HSEKPNG_SRVC_OFSITE_RSDNT_SW COBOL Name: HSEKPNG-SRVC-OFSITE-RSDNT-SW Services: Housekeeping On-Site Nonresidents Indicator 1 722 722 VARCHAR2 Description: Indicates if housekeeping services are provided on-site to nonresidents. SAS Name: HSEKPNG_SRVC_ONST_NRSDNT_SW COBOL Name: HSEKPNG-SRVC-ONST-NRSDNT-SW Services: Housekeeping On-Site Residents Indicator 1 723 723 VARCHAR2 Description: Indicates if housekeeping services are provided on-site to residents. SAS Name: HSEKPNG_SRVC_ONST_RSDNT_SW COBOL Name: HSEKPNG-SRVC-ONST-RSDNT-SW Services: Mental Health Off-Site Residents Indicator 1 730 730 VARCHAR2 Description: Indicates if mental health services are provided off-site to residents. SAS Name: MENTL_HLTH_OFSITE_RSDNT_SW COBOL Name: MENTL-HLTH-OFSITE-RSDNT-SW Services: Mental Health On-Site Nonresidents 1 731 731 VARCHAR2 Indicator Description: Indicates if mental health services are provided on-site to nonresidents. SAS Name: MENTL_HLTH_ONST_NRSDNT_SW COBOL Name: MENTL-HLTH-ONST-NRSDNT-SW Services: Mental Health On-Site Residents Indicator 1 732 732 VARCHAR2 Description: Indicates if mental health services are provided on-site to residents. SAS Name: MENTL_HLTH_ONST_RSDNT_SW DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 25 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: MENTL-HLTH-ONST-RSDNT-SW Services: Nursing Off-Site Residents Indicator 1 743 743 VARCHAR2 Description: Indicates if nursing services are provided off-site to residents. SAS Name: NRSNG_SRVC_OFSITE_RSDNT_SW COBOL Name: NRSNG-SRVC-OFSITE-RSDNT-SW Services: Nursing On-Site Nonresidents Indicator 1 744 744 VARCHAR2 Description: Indicates if nursing services are provided on-site to nonresidents. SAS Name: NRSNG_SRVC_ONST_NRSDNT_SW COBOL Name: NRSNG-SRVC-ONST-NRSDNT-SW Services: Nursing On-Site Residents Indicator 1 745 745 VARCHAR2 Description: Indicates if nursing services are provided on-site to residents. SAS Name: NRSNG_SRVC_ONST_RSDNT_SW COBOL Name: NRSNG-SRVC-ONST-RSDNT-SW Services: OT Off-Site Residents Indicator 1 759 759 VARCHAR2 Description: Indicates if occupational therapy services are provided off-site to residents. SAS Name: OT_SRVC_OFSITE_RSDNT_SW COBOL Name: OT-SRVC-OFSITE-RSDNT-SW Services: OT On-Site Nonresidents Indicator 1 760 760 VARCHAR2 Description: Indicates if occupational therapy services are provided on-site to nonresidents. SAS Name: OT_SRVC_ONST_NRSDNT_SW COBOL Name: OT-SRVC-ONST-NRSDNT-SW Services: OT On-Site Residents Indicator 1 761 761 VARCHAR2 Description: Indicates if occupational therapy services are provided on-site to residents. SAS Name: OT_SRVC_ONST_RSDNT_SW COBOL Name: OT-SRVC-ONST-RSDNT-SW Services: Pharmacy Off-Site Residents Indicator 1 772 772 VARCHAR2 Description: Indicates if pharmacy services are provided off-site to residents. SAS Name: PHRMCY_SRVC_OFSITE_RSDNT_SW COBOL Name: PHRMCY-SRVC-OFSITE-RSDNT-SW Services: Pharmacy On-Site Nonresidents Indicator 1 773 773 VARCHAR2 Description: Indicates if pharmacy services are provided on-site to nonresidents. SAS Name: PHRMCY_SRVC_ONST_NRSDNT_SW COBOL Name: PHRMCY-SRVC-ONST-NRSDNT-SW Services: Pharmacy On-Site Residents Indicator 1 774 774 VARCHAR2 Description: Indicates if pharmacy services are provided on-site to residents. SAS Name: PHRMCY_SRVC_ONST_RSDNT_SW COBOL Name: PHRMCY-SRVC-ONST-RSDNT-SW Services: Physician Extender Off-Site Residents 1 779 779 VARCHAR2 Indicator Description: Indicates if physician extender services are provided off-site to residents. SAS Name: PHYSN_EXT_SRVC_OFSITE_RSDNT_SW COBOL Name: PHYSN-EXT-SRVC-OFSITE-RSDNT-SW Services: Physician Extender On-Site Nonresidents 1 780 780 VARCHAR2 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 26 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Indicator Description: Indicates if physician extender services are provided on-site to nonresidents. SAS Name: PHYSN_EXT_SRVC_ONST_NRSDNT_SW COBOL Name: PHYSN-EXT-SRVC-ONST-NRSDNT-SW Services: Physician Extender On-Site Residents 1 781 781 VARCHAR2 Indicator Description: Indicates if physician extender services are provided on-site to residents. SAS Name: PHYSN_EXT_SRVC_ONST_RSDNT_SW COBOL Name: PHYSN-EXT-SRVC-ONST-RSDNT-SW Services: Physician Off-Site Residents Indicator 1 782 782 VARCHAR2 Description: Indicates if physician services are provided off-site to residents. SAS Name: PHYSN_SRVC_OFSITE_RSDNT_SW COBOL Name: PHYSN-SRVC-OFSITE-RSDNT-SW Services: Physician On-Site Nonresidents Indicator 1 783 783 VARCHAR2 Description: Indicates if physician services are provided on-site to nonresidents. SAS Name: PHYSN_SRVC_ONST_NRSDNT_SW COBOL Name: PHYSN-SRVC-ONST-NRSDNT-SW Services: Physician On-Site Residents Indicator 1 784 784 VARCHAR2 Description: Indicates if physician services are provided on-site to residents. SAS Name: PHYSN_SRVC_ONST_RSDNT_SW COBOL Name: PHYSN-SRVC-ONST-RSDNT-SW Services: Podiatry Off-Site Residents Indicator 1 785 785 VARCHAR2 Description: Indicates if podiatry services are provided off-site to residents. SAS Name: PDTRY_SRVC_OFSITE_RSDNT_SW COBOL Name: PDTRY-SRVC-OFSITE-RSDNT-SW Services: Podiatry On-Site Nonresidents Indicator 1 786 786 VARCHAR2 Description: Indicates if podiatry services are provided on-site to nonresidents. SAS Name: PDTRY_SRVC_ONST_NRSDNT_SW COBOL Name: PDTRY-SRVC-ONST-NRSDNT-SW Services: Podiatry On-Site Residents Indicator 1 787 787 VARCHAR2 Description: Indicates if podiatry services are provided on-site to residents. SAS Name: PDTRY_SRVC_ONST_RSDNT_SW COBOL Name: PDTRY-SRVC-ONST-RSDNT-SW Services: PT Off-Site Residents Indicator 1 797 797 VARCHAR2 Description: Indicates if physical therapy services are provided off-site to residents. SAS Name: PT_OFSITE_RSDNT_SW COBOL Name: PT-OFSITE-RSDNT-SW Services: PT On-Site Nonresidents Indicator 1 798 798 VARCHAR2 Description: Indicates if physical therapy services are provided on-site to nonresidents. SAS Name: PT_ONST_NRSDNT_SW COBOL Name: PT-ONST-NRSDNT-SW Services: PT On-Site Residents Indicator 1 799 799 VARCHAR2 Description: Indicates if physical therapy services are provided on-site to residents. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 27 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: PT_ONST_RSDNT_SW COBOL Name: PT-ONST-RSDNT-SW Services: Social Work Off-Site Residents Indicator 1 810 810 VARCHAR2 Description: Indicates if social work services are provided off-site to residents. SAS Name: SCL_WORK_SRVC_OFSITE_RSDNT_SW COBOL Name: SCL-WORK-SRVC-OFSITE-RSDNT-SW Services: Social Work On-Site Nonresidents Indicator 1 811 811 VARCHAR2 Description: Indicates if social work services are provided on-site to nonresidents. SAS Name: SCL_WORK_SRVC_ONST_NRSDNT_SW COBOL Name: SCL-WORK-SRVC-ONST-NRSDNT-SW Services: Social Work On-Site Residents Indicator 1 812 812 VARCHAR2 Description: Indicates if social work services are provided on-site to residents. SAS Name: SCL_WORK_SRVC_ONST_RSDNT_SW COBOL Name: SCL-WORK-SRVC-ONST-RSDNT-SW Services: Speech Pathology Off-Site Residents 1 817 817 VARCHAR2 Indicator Description: Indicates if speech/language pathology services are provided off-site to residents. SAS Name: SPCH_PTHLGY_OFSITE_RSDNT_SW COBOL Name: SPCH-PTHLGY-OFSITE-RSDNT-SW Services: Speech Pathology On-Site Nonresidents 1 818 818 VARCHAR2 Indicator Description: Indicates if speech/language pathology services are provided on-site to nonresidents. SAS Name: SPCH_PTHLGY_ONST_NRSDNT_SW COBOL Name: SPCH-PTHLGY-ONST-NRSDNT-SW Services: Speech Pathology On-Site Residents 1 819 819 VARCHAR2 Indicator Description: Indicates if speech/language pathology services are provided on-site to residents. SAS Name: SPCH_PTHLGY_ONST_RSDNT_SW COBOL Name: SPCH-PTHLGY-ONST-RSDNT-SW Services: Therapeutic - Other Activities Staff - 1 822 822 VARCHAR2 Off-Site Residents Indicator Description: Indicates if therapeutic services are provided off-site to residents by other activities staff. SAS Name: ACTVTY_OTHR_OFSITE_RSDNT_SW COBOL Name: ACTVTY-OTHR-OFSITE-RSDNT-SW Services: Therapeutic - Other Activities Staff - 1 823 823 VARCHAR2 On-Site Nonresidents Indicator Description: Indicates if therapeutic services are provided on-site to nonresidents by other activities staff. SAS Name: ACTVTY_OTHR_ONST_NRSDNT_SW COBOL Name: ACTVTY-OTHR-ONST-NRSDNT-SW Services: Therapeutic - Other Activities Staff - 1 824 824 VARCHAR2 On-Site Residents Indicator Description: Indicates if therapeutic services are provided on-site to residents by other activities staff. SAS Name: ACTVTY_OTHR_ONST_RSDNT_SW COBOL Name: ACTVTY-OTHR-ONST-RSDNT-SW Services: Therapeutic - Other Social Services Staff - 1 825 825 VARCHAR2 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 28 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Off-Site Residents Indicator Description: Indicates if other therapeutic social services are provided off-site to residents. SAS Name: SCL_SRVC_OTHR_OFSITE_RSDNT_SW COBOL Name: SCL-SRVC-OTHR-OFSITE-RSDNT-SW Services: Therapeutic - Other Social Services Staff - 1 826 826 VARCHAR2 On-Site Nonresidents Indicator Description: Indicates if other therapeutic social services are provided on-site to nonresidents. SAS Name: SCL_SRVC_OTHR_ONST_NRSDNT_SW COBOL Name: SCL-SRVC-OTHR-ONST-NRSDNT-SW Services: Therapeutic - Other Social Services Staff - 1 827 827 VARCHAR2 On-Site Residents Indicator Description: Indicates if other therapeutic social services are provided on-site to residents. SAS Name: SCL_SRVC_OTHR_ONST_RSDNT_SW COBOL Name: SCL-SRVC-OTHR-ONST-RSDNT-SW Services: Therapeutic - Qualified Activities 1 828 828 VARCHAR2 Professional - Off-Site Residents Indicator Description: Indicates if therapeutic services are provided off-site to residents by qualified activities professionals. SAS Name: ACTVTY_OFSITE_RSDNT_SW COBOL Name: ACTVTY-OFSITE-RSDNT-SW Services: Therapeutic - Qualified Activities 1 829 829 VARCHAR2 Professional - On-Site Nonresidents Indicator Description: Indicates if therapeutic services are provided on-site to nonresidents by qualified activities professionals. SAS Name: ACTVTY_ONST_NRSDNT_SW COBOL Name: ACTVTY-ONST-NRSDNT-SW Services: Therapeutic - Qualified Activities 1 830 830 VARCHAR2 Professional - On-Site Residents Indicator Description: Indicates if therapeutic services are provided on-site to residents by qualified activities professionals. SAS Name: ACTVTY_ONST_RSDNT_SW COBOL Name: ACTVTY-ONST-RSDNT-SW Services: Therapeutic Recreational Specialty Off-Site 1 832 832 VARCHAR2 Residents Indicator Description: Indicates if therapeutic recreation specialist services are provided off-site to residents. SAS Name: THRPTC_RCRTNL_OFSITE_RSDNT_SW COBOL Name: THRPTC-RCRTNL-OFSITE-RSDNT-SW Services: Therapeutic Recreational Specialty On-Site 1 833 833 VARCHAR2 Nonresidents Indicator Description: Indicates if therapeutic recreation specialist services are provided on-site to nonresidents. SAS Name: THRPTC_RCRTNL_ONST_NRSDNT_SW COBOL Name: THRPTC-RCRTNL-ONST-NRSDNT-SW Services: Therapeutic Recreational Specialty On-Site 1 834 834 VARCHAR2 Residents Indicator Description: Indicates if therapeutic recreation specialist services are provided on-site to residents. SAS Name: THRPTC_RCRTNL_ONST_RSDNT_SW COBOL Name: THRPTC-RCRTNL-ONST-RSDNT-SW Services: Vocational Off-Site Residents Indicator 1 837 837 VARCHAR2 Description: Indicates if vocational services are provided off-site to DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 29 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE residents. SAS Name: VCTNL_SRVC_OFSITE_RSDNT_SW COBOL Name: VCTNL-SRVC-OFSITE-RSDNT-SW Services: Vocational On-Site Nonresidents Indicator 1 838 838 VARCHAR2 Description: Indicates if vocational services are provided on-site to nonresidents. SAS Name: VCTNL_SRVC_ONST_NRSDNT_SW COBOL Name: VCTNL-SRVC-ONST-NRSDNT-SW Services: Vocational On-Site Residents Indicator 1 839 839 VARCHAR2 Description: Indicates if vocational services are provided on-site to residents. SAS Name: VCTNL_SRVC_ONST_RSDNT_SW COBOL Name: VCTNL-SRVC-ONST-RSDNT-SW Services: X-ray Off-Site Residents Indicator 1 840 840 VARCHAR2 Description: Indicates if diagnostic X-ray services are provided off-site to residents. SAS Name: DGNSTC_XRAY_OFSITE_RSDNT_SW COBOL Name: DGNSTC-XRAY-OFSITE-RSDNT-SW Services: X-ray On-Site Nonresidents Indicator 1 841 841 VARCHAR2 Description: Indicates if diagnostic X-ray services are provided on-site to nonresidents. SAS Name: DGNSTC_XRAY_ONST_NRSDNT_SW COBOL Name: DGNSTC-XRAY-ONST-NRSDNT-SW Services: X-ray On-Site Residents Indicator 1 842 842 VARCHAR2 Description: Indicates if diagnostic X-ray services are provided on-site to residents. SAS Name: DGNSTC_XRAY_ONST_RSDNT_SW COBOL Name: DGNSTC-XRAY-ONST-RSDNT-SW Staff Count Override Indicator 1 844 844 CHAR Description: Indicates if the regional office has approved a significant staff count change from the previous certification. SAS Name: OVRRD_STFG_SW COBOL Name: OVRRD-STFG-SW Staff Count: Administrative Staff - Contract 8 845 852 NUMBER Description: Number of full-time equivalent administrative staff under contract to a facility. SAS Name: PROFNL_ADMIN_CNTRCT_CNT COBOL Name: PROFNL-ADMIN-CNTRCT-CNT Staff Count: Administrative Staff - Full-Time 8 853 860 NUMBER Description: Number of full-time equivalent administrative staff employed on a full-time basis by a facility. SAS Name: PROFNL_ADMIN_FLTM_CNT COBOL Name: PROFNL-ADMIN-FLTM-CNT Staff Count: Administrative Staff - Part-Time 8 861 868 NUMBER Description: Number of full-time equivalent administrative staff employed on a part-time basis by a facility. SAS Name: PROFNL_ADMIN_PRTM_CNT COBOL Name: PROFNL-ADMIN-PRTM-CNT Staff Count: Certified Nurse Aide - Contract 8 893 900 NUMBER Description: Number of full-time equivalent certified nurse aides under contract to a facility. SAS Name: NRS_AIDE_CNTRCT_CNT COBOL Name: NRS-AIDE-CNTRCT-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 30 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Staff Count: Certified Nurse Aide - Full-Time 8 901 908 NUMBER Description: Number of full-time equivalent certified nurse aides employed full-time by a facility. SAS Name: NRS_AIDE_FLTM_CNT COBOL Name: NRS-AIDE-FLTM-CNT Staff Count: Certified Nurse Aide - Part-Time 8 909 916 NUMBER Description: Number of full-time equivalent certified nurse aides employed part-time by a facility. SAS Name: NRS_AIDE_PRTM_CNT COBOL Name: NRS-AIDE-PRTM-CNT Staff Count: Dentist - Contract 8 941 948 NUMBER Description: Number of full-time equivalent dentists under contract to a facility. SAS Name: DNTST_CNTRCT_CNT COBOL Name: DNTST-CNTRCT-CNT Staff Count: Dentist - Full-Time 8 949 956 NUMBER Description: Number of full-time equivalent dentists employed full time by a facility. SAS Name: DNTST_FLTM_CNT COBOL Name: DNTST-FLTM-CNT Staff Count: Dentist - Part-Time 8 957 964 NUMBER Description: Number of full-time equivalent dentists employed part time by a facility. SAS Name: DNTST_PRTM_CNT COBOL Name: DNTST-PRTM-CNT Staff Count: Dietitian - Contract 8 973 980 NUMBER Description: Number of full-time equivalent dietitians under contract to a facility. SAS Name: DIETN_CNTRCT_CNT COBOL Name: DIETN-CNTRCT-CNT Staff Count: Dietitian - Full-Time 8 981 988 NUMBER Description: Number of full-time equivalent dietitians employed full time by a facility. SAS Name: DIETN_FLTM_CNT COBOL Name: DIETN-FLTM-CNT Staff Count: Dietitian - Part-Time 8 989 996 NUMBER Description: Number of full-time equivalent dietitians employed part time by a facility. SAS Name: DIETN_PRTM_CNT COBOL Name: DIETN-PRTM-CNT Staff Count: Food Service Worker - Contract 8 1005 1012 NUMBER Description: Number of full-time equivalent food service personnel under contract to a facility. SAS Name: FOOD_SRVC_CNTRCT_CNT COBOL Name: FOOD-SRVC-CNTRCT-CNT Staff Count: Food Service Worker - Full-Time 8 1013 1020 NUMBER Description: Number of full-time equivalent food service personnel employed full-time by a facility. SAS Name: FOOD_SRVC_FLTM_CNT COBOL Name: FOOD-SRVC-FLTM-CNT Staff Count: Food Service Worker - Part-Time 8 1021 1028 NUMBER Description: Number of full-time equivalent food service personnel employed part-time by a facility. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 31 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: FOOD_SRVC_PRTM_CNT COBOL Name: FOOD-SRVC-PRTM-CNT Staff Count: Housekeeping - Contract 8 1053 1060 NUMBER Description: Number of full-time equivalent housekeeping personnel under contract to a facility. SAS Name: HSEKPNG_CNTRCT_CNT COBOL Name: HSEKPNG-CNTRCT-CNT Staff Count: Housekeeping - Full-Time 8 1061 1068 NUMBER Description: Number of full-time equivalent housekeeping personnel employed full-time by a facility. SAS Name: HSEKPNG_FLTM_CNT COBOL Name: HSEKPNG-FLTM-CNT Staff Count: Housekeeping - Part-Time 8 1069 1076 NUMBER Description: Number of full-time equivalent housekeeping personnel employed part-time by a facility. SAS Name: HSEKPNG_PRTM_CNT COBOL Name: HSEKPNG-PRTM-CNT Staff Count: LPN/LVN - Contract 8 1101 1108 NUMBER Description: Number of full-time equivalent licensed practical/vocational nurses under contract to a facility. SAS Name: LPN_LVN_CNTRCT_CNT COBOL Name: LPN-LVN-CNTRCT-CNT Staff Count: LPN/LVN - Full-Time 8 1109 1116 NUMBER Description: Number of full-time equivalent licensed practical/vocational nurses employed full-time by a facility. SAS Name: LPN_LVN_FLTM_CNT COBOL Name: LPN-LVN-FLTM-CNT Staff Count: LPN/LVN - Part-Time 8 1117 1124 NUMBER Description: Number of full-time equivalent licensed practical/vocational nurses employed part-time by a facility. SAS Name: LPN_LVN_PRTM_CNT COBOL Name: LPN-LVN-PRTM-CNT Staff Count: Medical Director - Contract 8 1133 1140 NUMBER Description: Number of full-time equivalent medical directors under contract to a facility. SAS Name: MDCL_DRCTR_CNTRCT_CNT COBOL Name: MDCL-DRCTR-CNTRCT-CNT Staff Count: Medical Director - Full-Time 8 1141 1148 NUMBER Description: Number of full-time equivalent medical directors employed full-time by a facility. SAS Name: MDCL_DRCTR_FLTM_CNT COBOL Name: MDCL-DRCTR-FLTM-CNT Staff Count: Medical Director - Part-Time 8 1149 1156 NUMBER Description: Number of full-time equivalent medical directors employed part-time by a facility. SAS Name: MDCL_DRCTR_PRTM_CNT COBOL Name: MDCL-DRCTR-PRTM-CNT Staff Count: Medication Aide/Technician - Contract 8 1181 1188 NUMBER Description: Number of full-time equivalent medication aides/ technicians under contract to a facility. SAS Name: MDCTN_AIDE_CNTRCT_CNT COBOL Name: MDCTN-AIDE-CNTRCT-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 32 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Staff Count: Medication Aide/Technician - Full-Time 8 1189 1196 NUMBER Description: Number of full-time equivalent medication aides/ technicians employed full-time by a facility. SAS Name: MDCTN_AIDE_FLTM_CNT COBOL Name: MDCTN-AIDE-FLTM-CNT Staff Count: Medication Aide/Technician - Part-Time 8 1197 1204 NUMBER Description: Number of full-time equivalent medication aides/ technicians employed part-time by a facility. SAS Name: MDCTN_AIDE_PRTM_CNT COBOL Name: MDCTN-AIDE-PRTM-CNT Staff Count: Mental Health Services - Contract 8 1205 1212 NUMBER Description: Number of full-time equivalent mental health services personnel under contract to a facility. SAS Name: MENTL_HLTH_SRVC_CNTRCT_CNT COBOL Name: MENTL-HLTH-SRVC-CNTRCT-CNT Staff Count: Mental Health Services - Full-Time 8 1213 1220 NUMBER Description: Number of full-time equivalent mental health services personnel employed full-time by a facility. SAS Name: MENTL_HLTH_SRVC_FLTM_CNT COBOL Name: MENTL-HLTH-SRVC-FLTM-CNT Staff Count: Mental Health Services - Part-Time 8 1221 1228 NUMBER Description: Number of full-time equivalent mental health services personnel employed part-time by a facility. SAS Name: MENTL_HLTH_SRVC_PRTM_CNT COBOL Name: MENTL-HLTH-SRVC-PRTM-CNT Staff Count: Nurse Aide in Training - Contract 8 1237 1244 NUMBER Description: Number of full-time equivalent nurse aides in training under contract to a facility. SAS Name: NAT_CNTRCT_CNT COBOL Name: NAT-CNTRCT-CNT Staff Count: Nurse Aide in Training - Full-Time 8 1245 1252 NUMBER Description: Number of full-time equivalent nurse aides in training employed full-time by a facility. SAS Name: NAT_FLTM_CNT COBOL Name: NAT-FLTM-CNT Staff Count: Nurse Aide in Training - Part-Time 8 1253 1260 NUMBER Description: Number of full-time equivalent nurse aides in training employed part-time by a facility. SAS Name: NAT_PRTM_CNT COBOL Name: NAT-PRTM-CNT Staff Count: Nurse With Administrative Duties - 8 1269 1276 NUMBER Contract Description: Number of full-time equivalent nurses with administrative duties under contract to a facility. SAS Name: NRS_ADMINV_CNTRCT_CNT COBOL Name: NRS-ADMINV-CNTRCT-CNT Staff Count: Nurse With Administrative Duties - 8 1277 1284 NUMBER Full-Time Description: Number of full-time equivalent nurses with administrative duties employed full-time by a facility. SAS Name: NRS_ADMINV_FLTM_CNT COBOL Name: NRS-ADMINV-FLTM-CNT Staff Count: Nurse With Administrative Duties - 8 1285 1292 NUMBER DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 33 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Part-Time Description: Number of full-time equivalent nurses with administrative duties employed part-time by a facility. SAS Name: NRS_ADMINV_PRTM_CNT COBOL Name: NRS-ADMINV-PRTM-CNT Staff Count: OT - Arrangement 8 1301 1308 NUMBER Description: Number of full-time equivalent occupational therapists under arrangement to the provider SAS Name: OCPTNL_THRPST_CNTRCT_CNT COBOL Name: OCPTNL-THRPST-CNTRCT-CNT Staff Count: OT - Full-Time 8 1309 1316 NUMBER Description: Number of full-time equivalent occupational therapists employed full-time by a facility. SAS Name: OCPTNL_THRPST_FLTM_CNT COBOL Name: OCPTNL-THRPST-FLTM-CNT Staff Count: OT - Part-Time 8 1317 1324 NUMBER Description: Number of full-time equivalent occupational therapists employed part-time by a facility. SAS Name: OCPTNL_THRPST_PRTM_CNT COBOL Name: OCPTNL-THRPST-PRTM-CNT Staff Count: OT Aide - Contract 8 1325 1332 NUMBER Description: Number of full-time equivalent occupational therapy aides under contract to a facility. SAS Name: OT_AIDE_CNTRCT_CNT COBOL Name: OT-AIDE-CNTRCT-CNT Staff Count: OT Aide - Full-Time 8 1333 1340 NUMBER Description: Number of full-time equivalent occupational therapy aides employed full-time by a facility. SAS Name: OT_AIDE_FLTM_CNT COBOL Name: OT-AIDE-FLTM-CNT Staff Count: OT Aide - Part-Time 8 1341 1348 NUMBER Description: Number of full-time equivalent occupational therapy aides employed part-time by a facility. SAS Name: OT_AIDE_PRTM_CNT COBOL Name: OT-AIDE-PRTM-CNT Staff Count: OT Assistant - Contract 8 1349 1356 NUMBER Description: Number of full-time equivalent occupational therapy assistants under contract to a facility. SAS Name: OT_ASTNT_CNTRCT_CNT COBOL Name: OT-ASTNT-CNTRCT-CNT Staff Count: OT Assistant - Full-Time 8 1357 1364 NUMBER Description: Number of full-time equivalent occupational therapy assistants employed full-time by a facility. SAS Name: OT_ASTNT_FLTM_CNT COBOL Name: OT-ASTNT-FLTM-CNT Staff Count: OT Assistant - Part-Time 8 1365 1372 NUMBER Description: Number of full-time equivalent occupational therapy assistants employed part-time by a facility. SAS Name: OT_ASTNT_PRTM_CNT COBOL Name: OT-ASTNT-PRTM-CNT Staff Count: Other Activities - Contract 8 1381 1388 NUMBER Description: Number of full-time equivalent other activities staff providing therapeutic services under contract to a facility. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 34 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: ACTVTY_STF_OTHR_CNTRCT_CNT COBOL Name: ACTVTY-STF-OTHR-CNTRCT-CNT Staff Count: Other Activities - Full-Time 8 1389 1396 NUMBER Description: Number of full-time equivalent other activities staff providing therapeutic services employed full time by a facility. SAS Name: ACTVTY_STF_OTHR_FLTM_CNT COBOL Name: ACTVTY-STF-OTHR-FLTM-CNT Staff Count: Other Activities - Part-Time 8 1397 1404 NUMBER Description: Number of full-time equivalent other activities staff providing therapeutic services employed part time by a facility. SAS Name: ACTVTY_STF_OTHR_PRTM_CNT COBOL Name: ACTVTY-STF-OTHR-PRTM-CNT Staff Count: Other Physician - Contract 8 1405 1412 NUMBER Description: Number of full-time equivalent other physicians under contract to a facility. SAS Name: PHYSN_OTHR_CNTRCT_CNT COBOL Name: PHYSN-OTHR-CNTRCT-CNT Staff Count: Other Physician - Full-Time 8 1413 1420 NUMBER Description: Number of full-time equivalent other physicians employed full-time by a facility. SAS Name: PHYSN_OTHR_FLTM_CNT COBOL Name: PHYSN-OTHR-FLTM-CNT Staff Count: Other Physician - Part-Time 8 1421 1428 NUMBER Description: Number of full-time equivalent other physicians employed part-time by a facility. SAS Name: PHYSN_OTHR_PRTM_CNT COBOL Name: PHYSN-OTHR-PRTM-CNT Staff Count: Other Social Services - Contract 8 1429 1436 NUMBER Description: Number of full-time equivalent other social services staff under contract to a facility. SAS Name: SCL_SRVC_OTHR_STF_CNTRCT_CNT COBOL Name: SCL-SRVC-OTHR-STF-CNTRCT-CNT Staff Count: Other Social Services - Full-Time 8 1437 1444 NUMBER Description: Number of full-time equivalent other social services staff employed full time by a facility. SAS Name: SCL_SRVC_OTHR_STF_FLTM_CNT COBOL Name: SCL-SRVC-OTHR-STF-FLTM-CNT Staff Count: Other Social Services - Part-Time 8 1445 1452 NUMBER Description: Number of full-time equivalent other social services staff employed part time by a facility. SAS Name: SCL_SRVC_OTHR_STF_PRTM_CNT COBOL Name: SCL-SRVC-OTHR-STF-PRTM-CNT Staff Count: Other Staff - Contract 8 1453 1460 NUMBER Description: Number of full-time equivalent staff not included in any other categories under contract to the facility. SAS Name: STF_OTHR_CNTRCT_CNT COBOL Name: STF-OTHR-CNTRCT-CNT Staff Count: Other Staff - Full-Time 8 1461 1468 NUMBER Description: Number of full-time equivalent persons not included in any other categories employed full-time by the facility. SAS Name: STF_OTHR_FLTM_CNT COBOL Name: STF-OTHR-FLTM-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 35 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Staff Count: Other Staff - Part-Time 8 1469 1476 NUMBER Description: Number of full-time equivalent persons not included in any other categories employed part-time by the facility. SAS Name: STF_OTHR_PRTM_CNT COBOL Name: STF-OTHR-PRTM-CNT Staff Count: Pharmacist - Contract 8 1477 1484 NUMBER Description: Number of full-time equivalent pharmacists under contract to a facility. SAS Name: PHRMCST_CNTRCT_CNT COBOL Name: PHRMCST-CNTRCT-CNT Staff Count: Pharmacist - Full-Time 8 1485 1492 NUMBER Description: Number of full-time equivalent pharmacists employed full-time by a facility. SAS Name: PHRMCST_FLTM_CNT COBOL Name: PHRMCST-FLTM-CNT Staff Count: Pharmacist - Part-Time 8 1493 1500 NUMBER Description: Number of full-time equivalent pharmacists employed part-time by a facility. SAS Name: PHRMCST_PRTM_CNT COBOL Name: PHRMCST-PRTM-CNT Staff Count: Physical Therapist - Contract 8 1501 1508 NUMBER Description: Number of full-time equivalent physical therapists under contract to a facility. SAS Name: PHYS_THRPST_CNTRCT_CNT COBOL Name: PHYS-THRPST-CNTRCT-CNT Staff Count: Physical Therapist - Full-Time 8 1509 1516 NUMBER Description: Number of full-time equivalent physical therapists employed full-time by a facility. SAS Name: PHYS_THRPST_FLTM_CNT COBOL Name: PHYS-THRPST-FLTM-CNT Staff Count: Physical Therapist - Part-Time 8 1517 1524 NUMBER Description: Number of full-time equivalent physical therapists employed part-time by a facility. SAS Name: PHYS_THRPST_PRTM_CNT COBOL Name: PHYS-THRPST-PRTM-CNT Staff Count: Physician Extender - Contract 8 1549 1556 NUMBER Description: Number of full-time equivalent physician extenders under contract to the facility. SAS Name: PHYSN_EXT_CNTRCT_CNT COBOL Name: PHYSN-EXT-CNTRCT-CNT Staff Count: Physician Extender - Full-Time 8 1557 1564 NUMBER Description: Number of full-time equivalent physician extenders employed full-time by the facility. SAS Name: PHYSN_EXT_FLTM_CNT COBOL Name: PHYSN-EXT-FLTM-CNT Staff Count: Physician Extender - Part-Time 8 1565 1572 NUMBER Description: Number of full-time equivalent physician extenders employed part-time by the facility. SAS Name: PHYSN_EXT_PRTM_CNT COBOL Name: PHYSN-EXT-PRTM-CNT Staff Count: Podiatrist - Contract 8 1581 1588 NUMBER Description: Number of full-time equivalent podiatrists under contract to a facility. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 36 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: PDTRST_CNTRCT_CNT COBOL Name: PDTRST-CNTRCT-CNT Staff Count: Podiatrist - Full-Time 8 1589 1596 NUMBER Description: Number of full-time equivalent podiatrists employed full-time by a facility. SAS Name: PDTRST_FLTM_CNT COBOL Name: PDTRST-FLTM-CNT Staff Count: Podiatrist - Part-Time 8 1597 1604 NUMBER Description: Number of full-time equivalent podiatrists employed part-time by a facility. SAS Name: PDTRST_PRTM_CNT COBOL Name: PDTRST-PRTM-CNT Staff Count: PT Aide - Contract 8 1637 1644 NUMBER Description: Number of full-time equivalent physical therapy aides under contract to a facility. SAS Name: PT_AIDE_CNTRCT_CNT COBOL Name: PT-AIDE-CNTRCT-CNT Staff Count: PT Aide - Full-Time 8 1645 1652 NUMBER Description: Number of full-time equivalent physical therapy aides employed full-time by a facility. SAS Name: PT_AIDE_FLTM_CNT COBOL Name: PT-AIDE-FLTM-CNT Staff Count: PT Aide - Part-Time 8 1653 1660 NUMBER Description: Number of full-time equivalent physical therapy aides employed part-time by a facility. SAS Name: PT_AIDE_PRTM_CNT COBOL Name: PT-AIDE-PRTM-CNT Staff Count: PT Assistant - Contract 8 1661 1668 NUMBER Description: Number of full-time equivalent physical therapy assistants under contract to a facility. SAS Name: PT_ASTNT_CNTRCT_CNT COBOL Name: PT-ASTNT-CNTRCT-CNT Staff Count: PT Assistant - Full-Time 8 1669 1676 NUMBER Description: Number of full-time equivalent physical therapy assistants employed full-time by a facility. SAS Name: PT_ASTNT_FLTM_CNT COBOL Name: PT-ASTNT-FLTM-CNT Staff Count: PT Assistant - Part-Time 8 1677 1684 NUMBER Description: Number of full-time equivalent physical therapy assistants employed part-time by a facility. SAS Name: PT_ASTNT_PRTM_CNT COBOL Name: PT-ASTNT-PRTM-CNT Staff Count: Qualified Activities Professional - 8 1685 1692 NUMBER Contract Description: Number of full-time equivalent qualified activities professionals providing therapeutic services under contract to a facility. SAS Name: ACTVTY_PROFNL_CNTRCT_CNT COBOL Name: ACTVTY-PROFNL-CNTRCT-CNT Staff Count: Qualified Activities Professional - 8 1693 1700 NUMBER Full-Time Description: Number of full-time equivalent qualified activities professionals providing therapeutic services employed full time by a facility. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 37 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: ACTVTY_PROFNL_FLTM_CNT COBOL Name: ACTVTY-PROFNL-FLTM-CNT Staff Count: Qualified Activities Professional - 8 1701 1708 NUMBER Part-Time Description: Number of full-time equivalent qualified activities professionals providing therapeutic services employed part time by a facility. SAS Name: ACTVTY_PROFNL_PRTM_CNT COBOL Name: ACTVTY-PROFNL-PRTM-CNT Staff Count: RN - Contract 8 1741 1748 NUMBER Description: Number of full-time equivalent registered nurses under contract to a facility. SAS Name: RN_CNTRCT_CNT COBOL Name: RN-CNTRCT-CNT Staff Count: RN - Full-Time 8 1749 1756 NUMBER Description: Number of full-time equivalent registered nurses employed full-time by a facility. SAS Name: RN_FLTM_CNT COBOL Name: RN-FLTM-CNT Staff Count: RN - Part-Time 8 1757 1764 NUMBER Description: Number of full-time equivalent registered nurses employed part-time by a facility. SAS Name: RN_PRTM_CNT COBOL Name: RN-PRTM-CNT Staff Count: RN Director of Nursing - Contract 8 1773 1780 NUMBER Description: Number of full-time equivalent registered nurse directors of nursing under contract to a facility. SAS Name: RN_DRCTR_CNTRCT_CNT COBOL Name: RN-DRCTR-CNTRCT-CNT Staff Count: RN Director of Nursing - Full-Time 8 1781 1788 NUMBER Description: Number of full-time equivalent registered nurse directors of nursing employed full-time by a facility. SAS Name: RN_DRCTR_FLTM_CNT COBOL Name: RN-DRCTR-FLTM-CNT Staff Count: RN Director of Nursing - Part-Time 8 1789 1796 NUMBER Description: Number of full-time equivalent registered nurse directors of nursing employed part-time by a facility. SAS Name: RN_DRCTR_PRTM_CNT COBOL Name: RN-DRCTR-PRTM-CNT Staff Count: Social Worker - Contract 8 1805 1812 NUMBER Description: Number of full-time equivalent social workers under contract to a facility. SAS Name: SCL_WORKR_CNTRCT_CNT COBOL Name: SCL-WORKR-CNTRCT-CNT Staff Count: Social Worker - Full-Time 8 1813 1820 NUMBER Description: Number of full-time equivalent social workers employed full-time by a facility. SAS Name: SCL_WORKR_FLTM_CNT COBOL Name: SCL-WORKR-FLTM-CNT Staff Count: Social Worker - Part-Time 8 1821 1828 NUMBER Description: Number of full-time equivalent social workers employed part-time by a facility. SAS Name: SCL_WORKR_PRTM_CNT COBOL Name: SCL-WORKR-PRTM-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 38 Nursing Facility, CATEGORY = "10" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Staff Count: Speech Pathologist - Contract 8 1837 1844 NUMBER Description: Number of full-time equivalent speech pathologists under contract to a facility. SAS Name: SPCH_PTHLGST_CNTRCT_CNT COBOL Name: SPCH-PTHLGST-CNTRCT-CNT Staff Count: Speech Pathologist - Full-Time 8 1845 1852 NUMBER Description: Number of full-time equivalent speech pathologists employed full-time by a facility. SAS Name: SPCH_PTHLGST_FLTM_CNT COBOL Name: SPCH-PTHLGST-FLTM-CNT Staff Count: Speech Pathologist - Part-Time 8 1853 1860 NUMBER Description: Number of full-time equivalent speech pathologists employed part-time by a facility. SAS Name: SPCH_PTHLGST_PRTM_CNT COBOL Name: SPCH-PTHLGST-PRTM-CNT Staff Count: Therapeutic Recreational Specialist - 8 1893 1900 NUMBER Contract Description: Number of full-time equivalent therapeutic recreation specialist staff under contract to a facility. SAS Name: THRPTC_RCRTNL_CNTRCT_CNT COBOL Name: THRPTC-RCRTNL-CNTRCT-CNT Staff Count: Therapeutic Recreational Specialist - 8 1901 1908 NUMBER Full-Time Description: Number of full-time equivalent therapeutic recreation specialist staff employed full-time by a facility. SAS Name: THRPTC_RCRTNL_FLTM_CNT COBOL Name: THRPTC-RCRTNL-FLTM-CNT Staff Count: Therapeutic Recreational Specialist - 8 1909 1916 NUMBER Part-Time Description: Number of full-time equivalent therapeutic recreation specialist staff employed full-time by a facility. SAS Name: THRPTC_RCRTNL_PRTM_CNT COBOL Name: THRPTC-RCRTNL-PRTM-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 1 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Provider Category Subtype Code 2 1 2 VARCHAR2 Description: Identifies the subtype of the provider, within the primary category. Used in reporting to show the breakdown of provider categories, mainly for hospitals and SNFs. SAS Name: PRVDR_CTGRY_SBTYP_CD COBOL Name: PRVDR-CTGRY-SBTYP-CD VALUES: 02=Title 19 Only Provider Category Code 2 3 4 VARCHAR2 Description: Identifies the type of provider participating in the Medicare/Medicaid program. SAS Name: PRVDR_CTGRY_CD COBOL Name: PRVDR-CTGRY-CD VALUES: 11=Intermediate Care Facility/Individuals with Intellectual Disabilities CHOW Count 2 5 6 NUMBER Description: Number of times this provider has undergone a change of ownership. SAS Name: CHOW_CNT COBOL Name: CHOW-CNT CHOW Date 8 7 14 DATE Description: Effective date of the most recent change of ownership for this provider. SAS Name: CHOW_DT COBOL Name: CHOW-DT Address: City 28 15 42 VARCHAR2 Description: City in which the provider is physically located. SAS Name: CITY_NAME COBOL Name: CITY-NAME Compliance: Acceptable POC 1 43 43 VARCHAR2 Description: Indicates if a provider is in compliance with program requirements based on an acceptable plan for correction of deficiencies. SAS Name: ACPTBL_POC_SW COBOL Name: ACPTBL-POC-SW Compliance: Status 1 44 44 VARCHAR2 Description: Compliance status of a provider at the time of certification survey. SAS Name: CMPLNC_STUS_CD COBOL Name: CMPLNC-STUS-CD VALUES: A=IN COMPLIANCE B=NOT IN COMPLIANCE SSA County Code 3 45 47 VARCHAR2 Description: Social Security Administration geographic code indicating the county where the provider is located. SAS Name: SSA_CNTY_CD COBOL Name: SSA-CNTY-CD Cross Ref Provider Number 10 48 57 CHAR Description: Cross reference provider number SAS Name: CROSS_REF_PROVIDER_NUMBER COBOL Name: CROSS-REF-PROVIDER-NUMBER Certification Date 8 58 65 DATE Description: Equal to the exit date of the initial visit of the Health survey for certifications completed after July 28, 2012. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 2 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE For certifications prior to that date, the certification date is equal to the exit date of the initial visit of the Health survey or LSC survey, whichever is later. SAS Name: CRTFCTN_DT COBOL Name: CRTFCTN-DT Eligibility Indicator 1 66 66 VARCHAR2 Description: Indicates if a facility is eligible to participate in the Medicare and/or Medicaid programs. SAS Name: ELGBLTY_SW COBOL Name: ELGBLTY-SW Facility Name 50 67 116 VARCHAR2 Description: Name of the provider certified to participate in the Medicare and/or Medicaid programs. SAS Name: FAC_NAME COBOL Name: FAC-NAME Medicare Administrative Contractor (MAC) or 5 117 121 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_CD COBOL Name: INTRMDRY-CARR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 3 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 4 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 5 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 6 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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 15 122 136 VARCHAR2 Description: Number which may be assigned to a provider by the state Medicaid agency for external control or billing purposes. SAS Name: MDCD_VNDR_NUM COBOL Name: MDCD-VNDR-NUM Original Participation Date 8 137 144 DATE Description: Date a provider is first approved to provide Medicare and/or Medicaid services. SAS Name: ORGNL_PRTCPTN_DT COBOL Name: ORGNL-PRTCPTN-DT Prior CHOW Date 8 145 152 DATE Description: Effective date of the previous change of ownership for this provider. SAS Name: CHOW_PRIOR_DT COBOL Name: CHOW-PRIOR-DT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 7 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Prior Medicare Administrative Contractor (MAC) or 5 153 157 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the previous Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_PRIOR_CD COBOL Name: INTRMDRY-CARR-PRIOR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 8 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 9 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 10 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 11 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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) CCN 10 158 167 VARCHAR2 Description: Six or ten position identification number that is assigned to a certified provider. This is the CMS Certification Number. SAS Name: PRVDR_NUM COBOL Name: PRVDR-NUM Region Code 2 168 169 VARCHAR2 Description: Indicates the CMS Regional Office responsible for the certification of the provider. SAS Name: RGN_CD COBOL Name: RGN-CD VALUES: 01=Boston 02=New York 03=Philadelphia 04=Atlanta 05=Chicago 06=Dallas 07=Kansas City 08=Denver 09=San Francisco 10=Seattle Skeleton Record Indicator 1 170 170 VARCHAR2 Description: Indicates if the record is a skeleton record. Only a limited set of data is available for this provider; no survey data exists. SAS Name: SKLTN_REC_SW COBOL Name: SKLTN-REC-SW State Abbreviation 2 171 172 VARCHAR2 Description: Two-character state abbreviation. SAS Name: STATE_CD COBOL Name: STATE-CD VALUES: AK=ALASKA AL=ALABAMA DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 12 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE AR=ARKANSAS AS=AMERICAN SAMOA AZ=ARIZONA CA=CALIFORNIA CN=CANADA CO=COLORADO CT=CONNECTICUT DC=DISTRICT OF COLUMBIA DE=DELAWARE FL=FLORIDA FN=INTERNATIONAL GA=GEORGIA GU=GUAM HI=HAWAII IA=IOWA ID=IDAHO IL=ILLINOIS IN=INDIANA KS=KANSAS KY=KENTUCKY LA=LOUISIANA MA=MASSACHUSETTS MD=MARYLAND ME=MAINE MI=MICHIGAN MN=MINNESOTA MO=MISSOURI MP=SAIPAN MS=MISSISSIPPI MT=MONTANA MX=MEXICO NC=NORTH CAROLINA ND=NORTH DAKOTA NE=NEBRASKA NH=NEW HAMPSHIRE NJ=NEW JERSEY NM=NEW MEXICO NV=NEVADA NY=NEW YORK OH=OHIO OK=OKLAHOMA OR=OREGON PA=PENNSYLVANIA PR=PUERTO RICO RI=RHODE ISLAND SC=SOUTH CAROLINA SD=SOUTH DAKOTA TN=TENNESSEE TX=TEXAS UT=UTAH VA=VIRGINIA VI=VIRGIN ISLANDS VT=VERMONT WA=WASHINGTON WI=WISCONSIN WV=WEST VIRGINIA WY=WYOMING SSA State Code 2 173 174 VARCHAR2 Description: Social Security Administration geographic code indicating the state where the provider is located. SAS Name: SSA_STATE_CD COBOL Name: SSA-STATE-CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 13 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 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 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 56=CANADA 57=WEST INDIES 58=EUROPE 59=MEXICO 60=OCEANIA 61=PHILIPPINES 62=SOUTH AMERICA 63=UNITED STATES POSSESSIONS 64=AMERICAN SAMOA DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 14 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 65=GUAM 66=SAIPAN 99=INTERNATIONAL State Region Code 3 175 177 VARCHAR2 Description: Identifies the region within a state where the provider is located. SAS Name: STATE_RGN_CD COBOL Name: STATE-RGN-CD VALUES: AK/001=ALASKA AK/LAB=LABORATORIES AL/001=ALABAMA AL/LAB=LABORATORIES AR/001=ARKANSAS AR/LAB=LABORATORIES AS/001=AMERICAN SAMOA AS/LAB=LABORATORY AZ/AZ=PHOENIX AZ/LAB=ARIZONA LAB AZ/TUC=TUCSON CA/BAK=BAKERSFIELD CA/BER=SAN BERNARDINO CA/BK=BERKELEY CA/BK1=CONTRA COSTA CA/FR=FRESNO CA/L1=L.A. WEST CA/L2=L.A. NORTH CA/L3=L.A. CENTRAL CA/L4=L.A. EAST CA/L5=SAN GABRIEL CA/LAB=LABORATORIES CA/M1=LAB. SOUTH CA/M2=LAB. NORTH CA/ORG=ORANGE CO CA/RIV=RIVERSIDE CA/RWC=REDWOOD COAST CA/S1=SACRAMENTO CA/S2=SACTO SOUTH CA/S3=CHICO CA/SD=SAN DIEGO CA/SDS=SAN DIEGO SOUTH CA/SF=SAN FRANCISCO CA/SJ=SAN JOSE CA/SR=SANTA ROSA CA/VEN=VENTURA CN/001=CANADA CN/LAB=LABORATORY CO/001=COLORADO CO/LAB=LABORATORIES CT/001=CONNECTICUT CT/LAB=LABORATORIES DC/001=DISTRICT OF COLUMBIA DC/LAB=LABORATORIES DE/001=DELAWARE DE/LAB=LABORATORIES FL/FTM=FT. MYERS FL/GAI=GAINESVILLE FL/JAX=JACKSONVILLE FL/LAB=LABORATORIES FL/LAN=LANTANA FL/LAU=LAUDERHILL FL/MIA=MIAMI FL/ORL=ORLANDO DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 15 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE FL/PEN=PENSACOLA FL/STP=ST. PETERSBURG FL/TAL=TALLAHASSEE FL/TAM=TAMPA FM/001=FEDERATED STATES OF MICRO FN/001=INTERNATIONAL FN/LAB=LABORATORIES GA/001=GEORGIA GA/GAA=GEORGIA ALL GA/GAC=GEORGIA CENTRAL GA/GAE=GEORGIA EASTERN GA/GAN=GEORGIA NORTH GA/GAS=GEORGIA SOUTH GA/GAW=GEORGIA WESTERN GA/LAB=LABORATORIES GU/001=GUAM GU/LAB=LABORATORIES HI/001=HAWAII HI/LAB=LABORATORIES IA/001=IOWA IA/LAB=LABORATORIES ID/001=IDAHO ID/LAB=LABORATORIES IL/001=ILLINOIS IL/LAB=LABORATORIES IN/001=INDIANA IN/LAB=LABORATORIES KS/KCK=KANSAS CITY KS/KDH=KDHE KS/LAB=LABORATORIES KS/LAW=LAWRENCE KS/NC=NORTH CENTRAL KANSAS KS/NE=NORTH EAST KANSAS KS/NW=NORTH WEST KANSAS KS/SC=SOUTH CENTRAL KANSAS KS/SE=SOUTH EAST KANSAS KS/SW=SOUTH WEST KANSAS KS/WST=WEST KY/2C1=HOPKINSVILLE KY/2C2=LOUISVILLE KY/2C3=LONDON KY/2C4=LEXINGTON KY/LAB=LABORATORIES LA/001=LOUISIANA LA/LA1=NEW ORLEANS LA/LA2=MANDEVILLE LA/LA3=LAFAYETTE LA/LA4=MONROE LA/LA5=SHREVEPORT LA/LA6=ALEXANDRIA LA/LAB=LABORATORIES LA/LB1=CLIA NEW ORLEANS LA/LB5=CLIA SHREVEPORT LA/LB6=CLIA ALEXANDRIA MA/001=MASSACHUSETTS MA/LAB=LABORATORIES MD/001=MARYLAND MD/LAB=LABORATORIES ME/001=MAINE ME/LAB=LABORATORIES MH/001=MARSHALL ISLANDS MI/001=MICHIGAN MI/LAB=LABORATORIES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 16 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE MN/001=MINNESOTA MN/LAB=LABORATORIES MO/01=REGION01 MO/02=REGION02 MO/03=REGION 03 MO/04=REGION 04 MO/05=REGION 05 MO/06=REGION 06 MO/07=REGION 07 MO/1NH=REGION 1 NH MO/2NH=REGION 2 NH MO/3NH=REGION 3 NH MO/4NH=REGION 4 NH MO/5NH=REGION 5 NH MO/6NH=REGION 6 NH MO/7NH=REGION 7 NH MO/LAB=LABORATORIES MO/MO=STATEWIDE MP/001=NORTHERN MARIANA ISLANDS MP/LAB=LABORATORIES MS/001=MISSISSIPPI MS/LAB=LABORATORIES MT/001=MONTANA MT/LAB=LABORATORIES MX/001=MEXICO MX/LAB=LABORATORY NC/LAB=LABORATORIES NC/NCC=NORTH CAROLINA CENTRAL NC/NCE=NORTH CAROLINA EAST NC/NCN=NORTH CAROLINA NORTH NC/NCS=NORTH CAROLINA SOUTH NC/NCW=NORTH CAROLINA WEST ND/001=NORTH DAKOTA ND/LAB=LABORATORIES NE/1=NORTH CENTRAL NE/2=CENTRAL NE/3=NORTHEAST NE/4=SOUTHEAST NE/5=WESTERN NE/LAB=LABORATORIES NH/001=NEW HAMPSHIRE NH/LAB=LABORATORIES NJ/001=NEW JERSEY NJ/LAB=LABORATORIES NM/001=NEW MEXICO NM/LAB=LABORATORIES NV/CC=CARSON CITY NV/LAB=LABORATORIES NV/LV=LAS VEGAS NY/001=BUFFALO NY/002=ROCHESTER NY/003=SYRACUSE NY/004=ALBANY NY/005=NEW ROCHELLE NY/006=NEW YORK CITY NY/007=SUFFOLK/NASSAU COUNTY NY/LAB=LABORATORIES OH/001=OHIO OH/LAB=LABORATORIES OK/001=OKLAHOMA OK/LAB=LABORATORIES OR/001=OFFICE #1 OR/002=OFFICE #2 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 17 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE OR/003=OFFICE #3 OR/LAB=LABORATORIES PA/001=PENNSYLVANIA PA/LAB=LABORATORIES PR/001=PUERTO RICO PR/LAB=LABORATORIES PW/001=PALAU RI/001=RHODE ISLAND RI/LAB=LABORATORIES SC/001=SOUTH CAROLINA SC/LAB=LABORATORIES SD/001=SOUTH DAKOTA SD/LAB=LABORATORIES TN/LAB=LABORATORIES TN/TNC=TENNESSEE COOKEVILLE TN/TNE=TENNESSEE EASTERN TN/TNM=TENNESSEE MIDDLE TN/TNW=TENNESSEE WESTERN TX/001=TEXAS TX/L01=AMARILLO-LTC TX/L02=ABILENE-LTC TX/L03=ARLINGTON-LTC TX/L04=TYLER-LTC TX/L05=BEAUMONT-LTC TX/L06=HOUSTON-LTC TX/L07=TEMPLE-LTC TX/L08=SAN ANTONIO-LTC TX/L09=SAN ANGELO-LTC TX/L10=EL PASO-LTC TX/L11=CORPUS CHRISTI-LTC TX/LAB=LABORATORIES TX/TX1=LUBBOCK TX/TX2=ARLINGTON TX/TX3=SAN ANTONIO TX/TX4=HOUSTON TX/TX5=TYLER TX/TX6=AUSTIN UT/001=UTAH UT/LAB=LABORATORIES VA/001=VIRGINIA VA/LAB=LABORATORIES VI/001=VIRGIN ISLANDS VI/LAB=LABORATORIES VT/001=VERMONT VT/LAB=LABORATORIES WA/001=ALL OTHERS (NON-LTC FAC) WA/D1=SPOKANE & YAKIMA AREAS WA/D1A=District 1, Unit A WA/D1B=District 1, Unit B WA/D1C=District 1, Unit C WA/D1D=District 1, Unit D WA/D2=SPOKANE & SE WA/D2A=District 2, Unit A WA/D2B=District 2, Unit B WA/D2C=District 2, Unit C WA/D2D=District 2, Unit D WA/D2E=District 2, Unit E WA/D2F=District 2, Unit F WA/D2G=District 2, Unit G WA/D3=NW WASHINGTON WA/D3A=District 3, Unit A WA/D3B=District 3, Unit B WA/D3C=District 3, Unit C DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 18 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE WA/D3D=District 3, Unit D WA/D3E=District 3, Unit E WA/D4A=GREATER SEATTLE AREA WA/D4B=S KING COUNTY WA/D5A=PIERCE CTY & PENINSULA WA/D5B=PIERCE CTY & GRAYS HARBOR WA/D6=OLYMPIA AREA WA/LAB=LABORATORIES WI/001=WISCONSIN WI/LAB=LABORATORIES WV/001=WEST VIRGINIA WV/LAB=LABORATORIES WY/001=WYOMING WY/LAB=LABORATORIES Address: Street 50 178 227 VARCHAR2 Description: Street address where the provider is located. SAS Name: ST_ADR COBOL Name: ST-ADR Telephone Number 10 228 237 VARCHAR2 Description: Telephone number of the provider. SAS Name: PHNE_NUM COBOL Name: PHNE-NUM Termination Code 2 238 239 VARCHAR2 Description: Indicates the current termination status for the provider. SAS Name: PGM_TRMNTN_CD COBOL Name: PGM-TRMNTN-CD VALUES: 00=ACTIVE PROVIDER 01=VOLUNTARY-MERGER, CLOSURE 02=VOLUNTARY-DISSATISFACTION WITH REIMBURSEMENT 03=VOLUNTARY-RISK OF INVOLUNTARY TERMINATION 04=VOLUNTARY-OTHER REASON FOR WITHDRAWAL 05=INVOLUNTARY-FAILURE TO MEET HEALTH/SAFETY REQ 06=INVOLUNTARY-FAILURE TO MEET AGREEMENT 07=OTHER-PROVIDER STATUS CHANGE 08=NONPAYMENT OF FEES - CLIA Only 09=REV/UNSUCCESSFUL PARTICIPATION IN PT - CLIA Only 10=REV/OTHER REASON - CLIA Only 11=INCOMPLETE CLIA APPLICATION INFORMATION - CLIA Only 12=NO LONGER PERFORMING TESTS - CLIA Only 13=MULTIPLE TO SINGLE SITE CERTIFICATE - CLIA Only 14=SHARED LABORATORY - CLIA Only 15=FAILURE TO RENEW WAIVER PPM CERTIFICATE - CLIA Only 16=DUPLICATE CLIA NUMBER - CLIA Only 17=MAIL RETURNED NO FORWARD ADDRESS CERT ENDED - CLIA Only 20=NOTIFICATION BANKRUPTCY - CLIA Only 33=ACCREDITATION NOT CONFIRMED - CLIA Only 80=AWAITING STATE APPROVAL 99=OIG ACTION - DO NOT ACTIVATE - CLIA Only Termination or Expiration Date 8 240 247 DATE Description: Date the provider was terminated. For CLIA providers, date the laboratory's certificate was terminated or the expiration date of the current CLIA certificate. SAS Name: TRMNTN_EXPRTN_DT COBOL Name: TRMNTN-EXPRTN-DT Type of Action Code 1 248 248 VARCHAR2 Description: Identifies the reason for the certification. Type of action from the official survey record, CMS 1539 form. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 19 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: CRTFCTN_ACTN_TYPE_CD COBOL Name: CRTFCTN-ACTN-TYPE-CD VALUES: 1=INITIAL 2=RECERTIFICATION 3=TERMINATION 4=CHANGE OF OWNERSHIP 5=VALIDATION 8=FULL SURVEY AFTER COMPLAINT Ownership Type Code 2 249 250 VARCHAR2 Description: Indicates the ownership type of the provider. SAS Name: GNRL_CNTL_TYPE_CD COBOL Name: GNRL-CNTL-TYPE-CD VALUES: 01=PRIVATE NON PROFIT 02=PRIVATE PROPRIETARY 03=STATE 04=CITY/TOWN 05=COUNTY 06=CITY/COUNTY 07=OTHER Address: ZIP Code 5 251 255 VARCHAR2 Description: Five-digit ZIP code for a provider's physical address. SAS Name: ZIP_CD COBOL Name: ZIP-CD FIPS State Code 2 256 257 VARCHAR2 Description: FIPS State Code SAS Name: FIPS_STATE_CD COBOL Name: FIPS-STATE-CD VALUES: 01=ALABAMA 02=ALASKA 04=ARIZONA 05=ARKANSAS 06=CALIFORNIA 08=COLORADO 09=CONNECTICUT 10=DELAWARE 11=DISTRICT OF COLUMBIA 12=FLORIDA 13=GEORGIA 15=HAWAII 16=IDAHO 17=ILLINOIS 18=INDIANA 19=IOWA 20=KANSAS 21=KENTUCKY 22=LOUISIANA 23=MAINE 24=MARYLAND 25=MASSACHUSETTS 26=MICHIGAN 27=MINNESOTA 28=MISSISSIPPI 29=MISSOURI 30=MONTANA 31=NEBRASKA 32=NEVADA 33=NEW HAMPSHIRE 34=NEW JERSEY 35=NEW MEXICO 36=NEW YORK DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 20 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 37=NORTH CAROLINA 38=NORTH DAKOTA 39=OHIO 40=OKLAHOMA 41=OREGON 42=PENNSYLVANIA 43=PUERTO RICO 44=RHODE ISLAND 45=SOUTH CAROLINA 46=SOUTH DAKOTA 47=TENNESSEE 48=TEXAS 49=UTAH 50=VERMONT 51=VIRGINIA 53=WASHINGTON 54=WEST VIRGINIA 55=WISCONSIN 56=WYOMING 64=AMERICAN SAMOA 65=GUAM 66=SAIPAN/MARIANA IS. 78=VIRGIN ISLANDS FIPS County Code 3 258 260 VARCHAR2 Description: FIPS County Code SAS Name: FIPS_CNTY_CD COBOL Name: FIPS-CNTY-CD CBSA Urban Rural Indicator 1 261 261 VARCHAR2 Description: CBSA (Core Based Statistical Area) indicates whether the county is defined as Urban or Rural. SAS Name: CBSA_URBN_RRL_IND COBOL Name: CBSA-URBN-RRL-IND CBSA Code 5 262 266 VARCHAR2 Description: CBSA (Core Based Statistical Area) geographic entities defined by the U.S. Office of Management and Budget (OMB) on June 6, 2003 for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics. CBSA collectively refers to MSA. SAS Name: CBSA_CD COBOL Name: CBSA-CD Bed Count Override Indicator 1 325 325 CHAR Description: Indicates if the regional office has approved a significant bed count change from the previous certification. SAS Name: OVRRD_BED_CNT_SW COBOL Name: OVRRD-BED-CNT-SW Bed Count: Certified 4 326 329 NUMBER Description: Number of beds in Medicare and/or Medicaid certified areas within a facility. SAS Name: CRTFD_BED_CNT COBOL Name: CRTFD-BED-CNT Bed Count: Certified - Total 4 330 333 NUMBER Description: Number of certified beds in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID). SAS Name: ICFIID_BED_CNT COBOL Name: ICFIID-BED-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 21 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Bed Count: Total 4 373 376 NUMBER Description: Total number of beds in a provider, including those in non-participating or non-licensed areas. SAS Name: BED_CNT COBOL Name: BED-CNT Compliance: Beds Per Room Waiver Indicator 1 444 444 CHAR Description: Indicates if a waiver of the beds per room requirement has been recommended for a facility. SAS Name: BED_PER_ROOM_WVR_SW COBOL Name: BED-PER-ROOM-WVR-SW Compliance: LSC Waiver Indicator 1 445 445 CHAR Description: Indicates if a waiver of any life safety code provision has been recommended for a provider. SAS Name: LSC_WVR_SW COBOL Name: LSC-WVR-SW Compliance: Patient Room Size Waiver Indicator 1 446 446 CHAR Description: Indicates if a waiver of the patient room size provision has been recommended for a provider. SAS Name: ROOM_SIZE_WVR_SW COBOL Name: ROOM-SIZE-WVR-SW Fiscal Year End Date (MMDD) 4 464 467 VARCHAR2 Description: End date, consisting of the month and day, of the provider's fiscal year. SAS Name: FY_END_MO_DAY_CD COBOL Name: FY-END-MO-DAY-CD Program Participation Code 1 623 623 CHAR Description: Indicates if the provider participates in Medicare, Medicaid, or both programs. SAS Name: PGM_PRTCPTN_CD COBOL Name: PGM-PRTCPTN-CD VALUES: 1=MEDICARE ONLY 2=MEDICAID ONLY 3=MEDICARE AND MEDICAID Provider Based Facility Indicator 1 624 624 VARCHAR2 Description: Indicates if an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) facility is provider-based, a distinct part of a Hospital, Skilled Nursing Facility or Nursing Facility. Related CCN is found in the Provider Auxiliary Facility Table. SAS Name: PRVDR_BSD_FAC_SW COBOL Name: PRVDR-BSD-FAC-SW Related Provider Number 10 669 678 CHAR Description: Related provider number SAS Name: RELATED_PROVIDER_NUMBER COBOL Name: RELATED-PROVIDER-NUMBER Staff Count: Direct Care 8 997 1004 NUMBER Description: Number of full-time equivalent direct care personnel employed by an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID). SAS Name: DRCT_CARE_PRSNEL_CNT COBOL Name: DRCT-CARE-PRSNEL-CNT Staff Count: LPN/LVN - Employee 8 1093 1100 NUMBER Description: Number of full-time equivalent licensed practical or DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 22 Intermediate Care Facility/Individuals with Intellectual Disabilities, CATEGORY = "11" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE vocational nurses employed by a provider. SAS Name: LPN_LVN_CNT COBOL Name: LPN-LVN-CNT Staff Count: RN 8 1733 1740 NUMBER Description: Number of full-time equivalent registered nurses employed by a provider. SAS Name: RN_CNT COBOL Name: RN-CNT Staff Count: Total - Employee 9 1917 1925 NUMBER Description: Total number of full-time equivalent employees of a provider. SAS Name: EMPLEE_CNT COBOL Name: EMPLEE-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 1 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Provider Category Subtype Code 2 1 2 VARCHAR2 Description: Identifies the subtype of the provider, within the primary category. Used in reporting to show the breakdown of provider categories, mainly for hospitals and SNFs. SAS Name: PRVDR_CTGRY_SBTYP_CD COBOL Name: PRVDR-CTGRY-SBTYP-CD VALUES: 01=Rural Health Clinics Provider Category Code 2 3 4 VARCHAR2 Description: Identifies the type of provider participating in the Medicare/Medicaid program. SAS Name: PRVDR_CTGRY_CD COBOL Name: PRVDR-CTGRY-CD VALUES: 12=Rural Health Clinic CHOW Count 2 5 6 NUMBER Description: Number of times this provider has undergone a change of ownership. SAS Name: CHOW_CNT COBOL Name: CHOW-CNT CHOW Date 8 7 14 DATE Description: Effective date of the most recent change of ownership for this provider. SAS Name: CHOW_DT COBOL Name: CHOW-DT Address: City 28 15 42 VARCHAR2 Description: City in which the provider is physically located. SAS Name: CITY_NAME COBOL Name: CITY-NAME Compliance: Acceptable POC 1 43 43 VARCHAR2 Description: Indicates if a provider is in compliance with program requirements based on an acceptable plan for correction of deficiencies. SAS Name: ACPTBL_POC_SW COBOL Name: ACPTBL-POC-SW Compliance: Status 1 44 44 VARCHAR2 Description: Compliance status of a provider at the time of certification survey. SAS Name: CMPLNC_STUS_CD COBOL Name: CMPLNC-STUS-CD VALUES: A=IN COMPLIANCE B=NOT IN COMPLIANCE SSA County Code 3 45 47 VARCHAR2 Description: Social Security Administration geographic code indicating the county where the provider is located. SAS Name: SSA_CNTY_CD COBOL Name: SSA-CNTY-CD Cross Ref Provider Number 10 48 57 CHAR Description: Cross reference provider number SAS Name: CROSS_REF_PROVIDER_NUMBER COBOL Name: CROSS-REF-PROVIDER-NUMBER Certification Date 8 58 65 DATE Description: Equal to the exit date of the initial visit of the Health survey for certifications completed after July 28, 2012. For certifications prior to that date, the certification DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 2 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE date is equal to the exit date of the initial visit of the Health survey or LSC survey, whichever is later. SAS Name: CRTFCTN_DT COBOL Name: CRTFCTN-DT Eligibility Indicator 1 66 66 VARCHAR2 Description: Indicates if a facility is eligible to participate in the Medicare and/or Medicaid programs. SAS Name: ELGBLTY_SW COBOL Name: ELGBLTY-SW Facility Name 50 67 116 VARCHAR2 Description: Name of the provider certified to participate in the Medicare and/or Medicaid programs. SAS Name: FAC_NAME COBOL Name: FAC-NAME Medicare Administrative Contractor (MAC) or 5 117 121 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_CD COBOL Name: INTRMDRY-CARR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 3 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 4 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 5 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 6 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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 15 122 136 VARCHAR2 Description: Number which may be assigned to a provider by the state Medicaid agency for external control or billing purposes. SAS Name: MDCD_VNDR_NUM COBOL Name: MDCD-VNDR-NUM Original Participation Date 8 137 144 DATE Description: Date a provider is first approved to provide Medicare and/or Medicaid services. SAS Name: ORGNL_PRTCPTN_DT COBOL Name: ORGNL-PRTCPTN-DT Prior CHOW Date 8 145 152 DATE Description: Effective date of the previous change of ownership for this provider. SAS Name: CHOW_PRIOR_DT COBOL Name: CHOW-PRIOR-DT Prior Medicare Administrative Contractor (MAC) or 5 153 157 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the previous Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_PRIOR_CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 7 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: INTRMDRY-CARR-PRIOR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 00520=BLUE SHIELD (ARKANSAS) 00528=BLUE SHIELD (ARKANSAS/LOUISIANA) 00542=BLUE SHIELD (CALIFORNIA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 8 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00550=BLUE SHIELD (COLORADO) 00570=BLUE SHIELD (DELAWARE) 00580=BLUE SHIELD (DISTRICT OF COLUMBIA) 00590=BLUE SHIELD (FLORIDA) 00621=BLUE SHIELD (ILLINOIS) 00630=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 9 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 10 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 11 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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) CCN 10 158 167 VARCHAR2 Description: Six or ten position identification number that is assigned to a certified provider. This is the CMS Certification Number. SAS Name: PRVDR_NUM COBOL Name: PRVDR-NUM Region Code 2 168 169 VARCHAR2 Description: Indicates the CMS Regional Office responsible for the certification of the provider. SAS Name: RGN_CD COBOL Name: RGN-CD VALUES: 01=Boston 02=New York 03=Philadelphia 04=Atlanta 05=Chicago 06=Dallas 07=Kansas City 08=Denver 09=San Francisco 10=Seattle Skeleton Record Indicator 1 170 170 VARCHAR2 Description: Indicates if the record is a skeleton record. Only a limited set of data is available for this provider; no survey data exists. SAS Name: SKLTN_REC_SW COBOL Name: SKLTN-REC-SW State Abbreviation 2 171 172 VARCHAR2 Description: Two-character state abbreviation. SAS Name: STATE_CD COBOL Name: STATE-CD VALUES: AK=ALASKA AL=ALABAMA AR=ARKANSAS AS=AMERICAN SAMOA AZ=ARIZONA CA=CALIFORNIA CN=CANADA CO=COLORADO CT=CONNECTICUT DC=DISTRICT OF COLUMBIA DE=DELAWARE FL=FLORIDA FN=INTERNATIONAL DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 12 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA=GEORGIA GU=GUAM HI=HAWAII IA=IOWA ID=IDAHO IL=ILLINOIS IN=INDIANA KS=KANSAS KY=KENTUCKY LA=LOUISIANA MA=MASSACHUSETTS MD=MARYLAND ME=MAINE MI=MICHIGAN MN=MINNESOTA MO=MISSOURI MP=SAIPAN MS=MISSISSIPPI MT=MONTANA MX=MEXICO NC=NORTH CAROLINA ND=NORTH DAKOTA NE=NEBRASKA NH=NEW HAMPSHIRE NJ=NEW JERSEY NM=NEW MEXICO NV=NEVADA NY=NEW YORK OH=OHIO OK=OKLAHOMA OR=OREGON PA=PENNSYLVANIA PR=PUERTO RICO RI=RHODE ISLAND SC=SOUTH CAROLINA SD=SOUTH DAKOTA TN=TENNESSEE TX=TEXAS UT=UTAH VA=VIRGINIA VI=VIRGIN ISLANDS VT=VERMONT WA=WASHINGTON WI=WISCONSIN WV=WEST VIRGINIA WY=WYOMING SSA State Code 2 173 174 VARCHAR2 Description: Social Security Administration geographic code indicating the state where the provider is located. SAS Name: SSA_STATE_CD COBOL Name: SSA-STATE-CD 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 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 13 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 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 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 99=INTERNATIONAL State Region Code 3 175 177 VARCHAR2 Description: Identifies the region within a state where the provider is located. SAS Name: STATE_RGN_CD COBOL Name: STATE-RGN-CD VALUES: AK/001=ALASKA AK/LAB=LABORATORIES AL/001=ALABAMA AL/LAB=LABORATORIES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 14 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE AR/001=ARKANSAS AR/LAB=LABORATORIES AS/001=AMERICAN SAMOA AS/LAB=LABORATORY AZ/AZ=PHOENIX AZ/LAB=ARIZONA LAB AZ/TUC=TUCSON CA/BAK=BAKERSFIELD CA/BER=SAN BERNARDINO CA/BK=BERKELEY CA/BK1=CONTRA COSTA CA/FR=FRESNO CA/L1=L.A. WEST CA/L2=L.A. NORTH CA/L3=L.A. CENTRAL CA/L4=L.A. EAST CA/L5=SAN GABRIEL CA/LAB=LABORATORIES CA/M1=LAB. SOUTH CA/M2=LAB. NORTH CA/ORG=ORANGE CO CA/RIV=RIVERSIDE CA/RWC=REDWOOD COAST CA/S1=SACRAMENTO CA/S2=SACTO SOUTH CA/S3=CHICO CA/SD=SAN DIEGO CA/SDS=SAN DIEGO SOUTH CA/SF=SAN FRANCISCO CA/SJ=SAN JOSE CA/SR=SANTA ROSA CA/VEN=VENTURA CN/001=CANADA CN/LAB=LABORATORY CO/001=COLORADO CO/LAB=LABORATORIES CT/001=CONNECTICUT CT/LAB=LABORATORIES DC/001=DISTRICT OF COLUMBIA DC/LAB=LABORATORIES DE/001=DELAWARE DE/LAB=LABORATORIES FL/FTM=FT. MYERS FL/GAI=GAINESVILLE FL/JAX=JACKSONVILLE FL/LAB=LABORATORIES FL/LAN=LANTANA FL/LAU=LAUDERHILL FL/MIA=MIAMI FL/ORL=ORLANDO FL/PEN=PENSACOLA FL/STP=ST. PETERSBURG FL/TAL=TALLAHASSEE FL/TAM=TAMPA FM/001=FEDERATED STATES OF MICRO FN/001=INTERNATIONAL FN/LAB=LABORATORIES GA/001=GEORGIA GA/GAA=GEORGIA ALL GA/GAC=GEORGIA CENTRAL GA/GAE=GEORGIA EASTERN GA/GAN=GEORGIA NORTH GA/GAS=GEORGIA SOUTH GA/GAW=GEORGIA WESTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 15 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA/LAB=LABORATORIES GU/001=GUAM GU/LAB=LABORATORIES HI/001=HAWAII HI/LAB=LABORATORIES IA/001=IOWA IA/LAB=LABORATORIES ID/001=IDAHO ID/LAB=LABORATORIES IL/001=ILLINOIS IL/LAB=LABORATORIES IN/001=INDIANA IN/LAB=LABORATORIES KS/KCK=KANSAS CITY KS/KDH=KDHE KS/LAB=LABORATORIES KS/LAW=LAWRENCE KS/NC=NORTH CENTRAL KANSAS KS/NE=NORTH EAST KANSAS KS/NW=NORTH WEST KANSAS KS/SC=SOUTH CENTRAL KANSAS KS/SE=SOUTH EAST KANSAS KS/SW=SOUTH WEST KANSAS KS/WST=WEST KY/2C1=HOPKINSVILLE KY/2C2=LOUISVILLE KY/2C3=LONDON KY/2C4=LEXINGTON KY/LAB=LABORATORIES LA/001=LOUISIANA LA/LA1=NEW ORLEANS LA/LA2=MANDEVILLE LA/LA3=LAFAYETTE LA/LA4=MONROE LA/LA5=SHREVEPORT LA/LA6=ALEXANDRIA LA/LAB=LABORATORIES LA/LB1=CLIA NEW ORLEANS LA/LB5=CLIA SHREVEPORT LA/LB6=CLIA ALEXANDRIA MA/001=MASSACHUSETTS MA/LAB=LABORATORIES MD/001=MARYLAND MD/LAB=LABORATORIES ME/001=MAINE ME/LAB=LABORATORIES MH/001=MARSHALL ISLANDS MI/001=MICHIGAN MI/LAB=LABORATORIES MN/001=MINNESOTA MN/LAB=LABORATORIES MO/01=REGION01 MO/02=REGION02 MO/03=REGION 03 MO/04=REGION 04 MO/05=REGION 05 MO/06=REGION 06 MO/07=REGION 07 MO/1NH=REGION 1 NH MO/2NH=REGION 2 NH MO/3NH=REGION 3 NH MO/4NH=REGION 4 NH MO/5NH=REGION 5 NH MO/6NH=REGION 6 NH DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 16 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE MO/7NH=REGION 7 NH MO/LAB=LABORATORIES MO/MO=STATEWIDE MP/001=NORTHERN MARIANA ISLANDS MP/LAB=LABORATORIES MS/001=MISSISSIPPI MS/LAB=LABORATORIES MT/001=MONTANA MT/LAB=LABORATORIES MX/001=MEXICO MX/LAB=LABORATORY NC/LAB=LABORATORIES NC/NCC=NORTH CAROLINA CENTRAL NC/NCE=NORTH CAROLINA EAST NC/NCN=NORTH CAROLINA NORTH NC/NCS=NORTH CAROLINA SOUTH NC/NCW=NORTH CAROLINA WEST ND/001=NORTH DAKOTA ND/LAB=LABORATORIES NE/1=NORTH CENTRAL NE/2=CENTRAL NE/3=NORTHEAST NE/4=SOUTHEAST NE/5=WESTERN NE/LAB=LABORATORIES NH/001=NEW HAMPSHIRE NH/LAB=LABORATORIES NJ/001=NEW JERSEY NJ/LAB=LABORATORIES NM/001=NEW MEXICO NM/LAB=LABORATORIES NV/CC=CARSON CITY NV/LAB=LABORATORIES NV/LV=LAS VEGAS NY/001=BUFFALO NY/002=ROCHESTER NY/003=SYRACUSE NY/004=ALBANY NY/005=NEW ROCHELLE NY/006=NEW YORK CITY NY/007=SUFFOLK/NASSAU COUNTY NY/LAB=LABORATORIES OH/001=OHIO OH/LAB=LABORATORIES OK/001=OKLAHOMA OK/LAB=LABORATORIES OR/001=OFFICE #1 OR/002=OFFICE #2 OR/003=OFFICE #3 OR/LAB=LABORATORIES PA/001=PENNSYLVANIA PA/LAB=LABORATORIES PR/001=PUERTO RICO PR/LAB=LABORATORIES PW/001=PALAU RI/001=RHODE ISLAND RI/LAB=LABORATORIES SC/001=SOUTH CAROLINA SC/LAB=LABORATORIES SD/001=SOUTH DAKOTA SD/LAB=LABORATORIES TN/LAB=LABORATORIES TN/TNC=TENNESSEE COOKEVILLE TN/TNE=TENNESSEE EASTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 17 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE TN/TNM=TENNESSEE MIDDLE TN/TNW=TENNESSEE WESTERN TX/001=TEXAS TX/L01=AMARILLO-LTC TX/L02=ABILENE-LTC TX/L03=ARLINGTON-LTC TX/L04=TYLER-LTC TX/L05=BEAUMONT-LTC TX/L06=HOUSTON-LTC TX/L07=TEMPLE-LTC TX/L08=SAN ANTONIO-LTC TX/L09=SAN ANGELO-LTC TX/L10=EL PASO-LTC TX/L11=CORPUS CHRISTI-LTC TX/LAB=LABORATORIES TX/TX1=LUBBOCK TX/TX2=ARLINGTON TX/TX3=SAN ANTONIO TX/TX4=HOUSTON TX/TX5=TYLER TX/TX6=AUSTIN UT/001=UTAH UT/LAB=LABORATORIES VA/001=VIRGINIA VA/LAB=LABORATORIES VI/001=VIRGIN ISLANDS VI/LAB=LABORATORIES VT/001=VERMONT VT/LAB=LABORATORIES WA/001=ALL OTHERS (NON-LTC FAC) WA/D1=SPOKANE & YAKIMA AREAS WA/D1A=District 1, Unit A WA/D1B=District 1, Unit B WA/D1C=District 1, Unit C WA/D1D=District 1, Unit D WA/D2=SPOKANE & SE WA/D2A=District 2, Unit A WA/D2B=District 2, Unit B WA/D2C=District 2, Unit C WA/D2D=District 2, Unit D WA/D2E=District 2, Unit E WA/D2F=District 2, Unit F WA/D2G=District 2, Unit G WA/D3=NW WASHINGTON WA/D3A=District 3, Unit A WA/D3B=District 3, Unit B WA/D3C=District 3, Unit C WA/D3D=District 3, Unit D WA/D3E=District 3, Unit E WA/D4A=GREATER SEATTLE AREA WA/D4B=S KING COUNTY WA/D5A=PIERCE CTY & PENINSULA WA/D5B=PIERCE CTY & GRAYS HARBOR WA/D6=OLYMPIA AREA WA/LAB=LABORATORIES WI/001=WISCONSIN WI/LAB=LABORATORIES WV/001=WEST VIRGINIA WV/LAB=LABORATORIES WY/001=WYOMING WY/LAB=LABORATORIES Address: Street 50 178 227 VARCHAR2 Description: Street address where the provider is located. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 18 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: ST_ADR COBOL Name: ST-ADR Telephone Number 10 228 237 VARCHAR2 Description: Telephone number of the provider. SAS Name: PHNE_NUM COBOL Name: PHNE-NUM Termination Code 2 238 239 VARCHAR2 Description: Indicates the current termination status for the provider. SAS Name: PGM_TRMNTN_CD COBOL Name: PGM-TRMNTN-CD VALUES: 00=ACTIVE PROVIDER 01=VOLUNTARY-MERGER, CLOSURE 02=VOLUNTARY-DISSATISFACTION WITH REIMBURSEMENT 03=VOLUNTARY-RISK OF INVOLUNTARY TERMINATION 04=VOLUNTARY-OTHER REASON FOR WITHDRAWAL 05=INVOLUNTARY-FAILURE TO MEET HEALTH/SAFETY REQ 06=INVOLUNTARY-FAILURE TO MEET AGREEMENT 07=OTHER-PROVIDER STATUS CHANGE 08=NONPAYMENT OF FEES - CLIA Only 09=REV/UNSUCCESSFUL PARTICIPATION IN PT - CLIA Only 10=REV/OTHER REASON - CLIA Only 11=INCOMPLETE CLIA APPLICATION INFORMATION - CLIA Only 12=NO LONGER PERFORMING TESTS - CLIA Only 13=MULTIPLE TO SINGLE SITE CERTIFICATE - CLIA Only 14=SHARED LABORATORY - CLIA Only 15=FAILURE TO RENEW WAIVER PPM CERTIFICATE - CLIA Only 16=DUPLICATE CLIA NUMBER - CLIA Only 17=MAIL RETURNED NO FORWARD ADDRESS CERT ENDED - CLIA Only 20=NOTIFICATION BANKRUPTCY - CLIA Only 33=ACCREDITATION NOT CONFIRMED - CLIA Only 80=AWAITING STATE APPROVAL 99=OIG ACTION - DO NOT ACTIVATE - CLIA Only Termination or Expiration Date 8 240 247 DATE Description: Date the provider was terminated. For CLIA providers, date the laboratory's certificate was terminated or the expiration date of the current CLIA certificate. SAS Name: TRMNTN_EXPRTN_DT COBOL Name: TRMNTN-EXPRTN-DT Type of Action Code 1 248 248 VARCHAR2 Description: Identifies the reason for the certification. Type of action from the official survey record, CMS 1539 form. SAS Name: CRTFCTN_ACTN_TYPE_CD COBOL Name: CRTFCTN-ACTN-TYPE-CD VALUES: 1=INITIAL 2=RECERTIFICATION 3=TERMINATION 4=CHANGE OF OWNERSHIP 5=VALIDATION 8=FULL SURVEY AFTER COMPLAINT Ownership Type Code 2 249 250 VARCHAR2 Description: Indicates the ownership type of the provider. SAS Name: GNRL_CNTL_TYPE_CD COBOL Name: GNRL-CNTL-TYPE-CD VALUES: 03=STATE GOVERNMENT 04=LOCAL GOVERNMENT 05=FEDERAL GOVERNMENT 1A=FOR PROFIT INDIVIDUAL 1B=FOR PROFIT CORPORATION DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 19 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 1C=FOR PROFIT PARTNERSHIP 2A=NON PROFIT INDIVIDUAL 2B=NON PROFIT CORPORATION 2C=NON PROFIT PARTNERSHIP Address: ZIP Code 5 251 255 VARCHAR2 Description: Five-digit ZIP code for a provider's physical address. SAS Name: ZIP_CD COBOL Name: ZIP-CD FIPS State Code 2 256 257 VARCHAR2 Description: FIPS State Code SAS Name: FIPS_STATE_CD COBOL Name: FIPS-STATE-CD VALUES: 01=ALABAMA 02=ALASKA 04=ARIZONA 05=ARKANSAS 06=CALIFORNIA 08=COLORADO 09=CONNECTICUT 10=DELAWARE 11=DISTRICT OF COLUMBIA 12=FLORIDA 13=GEORGIA 15=HAWAII 16=IDAHO 17=ILLINOIS 18=INDIANA 19=IOWA 20=KANSAS 21=KENTUCKY 22=LOUISIANA 23=MAINE 24=MARYLAND 25=MASSACHUSETTS 26=MICHIGAN 27=MINNESOTA 28=MISSISSIPPI 29=MISSOURI 30=MONTANA 31=NEBRASKA 32=NEVADA 33=NEW HAMPSHIRE 34=NEW JERSEY 35=NEW MEXICO 36=NEW YORK 37=NORTH CAROLINA 38=NORTH DAKOTA 39=OHIO 40=OKLAHOMA 41=OREGON 42=PENNSYLVANIA 43=PUERTO RICO 44=RHODE ISLAND 45=SOUTH CAROLINA 46=SOUTH DAKOTA 47=TENNESSEE 48=TEXAS 49=UTAH 50=VERMONT 51=VIRGINIA 53=WASHINGTON 54=WEST VIRGINIA DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 20 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 55=WISCONSIN 56=WYOMING 64=AMERICAN SAMOA 65=GUAM 66=SAIPAN/MARIANA IS. 78=VIRGIN ISLANDS FIPS County Code 3 258 260 VARCHAR2 Description: FIPS County Code SAS Name: FIPS_CNTY_CD COBOL Name: FIPS-CNTY-CD CBSA Urban Rural Indicator 1 261 261 VARCHAR2 Description: CBSA (Core Based Statistical Area) indicates whether the county is defined as Urban or Rural. SAS Name: CBSA_URBN_RRL_IND COBOL Name: CBSA-URBN-RRL-IND CBSA Code 5 262 266 VARCHAR2 Description: CBSA (Core Based Statistical Area) geographic entities defined by the U.S. Office of Management and Budget (OMB) on June 6, 2003 for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics. CBSA collectively refers to MSA. SAS Name: CBSA_CD COBOL Name: CBSA-CD Accreditation Type Code 1 283 283 VARCHAR2 Description: Indicates an accrediting organization deeming the provider. If a provider is deemed by multiple accrediting organizations then the accrediting organization with the earliest active deeming effective date is displayed in this field. SAS Name: ACRDTN_TYPE_CD COBOL Name: ACRDTN-TYPE-CD VALUES: 0=UNACCREDITED 1=AAAASF 2=TCT Fiscal Year End Date (MMDD) 4 464 467 VARCHAR2 Description: End date, consisting of the month and day, of the provider's fiscal year. SAS Name: FY_END_MO_DAY_CD COBOL Name: FY-END-MO-DAY-CD Parent Provider Number 10 611 620 CHAR Description: Parent provider number SAS Name: PARENT_PROVIDER_NUMBER COBOL Name: PARENT-PROVIDER-NUMBER Related Provider Number 10 669 678 CHAR Description: Related provider number SAS Name: RELATED_PROVIDER_NUMBER COBOL Name: RELATED-PROVIDER-NUMBER Staff Count: Other Personnel 8 885 892 NUMBER Description: Number of full-time equivalent other personnel employed by a provider SAS Name: PRSNEL_OTHR_CNT COBOL Name: PRSNEL-OTHR-CNT Staff Count: Nurse Practitioner 8 1261 1268 NUMBER Description: Number of full-time equivalent nurse practitioners employed by a provider. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 21 Rural Health Clinic, CATEGORY = "12" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: NRS_PRCTNR_CNT COBOL Name: NRS-PRCTNR-CNT Staff Count: Physician - Employee 8 1525 1532 NUMBER Description: Number of full-time equivalent physicians employed by a provider. SAS Name: PHYSN_CNT COBOL Name: PHYSN-CNT Staff Count: Physician Assistant 8 1541 1548 NUMBER Description: Number of full-time equivalent physician assistants employed by a provider. SAS Name: PHYSN_ASTNT_CNT COBOL Name: PHYSN-ASTNT-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 1 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Provider Category Subtype Code 2 1 2 VARCHAR2 Description: Identifies the subtype of the provider, within the primary category. Used in reporting to show the breakdown of provider categories, mainly for hospitals and SNFs. SAS Name: PRVDR_CTGRY_SBTYP_CD COBOL Name: PRVDR-CTGRY-SBTYP-CD VALUES: 01=Comprehensive Outpatient Provider Category Code 2 3 4 VARCHAR2 Description: Identifies the type of provider participating in the Medicare/Medicaid program. SAS Name: PRVDR_CTGRY_CD COBOL Name: PRVDR-CTGRY-CD VALUES: 14=Comprehensive Outpatient Rehab Facility CHOW Count 2 5 6 NUMBER Description: Number of times this provider has undergone a change of ownership. SAS Name: CHOW_CNT COBOL Name: CHOW-CNT CHOW Date 8 7 14 DATE Description: Effective date of the most recent change of ownership for this provider. SAS Name: CHOW_DT COBOL Name: CHOW-DT Address: City 28 15 42 VARCHAR2 Description: City in which the provider is physically located. SAS Name: CITY_NAME COBOL Name: CITY-NAME Compliance: Acceptable POC 1 43 43 VARCHAR2 Description: Indicates if a provider is in compliance with program requirements based on an acceptable plan for correction of deficiencies. SAS Name: ACPTBL_POC_SW COBOL Name: ACPTBL-POC-SW Compliance: Status 1 44 44 VARCHAR2 Description: Compliance status of a provider at the time of certification survey. SAS Name: CMPLNC_STUS_CD COBOL Name: CMPLNC-STUS-CD VALUES: A=IN COMPLIANCE B=NOT IN COMPLIANCE SSA County Code 3 45 47 VARCHAR2 Description: Social Security Administration geographic code indicating the county where the provider is located. SAS Name: SSA_CNTY_CD COBOL Name: SSA-CNTY-CD Cross Ref Provider Number 10 48 57 CHAR Description: Cross reference provider number SAS Name: CROSS_REF_PROVIDER_NUMBER COBOL Name: CROSS-REF-PROVIDER-NUMBER Certification Date 8 58 65 DATE Description: Equal to the exit date of the initial visit of the Health survey for certifications completed after July 28, 2012. For certifications prior to that date, the certification DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 2 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE date is equal to the exit date of the initial visit of the Health survey or LSC survey, whichever is later. SAS Name: CRTFCTN_DT COBOL Name: CRTFCTN-DT Eligibility Indicator 1 66 66 VARCHAR2 Description: Indicates if a facility is eligible to participate in the Medicare and/or Medicaid programs. SAS Name: ELGBLTY_SW COBOL Name: ELGBLTY-SW Facility Name 50 67 116 VARCHAR2 Description: Name of the provider certified to participate in the Medicare and/or Medicaid programs. SAS Name: FAC_NAME COBOL Name: FAC-NAME Medicare Administrative Contractor (MAC) or 5 117 121 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_CD COBOL Name: INTRMDRY-CARR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 3 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 4 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 5 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 6 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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 15 122 136 VARCHAR2 Description: Number which may be assigned to a provider by the state Medicaid agency for external control or billing purposes. SAS Name: MDCD_VNDR_NUM COBOL Name: MDCD-VNDR-NUM Original Participation Date 8 137 144 DATE Description: Date a provider is first approved to provide Medicare and/or Medicaid services. SAS Name: ORGNL_PRTCPTN_DT COBOL Name: ORGNL-PRTCPTN-DT Prior CHOW Date 8 145 152 DATE Description: Effective date of the previous change of ownership for this provider. SAS Name: CHOW_PRIOR_DT COBOL Name: CHOW-PRIOR-DT Prior Medicare Administrative Contractor (MAC) or 5 153 157 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the previous Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_PRIOR_CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 7 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: INTRMDRY-CARR-PRIOR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 00520=BLUE SHIELD (ARKANSAS) 00528=BLUE SHIELD (ARKANSAS/LOUISIANA) 00542=BLUE SHIELD (CALIFORNIA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 8 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00550=BLUE SHIELD (COLORADO) 00570=BLUE SHIELD (DELAWARE) 00580=BLUE SHIELD (DISTRICT OF COLUMBIA) 00590=BLUE SHIELD (FLORIDA) 00621=BLUE SHIELD (ILLINOIS) 00630=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 9 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 10 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 11 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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) CCN 10 158 167 VARCHAR2 Description: Six or ten position identification number that is assigned to a certified provider. This is the CMS Certification Number. SAS Name: PRVDR_NUM COBOL Name: PRVDR-NUM Region Code 2 168 169 VARCHAR2 Description: Indicates the CMS Regional Office responsible for the certification of the provider. SAS Name: RGN_CD COBOL Name: RGN-CD VALUES: 01=Boston 02=New York 03=Philadelphia 04=Atlanta 05=Chicago 06=Dallas 07=Kansas City 08=Denver 09=San Francisco 10=Seattle Skeleton Record Indicator 1 170 170 VARCHAR2 Description: Indicates if the record is a skeleton record. Only a limited set of data is available for this provider; no survey data exists. SAS Name: SKLTN_REC_SW COBOL Name: SKLTN-REC-SW State Abbreviation 2 171 172 VARCHAR2 Description: Two-character state abbreviation. SAS Name: STATE_CD COBOL Name: STATE-CD VALUES: AK=ALASKA AL=ALABAMA AR=ARKANSAS AS=AMERICAN SAMOA AZ=ARIZONA CA=CALIFORNIA CN=CANADA CO=COLORADO CT=CONNECTICUT DC=DISTRICT OF COLUMBIA DE=DELAWARE FL=FLORIDA FN=INTERNATIONAL DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 12 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA=GEORGIA GU=GUAM HI=HAWAII IA=IOWA ID=IDAHO IL=ILLINOIS IN=INDIANA KS=KANSAS KY=KENTUCKY LA=LOUISIANA MA=MASSACHUSETTS MD=MARYLAND ME=MAINE MI=MICHIGAN MN=MINNESOTA MO=MISSOURI MP=SAIPAN MS=MISSISSIPPI MT=MONTANA MX=MEXICO NC=NORTH CAROLINA ND=NORTH DAKOTA NE=NEBRASKA NH=NEW HAMPSHIRE NJ=NEW JERSEY NM=NEW MEXICO NV=NEVADA NY=NEW YORK OH=OHIO OK=OKLAHOMA OR=OREGON PA=PENNSYLVANIA PR=PUERTO RICO RI=RHODE ISLAND SC=SOUTH CAROLINA SD=SOUTH DAKOTA TN=TENNESSEE TX=TEXAS UT=UTAH VA=VIRGINIA VI=VIRGIN ISLANDS VT=VERMONT WA=WASHINGTON WI=WISCONSIN WV=WEST VIRGINIA WY=WYOMING SSA State Code 2 173 174 VARCHAR2 Description: Social Security Administration geographic code indicating the state where the provider is located. SAS Name: SSA_STATE_CD COBOL Name: SSA-STATE-CD 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 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 13 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 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 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 99=INTERNATIONAL State Region Code 3 175 177 VARCHAR2 Description: Identifies the region within a state where the provider is located. SAS Name: STATE_RGN_CD COBOL Name: STATE-RGN-CD VALUES: AK/001=ALASKA AK/LAB=LABORATORIES AL/001=ALABAMA AL/LAB=LABORATORIES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 14 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE AR/001=ARKANSAS AR/LAB=LABORATORIES AS/001=AMERICAN SAMOA AS/LAB=LABORATORY AZ/AZ=PHOENIX AZ/LAB=ARIZONA LAB AZ/TUC=TUCSON CA/BAK=BAKERSFIELD CA/BER=SAN BERNARDINO CA/BK=BERKELEY CA/BK1=CONTRA COSTA CA/FR=FRESNO CA/L1=L.A. WEST CA/L2=L.A. NORTH CA/L3=L.A. CENTRAL CA/L4=L.A. EAST CA/L5=SAN GABRIEL CA/LAB=LABORATORIES CA/M1=LAB. SOUTH CA/M2=LAB. NORTH CA/ORG=ORANGE CO CA/RIV=RIVERSIDE CA/RWC=REDWOOD COAST CA/S1=SACRAMENTO CA/S2=SACTO SOUTH CA/S3=CHICO CA/SD=SAN DIEGO CA/SDS=SAN DIEGO SOUTH CA/SF=SAN FRANCISCO CA/SJ=SAN JOSE CA/SR=SANTA ROSA CA/VEN=VENTURA CN/001=CANADA CN/LAB=LABORATORY CO/001=COLORADO CO/LAB=LABORATORIES CT/001=CONNECTICUT CT/LAB=LABORATORIES DC/001=DISTRICT OF COLUMBIA DC/LAB=LABORATORIES DE/001=DELAWARE DE/LAB=LABORATORIES FL/FTM=FT. MYERS FL/GAI=GAINESVILLE FL/JAX=JACKSONVILLE FL/LAB=LABORATORIES FL/LAN=LANTANA FL/LAU=LAUDERHILL FL/MIA=MIAMI FL/ORL=ORLANDO FL/PEN=PENSACOLA FL/STP=ST. PETERSBURG FL/TAL=TALLAHASSEE FL/TAM=TAMPA FM/001=FEDERATED STATES OF MICRO FN/001=INTERNATIONAL FN/LAB=LABORATORIES GA/001=GEORGIA GA/GAA=GEORGIA ALL GA/GAC=GEORGIA CENTRAL GA/GAE=GEORGIA EASTERN GA/GAN=GEORGIA NORTH GA/GAS=GEORGIA SOUTH GA/GAW=GEORGIA WESTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 15 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA/LAB=LABORATORIES GU/001=GUAM GU/LAB=LABORATORIES HI/001=HAWAII HI/LAB=LABORATORIES IA/001=IOWA IA/LAB=LABORATORIES ID/001=IDAHO ID/LAB=LABORATORIES IL/001=ILLINOIS IL/LAB=LABORATORIES IN/001=INDIANA IN/LAB=LABORATORIES KS/KCK=KANSAS CITY KS/KDH=KDHE KS/LAB=LABORATORIES KS/LAW=LAWRENCE KS/NC=NORTH CENTRAL KANSAS KS/NE=NORTH EAST KANSAS KS/NW=NORTH WEST KANSAS KS/SC=SOUTH CENTRAL KANSAS KS/SE=SOUTH EAST KANSAS KS/SW=SOUTH WEST KANSAS KS/WST=WEST KY/2C1=HOPKINSVILLE KY/2C2=LOUISVILLE KY/2C3=LONDON KY/2C4=LEXINGTON KY/LAB=LABORATORIES LA/001=LOUISIANA LA/LA1=NEW ORLEANS LA/LA2=MANDEVILLE LA/LA3=LAFAYETTE LA/LA4=MONROE LA/LA5=SHREVEPORT LA/LA6=ALEXANDRIA LA/LAB=LABORATORIES LA/LB1=CLIA NEW ORLEANS LA/LB5=CLIA SHREVEPORT LA/LB6=CLIA ALEXANDRIA MA/001=MASSACHUSETTS MA/LAB=LABORATORIES MD/001=MARYLAND MD/LAB=LABORATORIES ME/001=MAINE ME/LAB=LABORATORIES MH/001=MARSHALL ISLANDS MI/001=MICHIGAN MI/LAB=LABORATORIES MN/001=MINNESOTA MN/LAB=LABORATORIES MO/01=REGION01 MO/02=REGION02 MO/03=REGION 03 MO/04=REGION 04 MO/05=REGION 05 MO/06=REGION 06 MO/07=REGION 07 MO/1NH=REGION 1 NH MO/2NH=REGION 2 NH MO/3NH=REGION 3 NH MO/4NH=REGION 4 NH MO/5NH=REGION 5 NH MO/6NH=REGION 6 NH DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 16 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE MO/7NH=REGION 7 NH MO/LAB=LABORATORIES MO/MO=STATEWIDE MP/001=NORTHERN MARIANA ISLANDS MP/LAB=LABORATORIES MS/001=MISSISSIPPI MS/LAB=LABORATORIES MT/001=MONTANA MT/LAB=LABORATORIES MX/001=MEXICO MX/LAB=LABORATORY NC/LAB=LABORATORIES NC/NCC=NORTH CAROLINA CENTRAL NC/NCE=NORTH CAROLINA EAST NC/NCN=NORTH CAROLINA NORTH NC/NCS=NORTH CAROLINA SOUTH NC/NCW=NORTH CAROLINA WEST ND/001=NORTH DAKOTA ND/LAB=LABORATORIES NE/1=NORTH CENTRAL NE/2=CENTRAL NE/3=NORTHEAST NE/4=SOUTHEAST NE/5=WESTERN NE/LAB=LABORATORIES NH/001=NEW HAMPSHIRE NH/LAB=LABORATORIES NJ/001=NEW JERSEY NJ/LAB=LABORATORIES NM/001=NEW MEXICO NM/LAB=LABORATORIES NV/CC=CARSON CITY NV/LAB=LABORATORIES NV/LV=LAS VEGAS NY/001=BUFFALO NY/002=ROCHESTER NY/003=SYRACUSE NY/004=ALBANY NY/005=NEW ROCHELLE NY/006=NEW YORK CITY NY/007=SUFFOLK/NASSAU COUNTY NY/LAB=LABORATORIES OH/001=OHIO OH/LAB=LABORATORIES OK/001=OKLAHOMA OK/LAB=LABORATORIES OR/001=OFFICE #1 OR/002=OFFICE #2 OR/003=OFFICE #3 OR/LAB=LABORATORIES PA/001=PENNSYLVANIA PA/LAB=LABORATORIES PR/001=PUERTO RICO PR/LAB=LABORATORIES PW/001=PALAU RI/001=RHODE ISLAND RI/LAB=LABORATORIES SC/001=SOUTH CAROLINA SC/LAB=LABORATORIES SD/001=SOUTH DAKOTA SD/LAB=LABORATORIES TN/LAB=LABORATORIES TN/TNC=TENNESSEE COOKEVILLE TN/TNE=TENNESSEE EASTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 17 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE TN/TNM=TENNESSEE MIDDLE TN/TNW=TENNESSEE WESTERN TX/001=TEXAS TX/L01=AMARILLO-LTC TX/L02=ABILENE-LTC TX/L03=ARLINGTON-LTC TX/L04=TYLER-LTC TX/L05=BEAUMONT-LTC TX/L06=HOUSTON-LTC TX/L07=TEMPLE-LTC TX/L08=SAN ANTONIO-LTC TX/L09=SAN ANGELO-LTC TX/L10=EL PASO-LTC TX/L11=CORPUS CHRISTI-LTC TX/LAB=LABORATORIES TX/TX1=LUBBOCK TX/TX2=ARLINGTON TX/TX3=SAN ANTONIO TX/TX4=HOUSTON TX/TX5=TYLER TX/TX6=AUSTIN UT/001=UTAH UT/LAB=LABORATORIES VA/001=VIRGINIA VA/LAB=LABORATORIES VI/001=VIRGIN ISLANDS VI/LAB=LABORATORIES VT/001=VERMONT VT/LAB=LABORATORIES WA/001=ALL OTHERS (NON-LTC FAC) WA/D1=SPOKANE & YAKIMA AREAS WA/D1A=District 1, Unit A WA/D1B=District 1, Unit B WA/D1C=District 1, Unit C WA/D1D=District 1, Unit D WA/D2=SPOKANE & SE WA/D2A=District 2, Unit A WA/D2B=District 2, Unit B WA/D2C=District 2, Unit C WA/D2D=District 2, Unit D WA/D2E=District 2, Unit E WA/D2F=District 2, Unit F WA/D2G=District 2, Unit G WA/D3=NW WASHINGTON WA/D3A=District 3, Unit A WA/D3B=District 3, Unit B WA/D3C=District 3, Unit C WA/D3D=District 3, Unit D WA/D3E=District 3, Unit E WA/D4A=GREATER SEATTLE AREA WA/D4B=S KING COUNTY WA/D5A=PIERCE CTY & PENINSULA WA/D5B=PIERCE CTY & GRAYS HARBOR WA/D6=OLYMPIA AREA WA/LAB=LABORATORIES WI/001=WISCONSIN WI/LAB=LABORATORIES WV/001=WEST VIRGINIA WV/LAB=LABORATORIES WY/001=WYOMING WY/LAB=LABORATORIES Address: Street 50 178 227 VARCHAR2 Description: Street address where the provider is located. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 18 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: ST_ADR COBOL Name: ST-ADR Telephone Number 10 228 237 VARCHAR2 Description: Telephone number of the provider. SAS Name: PHNE_NUM COBOL Name: PHNE-NUM Termination Code 2 238 239 VARCHAR2 Description: Indicates the current termination status for the provider. SAS Name: PGM_TRMNTN_CD COBOL Name: PGM-TRMNTN-CD VALUES: 00=ACTIVE PROVIDER 01=VOLUNTARY-MERGER, CLOSURE 02=VOLUNTARY-DISSATISFACTION WITH REIMBURSEMENT 03=VOLUNTARY-RISK OF INVOLUNTARY TERMINATION 04=VOLUNTARY-OTHER REASON FOR WITHDRAWAL 05=INVOLUNTARY-FAILURE TO MEET HEALTH/SAFETY REQ 06=INVOLUNTARY-FAILURE TO MEET AGREEMENT 07=OTHER-PROVIDER STATUS CHANGE 08=NONPAYMENT OF FEES - CLIA Only 09=REV/UNSUCCESSFUL PARTICIPATION IN PT - CLIA Only 10=REV/OTHER REASON - CLIA Only 11=INCOMPLETE CLIA APPLICATION INFORMATION - CLIA Only 12=NO LONGER PERFORMING TESTS - CLIA Only 13=MULTIPLE TO SINGLE SITE CERTIFICATE - CLIA Only 14=SHARED LABORATORY - CLIA Only 15=FAILURE TO RENEW WAIVER PPM CERTIFICATE - CLIA Only 16=DUPLICATE CLIA NUMBER - CLIA Only 17=MAIL RETURNED NO FORWARD ADDRESS CERT ENDED - CLIA Only 20=NOTIFICATION BANKRUPTCY - CLIA Only 33=ACCREDITATION NOT CONFIRMED - CLIA Only 80=AWAITING STATE APPROVAL 99=OIG ACTION - DO NOT ACTIVATE - CLIA Only Termination or Expiration Date 8 240 247 DATE Description: Date the provider was terminated. For CLIA providers, date the laboratory's certificate was terminated or the expiration date of the current CLIA certificate. SAS Name: TRMNTN_EXPRTN_DT COBOL Name: TRMNTN-EXPRTN-DT Type of Action Code 1 248 248 VARCHAR2 Description: Identifies the reason for the certification. Type of action from the official survey record, CMS 1539 form. SAS Name: CRTFCTN_ACTN_TYPE_CD COBOL Name: CRTFCTN-ACTN-TYPE-CD VALUES: 1=INITIAL 2=RECERTIFICATION 3=TERMINATION 4=CHANGE OF OWNERSHIP 5=VALIDATION 8=FULL SURVEY AFTER COMPLAINT Ownership Type Code 2 249 250 VARCHAR2 Description: Indicates the ownership type of the provider. SAS Name: GNRL_CNTL_TYPE_CD COBOL Name: GNRL-CNTL-TYPE-CD VALUES: 01=PROPRIETARY 02=NON PROFIT CHURCH 03=NON PROFIT OTHER 04=GOVERNMENT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 19 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Address: ZIP Code 5 251 255 VARCHAR2 Description: Five-digit ZIP code for a provider's physical address. SAS Name: ZIP_CD COBOL Name: ZIP-CD FIPS State Code 2 256 257 VARCHAR2 Description: FIPS State Code SAS Name: FIPS_STATE_CD COBOL Name: FIPS-STATE-CD VALUES: 01=ALABAMA 02=ALASKA 04=ARIZONA 05=ARKANSAS 06=CALIFORNIA 08=COLORADO 09=CONNECTICUT 10=DELAWARE 11=DISTRICT OF COLUMBIA 12=FLORIDA 13=GEORGIA 15=HAWAII 16=IDAHO 17=ILLINOIS 18=INDIANA 19=IOWA 20=KANSAS 21=KENTUCKY 22=LOUISIANA 23=MAINE 24=MARYLAND 25=MASSACHUSETTS 26=MICHIGAN 27=MINNESOTA 28=MISSISSIPPI 29=MISSOURI 30=MONTANA 31=NEBRASKA 32=NEVADA 33=NEW HAMPSHIRE 34=NEW JERSEY 35=NEW MEXICO 36=NEW YORK 37=NORTH CAROLINA 38=NORTH DAKOTA 39=OHIO 40=OKLAHOMA 41=OREGON 42=PENNSYLVANIA 43=PUERTO RICO 44=RHODE ISLAND 45=SOUTH CAROLINA 46=SOUTH DAKOTA 47=TENNESSEE 48=TEXAS 49=UTAH 50=VERMONT 51=VIRGINIA 53=WASHINGTON 54=WEST VIRGINIA 55=WISCONSIN 56=WYOMING 64=AMERICAN SAMOA 65=GUAM 66=SAIPAN/MARIANA IS. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 20 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 78=VIRGIN ISLANDS FIPS County Code 3 258 260 VARCHAR2 Description: FIPS County Code SAS Name: FIPS_CNTY_CD COBOL Name: FIPS-CNTY-CD CBSA Urban Rural Indicator 1 261 261 VARCHAR2 Description: CBSA (Core Based Statistical Area) indicates whether the county is defined as Urban or Rural. SAS Name: CBSA_URBN_RRL_IND COBOL Name: CBSA-URBN-RRL-IND CBSA Code 5 262 266 VARCHAR2 Description: CBSA (Core Based Statistical Area) geographic entities defined by the U.S. Office of Management and Budget (OMB) on June 6, 2003 for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics. CBSA collectively refers to MSA. SAS Name: CBSA_CD COBOL Name: CBSA-CD Accreditation Type Code 1 283 283 VARCHAR2 Description: Indicates an accrediting organization deeming the provider. If a provider is deemed by multiple accrediting organizations then the accrediting organization with the earliest active deeming effective date is displayed in this field. SAS Name: ACRDTN_TYPE_CD COBOL Name: ACRDTN-TYPE-CD VALUES: 0=UNACCREDITED 1=CARF 2=ACCREDISOURCE Fiscal Year End Date (MMDD) 4 464 467 VARCHAR2 Description: End date, consisting of the month and day, of the provider's fiscal year. SAS Name: FY_END_MO_DAY_CD COBOL Name: FY-END-MO-DAY-CD Parent Provider Number 10 611 620 CHAR Description: Parent provider number SAS Name: PARENT_PROVIDER_NUMBER COBOL Name: PARENT-PROVIDER-NUMBER Participation Medicare OPT/SP Indicator 1 622 622 VARCHAR2 Description: Indicates if this comprehensive outpatient rehabilitation facility also participates in Medicare as a provider of outpatient physical therapy and/or speech pathology. SAS Name: MDCR_PRTCPTN_OP_PT_SPCH_SW COBOL Name: MDCR-PRTCPTN-OP-PT-SPCH-SW Related Provider Number 10 669 678 CHAR Description: Related provider number SAS Name: RELATED_PROVIDER_NUMBER COBOL Name: RELATED-PROVIDER-NUMBER Services: Nursing - Employee Indicator 1 739 739 VARCHAR2 Description: Indicates if nursing services are provided by employees. SAS Name: NRSNG_SRVC_EMPLEE_SW COBOL Name: NRSNG-SRVC-EMPLEE-SW Services: Nursing - Independent Contractor Indicator 1 740 740 VARCHAR2 Description: Indicates if nursing services are provided by independent DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 21 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE contractors. SAS Name: NRSNG_SRVC_CNTRCTR_SW COBOL Name: NRSNG-SRVC-CNTRCTR-SW Services: Nursing - Under Arrangement Indicator 1 741 741 VARCHAR2 Description: Indicates if nursing services are provided under arrangement. SAS Name: NRSNG_SRVC_ARNGMT_SW COBOL Name: NRSNG-SRVC-ARNGMT-SW Services: Orthotic / Prosthetic - Employee Indicator 1 752 752 VARCHAR2 Description: Indicates if orthotic prosthetic services are provided by employees. SAS Name: ORTHTC_PRSTHTC_EMPLEE_SW COBOL Name: ORTHTC-PRSTHTC-EMPLEE-SW Services: Orthotic / Prosthetic - Independent 1 753 753 VARCHAR2 Contractor Indicator Description: Indicates if orthotic prosthetic services are provided by independent contractors. SAS Name: ORTHTC_PRSTHTC_CNTRCTR_SW COBOL Name: ORTHTC-PRSTHTC-CNTRCTR-SW Services: Orthotic / Prosthetic - Under Arrangement 1 754 754 VARCHAR2 Indicator Description: Indicates if orthotic/prosthetic services are provided under arrangement. SAS Name: ORTHTC_PRSTHTC_ARNGMT_SW COBOL Name: ORTHTC-PRSTHTC-ARNGMT-SW Services: OT - Employee Indicator 1 755 755 VARCHAR2 Description: Indicates if occupational therapy services are provided by employees. SAS Name: OT_EMPLEE_SW COBOL Name: OT-EMPLEE-SW Services: OT - Independent Contractor Indicator 1 756 756 VARCHAR2 Description: Indicates if occupational therapy services are provided by independent contractors. SAS Name: OT_CNTRCTR_SW COBOL Name: OT-CNTRCTR-SW Services: OT - Under Arrangement Indicator 1 757 757 VARCHAR2 Description: Indicates if occupational therapy services are provided under arrangement. SAS Name: OT_ARNGMT_SW COBOL Name: OT-ARNGMT-SW Services: Physician - Employee Indicator 1 775 775 VARCHAR2 Description: Indicates if physician services are provided by employees. SAS Name: PHYSN_EMPLEE_SW COBOL Name: PHYSN-EMPLEE-SW Services: Physician - Independent Contractor 1 776 776 VARCHAR2 Indicator Description: Indicates if physician services are provided by independent contractors. SAS Name: PHYSN_CNTRCTR_SW COBOL Name: PHYSN-CNTRCTR-SW Services: Physician - Under Arrangement Indicator 1 777 777 VARCHAR2 Description: Indicates if physician services are provided under arrangement. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 22 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: PHYSN_ARNGMT_SW COBOL Name: PHYSN-ARNGMT-SW Services: Psychological - Employee Indicator 1 790 790 VARCHAR2 Description: Indicates if psychological services are provided by employees. SAS Name: PSYCHLGCL_EMPLEE_SW COBOL Name: PSYCHLGCL-EMPLEE-SW Services: Psychological - Independent Contractor 1 791 791 VARCHAR2 Indicator Description: Indicates if psychological services are provided by independent contractors. SAS Name: PSYCHLGCL_CNTRCTR_SW COBOL Name: PSYCHLGCL-CNTRCTR-SW Services: Psychological - Under Arrangement Indicator 1 792 792 VARCHAR2 Description: Indicates if psychological services are provided under arrangement. SAS Name: PSYCHLGCL_ARNGMT_SW COBOL Name: PSYCHLGCL-ARNGMT-SW Services: PT - Employee Indicator 1 793 793 VARCHAR2 Description: Indicates if physical therapy services are provided by employees. SAS Name: PT_EMPLEE_SW COBOL Name: PT-EMPLEE-SW Services: PT - Independent Contractor Indicator 1 794 794 VARCHAR2 Description: Indicates if physical therapy services are provided by independent contractors. SAS Name: PT_CNTRCTR_SW COBOL Name: PT-CNTRCTR-SW Services: PT - Under Arrangement Indicator 1 795 795 VARCHAR2 Description: Indicates if physical therapy services are provided under arrangement. SAS Name: PT_ARNGMT_SW COBOL Name: PT-ARNGMT-SW Services: Respiratory Care - Employee Indicator 1 801 801 VARCHAR2 Description: Indicates if respiratory care services are provided by employees. SAS Name: RSPRTRY_CARE_EMPLEE_SW COBOL Name: RSPRTRY-CARE-EMPLEE-SW Services: Respiratory Care - Independent Contractor 1 802 802 VARCHAR2 Indicator Description: Indicates if respiratory care services are provided by independent contractors. SAS Name: RSPRTRY_CARE_CNTRCTR_SW COBOL Name: RSPRTRY-CARE-CNTRCTR-SW Services: Respiratory Care - Under Arrangement 1 803 803 VARCHAR2 Indicator Description: Indicates if respiratory care services are provided under arrangement. SAS Name: RSPRTRY_CARE_ARNGMT_SW COBOL Name: RSPRTRY-CARE-ARNGMT-SW Services: Social - Employee Indicator 1 806 806 VARCHAR2 Description: Indicates if social services are provided by employees. SAS Name: SCL_EMPLEE_SW COBOL Name: SCL-EMPLEE-SW DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 23 Comprehensive Outpatient Rehab Facility, CATEGORY = "14" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Services: Social - Independent Contractor Indicator 1 807 807 VARCHAR2 Description: Indicates if social services are provided by independent contractors. SAS Name: SCL_CNTRCTR_SW COBOL Name: SCL-CNTRCTR-SW Services: Social - Under Arrangement Indicator 1 808 808 VARCHAR2 Description: Indicates if social services are provided under arrangement. SAS Name: SCL_ARNGMT_SW COBOL Name: SCL-ARNGMT-SW Services: Speech Pathology - Employee Indicator 1 813 813 VARCHAR2 Description: Indicates if speech pathology services are provided by employees. SAS Name: SPCH_PTHLGY_EMPLEE_SW COBOL Name: SPCH-PTHLGY-EMPLEE-SW Services: Speech Pathology - Independent Contractor 1 814 814 VARCHAR2 Indicator Description: Indicates if speech pathology services are provided by independent contractors. SAS Name: SPCH_PTHLGY_CNTRCTR_SW COBOL Name: SPCH-PTHLGY-CNTRCTR-SW Services: Speech Pathology - Under Arrangement 1 815 815 VARCHAR2 Indicator Description: Indicates if speech pathology services are provided under arrangement. SAS Name: SPCH_PTHLGY_ARNGMT_SW COBOL Name: SPCH-PTHLGY-ARNGMT-SW DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 1 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Provider Category Subtype Code 2 1 2 VARCHAR2 Description: Identifies the subtype of the provider, within the primary category. Used in reporting to show the breakdown of provider categories, mainly for hospitals and SNFs. SAS Name: PRVDR_CTGRY_SBTYP_CD COBOL Name: PRVDR-CTGRY-SBTYP-CD VALUES: 01=Ambulatory Surgical Center Provider Category Code 2 3 4 VARCHAR2 Description: Identifies the type of provider participating in the Medicare/Medicaid program. SAS Name: PRVDR_CTGRY_CD COBOL Name: PRVDR-CTGRY-CD VALUES: 15=Ambulatory Surgical Center CHOW Count 2 5 6 NUMBER Description: Number of times this provider has undergone a change of ownership. SAS Name: CHOW_CNT COBOL Name: CHOW-CNT CHOW Date 8 7 14 DATE Description: Effective date of the most recent change of ownership for this provider. SAS Name: CHOW_DT COBOL Name: CHOW-DT Address: City 28 15 42 VARCHAR2 Description: City in which the provider is physically located. SAS Name: CITY_NAME COBOL Name: CITY-NAME Compliance: Acceptable POC 1 43 43 VARCHAR2 Description: Indicates if a provider is in compliance with program requirements based on an acceptable plan for correction of deficiencies. SAS Name: ACPTBL_POC_SW COBOL Name: ACPTBL-POC-SW Compliance: Status 1 44 44 VARCHAR2 Description: Compliance status of a provider at the time of certification survey. SAS Name: CMPLNC_STUS_CD COBOL Name: CMPLNC-STUS-CD VALUES: A=IN COMPLIANCE B=NOT IN COMPLIANCE SSA County Code 3 45 47 VARCHAR2 Description: Social Security Administration geographic code indicating the county where the provider is located. SAS Name: SSA_CNTY_CD COBOL Name: SSA-CNTY-CD Cross Ref Provider Number 10 48 57 CHAR Description: Cross reference provider number SAS Name: CROSS_REF_PROVIDER_NUMBER COBOL Name: CROSS-REF-PROVIDER-NUMBER Certification Date 8 58 65 DATE Description: Equal to the exit date of the initial visit of the Health survey for certifications completed after July 28, 2012. For certifications prior to that date, the certification DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 2 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE date is equal to the exit date of the initial visit of the Health survey or LSC survey, whichever is later. SAS Name: CRTFCTN_DT COBOL Name: CRTFCTN-DT Eligibility Indicator 1 66 66 VARCHAR2 Description: Indicates if a facility is eligible to participate in the Medicare and/or Medicaid programs. SAS Name: ELGBLTY_SW COBOL Name: ELGBLTY-SW Facility Name 50 67 116 VARCHAR2 Description: Name of the provider certified to participate in the Medicare and/or Medicaid programs. SAS Name: FAC_NAME COBOL Name: FAC-NAME Medicare Administrative Contractor (MAC) or 5 117 121 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_CD COBOL Name: INTRMDRY-CARR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 3 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 4 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 5 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 6 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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 15 122 136 VARCHAR2 Description: Number which may be assigned to a provider by the state Medicaid agency for external control or billing purposes. SAS Name: MDCD_VNDR_NUM COBOL Name: MDCD-VNDR-NUM Original Participation Date 8 137 144 DATE Description: Date a provider is first approved to provide Medicare and/or Medicaid services. SAS Name: ORGNL_PRTCPTN_DT COBOL Name: ORGNL-PRTCPTN-DT Prior CHOW Date 8 145 152 DATE Description: Effective date of the previous change of ownership for this provider. SAS Name: CHOW_PRIOR_DT COBOL Name: CHOW-PRIOR-DT Prior Medicare Administrative Contractor (MAC) or 5 153 157 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the previous Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_PRIOR_CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 7 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: INTRMDRY-CARR-PRIOR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 00520=BLUE SHIELD (ARKANSAS) 00528=BLUE SHIELD (ARKANSAS/LOUISIANA) 00542=BLUE SHIELD (CALIFORNIA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 8 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00550=BLUE SHIELD (COLORADO) 00570=BLUE SHIELD (DELAWARE) 00580=BLUE SHIELD (DISTRICT OF COLUMBIA) 00590=BLUE SHIELD (FLORIDA) 00621=BLUE SHIELD (ILLINOIS) 00630=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 9 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 10 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 11 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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) CCN 10 158 167 VARCHAR2 Description: Six or ten position identification number that is assigned to a certified provider. This is the CMS Certification Number. SAS Name: PRVDR_NUM COBOL Name: PRVDR-NUM Region Code 2 168 169 VARCHAR2 Description: Indicates the CMS Regional Office responsible for the certification of the provider. SAS Name: RGN_CD COBOL Name: RGN-CD VALUES: 01=Boston 02=New York 03=Philadelphia 04=Atlanta 05=Chicago 06=Dallas 07=Kansas City 08=Denver 09=San Francisco 10=Seattle Skeleton Record Indicator 1 170 170 VARCHAR2 Description: Indicates if the record is a skeleton record. Only a limited set of data is available for this provider; no survey data exists. SAS Name: SKLTN_REC_SW COBOL Name: SKLTN-REC-SW State Abbreviation 2 171 172 VARCHAR2 Description: Two-character state abbreviation. SAS Name: STATE_CD COBOL Name: STATE-CD VALUES: AK=ALASKA AL=ALABAMA AR=ARKANSAS AS=AMERICAN SAMOA AZ=ARIZONA CA=CALIFORNIA CN=CANADA CO=COLORADO CT=CONNECTICUT DC=DISTRICT OF COLUMBIA DE=DELAWARE FL=FLORIDA FN=INTERNATIONAL DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 12 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA=GEORGIA GU=GUAM HI=HAWAII IA=IOWA ID=IDAHO IL=ILLINOIS IN=INDIANA KS=KANSAS KY=KENTUCKY LA=LOUISIANA MA=MASSACHUSETTS MD=MARYLAND ME=MAINE MI=MICHIGAN MN=MINNESOTA MO=MISSOURI MP=SAIPAN MS=MISSISSIPPI MT=MONTANA MX=MEXICO NC=NORTH CAROLINA ND=NORTH DAKOTA NE=NEBRASKA NH=NEW HAMPSHIRE NJ=NEW JERSEY NM=NEW MEXICO NV=NEVADA NY=NEW YORK OH=OHIO OK=OKLAHOMA OR=OREGON PA=PENNSYLVANIA PR=PUERTO RICO RI=RHODE ISLAND SC=SOUTH CAROLINA SD=SOUTH DAKOTA TN=TENNESSEE TX=TEXAS UT=UTAH VA=VIRGINIA VI=VIRGIN ISLANDS VT=VERMONT WA=WASHINGTON WI=WISCONSIN WV=WEST VIRGINIA WY=WYOMING SSA State Code 2 173 174 VARCHAR2 Description: Social Security Administration geographic code indicating the state where the provider is located. SAS Name: SSA_STATE_CD COBOL Name: SSA-STATE-CD 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 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 13 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 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 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 99=INTERNATIONAL State Region Code 3 175 177 VARCHAR2 Description: Identifies the region within a state where the provider is located. SAS Name: STATE_RGN_CD COBOL Name: STATE-RGN-CD VALUES: AK/001=ALASKA AK/LAB=LABORATORIES AL/001=ALABAMA AL/LAB=LABORATORIES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 14 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE AR/001=ARKANSAS AR/LAB=LABORATORIES AS/001=AMERICAN SAMOA AS/LAB=LABORATORY AZ/AZ=PHOENIX AZ/LAB=ARIZONA LAB AZ/TUC=TUCSON CA/BAK=BAKERSFIELD CA/BER=SAN BERNARDINO CA/BK=BERKELEY CA/BK1=CONTRA COSTA CA/FR=FRESNO CA/L1=L.A. WEST CA/L2=L.A. NORTH CA/L3=L.A. CENTRAL CA/L4=L.A. EAST CA/L5=SAN GABRIEL CA/LAB=LABORATORIES CA/M1=LAB. SOUTH CA/M2=LAB. NORTH CA/ORG=ORANGE CO CA/RIV=RIVERSIDE CA/RWC=REDWOOD COAST CA/S1=SACRAMENTO CA/S2=SACTO SOUTH CA/S3=CHICO CA/SD=SAN DIEGO CA/SDS=SAN DIEGO SOUTH CA/SF=SAN FRANCISCO CA/SJ=SAN JOSE CA/SR=SANTA ROSA CA/VEN=VENTURA CN/001=CANADA CN/LAB=LABORATORY CO/001=COLORADO CO/LAB=LABORATORIES CT/001=CONNECTICUT CT/LAB=LABORATORIES DC/001=DISTRICT OF COLUMBIA DC/LAB=LABORATORIES DE/001=DELAWARE DE/LAB=LABORATORIES FL/FTM=FT. MYERS FL/GAI=GAINESVILLE FL/JAX=JACKSONVILLE FL/LAB=LABORATORIES FL/LAN=LANTANA FL/LAU=LAUDERHILL FL/MIA=MIAMI FL/ORL=ORLANDO FL/PEN=PENSACOLA FL/STP=ST. PETERSBURG FL/TAL=TALLAHASSEE FL/TAM=TAMPA FM/001=FEDERATED STATES OF MICRO FN/001=INTERNATIONAL FN/LAB=LABORATORIES GA/001=GEORGIA GA/GAA=GEORGIA ALL GA/GAC=GEORGIA CENTRAL GA/GAE=GEORGIA EASTERN GA/GAN=GEORGIA NORTH GA/GAS=GEORGIA SOUTH GA/GAW=GEORGIA WESTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 15 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA/LAB=LABORATORIES GU/001=GUAM GU/LAB=LABORATORIES HI/001=HAWAII HI/LAB=LABORATORIES IA/001=IOWA IA/LAB=LABORATORIES ID/001=IDAHO ID/LAB=LABORATORIES IL/001=ILLINOIS IL/LAB=LABORATORIES IN/001=INDIANA IN/LAB=LABORATORIES KS/KCK=KANSAS CITY KS/KDH=KDHE KS/LAB=LABORATORIES KS/LAW=LAWRENCE KS/NC=NORTH CENTRAL KANSAS KS/NE=NORTH EAST KANSAS KS/NW=NORTH WEST KANSAS KS/SC=SOUTH CENTRAL KANSAS KS/SE=SOUTH EAST KANSAS KS/SW=SOUTH WEST KANSAS KS/WST=WEST KY/2C1=HOPKINSVILLE KY/2C2=LOUISVILLE KY/2C3=LONDON KY/2C4=LEXINGTON KY/LAB=LABORATORIES LA/001=LOUISIANA LA/LA1=NEW ORLEANS LA/LA2=MANDEVILLE LA/LA3=LAFAYETTE LA/LA4=MONROE LA/LA5=SHREVEPORT LA/LA6=ALEXANDRIA LA/LAB=LABORATORIES LA/LB1=CLIA NEW ORLEANS LA/LB5=CLIA SHREVEPORT LA/LB6=CLIA ALEXANDRIA MA/001=MASSACHUSETTS MA/LAB=LABORATORIES MD/001=MARYLAND MD/LAB=LABORATORIES ME/001=MAINE ME/LAB=LABORATORIES MH/001=MARSHALL ISLANDS MI/001=MICHIGAN MI/LAB=LABORATORIES MN/001=MINNESOTA MN/LAB=LABORATORIES MO/01=REGION01 MO/02=REGION02 MO/03=REGION 03 MO/04=REGION 04 MO/05=REGION 05 MO/06=REGION 06 MO/07=REGION 07 MO/1NH=REGION 1 NH MO/2NH=REGION 2 NH MO/3NH=REGION 3 NH MO/4NH=REGION 4 NH MO/5NH=REGION 5 NH MO/6NH=REGION 6 NH DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 16 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE MO/7NH=REGION 7 NH MO/LAB=LABORATORIES MO/MO=STATEWIDE MP/001=NORTHERN MARIANA ISLANDS MP/LAB=LABORATORIES MS/001=MISSISSIPPI MS/LAB=LABORATORIES MT/001=MONTANA MT/LAB=LABORATORIES MX/001=MEXICO MX/LAB=LABORATORY NC/LAB=LABORATORIES NC/NCC=NORTH CAROLINA CENTRAL NC/NCE=NORTH CAROLINA EAST NC/NCN=NORTH CAROLINA NORTH NC/NCS=NORTH CAROLINA SOUTH NC/NCW=NORTH CAROLINA WEST ND/001=NORTH DAKOTA ND/LAB=LABORATORIES NE/1=NORTH CENTRAL NE/2=CENTRAL NE/3=NORTHEAST NE/4=SOUTHEAST NE/5=WESTERN NE/LAB=LABORATORIES NH/001=NEW HAMPSHIRE NH/LAB=LABORATORIES NJ/001=NEW JERSEY NJ/LAB=LABORATORIES NM/001=NEW MEXICO NM/LAB=LABORATORIES NV/CC=CARSON CITY NV/LAB=LABORATORIES NV/LV=LAS VEGAS NY/001=BUFFALO NY/002=ROCHESTER NY/003=SYRACUSE NY/004=ALBANY NY/005=NEW ROCHELLE NY/006=NEW YORK CITY NY/007=SUFFOLK/NASSAU COUNTY NY/LAB=LABORATORIES OH/001=OHIO OH/LAB=LABORATORIES OK/001=OKLAHOMA OK/LAB=LABORATORIES OR/001=OFFICE #1 OR/002=OFFICE #2 OR/003=OFFICE #3 OR/LAB=LABORATORIES PA/001=PENNSYLVANIA PA/LAB=LABORATORIES PR/001=PUERTO RICO PR/LAB=LABORATORIES PW/001=PALAU RI/001=RHODE ISLAND RI/LAB=LABORATORIES SC/001=SOUTH CAROLINA SC/LAB=LABORATORIES SD/001=SOUTH DAKOTA SD/LAB=LABORATORIES TN/LAB=LABORATORIES TN/TNC=TENNESSEE COOKEVILLE TN/TNE=TENNESSEE EASTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 17 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE TN/TNM=TENNESSEE MIDDLE TN/TNW=TENNESSEE WESTERN TX/001=TEXAS TX/L01=AMARILLO-LTC TX/L02=ABILENE-LTC TX/L03=ARLINGTON-LTC TX/L04=TYLER-LTC TX/L05=BEAUMONT-LTC TX/L06=HOUSTON-LTC TX/L07=TEMPLE-LTC TX/L08=SAN ANTONIO-LTC TX/L09=SAN ANGELO-LTC TX/L10=EL PASO-LTC TX/L11=CORPUS CHRISTI-LTC TX/LAB=LABORATORIES TX/TX1=LUBBOCK TX/TX2=ARLINGTON TX/TX3=SAN ANTONIO TX/TX4=HOUSTON TX/TX5=TYLER TX/TX6=AUSTIN UT/001=UTAH UT/LAB=LABORATORIES VA/001=VIRGINIA VA/LAB=LABORATORIES VI/001=VIRGIN ISLANDS VI/LAB=LABORATORIES VT/001=VERMONT VT/LAB=LABORATORIES WA/001=ALL OTHERS (NON-LTC FAC) WA/D1=SPOKANE & YAKIMA AREAS WA/D1A=District 1, Unit A WA/D1B=District 1, Unit B WA/D1C=District 1, Unit C WA/D1D=District 1, Unit D WA/D2=SPOKANE & SE WA/D2A=District 2, Unit A WA/D2B=District 2, Unit B WA/D2C=District 2, Unit C WA/D2D=District 2, Unit D WA/D2E=District 2, Unit E WA/D2F=District 2, Unit F WA/D2G=District 2, Unit G WA/D3=NW WASHINGTON WA/D3A=District 3, Unit A WA/D3B=District 3, Unit B WA/D3C=District 3, Unit C WA/D3D=District 3, Unit D WA/D3E=District 3, Unit E WA/D4A=GREATER SEATTLE AREA WA/D4B=S KING COUNTY WA/D5A=PIERCE CTY & PENINSULA WA/D5B=PIERCE CTY & GRAYS HARBOR WA/D6=OLYMPIA AREA WA/LAB=LABORATORIES WI/001=WISCONSIN WI/LAB=LABORATORIES WV/001=WEST VIRGINIA WV/LAB=LABORATORIES WY/001=WYOMING WY/LAB=LABORATORIES Address: Street 50 178 227 VARCHAR2 Description: Street address where the provider is located. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 18 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: ST_ADR COBOL Name: ST-ADR Telephone Number 10 228 237 VARCHAR2 Description: Telephone number of the provider. SAS Name: PHNE_NUM COBOL Name: PHNE-NUM Termination Code 2 238 239 VARCHAR2 Description: Indicates the current termination status for the provider. SAS Name: PGM_TRMNTN_CD COBOL Name: PGM-TRMNTN-CD VALUES: 00=ACTIVE PROVIDER 01=VOLUNTARY-MERGER, CLOSURE 02=VOLUNTARY-DISSATISFACTION WITH REIMBURSEMENT 03=VOLUNTARY-RISK OF INVOLUNTARY TERMINATION 04=VOLUNTARY-OTHER REASON FOR WITHDRAWAL 05=INVOLUNTARY-FAILURE TO MEET HEALTH/SAFETY REQ 06=INVOLUNTARY-FAILURE TO MEET AGREEMENT 07=OTHER-PROVIDER STATUS CHANGE 08=NONPAYMENT OF FEES - CLIA Only 09=REV/UNSUCCESSFUL PARTICIPATION IN PT - CLIA Only 10=REV/OTHER REASON - CLIA Only 11=INCOMPLETE CLIA APPLICATION INFORMATION - CLIA Only 12=NO LONGER PERFORMING TESTS - CLIA Only 13=MULTIPLE TO SINGLE SITE CERTIFICATE - CLIA Only 14=SHARED LABORATORY - CLIA Only 15=FAILURE TO RENEW WAIVER PPM CERTIFICATE - CLIA Only 16=DUPLICATE CLIA NUMBER - CLIA Only 17=MAIL RETURNED NO FORWARD ADDRESS CERT ENDED - CLIA Only 20=NOTIFICATION BANKRUPTCY - CLIA Only 33=ACCREDITATION NOT CONFIRMED - CLIA Only 80=AWAITING STATE APPROVAL 99=OIG ACTION - DO NOT ACTIVATE - CLIA Only Termination or Expiration Date 8 240 247 DATE Description: Date the provider was terminated. For CLIA providers, date the laboratory's certificate was terminated or the expiration date of the current CLIA certificate. SAS Name: TRMNTN_EXPRTN_DT COBOL Name: TRMNTN-EXPRTN-DT Type of Action Code 1 248 248 VARCHAR2 Description: Identifies the reason for the certification. Type of action from the official survey record, CMS 1539 form. SAS Name: CRTFCTN_ACTN_TYPE_CD COBOL Name: CRTFCTN-ACTN-TYPE-CD VALUES: 1=INITIAL 2=RECERTIFICATION 3=TERMINATION 4=CHANGE OF OWNERSHIP 5=VALIDATION 8=FULL SURVEY AFTER COMPLAINT Ownership Type Code 2 249 250 VARCHAR2 Description: Indicates the ownership type of the provider. SAS Name: GNRL_CNTL_TYPE_CD COBOL Name: GNRL-CNTL-TYPE-CD VALUES: 01=PROPRIETARY 02=NON PROFIT 03=GOVERNMENT Address: ZIP Code 5 251 255 VARCHAR2 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 19 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Five-digit ZIP code for a provider's physical address. SAS Name: ZIP_CD COBOL Name: ZIP-CD FIPS State Code 2 256 257 VARCHAR2 Description: FIPS State Code SAS Name: FIPS_STATE_CD COBOL Name: FIPS-STATE-CD VALUES: 01=ALABAMA 02=ALASKA 04=ARIZONA 05=ARKANSAS 06=CALIFORNIA 08=COLORADO 09=CONNECTICUT 10=DELAWARE 11=DISTRICT OF COLUMBIA 12=FLORIDA 13=GEORGIA 15=HAWAII 16=IDAHO 17=ILLINOIS 18=INDIANA 19=IOWA 20=KANSAS 21=KENTUCKY 22=LOUISIANA 23=MAINE 24=MARYLAND 25=MASSACHUSETTS 26=MICHIGAN 27=MINNESOTA 28=MISSISSIPPI 29=MISSOURI 30=MONTANA 31=NEBRASKA 32=NEVADA 33=NEW HAMPSHIRE 34=NEW JERSEY 35=NEW MEXICO 36=NEW YORK 37=NORTH CAROLINA 38=NORTH DAKOTA 39=OHIO 40=OKLAHOMA 41=OREGON 42=PENNSYLVANIA 43=PUERTO RICO 44=RHODE ISLAND 45=SOUTH CAROLINA 46=SOUTH DAKOTA 47=TENNESSEE 48=TEXAS 49=UTAH 50=VERMONT 51=VIRGINIA 53=WASHINGTON 54=WEST VIRGINIA 55=WISCONSIN 56=WYOMING 64=AMERICAN SAMOA 65=GUAM 66=SAIPAN/MARIANA IS. 78=VIRGIN ISLANDS DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 20 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE FIPS County Code 3 258 260 VARCHAR2 Description: FIPS County Code SAS Name: FIPS_CNTY_CD COBOL Name: FIPS-CNTY-CD CBSA Urban Rural Indicator 1 261 261 VARCHAR2 Description: CBSA (Core Based Statistical Area) indicates whether the county is defined as Urban or Rural. SAS Name: CBSA_URBN_RRL_IND COBOL Name: CBSA-URBN-RRL-IND CBSA Code 5 262 266 VARCHAR2 Description: CBSA (Core Based Statistical Area) geographic entities defined by the U.S. Office of Management and Budget (OMB) on June 6, 2003 for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics. CBSA collectively refers to MSA. SAS Name: CBSA_CD COBOL Name: CBSA-CD Accreditation Type Code 1 283 283 VARCHAR2 Description: Indicates an accrediting organization deeming the provider. If a provider is deemed by multiple accrediting organizations then the accrediting organization with the earliest active deeming effective date is displayed in this field. SAS Name: ACRDTN_TYPE_CD COBOL Name: ACRDTN-TYPE-CD VALUES: 0=UNACCREDITED 1=JC 2=AAAHC 3=AAAASF 4=AOA/HFAP 5=DNV Services: Laboratory Code 1 313 313 CHAR Description: Indicates how laboratory services are provided. SAS Name: LAB_SRVC_CD COBOL Name: LAB-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: Pharmacy Code 1 314 314 CHAR Description: Indicates how pharmaceutical services are provided. SAS Name: PHRMCY_SRVC_CD COBOL Name: PHRMCY-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Ancillary Services: Radiology Code 1 315 315 VARCHAR2 Description: Indicates how radiology services are provided. SAS Name: RDLGY_SRVC_CD COBOL Name: RDLGY-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION ASC Begin Service Date 8 316 323 DATE DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 21 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Description: Date an ambulatory surgical center began providing health care services. SAS Name: ASC_BGN_SRVC_DT COBOL Name: ASC-BGN-SRVC-DT ASC Free Standing Indicator 1 324 324 VARCHAR2 Description: Indicates if the ambulatory surgical center is freestanding. SAS Name: FREESTNDNG_ASC_SW COBOL Name: FREESTNDNG-ASC-SW Compliance: LSC Waiver Indicator 1 445 445 CHAR Description: Indicates if a waiver of any life safety code provision has been recommended for a provider. SAS Name: LSC_WVR_SW COBOL Name: LSC-WVR-SW Fiscal Year End Date (MMDD) 4 464 467 VARCHAR2 Description: End date, consisting of the month and day, of the provider's fiscal year. SAS Name: FY_END_MO_DAY_CD COBOL Name: FY-END-MO-DAY-CD Operating Room Count 4 605 608 NUMBER Description: Number of operating rooms in an ambulatory surgical center. SAS Name: OPRTG_ROOM_CNT COBOL Name: OPRTG-ROOM-CNT Related Provider Number 10 669 678 CHAR Description: Related provider number SAS Name: RELATED_PROVIDER_NUMBER COBOL Name: RELATED-PROVIDER-NUMBER Surgical Specialty: Dental Indicator 1 1940 1940 VARCHAR2 Description: Indicates if dental surgery is offered by an ambulatory surgical center. SAS Name: DNTL_SRGRY_SW COBOL Name: DNTL-SRGRY-SW Surgical Specialty: Ear/Nose/Throat Indicator 1 1941 1941 VARCHAR2 Description: Indicates if ear, nose and throat surgery is offered by an ambulatory surgical center. SAS Name: OTLRYNGLGY_SRGRY_SW COBOL Name: OTLRYNGLGY-SRGRY-SW Surgical Specialty: Endoscopy Indicator 1 1942 1942 VARCHAR2 Description: Indicates if endoscopy surgery is offered by an ambulatory surgical center. SAS Name: ENDSCPY_SRGRY_SW COBOL Name: ENDSCPY-SRGRY-SW Surgical Specialty: Obstetrics / Gynecology Indicator 1 1943 1943 VARCHAR2 Description: Indicates if obstetrics/gynecology surgery is offered by an ambulatory surgical center. SAS Name: OB_GYN_SRGRY_SW COBOL Name: OB-GYN-SRGRY-SW Surgical Specialty: Ophthalmologic Indicator 1 1944 1944 VARCHAR2 Description: Indicates if ophthalmologic surgery is offered by an ambulatory surgical center. SAS Name: OPTHMLGY_SRGRY_SW COBOL Name: OPTHMLGY-SRGRY-SW DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 22 Ambulatory Surgical Center, CATEGORY = "15" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Surgical Specialty: Orthopedic Indicator 1 1945 1945 VARCHAR2 Description: Indicates if orthopedic surgery is offered by an ambulatory surgical center. SAS Name: ORTHPDC_SRGRY_SW COBOL Name: ORTHPDC-SRGRY-SW Surgical Specialty: Other Indicator 1 1946 1946 VARCHAR2 Description: Indicates if other surgery types are performed at an ambulatory surgical center. SAS Name: OTHR_SRGRY_SW COBOL Name: OTHR-SRGRY-SW Surgical Specialty: Pain Indicator 1 1947 1947 VARCHAR2 Description: Indicates if pain surgery is offered by an ambulatory surgical center. SAS Name: PAIN_SRGRY_SW COBOL Name: PAIN-SRGRY-SW Surgical Specialty: Plastic / Reconstructive 1 1948 1948 VARCHAR2 Indicator Description: Indicates if plastic and reconstructive surgery is offered by an ambulatory surgical center. SAS Name: PLSTC_SRGRY_SW COBOL Name: PLSTC-SRGRY-SW Surgical Specialty: Podiatry Indicator 1 1949 1949 VARCHAR2 Description: Indicates if podiatric surgery is offered by an ambulatory surgical center. SAS Name: FT_SRGRY_SW COBOL Name: FT-SRGRY-SW DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 1 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Provider Category Subtype Code 2 1 2 VARCHAR2 Description: Identifies the subtype of the provider, within the primary category. Used in reporting to show the breakdown of provider categories, mainly for hospitals and SNFs. SAS Name: PRVDR_CTGRY_SBTYP_CD COBOL Name: PRVDR-CTGRY-SBTYP-CD VALUES: 01=Hospice Provider Category Code 2 3 4 VARCHAR2 Description: Identifies the type of provider participating in the Medicare/Medicaid program. SAS Name: PRVDR_CTGRY_CD COBOL Name: PRVDR-CTGRY-CD VALUES: 16=Hospice CHOW Count 2 5 6 NUMBER Description: Number of times this provider has undergone a change of ownership. SAS Name: CHOW_CNT COBOL Name: CHOW-CNT CHOW Date 8 7 14 DATE Description: Effective date of the most recent change of ownership for this provider. SAS Name: CHOW_DT COBOL Name: CHOW-DT Address: City 28 15 42 VARCHAR2 Description: City in which the provider is physically located. SAS Name: CITY_NAME COBOL Name: CITY-NAME Compliance: Acceptable POC 1 43 43 VARCHAR2 Description: Indicates if a provider is in compliance with program requirements based on an acceptable plan for correction of deficiencies. SAS Name: ACPTBL_POC_SW COBOL Name: ACPTBL-POC-SW Compliance: Status 1 44 44 VARCHAR2 Description: Compliance status of a provider at the time of certification survey. SAS Name: CMPLNC_STUS_CD COBOL Name: CMPLNC-STUS-CD VALUES: A=IN COMPLIANCE B=NOT IN COMPLIANCE SSA County Code 3 45 47 VARCHAR2 Description: Social Security Administration geographic code indicating the county where the provider is located. SAS Name: SSA_CNTY_CD COBOL Name: SSA-CNTY-CD Cross Ref Provider Number 10 48 57 CHAR Description: Cross reference provider number SAS Name: CROSS_REF_PROVIDER_NUMBER COBOL Name: CROSS-REF-PROVIDER-NUMBER Certification Date 8 58 65 DATE Description: Equal to the exit date of the initial visit of the Health survey for certifications completed after July 28, 2012. For certifications prior to that date, the certification DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 2 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE date is equal to the exit date of the initial visit of the Health survey or LSC survey, whichever is later. SAS Name: CRTFCTN_DT COBOL Name: CRTFCTN-DT Eligibility Indicator 1 66 66 VARCHAR2 Description: Indicates if a facility is eligible to participate in the Medicare and/or Medicaid programs. SAS Name: ELGBLTY_SW COBOL Name: ELGBLTY-SW Facility Name 50 67 116 VARCHAR2 Description: Name of the provider certified to participate in the Medicare and/or Medicaid programs. SAS Name: FAC_NAME COBOL Name: FAC-NAME Medicare Administrative Contractor (MAC) or 5 117 121 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_CD COBOL Name: INTRMDRY-CARR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 3 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 4 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 5 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 6 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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 15 122 136 VARCHAR2 Description: Number which may be assigned to a provider by the state Medicaid agency for external control or billing purposes. SAS Name: MDCD_VNDR_NUM COBOL Name: MDCD-VNDR-NUM Original Participation Date 8 137 144 DATE Description: Date a provider is first approved to provide Medicare and/or Medicaid services. SAS Name: ORGNL_PRTCPTN_DT COBOL Name: ORGNL-PRTCPTN-DT Prior CHOW Date 8 145 152 DATE Description: Effective date of the previous change of ownership for this provider. SAS Name: CHOW_PRIOR_DT COBOL Name: CHOW-PRIOR-DT Prior Medicare Administrative Contractor (MAC) or 5 153 157 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the previous Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_PRIOR_CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 7 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: INTRMDRY-CARR-PRIOR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 00520=BLUE SHIELD (ARKANSAS) 00528=BLUE SHIELD (ARKANSAS/LOUISIANA) 00542=BLUE SHIELD (CALIFORNIA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 8 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00550=BLUE SHIELD (COLORADO) 00570=BLUE SHIELD (DELAWARE) 00580=BLUE SHIELD (DISTRICT OF COLUMBIA) 00590=BLUE SHIELD (FLORIDA) 00621=BLUE SHIELD (ILLINOIS) 00630=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 9 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 10 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 11 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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) CCN 10 158 167 VARCHAR2 Description: Six or ten position identification number that is assigned to a certified provider. This is the CMS Certification Number. SAS Name: PRVDR_NUM COBOL Name: PRVDR-NUM Region Code 2 168 169 VARCHAR2 Description: Indicates the CMS Regional Office responsible for the certification of the provider. SAS Name: RGN_CD COBOL Name: RGN-CD VALUES: 01=Boston 02=New York 03=Philadelphia 04=Atlanta 05=Chicago 06=Dallas 07=Kansas City 08=Denver 09=San Francisco 10=Seattle Skeleton Record Indicator 1 170 170 VARCHAR2 Description: Indicates if the record is a skeleton record. Only a limited set of data is available for this provider; no survey data exists. SAS Name: SKLTN_REC_SW COBOL Name: SKLTN-REC-SW State Abbreviation 2 171 172 VARCHAR2 Description: Two-character state abbreviation. SAS Name: STATE_CD COBOL Name: STATE-CD VALUES: AK=ALASKA AL=ALABAMA AR=ARKANSAS AS=AMERICAN SAMOA AZ=ARIZONA CA=CALIFORNIA CN=CANADA CO=COLORADO CT=CONNECTICUT DC=DISTRICT OF COLUMBIA DE=DELAWARE FL=FLORIDA FN=INTERNATIONAL DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 12 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA=GEORGIA GU=GUAM HI=HAWAII IA=IOWA ID=IDAHO IL=ILLINOIS IN=INDIANA KS=KANSAS KY=KENTUCKY LA=LOUISIANA MA=MASSACHUSETTS MD=MARYLAND ME=MAINE MI=MICHIGAN MN=MINNESOTA MO=MISSOURI MP=SAIPAN MS=MISSISSIPPI MT=MONTANA MX=MEXICO NC=NORTH CAROLINA ND=NORTH DAKOTA NE=NEBRASKA NH=NEW HAMPSHIRE NJ=NEW JERSEY NM=NEW MEXICO NV=NEVADA NY=NEW YORK OH=OHIO OK=OKLAHOMA OR=OREGON PA=PENNSYLVANIA PR=PUERTO RICO RI=RHODE ISLAND SC=SOUTH CAROLINA SD=SOUTH DAKOTA TN=TENNESSEE TX=TEXAS UT=UTAH VA=VIRGINIA VI=VIRGIN ISLANDS VT=VERMONT WA=WASHINGTON WI=WISCONSIN WV=WEST VIRGINIA WY=WYOMING SSA State Code 2 173 174 VARCHAR2 Description: Social Security Administration geographic code indicating the state where the provider is located. SAS Name: SSA_STATE_CD COBOL Name: SSA-STATE-CD 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 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 13 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 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 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 99=INTERNATIONAL State Region Code 3 175 177 VARCHAR2 Description: Identifies the region within a state where the provider is located. SAS Name: STATE_RGN_CD COBOL Name: STATE-RGN-CD VALUES: AK/001=ALASKA AK/LAB=LABORATORIES AL/001=ALABAMA AL/LAB=LABORATORIES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 14 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE AR/001=ARKANSAS AR/LAB=LABORATORIES AS/001=AMERICAN SAMOA AS/LAB=LABORATORY AZ/AZ=PHOENIX AZ/LAB=ARIZONA LAB AZ/TUC=TUCSON CA/BAK=BAKERSFIELD CA/BER=SAN BERNARDINO CA/BK=BERKELEY CA/BK1=CONTRA COSTA CA/FR=FRESNO CA/L1=L.A. WEST CA/L2=L.A. NORTH CA/L3=L.A. CENTRAL CA/L4=L.A. EAST CA/L5=SAN GABRIEL CA/LAB=LABORATORIES CA/M1=LAB. SOUTH CA/M2=LAB. NORTH CA/ORG=ORANGE CO CA/RIV=RIVERSIDE CA/RWC=REDWOOD COAST CA/S1=SACRAMENTO CA/S2=SACTO SOUTH CA/S3=CHICO CA/SD=SAN DIEGO CA/SDS=SAN DIEGO SOUTH CA/SF=SAN FRANCISCO CA/SJ=SAN JOSE CA/SR=SANTA ROSA CA/VEN=VENTURA CN/001=CANADA CN/LAB=LABORATORY CO/001=COLORADO CO/LAB=LABORATORIES CT/001=CONNECTICUT CT/LAB=LABORATORIES DC/001=DISTRICT OF COLUMBIA DC/LAB=LABORATORIES DE/001=DELAWARE DE/LAB=LABORATORIES FL/FTM=FT. MYERS FL/GAI=GAINESVILLE FL/JAX=JACKSONVILLE FL/LAB=LABORATORIES FL/LAN=LANTANA FL/LAU=LAUDERHILL FL/MIA=MIAMI FL/ORL=ORLANDO FL/PEN=PENSACOLA FL/STP=ST. PETERSBURG FL/TAL=TALLAHASSEE FL/TAM=TAMPA FM/001=FEDERATED STATES OF MICRO FN/001=INTERNATIONAL FN/LAB=LABORATORIES GA/001=GEORGIA GA/GAA=GEORGIA ALL GA/GAC=GEORGIA CENTRAL GA/GAE=GEORGIA EASTERN GA/GAN=GEORGIA NORTH GA/GAS=GEORGIA SOUTH GA/GAW=GEORGIA WESTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 15 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA/LAB=LABORATORIES GU/001=GUAM GU/LAB=LABORATORIES HI/001=HAWAII HI/LAB=LABORATORIES IA/001=IOWA IA/LAB=LABORATORIES ID/001=IDAHO ID/LAB=LABORATORIES IL/001=ILLINOIS IL/LAB=LABORATORIES IN/001=INDIANA IN/LAB=LABORATORIES KS/KCK=KANSAS CITY KS/KDH=KDHE KS/LAB=LABORATORIES KS/LAW=LAWRENCE KS/NC=NORTH CENTRAL KANSAS KS/NE=NORTH EAST KANSAS KS/NW=NORTH WEST KANSAS KS/SC=SOUTH CENTRAL KANSAS KS/SE=SOUTH EAST KANSAS KS/SW=SOUTH WEST KANSAS KS/WST=WEST KY/2C1=HOPKINSVILLE KY/2C2=LOUISVILLE KY/2C3=LONDON KY/2C4=LEXINGTON KY/LAB=LABORATORIES LA/001=LOUISIANA LA/LA1=NEW ORLEANS LA/LA2=MANDEVILLE LA/LA3=LAFAYETTE LA/LA4=MONROE LA/LA5=SHREVEPORT LA/LA6=ALEXANDRIA LA/LAB=LABORATORIES LA/LB1=CLIA NEW ORLEANS LA/LB5=CLIA SHREVEPORT LA/LB6=CLIA ALEXANDRIA MA/001=MASSACHUSETTS MA/LAB=LABORATORIES MD/001=MARYLAND MD/LAB=LABORATORIES ME/001=MAINE ME/LAB=LABORATORIES MH/001=MARSHALL ISLANDS MI/001=MICHIGAN MI/LAB=LABORATORIES MN/001=MINNESOTA MN/LAB=LABORATORIES MO/01=REGION01 MO/02=REGION02 MO/03=REGION 03 MO/04=REGION 04 MO/05=REGION 05 MO/06=REGION 06 MO/07=REGION 07 MO/1NH=REGION 1 NH MO/2NH=REGION 2 NH MO/3NH=REGION 3 NH MO/4NH=REGION 4 NH MO/5NH=REGION 5 NH MO/6NH=REGION 6 NH DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 16 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE MO/7NH=REGION 7 NH MO/LAB=LABORATORIES MO/MO=STATEWIDE MP/001=NORTHERN MARIANA ISLANDS MP/LAB=LABORATORIES MS/001=MISSISSIPPI MS/LAB=LABORATORIES MT/001=MONTANA MT/LAB=LABORATORIES MX/001=MEXICO MX/LAB=LABORATORY NC/LAB=LABORATORIES NC/NCC=NORTH CAROLINA CENTRAL NC/NCE=NORTH CAROLINA EAST NC/NCN=NORTH CAROLINA NORTH NC/NCS=NORTH CAROLINA SOUTH NC/NCW=NORTH CAROLINA WEST ND/001=NORTH DAKOTA ND/LAB=LABORATORIES NE/1=NORTH CENTRAL NE/2=CENTRAL NE/3=NORTHEAST NE/4=SOUTHEAST NE/5=WESTERN NE/LAB=LABORATORIES NH/001=NEW HAMPSHIRE NH/LAB=LABORATORIES NJ/001=NEW JERSEY NJ/LAB=LABORATORIES NM/001=NEW MEXICO NM/LAB=LABORATORIES NV/CC=CARSON CITY NV/LAB=LABORATORIES NV/LV=LAS VEGAS NY/001=BUFFALO NY/002=ROCHESTER NY/003=SYRACUSE NY/004=ALBANY NY/005=NEW ROCHELLE NY/006=NEW YORK CITY NY/007=SUFFOLK/NASSAU COUNTY NY/LAB=LABORATORIES OH/001=OHIO OH/LAB=LABORATORIES OK/001=OKLAHOMA OK/LAB=LABORATORIES OR/001=OFFICE #1 OR/002=OFFICE #2 OR/003=OFFICE #3 OR/LAB=LABORATORIES PA/001=PENNSYLVANIA PA/LAB=LABORATORIES PR/001=PUERTO RICO PR/LAB=LABORATORIES PW/001=PALAU RI/001=RHODE ISLAND RI/LAB=LABORATORIES SC/001=SOUTH CAROLINA SC/LAB=LABORATORIES SD/001=SOUTH DAKOTA SD/LAB=LABORATORIES TN/LAB=LABORATORIES TN/TNC=TENNESSEE COOKEVILLE TN/TNE=TENNESSEE EASTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 17 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE TN/TNM=TENNESSEE MIDDLE TN/TNW=TENNESSEE WESTERN TX/001=TEXAS TX/L01=AMARILLO-LTC TX/L02=ABILENE-LTC TX/L03=ARLINGTON-LTC TX/L04=TYLER-LTC TX/L05=BEAUMONT-LTC TX/L06=HOUSTON-LTC TX/L07=TEMPLE-LTC TX/L08=SAN ANTONIO-LTC TX/L09=SAN ANGELO-LTC TX/L10=EL PASO-LTC TX/L11=CORPUS CHRISTI-LTC TX/LAB=LABORATORIES TX/TX1=LUBBOCK TX/TX2=ARLINGTON TX/TX3=SAN ANTONIO TX/TX4=HOUSTON TX/TX5=TYLER TX/TX6=AUSTIN UT/001=UTAH UT/LAB=LABORATORIES VA/001=VIRGINIA VA/LAB=LABORATORIES VI/001=VIRGIN ISLANDS VI/LAB=LABORATORIES VT/001=VERMONT VT/LAB=LABORATORIES WA/001=ALL OTHERS (NON-LTC FAC) WA/D1=SPOKANE & YAKIMA AREAS WA/D1A=District 1, Unit A WA/D1B=District 1, Unit B WA/D1C=District 1, Unit C WA/D1D=District 1, Unit D WA/D2=SPOKANE & SE WA/D2A=District 2, Unit A WA/D2B=District 2, Unit B WA/D2C=District 2, Unit C WA/D2D=District 2, Unit D WA/D2E=District 2, Unit E WA/D2F=District 2, Unit F WA/D2G=District 2, Unit G WA/D3=NW WASHINGTON WA/D3A=District 3, Unit A WA/D3B=District 3, Unit B WA/D3C=District 3, Unit C WA/D3D=District 3, Unit D WA/D3E=District 3, Unit E WA/D4A=GREATER SEATTLE AREA WA/D4B=S KING COUNTY WA/D5A=PIERCE CTY & PENINSULA WA/D5B=PIERCE CTY & GRAYS HARBOR WA/D6=OLYMPIA AREA WA/LAB=LABORATORIES WI/001=WISCONSIN WI/LAB=LABORATORIES WV/001=WEST VIRGINIA WV/LAB=LABORATORIES WY/001=WYOMING WY/LAB=LABORATORIES Address: Street 50 178 227 VARCHAR2 Description: Street address where the provider is located. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 18 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: ST_ADR COBOL Name: ST-ADR Telephone Number 10 228 237 VARCHAR2 Description: Telephone number of the provider. SAS Name: PHNE_NUM COBOL Name: PHNE-NUM Termination Code 2 238 239 VARCHAR2 Description: Indicates the current termination status for the provider. SAS Name: PGM_TRMNTN_CD COBOL Name: PGM-TRMNTN-CD VALUES: 00=ACTIVE PROVIDER 01=VOLUNTARY-MERGER, CLOSURE 02=VOLUNTARY-DISSATISFACTION WITH REIMBURSEMENT 03=VOLUNTARY-RISK OF INVOLUNTARY TERMINATION 04=VOLUNTARY-OTHER REASON FOR WITHDRAWAL 05=INVOLUNTARY-FAILURE TO MEET HEALTH/SAFETY REQ 06=INVOLUNTARY-FAILURE TO MEET AGREEMENT 07=OTHER-PROVIDER STATUS CHANGE 08=NONPAYMENT OF FEES - CLIA Only 09=REV/UNSUCCESSFUL PARTICIPATION IN PT - CLIA Only 10=REV/OTHER REASON - CLIA Only 11=INCOMPLETE CLIA APPLICATION INFORMATION - CLIA Only 12=NO LONGER PERFORMING TESTS - CLIA Only 13=MULTIPLE TO SINGLE SITE CERTIFICATE - CLIA Only 14=SHARED LABORATORY - CLIA Only 15=FAILURE TO RENEW WAIVER PPM CERTIFICATE - CLIA Only 16=DUPLICATE CLIA NUMBER - CLIA Only 17=MAIL RETURNED NO FORWARD ADDRESS CERT ENDED - CLIA Only 20=NOTIFICATION BANKRUPTCY - CLIA Only 33=ACCREDITATION NOT CONFIRMED - CLIA Only 80=AWAITING STATE APPROVAL 99=OIG ACTION - DO NOT ACTIVATE - CLIA Only Termination or Expiration Date 8 240 247 DATE Description: Date the provider was terminated. For CLIA providers, date the laboratory's certificate was terminated or the expiration date of the current CLIA certificate. SAS Name: TRMNTN_EXPRTN_DT COBOL Name: TRMNTN-EXPRTN-DT Type of Action Code 1 248 248 VARCHAR2 Description: Identifies the reason for the certification. Type of action from the official survey record, CMS 1539 form. SAS Name: CRTFCTN_ACTN_TYPE_CD COBOL Name: CRTFCTN-ACTN-TYPE-CD VALUES: 1=INITIAL 2=RECERTIFICATION 3=TERMINATION 4=CHANGE OF OWNERSHIP 5=VALIDATION 8=FULL SURVEY AFTER COMPLAINT Ownership Type Code 2 249 250 VARCHAR2 Description: Indicates the ownership type of the provider. SAS Name: GNRL_CNTL_TYPE_CD COBOL Name: GNRL-CNTL-TYPE-CD VALUES: 01=VOLUNTARY NON-PROFIT - CHURCH 02=VOLUNTARY NON-PROFIT - PRIVATE 03=VOLUNTARY NON-PROFIT - OTHER 04=PROPRIETARY - INDIVIDUAL 05=PROPRIETARY - PARTNERSHIP DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 19 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 06=PROPRIETARY - CORPORATION 07=PROPRIETARY - OTHER 08=GOVERNMENT - STATE 09=GOVERNMENT - COUNTY 10=GOVERNMENT - CITY 11=GOVERNMENT - CITY-COUNTY 12=COMBINATION GOVERNMENT & NONPROFIT 13=OTHER Address: ZIP Code 5 251 255 VARCHAR2 Description: Five-digit ZIP code for a provider's physical address. SAS Name: ZIP_CD COBOL Name: ZIP-CD FIPS State Code 2 256 257 VARCHAR2 Description: FIPS State Code SAS Name: FIPS_STATE_CD COBOL Name: FIPS-STATE-CD VALUES: 01=ALABAMA 02=ALASKA 04=ARIZONA 05=ARKANSAS 06=CALIFORNIA 08=COLORADO 09=CONNECTICUT 10=DELAWARE 11=DISTRICT OF COLUMBIA 12=FLORIDA 13=GEORGIA 15=HAWAII 16=IDAHO 17=ILLINOIS 18=INDIANA 19=IOWA 20=KANSAS 21=KENTUCKY 22=LOUISIANA 23=MAINE 24=MARYLAND 25=MASSACHUSETTS 26=MICHIGAN 27=MINNESOTA 28=MISSISSIPPI 29=MISSOURI 30=MONTANA 31=NEBRASKA 32=NEVADA 33=NEW HAMPSHIRE 34=NEW JERSEY 35=NEW MEXICO 36=NEW YORK 37=NORTH CAROLINA 38=NORTH DAKOTA 39=OHIO 40=OKLAHOMA 41=OREGON 42=PENNSYLVANIA 43=PUERTO RICO 44=RHODE ISLAND 45=SOUTH CAROLINA 46=SOUTH DAKOTA 47=TENNESSEE 48=TEXAS 49=UTAH DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 20 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 50=VERMONT 51=VIRGINIA 53=WASHINGTON 54=WEST VIRGINIA 55=WISCONSIN 56=WYOMING 64=AMERICAN SAMOA 65=GUAM 66=SAIPAN/MARIANA IS. 78=VIRGIN ISLANDS FIPS County Code 3 258 260 VARCHAR2 Description: FIPS County Code SAS Name: FIPS_CNTY_CD COBOL Name: FIPS-CNTY-CD CBSA Urban Rural Indicator 1 261 261 VARCHAR2 Description: CBSA (Core Based Statistical Area) indicates whether the county is defined as Urban or Rural. SAS Name: CBSA_URBN_RRL_IND COBOL Name: CBSA-URBN-RRL-IND CBSA Code 5 262 266 VARCHAR2 Description: CBSA (Core Based Statistical Area) geographic entities defined by the U.S. Office of Management and Budget (OMB) on June 6, 2003 for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics. CBSA collectively refers to MSA. SAS Name: CBSA_CD COBOL Name: CBSA-CD Accreditation Type Code 1 283 283 VARCHAR2 Description: Indicates an accrediting organization deeming the provider. If a provider is deemed by multiple accrediting organizations then the accrediting organization with the earliest active deeming effective date is displayed in this field. SAS Name: ACRDTN_TYPE_CD COBOL Name: ACRDTN-TYPE-CD VALUES: 0=UNACCREDITED 1=JC 2=CHAP 3=ACHC Category-specific Facility Type Code 2 388 389 VARCHAR2 Description: Indicates the category-specific facility type code, for certain provider categories only. SAS Name: GNRL_FAC_TYPE_CD COBOL Name: GNRL-FAC-TYPE-CD VALUES: 01=Hospital 02=Skilled Nursing Facility 03=Nursing Facility 04=Home Health Agency 05=Freestanding Hospice Compliance: LSC Waiver Indicator 1 445 445 CHAR Description: Indicates if a waiver of any life safety code provision has been recommended for a provider. SAS Name: LSC_WVR_SW COBOL Name: LSC-WVR-SW Fiscal Year End Date (MMDD) 4 464 467 VARCHAR2 Description: End date, consisting of the month and day, of the provider's fiscal year. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 21 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: FY_END_MO_DAY_CD COBOL Name: FY-END-MO-DAY-CD Related Provider Number 10 669 678 CHAR Description: Related provider number SAS Name: RELATED_PROVIDER_NUMBER COBOL Name: RELATED-PROVIDER-NUMBER Services: Home Health Aide Code 1 681 681 CHAR Description: Indicates how home health aide services are provided. SAS Name: HH_AIDE_SRVC_CD COBOL Name: HH-AIDE-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: Counseling Code 1 700 700 VARCHAR2 Description: Indicates how counseling services are provided by the hospice. SAS Name: CNSLNG_SRVC_CD COBOL Name: CNSLNG-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: Homemaker Code 1 720 720 VARCHAR2 Description: Indicates how homemaker services are provided by the hospice. SAS Name: HMMKR_SRVC_CD COBOL Name: HMMKR-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: Medical Social Code 1 726 726 CHAR Description: Indicates how medical social services are provided. SAS Name: MDCL_SCL_SRVC_CD COBOL Name: MDCL-SCL-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: Medical Supplies Code 1 727 727 VARCHAR2 Description: Indicates how medical supply services are provided by the hospice. SAS Name: MDCL_SUPLY_SRVC_CD COBOL Name: MDCL-SUPLY-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: Nursing Code 1 742 742 CHAR Description: Indicates how nursing services are provided. SAS Name: NRSNG_SRVC_CD COBOL Name: NRSNG-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 22 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Services: OT Code 1 758 758 CHAR Description: Indicates how occupational therapy services are provided. SAS Name: OT_SRVC_CD COBOL Name: OT-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: Other Code 1 762 762 CHAR Description: Indicates how other services are provided. SAS Name: OTHR_SRVC_CD COBOL Name: OTHR-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: Physician Code 1 778 778 VARCHAR2 Description: Indicates how physician services are provided by the hospice. SAS Name: PHYSN_SRVC_CD COBOL Name: PHYSN-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: PT Code 1 796 796 CHAR Description: Indicates how physical therapy services are provided. SAS Name: PT_SRVC_CD COBOL Name: PT-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: Short Term Inpatient Care Code 1 805 805 VARCHAR2 Description: Indicates how short term inpatient care services are provided by the hospice. SAS Name: SHRT_TERM_IP_SRVC_CD COBOL Name: SHRT-TERM-IP-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Services: Speech Pathology Code 1 816 816 CHAR Description: Indicates how speech pathology services are provided. SAS Name: SPCH_PTHLGY_SRVC_CD COBOL Name: SPCH-PTHLGY-SRVC-CD VALUES: 0=NOT PROVIDED 1=PROVIDED BY STAFF 2=PROVIDED UNDER ARRANGEMENT 3=COMBINATION Short Term Inpatient Acute/Respite Care Code 1 843 843 VARCHAR2 Description: Indicates the type of short-term inpatient care provided by the hospice. SAS Name: ACUTE_RESP_CARE_CD COBOL Name: ACUTE-RESP-CARE-CD VALUES: A=SHORT TERM INPATIENT ACUTE CARE PROV'D IN HSP B=SHORT TERM INPATIENT RESPITE CARE PROV IN HSP DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 23 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE C=ST INPATIENT ACUTE & RESPITE CARE PROV IN HSP Staff Count: Aide - Employee 8 869 876 NUMBER Description: Number of full-time equivalent aides employed by the hospice. SAS Name: HH_AIDE_EMPLEE_CNT COBOL Name: HH-AIDE-EMPLEE-CNT Staff Count: Aide - Volunteer 8 877 884 NUMBER Description: Number of full-time equivalent aides volunteering in a hospice. SAS Name: HH_AIDE_VLNTR_CNT COBOL Name: HH-AIDE-VLNTR-CNT Staff Count: Other Personnel 8 885 892 NUMBER Description: Number of full-time equivalent other personnel employed by a provider SAS Name: PRSNEL_OTHR_CNT COBOL Name: PRSNEL-OTHR-CNT Staff Count: Counselor - Employee 8 917 924 NUMBER Description: Number of full-time equivalent counselors employed by the hospice. SAS Name: CNSLR_EMPLEE_CNT COBOL Name: CNSLR-EMPLEE-CNT Staff Count: Counselor - Volunteer 8 925 932 NUMBER Description: Number of full-time equivalent counselors volunteering in a Hospice. SAS Name: CNSLR_VLNTR_CNT COBOL Name: CNSLR-VLNTR-CNT Staff Count: Homemaker - Employee 8 1037 1044 NUMBER Description: Number of full-time equivalent homemakers employed by the hospice. SAS Name: HMMKR_EMPLEE_CNT COBOL Name: HMMKR-EMPLEE-CNT Staff Count: Homemaker - Volunteer 8 1045 1052 NUMBER Description: Number of full-time equivalent homemaker volunteering in a hospice. SAS Name: HMMKR_VLNTR_CNT COBOL Name: HMMKR-VLNTR-CNT Staff Count: LPN/LVN - Employee 8 1093 1100 NUMBER Description: Number of full-time equivalent licensed practical or vocational nurses employed by a provider. SAS Name: LPN_LVN_CNT COBOL Name: LPN-LVN-CNT Staff Count: LPN/LVN - Volunteer 8 1125 1132 NUMBER Description: Number of full-time equivalent licensed practical or vocational nurses volunteering in the hospice. SAS Name: LPN_LVN_VLNTR_CNT COBOL Name: LPN-LVN-VLNTR-CNT Staff Count: Medical Social Worker - Employee 8 1157 1164 NUMBER Description: Number of full-time equivalent medical social workers employed by a provider. SAS Name: MDCL_SCL_WORKR_CNT COBOL Name: MDCL-SCL-WORKR-CNT Staff Count: Medical Social Worker - Volunteer 8 1165 1172 NUMBER Description: Number of full-time equivalent medical social workers DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 24 Hospice, CATEGORY = "16" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE volunteering in the hospice. SAS Name: MDCL_SCL_WORKR_VLNTR_CNT COBOL Name: MDCL-SCL-WORKR-VLNTR-CNT Staff Count: Other - Volunteer 8 1373 1380 NUMBER Description: Number of full-time equivalent others volunteering in the hospice. SAS Name: VLNTR_OTHR_CNT COBOL Name: VLNTR-OTHR-CNT Staff Count: Physician - Employee 8 1525 1532 NUMBER Description: Number of full-time equivalent physicians employed by a provider. SAS Name: PHYSN_CNT COBOL Name: PHYSN-CNT Staff Count: Physician - Volunteer 8 1533 1540 NUMBER Description: Number of full-time equivalent physicians volunteering in a hospice. SAS Name: PHYSN_VLNTR_CNT COBOL Name: PHYSN-VLNTR-CNT Staff Count: RN 8 1733 1740 NUMBER Description: Number of full-time equivalent registered nurses employed by a provider. SAS Name: RN_CNT COBOL Name: RN-CNT Staff Count: RN - Volunteer 8 1765 1772 NUMBER Description: Number of full-time equivalent registered nurses volunteering in a hospice. SAS Name: RN_VLNTR_CNT COBOL Name: RN-VLNTR-CNT Staff Count: Total - Employee 9 1917 1925 NUMBER Description: Total number of full-time equivalent employees of a provider. SAS Name: EMPLEE_CNT COBOL Name: EMPLEE-CNT Staff Count: Total - Volunteer 9 1926 1934 NUMBER Description: Number of full-time equivalent volunteers in the hospice. SAS Name: VLNTR_CNT COBOL Name: VLNTR-CNT DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 1 Organ Procurement Organization, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Provider Category Subtype Code 2 1 2 VARCHAR2 Description: Identifies the subtype of the provider, within the primary category. Used in reporting to show the breakdown of provider categories, mainly for hospitals and SNFs. SAS Name: PRVDR_CTGRY_SBTYP_CD COBOL Name: PRVDR-CTGRY-SBTYP-CD VALUES: 01=Organ Procurement Provider Category Code 2 3 4 VARCHAR2 Description: Identifies the type of provider participating in the Medicare/Medicaid program. SAS Name: PRVDR_CTGRY_CD COBOL Name: PRVDR-CTGRY-CD VALUES: 17=Organ Procurement Organization CHOW Count 2 5 6 NUMBER Description: Number of times this provider has undergone a change of ownership. SAS Name: CHOW_CNT COBOL Name: CHOW-CNT CHOW Date 8 7 14 DATE Description: Effective date of the most recent change of ownership for this provider. SAS Name: CHOW_DT COBOL Name: CHOW-DT Address: City 28 15 42 VARCHAR2 Description: City in which the provider is physically located. SAS Name: CITY_NAME COBOL Name: CITY-NAME Compliance: Acceptable POC 1 43 43 VARCHAR2 Description: Indicates if a provider is in compliance with program requirements based on an acceptable plan for correction of deficiencies. SAS Name: ACPTBL_POC_SW COBOL Name: ACPTBL-POC-SW Compliance: Status 1 44 44 VARCHAR2 Description: Compliance status of a provider at the time of certification survey. SAS Name: CMPLNC_STUS_CD COBOL Name: CMPLNC-STUS-CD VALUES: A=IN COMPLIANCE B=NOT IN COMPLIANCE SSA County Code 3 45 47 VARCHAR2 Description: Social Security Administration geographic code indicating the county where the provider is located. SAS Name: SSA_CNTY_CD COBOL Name: SSA-CNTY-CD Cross Ref Provider Number 10 48 57 CHAR Description: Cross reference provider number SAS Name: CROSS_REF_PROVIDER_NUMBER COBOL Name: CROSS-REF-PROVIDER-NUMBER Certification Date 8 58 65 DATE Description: Equal to the exit date of the initial visit of the Health survey for certifications completed after July 28, 2012. For certifications prior to that date, the certification DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 2 Organ Procurement Organization, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE date is equal to the exit date of the initial visit of the Health survey or LSC survey, whichever is later. SAS Name: CRTFCTN_DT COBOL Name: CRTFCTN-DT Eligibility Indicator 1 66 66 VARCHAR2 Description: Indicates if a facility is eligible to participate in the Medicare and/or Medicaid programs. SAS Name: ELGBLTY_SW COBOL Name: ELGBLTY-SW Facility Name 50 67 116 VARCHAR2 Description: Name of the provider certified to participate in the Medicare and/or Medicaid programs. SAS Name: FAC_NAME COBOL Name: FAC-NAME Medicare Administrative Contractor (MAC) or 5 117 121 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_CD COBOL Name: INTRMDRY-CARR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 3 Organ Procurement Organization, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 4 Organ Procurement Organization, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 5 Organ Procurement Organization, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 6 Organ Procurement Organization, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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 15 122 136 VARCHAR2 Description: Number which may be assigned to a provider by the state Medicaid agency for external control or billing purposes. SAS Name: MDCD_VNDR_NUM COBOL Name: MDCD-VNDR-NUM Original Participation Date 8 137 144 DATE Description: Date a provider is first approved to provide Medicare and/or Medicaid services. SAS Name: ORGNL_PRTCPTN_DT COBOL Name: ORGNL-PRTCPTN-DT Prior CHOW Date 8 145 152 DATE Description: Effective date of the previous change of ownership for this provider. SAS Name: CHOW_PRIOR_DT COBOL Name: CHOW-PRIOR-DT Prior Medicare Administrative Contractor (MAC) or 5 153 157 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the previous Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_PRIOR_CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 7 Organ Procurement Organization, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: INTRMDRY-CARR-PRIOR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 00520=BLUE SHIELD (ARKANSAS) 00528=BLUE SHIELD (ARKANSAS/LOUISIANA) 00542=BLUE SHIELD (CALIFORNIA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 8 Organ Procurement Organization, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00550=BLUE SHIELD (COLORADO) 00570=BLUE SHIELD (DELAWARE) 00580=BLUE SHIELD (DISTRICT OF COLUMBIA) 00590=BLUE SHIELD (FLORIDA) 00621=BLUE SHIELD (ILLINOIS) 00630=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 9 Organ Procurement Organization, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 10 Organ Procurement Organization, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 11 Organ Procurement Organization, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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) CCN 10 158 167 VARCHAR2 Description: Six or ten position identification number that is assigned to a certified provider. This is the CMS Certification Number. SAS Name: PRVDR_NUM COBOL Name: PRVDR-NUM Region Code 2 168 169 VARCHAR2 Description: Indicates the CMS Regional Office responsible for the certification of the provider. SAS Name: RGN_CD COBOL Name: RGN-CD VALUES: 01=Boston 02=New York 03=Philadelphia 04=Atlanta 05=Chicago 06=Dallas 07=Kansas City 08=Denver 09=San Francisco 10=Seattle Skeleton Record Indicator 1 170 170 VARCHAR2 Description: Indicates if the record is a skeleton record. Only a limited set of data is available for this provider; no survey data exists. SAS Name: SKLTN_REC_SW COBOL Name: SKLTN-REC-SW State Abbreviation 2 171 172 VARCHAR2 Description: Two-character state abbreviation. SAS Name: STATE_CD COBOL Name: STATE-CD VALUES: AK=ALASKA AL=ALABAMA AR=ARKANSAS AS=AMERICAN SAMOA AZ=ARIZONA CA=CALIFORNIA CN=CANADA CO=COLORADO CT=CONNECTICUT DC=DISTRICT OF COLUMBIA DE=DELAWARE FL=FLORIDA FN=INTERNATIONAL DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 12 Organ Procurement Organization, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA=GEORGIA GU=GUAM HI=HAWAII IA=IOWA ID=IDAHO IL=ILLINOIS IN=INDIANA KS=KANSAS KY=KENTUCKY LA=LOUISIANA MA=MASSACHUSETTS MD=MARYLAND ME=MAINE MI=MICHIGAN MN=MINNESOTA MO=MISSOURI MP=SAIPAN MS=MISSISSIPPI MT=MONTANA MX=MEXICO NC=NORTH CAROLINA ND=NORTH DAKOTA NE=NEBRASKA NH=NEW HAMPSHIRE NJ=NEW JERSEY NM=NEW MEXICO NV=NEVADA NY=NEW YORK OH=OHIO OK=OKLAHOMA OR=OREGON PA=PENNSYLVANIA PR=PUERTO RICO RI=RHODE ISLAND SC=SOUTH CAROLINA SD=SOUTH DAKOTA TN=TENNESSEE TX=TEXAS UT=UTAH VA=VIRGINIA VI=VIRGIN ISLANDS VT=VERMONT WA=WASHINGTON WI=WISCONSIN WV=WEST VIRGINIA WY=WYOMING SSA State Code 2 173 174 VARCHAR2 Description: Social Security Administration geographic code indicating the state where the provider is located. SAS Name: SSA_STATE_CD COBOL Name: SSA-STATE-CD 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 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 13 Organ Procurement Organization, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 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 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 99=INTERNATIONAL State Region Code 3 175 177 VARCHAR2 Description: Identifies the region within a state where the provider is located. SAS Name: STATE_RGN_CD COBOL Name: STATE-RGN-CD VALUES: AK/001=ALASKA AK/LAB=LABORATORIES AL/001=ALABAMA AL/LAB=LABORATORIES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 14 Organ Procurement Organization, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE AR/001=ARKANSAS AR/LAB=LABORATORIES AS/001=AMERICAN SAMOA AS/LAB=LABORATORY AZ/AZ=PHOENIX AZ/LAB=ARIZONA LAB AZ/TUC=TUCSON CA/BAK=BAKERSFIELD CA/BER=SAN BERNARDINO CA/BK=BERKELEY CA/BK1=CONTRA COSTA CA/FR=FRESNO CA/L1=L.A. WEST CA/L2=L.A. NORTH CA/L3=L.A. CENTRAL CA/L4=L.A. EAST CA/L5=SAN GABRIEL CA/LAB=LABORATORIES CA/M1=LAB. SOUTH CA/M2=LAB. NORTH CA/ORG=ORANGE CO CA/RIV=RIVERSIDE CA/RWC=REDWOOD COAST CA/S1=SACRAMENTO CA/S2=SACTO SOUTH CA/S3=CHICO CA/SD=SAN DIEGO CA/SDS=SAN DIEGO SOUTH CA/SF=SAN FRANCISCO CA/SJ=SAN JOSE CA/SR=SANTA ROSA CA/VEN=VENTURA CN/001=CANADA CN/LAB=LABORATORY CO/001=COLORADO CO/LAB=LABORATORIES CT/001=CONNECTICUT CT/LAB=LABORATORIES DC/001=DISTRICT OF COLUMBIA DC/LAB=LABORATORIES DE/001=DELAWARE DE/LAB=LABORATORIES FL/FTM=FT. MYERS FL/GAI=GAINESVILLE FL/JAX=JACKSONVILLE FL/LAB=LABORATORIES FL/LAN=LANTANA FL/LAU=LAUDERHILL FL/MIA=MIAMI FL/ORL=ORLANDO FL/PEN=PENSACOLA FL/STP=ST. PETERSBURG FL/TAL=TALLAHASSEE FL/TAM=TAMPA FM/001=FEDERATED STATES OF MICRO FN/001=INTERNATIONAL FN/LAB=LABORATORIES GA/001=GEORGIA GA/GAA=GEORGIA ALL GA/GAC=GEORGIA CENTRAL GA/GAE=GEORGIA EASTERN GA/GAN=GEORGIA NORTH GA/GAS=GEORGIA SOUTH GA/GAW=GEORGIA WESTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 15 Organ Procurement Organization, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA/LAB=LABORATORIES GU/001=GUAM GU/LAB=LABORATORIES HI/001=HAWAII HI/LAB=LABORATORIES IA/001=IOWA IA/LAB=LABORATORIES ID/001=IDAHO ID/LAB=LABORATORIES IL/001=ILLINOIS IL/LAB=LABORATORIES IN/001=INDIANA IN/LAB=LABORATORIES KS/KCK=KANSAS CITY KS/KDH=KDHE KS/LAB=LABORATORIES KS/LAW=LAWRENCE KS/NC=NORTH CENTRAL KANSAS KS/NE=NORTH EAST KANSAS KS/NW=NORTH WEST KANSAS KS/SC=SOUTH CENTRAL KANSAS KS/SE=SOUTH EAST KANSAS KS/SW=SOUTH WEST KANSAS KS/WST=WEST KY/2C1=HOPKINSVILLE KY/2C2=LOUISVILLE KY/2C3=LONDON KY/2C4=LEXINGTON KY/LAB=LABORATORIES LA/001=LOUISIANA LA/LA1=NEW ORLEANS LA/LA2=MANDEVILLE LA/LA3=LAFAYETTE LA/LA4=MONROE LA/LA5=SHREVEPORT LA/LA6=ALEXANDRIA LA/LAB=LABORATORIES LA/LB1=CLIA NEW ORLEANS LA/LB5=CLIA SHREVEPORT LA/LB6=CLIA ALEXANDRIA MA/001=MASSACHUSETTS MA/LAB=LABORATORIES MD/001=MARYLAND MD/LAB=LABORATORIES ME/001=MAINE ME/LAB=LABORATORIES MH/001=MARSHALL ISLANDS MI/001=MICHIGAN MI/LAB=LABORATORIES MN/001=MINNESOTA MN/LAB=LABORATORIES MO/01=REGION01 MO/02=REGION02 MO/03=REGION 03 MO/04=REGION 04 MO/05=REGION 05 MO/06=REGION 06 MO/07=REGION 07 MO/1NH=REGION 1 NH MO/2NH=REGION 2 NH MO/3NH=REGION 3 NH MO/4NH=REGION 4 NH MO/5NH=REGION 5 NH MO/6NH=REGION 6 NH DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 16 Organ Procurement Organization, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE MO/7NH=REGION 7 NH MO/LAB=LABORATORIES MO/MO=STATEWIDE MP/001=NORTHERN MARIANA ISLANDS MP/LAB=LABORATORIES MS/001=MISSISSIPPI MS/LAB=LABORATORIES MT/001=MONTANA MT/LAB=LABORATORIES MX/001=MEXICO MX/LAB=LABORATORY NC/LAB=LABORATORIES NC/NCC=NORTH CAROLINA CENTRAL NC/NCE=NORTH CAROLINA EAST NC/NCN=NORTH CAROLINA NORTH NC/NCS=NORTH CAROLINA SOUTH NC/NCW=NORTH CAROLINA WEST ND/001=NORTH DAKOTA ND/LAB=LABORATORIES NE/1=NORTH CENTRAL NE/2=CENTRAL NE/3=NORTHEAST NE/4=SOUTHEAST NE/5=WESTERN NE/LAB=LABORATORIES NH/001=NEW HAMPSHIRE NH/LAB=LABORATORIES NJ/001=NEW JERSEY NJ/LAB=LABORATORIES NM/001=NEW MEXICO NM/LAB=LABORATORIES NV/CC=CARSON CITY NV/LAB=LABORATORIES NV/LV=LAS VEGAS NY/001=BUFFALO NY/002=ROCHESTER NY/003=SYRACUSE NY/004=ALBANY NY/005=NEW ROCHELLE NY/006=NEW YORK CITY NY/007=SUFFOLK/NASSAU COUNTY NY/LAB=LABORATORIES OH/001=OHIO OH/LAB=LABORATORIES OK/001=OKLAHOMA OK/LAB=LABORATORIES OR/001=OFFICE #1 OR/002=OFFICE #2 OR/003=OFFICE #3 OR/LAB=LABORATORIES PA/001=PENNSYLVANIA PA/LAB=LABORATORIES PR/001=PUERTO RICO PR/LAB=LABORATORIES PW/001=PALAU RI/001=RHODE ISLAND RI/LAB=LABORATORIES SC/001=SOUTH CAROLINA SC/LAB=LABORATORIES SD/001=SOUTH DAKOTA SD/LAB=LABORATORIES TN/LAB=LABORATORIES TN/TNC=TENNESSEE COOKEVILLE TN/TNE=TENNESSEE EASTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 17 Organ Procurement Organization, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE TN/TNM=TENNESSEE MIDDLE TN/TNW=TENNESSEE WESTERN TX/001=TEXAS TX/L01=AMARILLO-LTC TX/L02=ABILENE-LTC TX/L03=ARLINGTON-LTC TX/L04=TYLER-LTC TX/L05=BEAUMONT-LTC TX/L06=HOUSTON-LTC TX/L07=TEMPLE-LTC TX/L08=SAN ANTONIO-LTC TX/L09=SAN ANGELO-LTC TX/L10=EL PASO-LTC TX/L11=CORPUS CHRISTI-LTC TX/LAB=LABORATORIES TX/TX1=LUBBOCK TX/TX2=ARLINGTON TX/TX3=SAN ANTONIO TX/TX4=HOUSTON TX/TX5=TYLER TX/TX6=AUSTIN UT/001=UTAH UT/LAB=LABORATORIES VA/001=VIRGINIA VA/LAB=LABORATORIES VI/001=VIRGIN ISLANDS VI/LAB=LABORATORIES VT/001=VERMONT VT/LAB=LABORATORIES WA/001=ALL OTHERS (NON-LTC FAC) WA/D1=SPOKANE & YAKIMA AREAS WA/D1A=District 1, Unit A WA/D1B=District 1, Unit B WA/D1C=District 1, Unit C WA/D1D=District 1, Unit D WA/D2=SPOKANE & SE WA/D2A=District 2, Unit A WA/D2B=District 2, Unit B WA/D2C=District 2, Unit C WA/D2D=District 2, Unit D WA/D2E=District 2, Unit E WA/D2F=District 2, Unit F WA/D2G=District 2, Unit G WA/D3=NW WASHINGTON WA/D3A=District 3, Unit A WA/D3B=District 3, Unit B WA/D3C=District 3, Unit C WA/D3D=District 3, Unit D WA/D3E=District 3, Unit E WA/D4A=GREATER SEATTLE AREA WA/D4B=S KING COUNTY WA/D5A=PIERCE CTY & PENINSULA WA/D5B=PIERCE CTY & GRAYS HARBOR WA/D6=OLYMPIA AREA WA/LAB=LABORATORIES WI/001=WISCONSIN WI/LAB=LABORATORIES WV/001=WEST VIRGINIA WV/LAB=LABORATORIES WY/001=WYOMING WY/LAB=LABORATORIES Address: Street 50 178 227 VARCHAR2 Description: Street address where the provider is located. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 18 Organ Procurement Organization, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: ST_ADR COBOL Name: ST-ADR Telephone Number 10 228 237 VARCHAR2 Description: Telephone number of the provider. SAS Name: PHNE_NUM COBOL Name: PHNE-NUM Termination Code 2 238 239 VARCHAR2 Description: Indicates the current termination status for the provider. SAS Name: PGM_TRMNTN_CD COBOL Name: PGM-TRMNTN-CD VALUES: 00=ACTIVE PROVIDER 01=VOLUNTARY-MERGER, CLOSURE 02=VOLUNTARY-DISSATISFACTION WITH REIMBURSEMENT 03=VOLUNTARY-RISK OF INVOLUNTARY TERMINATION 04=VOLUNTARY-OTHER REASON FOR WITHDRAWAL 05=INVOLUNTARY-FAILURE TO MEET HEALTH/SAFETY REQ 06=INVOLUNTARY-FAILURE TO MEET AGREEMENT 07=OTHER-PROVIDER STATUS CHANGE 08=NONPAYMENT OF FEES - CLIA Only 09=REV/UNSUCCESSFUL PARTICIPATION IN PT - CLIA Only 10=REV/OTHER REASON - CLIA Only 11=INCOMPLETE CLIA APPLICATION INFORMATION - CLIA Only 12=NO LONGER PERFORMING TESTS - CLIA Only 13=MULTIPLE TO SINGLE SITE CERTIFICATE - CLIA Only 14=SHARED LABORATORY - CLIA Only 15=FAILURE TO RENEW WAIVER PPM CERTIFICATE - CLIA Only 16=DUPLICATE CLIA NUMBER - CLIA Only 17=MAIL RETURNED NO FORWARD ADDRESS CERT ENDED - CLIA Only 20=NOTIFICATION BANKRUPTCY - CLIA Only 33=ACCREDITATION NOT CONFIRMED - CLIA Only 80=AWAITING STATE APPROVAL 99=OIG ACTION - DO NOT ACTIVATE - CLIA Only Termination or Expiration Date 8 240 247 DATE Description: Date the provider was terminated. For CLIA providers, date the laboratory's certificate was terminated or the expiration date of the current CLIA certificate. SAS Name: TRMNTN_EXPRTN_DT COBOL Name: TRMNTN-EXPRTN-DT Type of Action Code 1 248 248 VARCHAR2 Description: Identifies the reason for the certification. Type of action from the official survey record, CMS 1539 form. SAS Name: CRTFCTN_ACTN_TYPE_CD COBOL Name: CRTFCTN-ACTN-TYPE-CD VALUES: 1=INITIAL 2=RECERTIFICATION 3=TERMINATION 4=CHANGE OF OWNERSHIP 5=VALIDATION 8=FULL SURVEY AFTER COMPLAINT Ownership Type Code 2 249 250 VARCHAR2 Description: Indicates the ownership type of the provider. SAS Name: GNRL_CNTL_TYPE_CD COBOL Name: GNRL-CNTL-TYPE-CD Address: ZIP Code 5 251 255 VARCHAR2 Description: Five-digit ZIP code for a provider's physical address. SAS Name: ZIP_CD COBOL Name: ZIP-CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 19 Organ Procurement Organization, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE FIPS State Code 2 256 257 VARCHAR2 Description: FIPS State Code SAS Name: FIPS_STATE_CD COBOL Name: FIPS-STATE-CD VALUES: 01=ALABAMA 02=ALASKA 04=ARIZONA 05=ARKANSAS 06=CALIFORNIA 08=COLORADO 09=CONNECTICUT 10=DELAWARE 11=DISTRICT OF COLUMBIA 12=FLORIDA 13=GEORGIA 15=HAWAII 16=IDAHO 17=ILLINOIS 18=INDIANA 19=IOWA 20=KANSAS 21=KENTUCKY 22=LOUISIANA 23=MAINE 24=MARYLAND 25=MASSACHUSETTS 26=MICHIGAN 27=MINNESOTA 28=MISSISSIPPI 29=MISSOURI 30=MONTANA 31=NEBRASKA 32=NEVADA 33=NEW HAMPSHIRE 34=NEW JERSEY 35=NEW MEXICO 36=NEW YORK 37=NORTH CAROLINA 38=NORTH DAKOTA 39=OHIO 40=OKLAHOMA 41=OREGON 42=PENNSYLVANIA 43=PUERTO RICO 44=RHODE ISLAND 45=SOUTH CAROLINA 46=SOUTH DAKOTA 47=TENNESSEE 48=TEXAS 49=UTAH 50=VERMONT 51=VIRGINIA 53=WASHINGTON 54=WEST VIRGINIA 55=WISCONSIN 56=WYOMING 64=AMERICAN SAMOA 65=GUAM 66=SAIPAN/MARIANA IS. 78=VIRGIN ISLANDS FIPS County Code 3 258 260 VARCHAR2 Description: FIPS County Code DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 20 Organ Procurement Organization, CATEGORY = "17" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: FIPS_CNTY_CD COBOL Name: FIPS-CNTY-CD CBSA Urban Rural Indicator 1 261 261 VARCHAR2 Description: CBSA (Core Based Statistical Area) indicates whether the county is defined as Urban or Rural. SAS Name: CBSA_URBN_RRL_IND COBOL Name: CBSA-URBN-RRL-IND CBSA Code 5 262 266 VARCHAR2 Description: CBSA (Core Based Statistical Area) geographic entities defined by the U.S. Office of Management and Budget (OMB) on June 6, 2003 for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics. CBSA collectively refers to MSA. SAS Name: CBSA_CD COBOL Name: CBSA-CD Fiscal Year End Date (MMDD) 4 464 467 VARCHAR2 Description: End date, consisting of the month and day, of the provider's fiscal year. SAS Name: FY_END_MO_DAY_CD COBOL Name: FY-END-MO-DAY-CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 1 Community Mental Health Center, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Provider Category Subtype Code 2 1 2 VARCHAR2 Description: Identifies the subtype of the provider, within the primary category. Used in reporting to show the breakdown of provider categories, mainly for hospitals and SNFs. SAS Name: PRVDR_CTGRY_SBTYP_CD COBOL Name: PRVDR-CTGRY-SBTYP-CD VALUES: 01=Community Mental Health Center Provider Category Code 2 3 4 VARCHAR2 Description: Identifies the type of provider participating in the Medicare/Medicaid program. SAS Name: PRVDR_CTGRY_CD COBOL Name: PRVDR-CTGRY-CD VALUES: 19=Community Mental Health Center CHOW Count 2 5 6 NUMBER Description: Number of times this provider has undergone a change of ownership. SAS Name: CHOW_CNT COBOL Name: CHOW-CNT CHOW Date 8 7 14 DATE Description: Effective date of the most recent change of ownership for this provider. SAS Name: CHOW_DT COBOL Name: CHOW-DT Address: City 28 15 42 VARCHAR2 Description: City in which the provider is physically located. SAS Name: CITY_NAME COBOL Name: CITY-NAME Compliance: Acceptable POC 1 43 43 VARCHAR2 Description: Indicates if a provider is in compliance with program requirements based on an acceptable plan for correction of deficiencies. SAS Name: ACPTBL_POC_SW COBOL Name: ACPTBL-POC-SW Compliance: Status 1 44 44 VARCHAR2 Description: Compliance status of a provider at the time of certification survey. SAS Name: CMPLNC_STUS_CD COBOL Name: CMPLNC-STUS-CD VALUES: A=IN COMPLIANCE B=NOT IN COMPLIANCE SSA County Code 3 45 47 VARCHAR2 Description: Social Security Administration geographic code indicating the county where the provider is located. SAS Name: SSA_CNTY_CD COBOL Name: SSA-CNTY-CD Cross Ref Provider Number 10 48 57 CHAR Description: Cross reference provider number SAS Name: CROSS_REF_PROVIDER_NUMBER COBOL Name: CROSS-REF-PROVIDER-NUMBER Certification Date 8 58 65 DATE Description: Equal to the exit date of the initial visit of the Health survey for certifications completed after July 28, 2012. For certifications prior to that date, the certification DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 2 Community Mental Health Center, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE date is equal to the exit date of the initial visit of the Health survey or LSC survey, whichever is later. SAS Name: CRTFCTN_DT COBOL Name: CRTFCTN-DT Eligibility Indicator 1 66 66 VARCHAR2 Description: Indicates if a facility is eligible to participate in the Medicare and/or Medicaid programs. SAS Name: ELGBLTY_SW COBOL Name: ELGBLTY-SW Facility Name 50 67 116 VARCHAR2 Description: Name of the provider certified to participate in the Medicare and/or Medicaid programs. SAS Name: FAC_NAME COBOL Name: FAC-NAME Medicare Administrative Contractor (MAC) or 5 117 121 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_CD COBOL Name: INTRMDRY-CARR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 3 Community Mental Health Center, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 4 Community Mental Health Center, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 5 Community Mental Health Center, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 6 Community Mental Health Center, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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 15 122 136 VARCHAR2 Description: Number which may be assigned to a provider by the state Medicaid agency for external control or billing purposes. SAS Name: MDCD_VNDR_NUM COBOL Name: MDCD-VNDR-NUM Original Participation Date 8 137 144 DATE Description: Date a provider is first approved to provide Medicare and/or Medicaid services. SAS Name: ORGNL_PRTCPTN_DT COBOL Name: ORGNL-PRTCPTN-DT Prior CHOW Date 8 145 152 DATE Description: Effective date of the previous change of ownership for this provider. SAS Name: CHOW_PRIOR_DT COBOL Name: CHOW-PRIOR-DT Prior Medicare Administrative Contractor (MAC) or 5 153 157 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the previous Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_PRIOR_CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 7 Community Mental Health Center, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: INTRMDRY-CARR-PRIOR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 00520=BLUE SHIELD (ARKANSAS) 00528=BLUE SHIELD (ARKANSAS/LOUISIANA) 00542=BLUE SHIELD (CALIFORNIA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 8 Community Mental Health Center, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00550=BLUE SHIELD (COLORADO) 00570=BLUE SHIELD (DELAWARE) 00580=BLUE SHIELD (DISTRICT OF COLUMBIA) 00590=BLUE SHIELD (FLORIDA) 00621=BLUE SHIELD (ILLINOIS) 00630=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 9 Community Mental Health Center, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 10 Community Mental Health Center, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 11 Community Mental Health Center, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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) CCN 10 158 167 VARCHAR2 Description: Six or ten position identification number that is assigned to a certified provider. This is the CMS Certification Number. SAS Name: PRVDR_NUM COBOL Name: PRVDR-NUM Region Code 2 168 169 VARCHAR2 Description: Indicates the CMS Regional Office responsible for the certification of the provider. SAS Name: RGN_CD COBOL Name: RGN-CD VALUES: 01=Boston 02=New York 03=Philadelphia 04=Atlanta 05=Chicago 06=Dallas 07=Kansas City 08=Denver 09=San Francisco 10=Seattle Skeleton Record Indicator 1 170 170 VARCHAR2 Description: Indicates if the record is a skeleton record. Only a limited set of data is available for this provider; no survey data exists. SAS Name: SKLTN_REC_SW COBOL Name: SKLTN-REC-SW State Abbreviation 2 171 172 VARCHAR2 Description: Two-character state abbreviation. SAS Name: STATE_CD COBOL Name: STATE-CD VALUES: AK=ALASKA AL=ALABAMA AR=ARKANSAS AS=AMERICAN SAMOA AZ=ARIZONA CA=CALIFORNIA CN=CANADA CO=COLORADO CT=CONNECTICUT DC=DISTRICT OF COLUMBIA DE=DELAWARE FL=FLORIDA FN=INTERNATIONAL DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 12 Community Mental Health Center, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA=GEORGIA GU=GUAM HI=HAWAII IA=IOWA ID=IDAHO IL=ILLINOIS IN=INDIANA KS=KANSAS KY=KENTUCKY LA=LOUISIANA MA=MASSACHUSETTS MD=MARYLAND ME=MAINE MI=MICHIGAN MN=MINNESOTA MO=MISSOURI MP=SAIPAN MS=MISSISSIPPI MT=MONTANA MX=MEXICO NC=NORTH CAROLINA ND=NORTH DAKOTA NE=NEBRASKA NH=NEW HAMPSHIRE NJ=NEW JERSEY NM=NEW MEXICO NV=NEVADA NY=NEW YORK OH=OHIO OK=OKLAHOMA OR=OREGON PA=PENNSYLVANIA PR=PUERTO RICO RI=RHODE ISLAND SC=SOUTH CAROLINA SD=SOUTH DAKOTA TN=TENNESSEE TX=TEXAS UT=UTAH VA=VIRGINIA VI=VIRGIN ISLANDS VT=VERMONT WA=WASHINGTON WI=WISCONSIN WV=WEST VIRGINIA WY=WYOMING SSA State Code 2 173 174 VARCHAR2 Description: Social Security Administration geographic code indicating the state where the provider is located. SAS Name: SSA_STATE_CD COBOL Name: SSA-STATE-CD 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 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 13 Community Mental Health Center, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 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 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 99=INTERNATIONAL State Region Code 3 175 177 VARCHAR2 Description: Identifies the region within a state where the provider is located. SAS Name: STATE_RGN_CD COBOL Name: STATE-RGN-CD VALUES: AK/001=ALASKA AK/LAB=LABORATORIES AL/001=ALABAMA AL/LAB=LABORATORIES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 14 Community Mental Health Center, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE AR/001=ARKANSAS AR/LAB=LABORATORIES AS/001=AMERICAN SAMOA AS/LAB=LABORATORY AZ/AZ=PHOENIX AZ/LAB=ARIZONA LAB AZ/TUC=TUCSON CA/BAK=BAKERSFIELD CA/BER=SAN BERNARDINO CA/BK=BERKELEY CA/BK1=CONTRA COSTA CA/FR=FRESNO CA/L1=L.A. WEST CA/L2=L.A. NORTH CA/L3=L.A. CENTRAL CA/L4=L.A. EAST CA/L5=SAN GABRIEL CA/LAB=LABORATORIES CA/M1=LAB. SOUTH CA/M2=LAB. NORTH CA/ORG=ORANGE CO CA/RIV=RIVERSIDE CA/RWC=REDWOOD COAST CA/S1=SACRAMENTO CA/S2=SACTO SOUTH CA/S3=CHICO CA/SD=SAN DIEGO CA/SDS=SAN DIEGO SOUTH CA/SF=SAN FRANCISCO CA/SJ=SAN JOSE CA/SR=SANTA ROSA CA/VEN=VENTURA CN/001=CANADA CN/LAB=LABORATORY CO/001=COLORADO CO/LAB=LABORATORIES CT/001=CONNECTICUT CT/LAB=LABORATORIES DC/001=DISTRICT OF COLUMBIA DC/LAB=LABORATORIES DE/001=DELAWARE DE/LAB=LABORATORIES FL/FTM=FT. MYERS FL/GAI=GAINESVILLE FL/JAX=JACKSONVILLE FL/LAB=LABORATORIES FL/LAN=LANTANA FL/LAU=LAUDERHILL FL/MIA=MIAMI FL/ORL=ORLANDO FL/PEN=PENSACOLA FL/STP=ST. PETERSBURG FL/TAL=TALLAHASSEE FL/TAM=TAMPA FM/001=FEDERATED STATES OF MICRO FN/001=INTERNATIONAL FN/LAB=LABORATORIES GA/001=GEORGIA GA/GAA=GEORGIA ALL GA/GAC=GEORGIA CENTRAL GA/GAE=GEORGIA EASTERN GA/GAN=GEORGIA NORTH GA/GAS=GEORGIA SOUTH GA/GAW=GEORGIA WESTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 15 Community Mental Health Center, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA/LAB=LABORATORIES GU/001=GUAM GU/LAB=LABORATORIES HI/001=HAWAII HI/LAB=LABORATORIES IA/001=IOWA IA/LAB=LABORATORIES ID/001=IDAHO ID/LAB=LABORATORIES IL/001=ILLINOIS IL/LAB=LABORATORIES IN/001=INDIANA IN/LAB=LABORATORIES KS/KCK=KANSAS CITY KS/KDH=KDHE KS/LAB=LABORATORIES KS/LAW=LAWRENCE KS/NC=NORTH CENTRAL KANSAS KS/NE=NORTH EAST KANSAS KS/NW=NORTH WEST KANSAS KS/SC=SOUTH CENTRAL KANSAS KS/SE=SOUTH EAST KANSAS KS/SW=SOUTH WEST KANSAS KS/WST=WEST KY/2C1=HOPKINSVILLE KY/2C2=LOUISVILLE KY/2C3=LONDON KY/2C4=LEXINGTON KY/LAB=LABORATORIES LA/001=LOUISIANA LA/LA1=NEW ORLEANS LA/LA2=MANDEVILLE LA/LA3=LAFAYETTE LA/LA4=MONROE LA/LA5=SHREVEPORT LA/LA6=ALEXANDRIA LA/LAB=LABORATORIES LA/LB1=CLIA NEW ORLEANS LA/LB5=CLIA SHREVEPORT LA/LB6=CLIA ALEXANDRIA MA/001=MASSACHUSETTS MA/LAB=LABORATORIES MD/001=MARYLAND MD/LAB=LABORATORIES ME/001=MAINE ME/LAB=LABORATORIES MH/001=MARSHALL ISLANDS MI/001=MICHIGAN MI/LAB=LABORATORIES MN/001=MINNESOTA MN/LAB=LABORATORIES MO/01=REGION01 MO/02=REGION02 MO/03=REGION 03 MO/04=REGION 04 MO/05=REGION 05 MO/06=REGION 06 MO/07=REGION 07 MO/1NH=REGION 1 NH MO/2NH=REGION 2 NH MO/3NH=REGION 3 NH MO/4NH=REGION 4 NH MO/5NH=REGION 5 NH MO/6NH=REGION 6 NH DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 16 Community Mental Health Center, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE MO/7NH=REGION 7 NH MO/LAB=LABORATORIES MO/MO=STATEWIDE MP/001=NORTHERN MARIANA ISLANDS MP/LAB=LABORATORIES MS/001=MISSISSIPPI MS/LAB=LABORATORIES MT/001=MONTANA MT/LAB=LABORATORIES MX/001=MEXICO MX/LAB=LABORATORY NC/LAB=LABORATORIES NC/NCC=NORTH CAROLINA CENTRAL NC/NCE=NORTH CAROLINA EAST NC/NCN=NORTH CAROLINA NORTH NC/NCS=NORTH CAROLINA SOUTH NC/NCW=NORTH CAROLINA WEST ND/001=NORTH DAKOTA ND/LAB=LABORATORIES NE/1=NORTH CENTRAL NE/2=CENTRAL NE/3=NORTHEAST NE/4=SOUTHEAST NE/5=WESTERN NE/LAB=LABORATORIES NH/001=NEW HAMPSHIRE NH/LAB=LABORATORIES NJ/001=NEW JERSEY NJ/LAB=LABORATORIES NM/001=NEW MEXICO NM/LAB=LABORATORIES NV/CC=CARSON CITY NV/LAB=LABORATORIES NV/LV=LAS VEGAS NY/001=BUFFALO NY/002=ROCHESTER NY/003=SYRACUSE NY/004=ALBANY NY/005=NEW ROCHELLE NY/006=NEW YORK CITY NY/007=SUFFOLK/NASSAU COUNTY NY/LAB=LABORATORIES OH/001=OHIO OH/LAB=LABORATORIES OK/001=OKLAHOMA OK/LAB=LABORATORIES OR/001=OFFICE #1 OR/002=OFFICE #2 OR/003=OFFICE #3 OR/LAB=LABORATORIES PA/001=PENNSYLVANIA PA/LAB=LABORATORIES PR/001=PUERTO RICO PR/LAB=LABORATORIES PW/001=PALAU RI/001=RHODE ISLAND RI/LAB=LABORATORIES SC/001=SOUTH CAROLINA SC/LAB=LABORATORIES SD/001=SOUTH DAKOTA SD/LAB=LABORATORIES TN/LAB=LABORATORIES TN/TNC=TENNESSEE COOKEVILLE TN/TNE=TENNESSEE EASTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 17 Community Mental Health Center, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE TN/TNM=TENNESSEE MIDDLE TN/TNW=TENNESSEE WESTERN TX/001=TEXAS TX/L01=AMARILLO-LTC TX/L02=ABILENE-LTC TX/L03=ARLINGTON-LTC TX/L04=TYLER-LTC TX/L05=BEAUMONT-LTC TX/L06=HOUSTON-LTC TX/L07=TEMPLE-LTC TX/L08=SAN ANTONIO-LTC TX/L09=SAN ANGELO-LTC TX/L10=EL PASO-LTC TX/L11=CORPUS CHRISTI-LTC TX/LAB=LABORATORIES TX/TX1=LUBBOCK TX/TX2=ARLINGTON TX/TX3=SAN ANTONIO TX/TX4=HOUSTON TX/TX5=TYLER TX/TX6=AUSTIN UT/001=UTAH UT/LAB=LABORATORIES VA/001=VIRGINIA VA/LAB=LABORATORIES VI/001=VIRGIN ISLANDS VI/LAB=LABORATORIES VT/001=VERMONT VT/LAB=LABORATORIES WA/001=ALL OTHERS (NON-LTC FAC) WA/D1=SPOKANE & YAKIMA AREAS WA/D1A=District 1, Unit A WA/D1B=District 1, Unit B WA/D1C=District 1, Unit C WA/D1D=District 1, Unit D WA/D2=SPOKANE & SE WA/D2A=District 2, Unit A WA/D2B=District 2, Unit B WA/D2C=District 2, Unit C WA/D2D=District 2, Unit D WA/D2E=District 2, Unit E WA/D2F=District 2, Unit F WA/D2G=District 2, Unit G WA/D3=NW WASHINGTON WA/D3A=District 3, Unit A WA/D3B=District 3, Unit B WA/D3C=District 3, Unit C WA/D3D=District 3, Unit D WA/D3E=District 3, Unit E WA/D4A=GREATER SEATTLE AREA WA/D4B=S KING COUNTY WA/D5A=PIERCE CTY & PENINSULA WA/D5B=PIERCE CTY & GRAYS HARBOR WA/D6=OLYMPIA AREA WA/LAB=LABORATORIES WI/001=WISCONSIN WI/LAB=LABORATORIES WV/001=WEST VIRGINIA WV/LAB=LABORATORIES WY/001=WYOMING WY/LAB=LABORATORIES Address: Street 50 178 227 VARCHAR2 Description: Street address where the provider is located. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 18 Community Mental Health Center, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: ST_ADR COBOL Name: ST-ADR Telephone Number 10 228 237 VARCHAR2 Description: Telephone number of the provider. SAS Name: PHNE_NUM COBOL Name: PHNE-NUM Termination Code 2 238 239 VARCHAR2 Description: Indicates the current termination status for the provider. SAS Name: PGM_TRMNTN_CD COBOL Name: PGM-TRMNTN-CD VALUES: 00=ACTIVE PROVIDER 01=VOLUNTARY-MERGER, CLOSURE 02=VOLUNTARY-DISSATISFACTION WITH REIMBURSEMENT 03=VOLUNTARY-RISK OF INVOLUNTARY TERMINATION 04=VOLUNTARY-OTHER REASON FOR WITHDRAWAL 05=INVOLUNTARY-FAILURE TO MEET HEALTH/SAFETY REQ 06=INVOLUNTARY-FAILURE TO MEET AGREEMENT 07=OTHER-PROVIDER STATUS CHANGE 08=NONPAYMENT OF FEES - CLIA Only 09=REV/UNSUCCESSFUL PARTICIPATION IN PT - CLIA Only 10=REV/OTHER REASON - CLIA Only 11=INCOMPLETE CLIA APPLICATION INFORMATION - CLIA Only 12=NO LONGER PERFORMING TESTS - CLIA Only 13=MULTIPLE TO SINGLE SITE CERTIFICATE - CLIA Only 14=SHARED LABORATORY - CLIA Only 15=FAILURE TO RENEW WAIVER PPM CERTIFICATE - CLIA Only 16=DUPLICATE CLIA NUMBER - CLIA Only 17=MAIL RETURNED NO FORWARD ADDRESS CERT ENDED - CLIA Only 20=NOTIFICATION BANKRUPTCY - CLIA Only 33=ACCREDITATION NOT CONFIRMED - CLIA Only 80=AWAITING STATE APPROVAL 99=OIG ACTION - DO NOT ACTIVATE - CLIA Only Termination or Expiration Date 8 240 247 DATE Description: Date the provider was terminated. For CLIA providers, date the laboratory's certificate was terminated or the expiration date of the current CLIA certificate. SAS Name: TRMNTN_EXPRTN_DT COBOL Name: TRMNTN-EXPRTN-DT Type of Action Code 1 248 248 VARCHAR2 Description: Identifies the reason for the certification. Type of action from the official survey record, CMS 1539 form. SAS Name: CRTFCTN_ACTN_TYPE_CD COBOL Name: CRTFCTN-ACTN-TYPE-CD VALUES: 1=INITIAL 2=RECERTIFICATION 3=TERMINATION 4=CHANGE OF OWNERSHIP 5=VALIDATION 8=FULL SURVEY AFTER COMPLAINT Ownership Type Code 2 249 250 VARCHAR2 Description: Indicates the ownership type of the provider. SAS Name: GNRL_CNTL_TYPE_CD COBOL Name: GNRL-CNTL-TYPE-CD VALUES: 01=PROPRIETARY 02=CHURCH RELATED 03=NONPROFIT CORPORATION 04=OTHER NONPROFIT 05=STATE DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 19 Community Mental Health Center, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 06=LOCAL 07=FEDERAL Address: ZIP Code 5 251 255 VARCHAR2 Description: Five-digit ZIP code for a provider's physical address. SAS Name: ZIP_CD COBOL Name: ZIP-CD FIPS State Code 2 256 257 VARCHAR2 Description: FIPS State Code SAS Name: FIPS_STATE_CD COBOL Name: FIPS-STATE-CD VALUES: 01=ALABAMA 02=ALASKA 04=ARIZONA 05=ARKANSAS 06=CALIFORNIA 08=COLORADO 09=CONNECTICUT 10=DELAWARE 11=DISTRICT OF COLUMBIA 12=FLORIDA 13=GEORGIA 15=HAWAII 16=IDAHO 17=ILLINOIS 18=INDIANA 19=IOWA 20=KANSAS 21=KENTUCKY 22=LOUISIANA 23=MAINE 24=MARYLAND 25=MASSACHUSETTS 26=MICHIGAN 27=MINNESOTA 28=MISSISSIPPI 29=MISSOURI 30=MONTANA 31=NEBRASKA 32=NEVADA 33=NEW HAMPSHIRE 34=NEW JERSEY 35=NEW MEXICO 36=NEW YORK 37=NORTH CAROLINA 38=NORTH DAKOTA 39=OHIO 40=OKLAHOMA 41=OREGON 42=PENNSYLVANIA 43=PUERTO RICO 44=RHODE ISLAND 45=SOUTH CAROLINA 46=SOUTH DAKOTA 47=TENNESSEE 48=TEXAS 49=UTAH 50=VERMONT 51=VIRGINIA 53=WASHINGTON 54=WEST VIRGINIA 55=WISCONSIN 56=WYOMING DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 20 Community Mental Health Center, CATEGORY = "19" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 64=AMERICAN SAMOA 65=GUAM 66=SAIPAN/MARIANA IS. 78=VIRGIN ISLANDS FIPS County Code 3 258 260 VARCHAR2 Description: FIPS County Code SAS Name: FIPS_CNTY_CD COBOL Name: FIPS-CNTY-CD CBSA Urban Rural Indicator 1 261 261 VARCHAR2 Description: CBSA (Core Based Statistical Area) indicates whether the county is defined as Urban or Rural. SAS Name: CBSA_URBN_RRL_IND COBOL Name: CBSA-URBN-RRL-IND CBSA Code 5 262 266 VARCHAR2 Description: CBSA (Core Based Statistical Area) geographic entities defined by the U.S. Office of Management and Budget (OMB) on June 6, 2003 for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics. CBSA collectively refers to MSA. SAS Name: CBSA_CD COBOL Name: CBSA-CD Fiscal Year End Date (MMDD) 4 464 467 VARCHAR2 Description: End date, consisting of the month and day, of the provider's fiscal year. SAS Name: FY_END_MO_DAY_CD COBOL Name: FY-END-MO-DAY-CD Related Provider Number 10 669 678 CHAR Description: Related provider number SAS Name: RELATED_PROVIDER_NUMBER COBOL Name: RELATED-PROVIDER-NUMBER DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 1 Federally Qualified Health Center, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE Provider Category Subtype Code 2 1 2 VARCHAR2 Description: Identifies the subtype of the provider, within the primary category. Used in reporting to show the breakdown of provider categories, mainly for hospitals and SNFs. SAS Name: PRVDR_CTGRY_SBTYP_CD COBOL Name: PRVDR-CTGRY-SBTYP-CD VALUES: 01=Federally Qualified Health Center Provider Category Code 2 3 4 VARCHAR2 Description: Identifies the type of provider participating in the Medicare/Medicaid program. SAS Name: PRVDR_CTGRY_CD COBOL Name: PRVDR-CTGRY-CD VALUES: 21=Federally Qualified Health Center CHOW Count 2 5 6 NUMBER Description: Number of times this provider has undergone a change of ownership. SAS Name: CHOW_CNT COBOL Name: CHOW-CNT CHOW Date 8 7 14 DATE Description: Effective date of the most recent change of ownership for this provider. SAS Name: CHOW_DT COBOL Name: CHOW-DT Address: City 28 15 42 VARCHAR2 Description: City in which the provider is physically located. SAS Name: CITY_NAME COBOL Name: CITY-NAME Compliance: Acceptable POC 1 43 43 VARCHAR2 Description: Indicates if a provider is in compliance with program requirements based on an acceptable plan for correction of deficiencies. SAS Name: ACPTBL_POC_SW COBOL Name: ACPTBL-POC-SW Compliance: Status 1 44 44 VARCHAR2 Description: Compliance status of a provider at the time of certification survey. SAS Name: CMPLNC_STUS_CD COBOL Name: CMPLNC-STUS-CD VALUES: A=IN COMPLIANCE B=NOT IN COMPLIANCE SSA County Code 3 45 47 VARCHAR2 Description: Social Security Administration geographic code indicating the county where the provider is located. SAS Name: SSA_CNTY_CD COBOL Name: SSA-CNTY-CD Cross Ref Provider Number 10 48 57 CHAR Description: Cross reference provider number SAS Name: CROSS_REF_PROVIDER_NUMBER COBOL Name: CROSS-REF-PROVIDER-NUMBER Certification Date 8 58 65 DATE Description: Equal to the exit date of the initial visit of the Health survey for certifications completed after July 28, 2012. For certifications prior to that date, the certification DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 2 Federally Qualified Health Center, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE date is equal to the exit date of the initial visit of the Health survey or LSC survey, whichever is later. SAS Name: CRTFCTN_DT COBOL Name: CRTFCTN-DT Eligibility Indicator 1 66 66 VARCHAR2 Description: Indicates if a facility is eligible to participate in the Medicare and/or Medicaid programs. SAS Name: ELGBLTY_SW COBOL Name: ELGBLTY-SW Facility Name 50 67 116 VARCHAR2 Description: Name of the provider certified to participate in the Medicare and/or Medicaid programs. SAS Name: FAC_NAME COBOL Name: FAC-NAME Medicare Administrative Contractor (MAC) or 5 117 121 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_CD COBOL Name: INTRMDRY-CARR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 3 Federally Qualified Health Center, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 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=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 4 Federally Qualified Health Center, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 5 Federally Qualified Health Center, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 6 Federally Qualified Health Center, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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 15 122 136 VARCHAR2 Description: Number which may be assigned to a provider by the state Medicaid agency for external control or billing purposes. SAS Name: MDCD_VNDR_NUM COBOL Name: MDCD-VNDR-NUM Original Participation Date 8 137 144 DATE Description: Date a provider is first approved to provide Medicare and/or Medicaid services. SAS Name: ORGNL_PRTCPTN_DT COBOL Name: ORGNL-PRTCPTN-DT Prior CHOW Date 8 145 152 DATE Description: Effective date of the previous change of ownership for this provider. SAS Name: CHOW_PRIOR_DT COBOL Name: CHOW-PRIOR-DT Prior Medicare Administrative Contractor (MAC) or 5 153 157 VARCHAR2 Intermediary or Carrier Code Description: Number assigned to the previous Medicare Administrative Contractor, intermediary or carrier servicing this provider. SAS Name: INTRMDRY_CARR_PRIOR_CD DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 7 Federally Qualified Health Center, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE COBOL Name: INTRMDRY-CARR-PRIOR-CD VALUES: 00000=DUMMY FOR MEDICAID HHA 00010=BLUE CROSS (ALABAMA) 00011=CAHABA 00020=BLUE CROSS (ARKANSAS) 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 00122=HCSC - MICHIGAN 00123=HCSC OF MICHIGAN 00130=NATIONAL GOVERNMENT SERVICES 00131=NATIONAL GOVERNMENT SERVICES 00140=BLUE CROSS (IOWA/SOUTH DAKOTA) 00150=BLUE CROSS (KANSAS) 00160=NATIONAL GOVERNMENT SERVICES 00180=NATIONAL GOVERNMENT SERVICES 00181=NATIONAL GOVERNMENT SERVICES 00190=BLUE CROSS (MARYLAND) 00200=BLUE CROSS (MASSACHUSETTS) 00210=BLUE CROSS (MICHIGAN) 00220=BLUE CROSS (MINNESOTA) 00230=BLUE CROSS (MISSISSIPPI) 00231=BLUE CROSS (LOUISIANA) 00233=PINNACLE 00241=BLUE CROSS (MISSOURI) 00260=BLUE CROSS (NEBRASKA) 00270=NATIONAL GOVERNMENT SERVICES 00280=BLUE CROSS (NEW JERSEY) 00290=BLUE CROSS (NEW MEXICO) 00308=NATIONAL GOVERNMENT SERVICES 00310=BLUE CROSS (NORTH CAROLINA) 00320=NORIDIAN PART A 00322=NORIDIAN PART A (AK/WA) 00323=NORIDIAN PART A (ID/OR) 00325=NORIDIAN 00332=NATIONAL GOVERNMENT SERVICES 00340=BLUE CROSS (OKLAHOMA) 00350=BLUE CROSS (OREGON) 00351=BLUE CROSS (OREGON) (IDAHO CLAIMS) 00362=BLUE CROSS (INDEPENDENCE) 00363=BLUE CROSS (WESTERN PENNSYLVANIA) 00366=HIGHMARK MEDICARE SERVICES 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=NATIONAL GOVERNMENT SERVICES 00452=NATIONAL GOVERNMENT SERVICES 00453=NATIONAL GOVERNMENT SERVICES 00454=NATIONAL GOVERNMENT SERVICES 00456=NATIONAL GOVERNMENT SERVICES 00468=BLUE CROSS (NORTH CAROLINA FOR PR) 00510=BLUE SHIELD (ALABAMA) 00511=CAHABA 00512=CAHABA 00520=BLUE SHIELD (ARKANSAS) 00528=BLUE SHIELD (ARKANSAS/LOUISIANA) 00542=BLUE SHIELD (CALIFORNIA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 8 Federally Qualified Health Center, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 00550=BLUE SHIELD (COLORADO) 00570=BLUE SHIELD (DELAWARE) 00580=BLUE SHIELD (DISTRICT OF COLUMBIA) 00590=BLUE SHIELD (FLORIDA) 00621=BLUE SHIELD (ILLINOIS) 00630=NATIONAL GOVERNMENT SERVICES 00640=BLUE SHIELD (IOWA) 00650=BLUE SHIELD (KANSAS) 00655=BLUE SHIELD (KANSAS/NEBRASKA) 00660=NATIONAL GOVERNMENT SERVICES 00690=BLUE SHIELD (MARYLAND) 00700=BLUE SHIELD (MASSACHUSETTS) 00710=BLUE SHIELD (MICHIGAN) 00720=BLUE SHIELD (MINNESOTA) 00740=BLUE SHIELD (KANSAS CITY) 00770=BLUE SHIELD (NEW HAMPSHIRE/VERMONT) 00780=BLUE SHIELD (TRI-STATE) 00801=BLUE SHIELD (BUFFALO) 00803=NATIONAL GOVERNMENT SERVICES 00805=NATIONAL GOVERNMENT SERVICES 00821=NORIDIAN 00824=NORIDIAN GVT SERVICES (CO) 00826=NORIDIAN GVT SERVICES (IA) 00831=NORIDIAN GVT SERVICES (AK) 00832=NORIDIAN GVT SERVICES (AZ) 00833=NORIDIAN GVT SERVICES (HI) 00834=NORIDIAN GVT SERVICES (NV) 00835=NORIDIAN GVT SERVICES (OR) 00836=NORIDIAN GVT SERVICES (WA) 00860=BLUE SHIELD (PENNSYLVANIA/NEW JERSEY) 00865=BLUE SHIELD (PENNSYLVANIA) 00870=BLUE SHIELD (RHODE ISLAND) 00880=BLUE SHIELD (SOUTH CAROLINA) 00883=PALMETTO GBA PART B 00884=PALMETTO GBA 00889=NORIDIAN GVT SERVICES (SD) 00900=BLUE SHIELD (TEXAS) 00901=TRAILBLAZERS HEALTH ENTERPRISES 00904=TRAILBLAZER 00910=BLUE SHIELD (UTAH) 00930=BLUE SHIELD (WASHINGTON) 00951=WISCONSIN PHYSICIANS SERVICE 00952=WPS - ILLINOIS 00953=WPS - MICHIGAN 00954=WI PHYSICIAN SERVICES - MN 00973=BLUE SHIELD (PUERTO RICO) 00974=BLUE SHIELD (VIRGIN ISLANDS) 01010=AETNA (PEORIA) 01020=AETNA (ALASKA) 01030=AETNA (ARIZONA) 01040=AETNA (GEORGIA) 01101=PALMETTO (CALIFORNIA) 01102=PALMETTO (CALIFORNIA (NORTH) 01120=AETNA (HAWAII) 01192=PALMETTO (CALIFORNIA SOUTH) 01201=PALMETTO (HAWAII) 01202=PALMETTO (HAWAII) 01290=AETNA (NEVADA) 01301=PALMETTO (NEVADA) 01302=PALMETTO (NEVADA) 01360=AETNA (NEW MEXICO) 01370=AETNA (OKLAHOMA) 01380=AETNA (OREGON) 01390=AETNA (WASHINGTON) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 9 Federally Qualified Health Center, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 01901=PALMETTO GBA 01902=PALMETTO GBA 02050=OCCIDENTAL (CALIFORNIA) 02101=NATIONAL HERITAGE (ALASKA) 02102=NATIONAL HERITAGE (ALASKA) 02201=NATIONAL HERITAGE (IDAHO) 02202=NATIONAL HERITAGE (IDAHO) 02301=NATIONAL HERITAGE (OREGON) 02302=NATIONAL HERITAGE (OREGON) 02401=NATIONAL HERITAGE (WASHINGTON) 02402=NATIONAL HERITAGE (WASHINGTON) 03001=NORIDIAN ADMIN SERVICES 03101=NORIDAN (ARIZONA) 03102=NORIDAN (ARIZONA) 03201=NORIDAN (MONTANA) 03202=NORIDAN (MONTANA) 03301=NORDIAN (NORTH DAKOTA) 03302=NORDIAN (NORTH DAKOTA) 03401=NORIDIAN (SOUTH DAKOTA) 03402=NORIDIAN (SOUTH DAKOTA) 03501=NORIDIAN (UTAH) 03502=NORIDIAN (UTAH) 03601=NORIDIAN (WYOMING) 03602=NORIDIAN (WYOMING) 04001=TRAILBLAZER 04101=TRAILBLAZER (COLORADO) 04102=TRAILBLAZER (COLORADO) 04111=NOVITAS (COLORADO) 04112=NOVITAS (COLORADO) 04201=TRAILBLAZER (NEW MEXICO) 04202=TRAILBLAZER (NEW MEXICO) 04211=NOVITAS (NEW MEXICO) 04212=NOVITAS (NEW MEXICO) 04301=TRAILBLAZER (OKLAHOMA) 04302=TRAILBLAZER (OKLAHOMA) 04311=NOVITAS (OKLAHOMA) 04312=NOVITAS (OKLAHOMA) 04401=TRAILBLAZER (TEXAS) 04402=TRAILBLAZER (TEXAS) 04411=NOVITAS (TEXAS) 04412=NOVITAS (TEXAS) 04901=MUTUAL LEGACY 04911=NOVITAS 05101=WPS (IOWA) 05102=WPS (IOWA) 05130=EQICOR (IDAHO) 05201=WPS (KANSAS) 05202=WPS (KANSAS) 05301=WPS (MISSOURI) 05302=WPS (MISSOURI WEST) 05392=WPS (MISSOURI EAST) 05401=WPS (NEBRASKA) 05402=WPS (NEBRASKA) 05440=EQICOR (TENNESSEE) 05535=EQICOR (NORTH CAROLINA) 05901=WISCONSIN PHYSICIANS SERVICE 06004=NORIDIAN HHH D 07101=PINNACLE (ARKANSAS) 07102=PINNACLE (ARKANSAS) 07201=PINNACLE (LOUISIANA) 07202=PINNACLE (LOUISIANA) 07301=PINNACLE (MISSISSIPPI) 07302=PINNACLE (MISSISSIPPI) 08101=PINNACLE (INDIANA) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 10 Federally Qualified Health Center, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 08102=PINNACLE (INDIANA) 08201=PINNACLE (MICHIGAN) 08202=PINNACLE (MICHIGAN) 09101=FIRST COAST (FLORIDA) 09102=FIRST COAST (FLORIDA) 09201=FIRST COAST (PUERTO RICO/VIRGIN ISLANDS) 09202=FIRST COAST (PUERTO RICO) 09302=FIRST COAST (VIRGIN ISLANDS) 10071=TRAVELERS (RRB) 10101=CAHABA GBA (AL) 10102=CAHABA GBA (AL) 10201=CAHABA GBA (GA) 10202=CAHABA GBA (GA) 10230=TRAVELERS (CONNECTICUT) 10240=TRAVELERS (MINNESOTA) 10250=TRAVELERS (MISSISSIPPI) 10301=CAHABA GBA (TN) 10302=CAHABA GBA (TN) 10490=TRAVELERS (VIRGINIA) 10492=TRAVELERS - VIRGINIA SPECIAL PROJECT 11004=PALMETTO HHH C 11201=PALMETTO GBA (SC) 11202=PALMETTO GBA (SC) 11260=GENERAL AMERICAN 11301=PALMETTO GBA (VA) 11302=PALMETTO GBA (VA) 11401=PALMETTO GBA (WV) 11402=PALMETTO GBA (WV) 11501=PALMETTO GBA (NC) 11502=PALMETTO GBA (NC) 12101=HIGHMARK (DELAWARE) 12102=HIGHMARK (DELAWARE) 12201=HIGHMARK (DISTRICT OF COLUMBIA) 12202=HIGHMARK (DISTRICT OF COLUMBIA) 12301=HIGHMARK (MARYLAND) 12302=HIGHMARK (MARYLAND) 12401=HIGHMARK (NEW JERSEY) 12402=HIGHMARK (NEW JERSEY) 12501=HIGHMARK (PENNSYLVANIA) 12502=HIGHMARK (PENNSYLVANIA) 12901=HIGHMARK 12902=HIGHMARK 13101=NATIONAL GOVT SERVICES (CONNECTICUT) 13102=NATIONAL GOVT SERVICES (CONNECTICUT) 13201=NATIONAL GOVT SERVICES (NEW YORK) 13202=NATIONAL GOVT SERVICES (NEW YORK - EMPIRE) 13282=NATIONAL GOVT SERVICES (NEW YORK - HEALTHNOW) 13292=NATIONAL GOVT SERVICES (NEW YORK - GHI) 14004=NATIONAL HERITAGE (HHA - A) 14101=NATIONAL HERITAGE (MAINE) 14102=NATIONAL HERITAGE (MAINE) 14201=NATIONAL HERITAGE (MASSACHUSETTS) 14202=NATIONAL HERITAGE (MASSACHUSETTS) 14301=NATIONAL HERITAGE (NEW HAMPSHIRE) 14302=NATIONAL HERITAGE (NEW HAMPSHIRE) 14330=GROUP HEALTH INC (NEW YORK) 14401=NATIONAL HERITAGE (RHODE ISLAND) 14402=NATIONAL HERITAGE (RHODE ISLAND) 14501=NATIONAL HERITAGE (VERMONT) 14502=NATIONAL HERITAGE (VERMONT) 15004=CIGNA HHH B 15101=CGS (KENTUCKY) 15102=CGS (KENTUCKY) 15201=CGS (OHIO) DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 11 Federally Qualified Health Center, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 15202=CGS (OHIO) 16360=NATIONWIDE (OHIO) 16510=NATIONWIDE (WEST VIRGINIA) 17120=HAWAII MEDICAL SERVICE ASSOCIATION 21200=MASSACHUSETTS/MAINE 31142=NATIONAL HERITAGE INSURANCE CO (MAINE) 31143=NATIONAL HERITAGE INSURANCE CO 31144=NATIONAL HERITAGE INSURANCE CO 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) CCN 10 158 167 VARCHAR2 Description: Six or ten position identification number that is assigned to a certified provider. This is the CMS Certification Number. SAS Name: PRVDR_NUM COBOL Name: PRVDR-NUM Region Code 2 168 169 VARCHAR2 Description: Indicates the CMS Regional Office responsible for the certification of the provider. SAS Name: RGN_CD COBOL Name: RGN-CD VALUES: 01=Boston 02=New York 03=Philadelphia 04=Atlanta 05=Chicago 06=Dallas 07=Kansas City 08=Denver 09=San Francisco 10=Seattle Skeleton Record Indicator 1 170 170 VARCHAR2 Description: Indicates if the record is a skeleton record. Only a limited set of data is available for this provider; no survey data exists. SAS Name: SKLTN_REC_SW COBOL Name: SKLTN-REC-SW State Abbreviation 2 171 172 VARCHAR2 Description: Two-character state abbreviation. SAS Name: STATE_CD COBOL Name: STATE-CD VALUES: AK=ALASKA AL=ALABAMA AR=ARKANSAS AS=AMERICAN SAMOA AZ=ARIZONA CA=CALIFORNIA CN=CANADA CO=COLORADO CT=CONNECTICUT DC=DISTRICT OF COLUMBIA DE=DELAWARE FL=FLORIDA FN=INTERNATIONAL DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 12 Federally Qualified Health Center, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA=GEORGIA GU=GUAM HI=HAWAII IA=IOWA ID=IDAHO IL=ILLINOIS IN=INDIANA KS=KANSAS KY=KENTUCKY LA=LOUISIANA MA=MASSACHUSETTS MD=MARYLAND ME=MAINE MI=MICHIGAN MN=MINNESOTA MO=MISSOURI MP=SAIPAN MS=MISSISSIPPI MT=MONTANA MX=MEXICO NC=NORTH CAROLINA ND=NORTH DAKOTA NE=NEBRASKA NH=NEW HAMPSHIRE NJ=NEW JERSEY NM=NEW MEXICO NV=NEVADA NY=NEW YORK OH=OHIO OK=OKLAHOMA OR=OREGON PA=PENNSYLVANIA PR=PUERTO RICO RI=RHODE ISLAND SC=SOUTH CAROLINA SD=SOUTH DAKOTA TN=TENNESSEE TX=TEXAS UT=UTAH VA=VIRGINIA VI=VIRGIN ISLANDS VT=VERMONT WA=WASHINGTON WI=WISCONSIN WV=WEST VIRGINIA WY=WYOMING SSA State Code 2 173 174 VARCHAR2 Description: Social Security Administration geographic code indicating the state where the provider is located. SAS Name: SSA_STATE_CD COBOL Name: SSA-STATE-CD 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 DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 13 Federally Qualified Health Center, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 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 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 99=INTERNATIONAL State Region Code 3 175 177 VARCHAR2 Description: Identifies the region within a state where the provider is located. SAS Name: STATE_RGN_CD COBOL Name: STATE-RGN-CD VALUES: AK/001=ALASKA AK/LAB=LABORATORIES AL/001=ALABAMA AL/LAB=LABORATORIES DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 14 Federally Qualified Health Center, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE AR/001=ARKANSAS AR/LAB=LABORATORIES AS/001=AMERICAN SAMOA AS/LAB=LABORATORY AZ/AZ=PHOENIX AZ/LAB=ARIZONA LAB AZ/TUC=TUCSON CA/BAK=BAKERSFIELD CA/BER=SAN BERNARDINO CA/BK=BERKELEY CA/BK1=CONTRA COSTA CA/FR=FRESNO CA/L1=L.A. WEST CA/L2=L.A. NORTH CA/L3=L.A. CENTRAL CA/L4=L.A. EAST CA/L5=SAN GABRIEL CA/LAB=LABORATORIES CA/M1=LAB. SOUTH CA/M2=LAB. NORTH CA/ORG=ORANGE CO CA/RIV=RIVERSIDE CA/RWC=REDWOOD COAST CA/S1=SACRAMENTO CA/S2=SACTO SOUTH CA/S3=CHICO CA/SD=SAN DIEGO CA/SDS=SAN DIEGO SOUTH CA/SF=SAN FRANCISCO CA/SJ=SAN JOSE CA/SR=SANTA ROSA CA/VEN=VENTURA CN/001=CANADA CN/LAB=LABORATORY CO/001=COLORADO CO/LAB=LABORATORIES CT/001=CONNECTICUT CT/LAB=LABORATORIES DC/001=DISTRICT OF COLUMBIA DC/LAB=LABORATORIES DE/001=DELAWARE DE/LAB=LABORATORIES FL/FTM=FT. MYERS FL/GAI=GAINESVILLE FL/JAX=JACKSONVILLE FL/LAB=LABORATORIES FL/LAN=LANTANA FL/LAU=LAUDERHILL FL/MIA=MIAMI FL/ORL=ORLANDO FL/PEN=PENSACOLA FL/STP=ST. PETERSBURG FL/TAL=TALLAHASSEE FL/TAM=TAMPA FM/001=FEDERATED STATES OF MICRO FN/001=INTERNATIONAL FN/LAB=LABORATORIES GA/001=GEORGIA GA/GAA=GEORGIA ALL GA/GAC=GEORGIA CENTRAL GA/GAE=GEORGIA EASTERN GA/GAN=GEORGIA NORTH GA/GAS=GEORGIA SOUTH GA/GAW=GEORGIA WESTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 15 Federally Qualified Health Center, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE GA/LAB=LABORATORIES GU/001=GUAM GU/LAB=LABORATORIES HI/001=HAWAII HI/LAB=LABORATORIES IA/001=IOWA IA/LAB=LABORATORIES ID/001=IDAHO ID/LAB=LABORATORIES IL/001=ILLINOIS IL/LAB=LABORATORIES IN/001=INDIANA IN/LAB=LABORATORIES KS/KCK=KANSAS CITY KS/KDH=KDHE KS/LAB=LABORATORIES KS/LAW=LAWRENCE KS/NC=NORTH CENTRAL KANSAS KS/NE=NORTH EAST KANSAS KS/NW=NORTH WEST KANSAS KS/SC=SOUTH CENTRAL KANSAS KS/SE=SOUTH EAST KANSAS KS/SW=SOUTH WEST KANSAS KS/WST=WEST KY/2C1=HOPKINSVILLE KY/2C2=LOUISVILLE KY/2C3=LONDON KY/2C4=LEXINGTON KY/LAB=LABORATORIES LA/001=LOUISIANA LA/LA1=NEW ORLEANS LA/LA2=MANDEVILLE LA/LA3=LAFAYETTE LA/LA4=MONROE LA/LA5=SHREVEPORT LA/LA6=ALEXANDRIA LA/LAB=LABORATORIES LA/LB1=CLIA NEW ORLEANS LA/LB5=CLIA SHREVEPORT LA/LB6=CLIA ALEXANDRIA MA/001=MASSACHUSETTS MA/LAB=LABORATORIES MD/001=MARYLAND MD/LAB=LABORATORIES ME/001=MAINE ME/LAB=LABORATORIES MH/001=MARSHALL ISLANDS MI/001=MICHIGAN MI/LAB=LABORATORIES MN/001=MINNESOTA MN/LAB=LABORATORIES MO/01=REGION01 MO/02=REGION02 MO/03=REGION 03 MO/04=REGION 04 MO/05=REGION 05 MO/06=REGION 06 MO/07=REGION 07 MO/1NH=REGION 1 NH MO/2NH=REGION 2 NH MO/3NH=REGION 3 NH MO/4NH=REGION 4 NH MO/5NH=REGION 5 NH MO/6NH=REGION 6 NH DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 16 Federally Qualified Health Center, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE MO/7NH=REGION 7 NH MO/LAB=LABORATORIES MO/MO=STATEWIDE MP/001=NORTHERN MARIANA ISLANDS MP/LAB=LABORATORIES MS/001=MISSISSIPPI MS/LAB=LABORATORIES MT/001=MONTANA MT/LAB=LABORATORIES MX/001=MEXICO MX/LAB=LABORATORY NC/LAB=LABORATORIES NC/NCC=NORTH CAROLINA CENTRAL NC/NCE=NORTH CAROLINA EAST NC/NCN=NORTH CAROLINA NORTH NC/NCS=NORTH CAROLINA SOUTH NC/NCW=NORTH CAROLINA WEST ND/001=NORTH DAKOTA ND/LAB=LABORATORIES NE/1=NORTH CENTRAL NE/2=CENTRAL NE/3=NORTHEAST NE/4=SOUTHEAST NE/5=WESTERN NE/LAB=LABORATORIES NH/001=NEW HAMPSHIRE NH/LAB=LABORATORIES NJ/001=NEW JERSEY NJ/LAB=LABORATORIES NM/001=NEW MEXICO NM/LAB=LABORATORIES NV/CC=CARSON CITY NV/LAB=LABORATORIES NV/LV=LAS VEGAS NY/001=BUFFALO NY/002=ROCHESTER NY/003=SYRACUSE NY/004=ALBANY NY/005=NEW ROCHELLE NY/006=NEW YORK CITY NY/007=SUFFOLK/NASSAU COUNTY NY/LAB=LABORATORIES OH/001=OHIO OH/LAB=LABORATORIES OK/001=OKLAHOMA OK/LAB=LABORATORIES OR/001=OFFICE #1 OR/002=OFFICE #2 OR/003=OFFICE #3 OR/LAB=LABORATORIES PA/001=PENNSYLVANIA PA/LAB=LABORATORIES PR/001=PUERTO RICO PR/LAB=LABORATORIES PW/001=PALAU RI/001=RHODE ISLAND RI/LAB=LABORATORIES SC/001=SOUTH CAROLINA SC/LAB=LABORATORIES SD/001=SOUTH DAKOTA SD/LAB=LABORATORIES TN/LAB=LABORATORIES TN/TNC=TENNESSEE COOKEVILLE TN/TNE=TENNESSEE EASTERN DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 17 Federally Qualified Health Center, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE TN/TNM=TENNESSEE MIDDLE TN/TNW=TENNESSEE WESTERN TX/001=TEXAS TX/L01=AMARILLO-LTC TX/L02=ABILENE-LTC TX/L03=ARLINGTON-LTC TX/L04=TYLER-LTC TX/L05=BEAUMONT-LTC TX/L06=HOUSTON-LTC TX/L07=TEMPLE-LTC TX/L08=SAN ANTONIO-LTC TX/L09=SAN ANGELO-LTC TX/L10=EL PASO-LTC TX/L11=CORPUS CHRISTI-LTC TX/LAB=LABORATORIES TX/TX1=LUBBOCK TX/TX2=ARLINGTON TX/TX3=SAN ANTONIO TX/TX4=HOUSTON TX/TX5=TYLER TX/TX6=AUSTIN UT/001=UTAH UT/LAB=LABORATORIES VA/001=VIRGINIA VA/LAB=LABORATORIES VI/001=VIRGIN ISLANDS VI/LAB=LABORATORIES VT/001=VERMONT VT/LAB=LABORATORIES WA/001=ALL OTHERS (NON-LTC FAC) WA/D1=SPOKANE & YAKIMA AREAS WA/D1A=District 1, Unit A WA/D1B=District 1, Unit B WA/D1C=District 1, Unit C WA/D1D=District 1, Unit D WA/D2=SPOKANE & SE WA/D2A=District 2, Unit A WA/D2B=District 2, Unit B WA/D2C=District 2, Unit C WA/D2D=District 2, Unit D WA/D2E=District 2, Unit E WA/D2F=District 2, Unit F WA/D2G=District 2, Unit G WA/D3=NW WASHINGTON WA/D3A=District 3, Unit A WA/D3B=District 3, Unit B WA/D3C=District 3, Unit C WA/D3D=District 3, Unit D WA/D3E=District 3, Unit E WA/D4A=GREATER SEATTLE AREA WA/D4B=S KING COUNTY WA/D5A=PIERCE CTY & PENINSULA WA/D5B=PIERCE CTY & GRAYS HARBOR WA/D6=OLYMPIA AREA WA/LAB=LABORATORIES WI/001=WISCONSIN WI/LAB=LABORATORIES WV/001=WEST VIRGINIA WV/LAB=LABORATORIES WY/001=WYOMING WY/LAB=LABORATORIES Address: Street 50 178 227 VARCHAR2 Description: Street address where the provider is located. DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 18 Federally Qualified Health Center, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE SAS Name: ST_ADR COBOL Name: ST-ADR Telephone Number 10 228 237 VARCHAR2 Description: Telephone number of the provider. SAS Name: PHNE_NUM COBOL Name: PHNE-NUM Termination Code 2 238 239 VARCHAR2 Description: Indicates the current termination status for the provider. SAS Name: PGM_TRMNTN_CD COBOL Name: PGM-TRMNTN-CD VALUES: 00=ACTIVE PROVIDER 01=VOLUNTARY-MERGER, CLOSURE 02=VOLUNTARY-DISSATISFACTION WITH REIMBURSEMENT 03=VOLUNTARY-RISK OF INVOLUNTARY TERMINATION 04=VOLUNTARY-OTHER REASON FOR WITHDRAWAL 05=INVOLUNTARY-FAILURE TO MEET HEALTH/SAFETY REQ 06=INVOLUNTARY-FAILURE TO MEET AGREEMENT 07=OTHER-PROVIDER STATUS CHANGE 08=NONPAYMENT OF FEES - CLIA Only 09=REV/UNSUCCESSFUL PARTICIPATION IN PT - CLIA Only 10=REV/OTHER REASON - CLIA Only 11=INCOMPLETE CLIA APPLICATION INFORMATION - CLIA Only 12=NO LONGER PERFORMING TESTS - CLIA Only 13=MULTIPLE TO SINGLE SITE CERTIFICATE - CLIA Only 14=SHARED LABORATORY - CLIA Only 15=FAILURE TO RENEW WAIVER PPM CERTIFICATE - CLIA Only 16=DUPLICATE CLIA NUMBER - CLIA Only 17=MAIL RETURNED NO FORWARD ADDRESS CERT ENDED - CLIA Only 20=NOTIFICATION BANKRUPTCY - CLIA Only 33=ACCREDITATION NOT CONFIRMED - CLIA Only 80=AWAITING STATE APPROVAL 99=OIG ACTION - DO NOT ACTIVATE - CLIA Only Termination or Expiration Date 8 240 247 DATE Description: Date the provider was terminated. For CLIA providers, date the laboratory's certificate was terminated or the expiration date of the current CLIA certificate. SAS Name: TRMNTN_EXPRTN_DT COBOL Name: TRMNTN-EXPRTN-DT Type of Action Code 1 248 248 VARCHAR2 Description: Identifies the reason for the certification. Type of action from the official survey record, CMS 1539 form. SAS Name: CRTFCTN_ACTN_TYPE_CD COBOL Name: CRTFCTN-ACTN-TYPE-CD VALUES: 1=INITIAL 2=RECERTIFICATION 3=TERMINATION 4=CHANGE OF OWNERSHIP 5=VALIDATION 8=FULL SURVEY AFTER COMPLAINT Ownership Type Code 2 249 250 VARCHAR2 Description: Indicates the ownership type of the provider. SAS Name: GNRL_CNTL_TYPE_CD COBOL Name: GNRL-CNTL-TYPE-CD VALUES: 01=RELIGIOUS AFFILIATION 02=PRIVATE 03=OTHER 04=PROPRIETARY 05=GOVERNMENT - STATE/COUNTY DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 19 Federally Qualified Health Center, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 06=GOVERNMENT - COMBINATION GOVT & VOLUNTARY Address: ZIP Code 5 251 255 VARCHAR2 Description: Five-digit ZIP code for a provider's physical address. SAS Name: ZIP_CD COBOL Name: ZIP-CD FIPS State Code 2 256 257 VARCHAR2 Description: FIPS State Code SAS Name: FIPS_STATE_CD COBOL Name: FIPS-STATE-CD VALUES: 01=ALABAMA 02=ALASKA 04=ARIZONA 05=ARKANSAS 06=CALIFORNIA 08=COLORADO 09=CONNECTICUT 10=DELAWARE 11=DISTRICT OF COLUMBIA 12=FLORIDA 13=GEORGIA 15=HAWAII 16=IDAHO 17=ILLINOIS 18=INDIANA 19=IOWA 20=KANSAS 21=KENTUCKY 22=LOUISIANA 23=MAINE 24=MARYLAND 25=MASSACHUSETTS 26=MICHIGAN 27=MINNESOTA 28=MISSISSIPPI 29=MISSOURI 30=MONTANA 31=NEBRASKA 32=NEVADA 33=NEW HAMPSHIRE 34=NEW JERSEY 35=NEW MEXICO 36=NEW YORK 37=NORTH CAROLINA 38=NORTH DAKOTA 39=OHIO 40=OKLAHOMA 41=OREGON 42=PENNSYLVANIA 43=PUERTO RICO 44=RHODE ISLAND 45=SOUTH CAROLINA 46=SOUTH DAKOTA 47=TENNESSEE 48=TEXAS 49=UTAH 50=VERMONT 51=VIRGINIA 53=WASHINGTON 54=WEST VIRGINIA 55=WISCONSIN 56=WYOMING 64=AMERICAN SAMOA DATE: 01/03/2015 POS RECORD LAYOUT PAGE: 20 Federally Qualified Health Center, CATEGORY = "21" (SEE POSITIONS 3-4) SHORT DESCRIPTION LEN START END TYPE 65=GUAM 66=SAIPAN/MARIANA IS. 78=VIRGIN ISLANDS FIPS County Code 3 258 260 VARCHAR2 Description: FIPS County Code SAS Name: FIPS_CNTY_CD COBOL Name: FIPS-CNTY-CD CBSA Urban Rural Indicator 1 261 261 VARCHAR2 Description: CBSA (Core Based Statistical Area) indicates whether the county is defined as Urban or Rural. SAS Name: CBSA_URBN_RRL_IND COBOL Name: CBSA-URBN-RRL-IND CBSA Code 5 262 266 VARCHAR2 Description: CBSA (Core Based Statistical Area) geographic entities defined by the U.S. Office of Management and Budget (OMB) on June 6, 2003 for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics. CBSA collectively refers to MSA. SAS Name: CBSA_CD COBOL Name: CBSA-CD Fiscal Year End Date (MMDD) 4 464 467 VARCHAR2 Description: End date, consisting of the month and day, of the provider's fiscal year. SAS Name: FY_END_MO_DAY_CD COBOL Name: FY-END-MO-DAY-CD FQHC Approved RHC Provider Num 10 468 477 CHAR Description: FQHC approved provider number SAS Name: FQHC_APPROVED_RHC_PROVIDER_NUM COBOL Name: FQHC-APPROVED-RHC-PROVIDER-NUM FQHC Federally Funded Indicator 1 478 478 VARCHAR2 Description: Indicates whether this facility receives federal funds. SAS Name: FED_FUNDD_FQHC_SW COBOL Name: FED-FUNDD-FQHC-SW Part of RHC Indicator 1 621 621 VARCHAR2 Description: Indicates if the facility is part of a Medicare approved Rural Health Clinic. SAS Name: FQHC_APRVD_RHC_SW COBOL Name: FQHC-APRVD-RHC-SW Related Provider Number 10 669 678 CHAR Description: Related provider number SAS Name: RELATED_PROVIDER_NUMBER COBOL Name: RELATED-PROVIDER-NUMBER