CMS Pub. 100-04, ch. 4, § 50.1

The Outpatient Provider Specific File (OPSF) contains the required information about

each provider to enable the pricing software to calculate the payment amount. Data

elements and formats are shown below. Contractors must maintain the accuracy of

the data, and update the file as changes occur in data element values, e.g., changes in

metropolitan statistical area (MSA), bed size, cost to charge ratio. An update is

accomplished by preparing and adding an additional complete record showing new

current values and the effective date of the change. The old record is retained without

change.

Contractors must also furnish CMS a quarterly file in the same format.

NOTE: All data elements, whether required or optional, must have a default value of

“0” (zero) if numerical, or blank if alphanumerical.

File

Position

Format

Title

Description

1-10 X(10) National Provider

Identifier (NPI)

Alpha-numeric 10 character provider number.

11-16 X(6) Provider Oscar

Number

Alpha-numeric 6 character provider number.

17-24 9(8) Effective Date Must be numeric, CCYYMMDD. This is the

effective date of the provider's first OPPS period.

For subsequent OPPS periods, the effective date

is the date of a change to the PROV file. If a

termination date is present for this record, the

effective date must be equal to or less than the

termination date.

25-32 9(8) Fiscal Year

Beginning Date

Must be numeric, CCYYMMDD.

Month: 01-12

Day: 01-31

The date must be greater than 19990630.

33-40 9(8) Report Date Must be numeric, CCYYMMDD.

Month: 01-12

Day: 01-31

The created/run date of the PROV report for

submittal to CO.

41-48 9(8) Termination Date Must be numeric, CCYYMMDD. Must be zeroes or

contain a termination date. (Once the official “tie-out” notice from CMS is received). Must be equal

to or greater than the effective date.

(Termination date is the date on which the

reporting contractor ceased servicing the provider

in question).

49 X(1) Waiver Indicator Enter a “Y” or “N.”

Y = waived (provider is not under OPPS)

For End Stage Renal Disease (ESRD) facilities

provider waived blended payment, pay full

PPS.

N = not waived (provider is under OPPS)

For ESRD facilities provider did not waive

blended payment. Pay according to

transitional payment method for ESRD PPS

through 2013.

50-54 9(5) Intermediary

Number

Enter the Contractor #.

55-56 X(2) Provider Type This identifies providers that require special

handling. Enter one of the following codes as

appropriate.

00 or blanks = Short Term Facility

02 Long Term

03 Psychiatric

04 Rehabilitation Facility

05 Pediatric

06 Reserved

07 Rural Referral Center

08 Indian Health Service

13 Cancer Facility

14 Medicare Dependent Hospital (during cost

reporting periods that began on or after April

1, 1990.

15 Medicare Dependent Hospital/Referral Center

(during cost reporting periods that began on

or after April 1, 1990. Invalid October 1, 1994

through September 30, 1997).

16 Re-based Sole Community Hospital

17 Re-based Sole Community Hospital /Referral

Center

18 Medical Assistance Facility

21 Essential Access Community Hospital

22 Essential Access Community Hospital/Referral

Center

23 Rural Primary Care Hospital

24 Rural Emergency Hospitals

32 Nursing Home Case Mix Quality

Demonstration Project – Phase II

33 Nursing Home Case Mix Quality

Demonstration Project – Phase III – Step 1 34

Free-standing Opioid Treatment Program

35 Hospice

36 Home Health Agency

37 Critical Access Hospital

38 Skilled Nursing Facility (SNF) – For non-demo

PPS SNFs – effective for cost reporting periods

beginning on or after July 1, 1998

40 Hospital Based ESRD Facility

41 Independent ESRD Facility

42 Federally Qualified Health Centers

43 Religious Non-Medical Health Care Institutions

44 Rural Health Clinics-Free Standing

45 Rural Health Clinics-Provider Based

46 Comprehensive Outpatient Rehab Facilities

47 Community Mental Health Centers

48 Outpatient Physical Therapy Services

49 Psychiatric Distinct Part

50 Rehabilitation Distinct Part

51 Short-Term Hospital – Swing Bed

52 Long-Term Care Hospital – Swing Bed

53 Rehabilitation Facility – Swing Bed

54 Critical Access Hospital – Swing Bed

57 X(1) Special Locality

Indicator

Indicates the type of special locality provision that

applies.

For End Stage Renal Disease (ESRD) facilities:

Dates of service prior to Jan 1, 2025:

value “Y” equals low volume adjustment

applicable.

Dates of service on or after Jan 1, 2025:

Value blank = No low volume adjustment

applicable

Value 1 or 2 = tier number applicable for low

volume adjustment

58 X(1) Change Code For

Wage Index

Reclassification

Enter “Y” if the hospital’s wage index location has

been reclassified for the year. Enter “N” if it has

not been reclassified for the year. Adjust

annually. Does not apply to ESRD Facilities.

59-62 X(4) Actual

Geographic

Location—MSA

Enter the appropriate code for MSA, 0040–9965,

or the rural area, (blank) (blank) 2-digit numeric

State code, such as _ _ 3 6 for Ohio, where the

facility is physically located.

63-66 X(4) Wage Index

Location—MSA

The appropriate code for the MSA, 0040-9965, or

the rural area, (blank)(blank) (2 digit numeric

State code) such as _ _ 3 6 for Ohio, to which a

hospital has been reclassified for wage index.

Leave blank or enter the actual location MSA if

not reclassified. Does not apply to ESRD Facilities.

67-70 9V9(3) Payment-to-Cost

Ratio

Enter the provider’s payment-to-cost ratio. Does

not apply to ESRD Facilities.

71-72 9(2) State Code Enter the 2-digit state where the provider is

located. Enter only the first (lowest) code for a

given state. For example, effective October 1,

2005, Florida has the following State Codes: 10,

68 and 69. Contractors shall enter a “10” for

Florida’s State Code.

List of valid State Codes is located in Pub. 10007,

Chapter 2, Section 2779A1.

73 X(1) TOPs Indicator Enter the code to indicate whether TOPs applies

or not.

Y = qualifies for TOPs

N = does not qualify for TOPs

74 X(1) Quality Indicator

Field

Hospital:

Enter the code to indicate whether the hospital

meets data submission criteria per HOP QDRP

requirements.

1 = Hospital quality reporting standards have

been met or hospital is not required to submit

quality data (e.g., hospitals that are

specifically excluded from the IPPS or which

are not paid under the OPPS, including

psychiatric, rehabilitation, long-term care and

children’s and cancer hospitals, Maryland

hospitals, Indian Health Service hospitals, or

hospital units; or hospitals that are located in

Puerto Rico or the U.S. territories). The

reduction does not apply to hospices, CORFs,

HHAs, CMHCs, critical access hospitals or to

any other provider type that is not a hospital.

Blank = Hospital does not meet criteria.

Independent and Hospital-based End Stage Renal

Disease (ESRD)Facilities:

Enter the code applicable to the ESRD Quality

Incentive Program (QIP):

Blank = no reduction

1 = ½ percent payment reduction

2 = 1 percent payment reduction

3 = 1 ½ percent payment reduction

4 = 2 percent payment reduction

* Please refer to file position 101 for ESRD

Children’s Hospitals Quality Indicator.

75 X(1) Filler Blank.

76-79 9V9(3) Outpatient Cost -

to-Charge Ratio

Derived from the latest available cost report data.

See §10.11 of this chapter for instructions on how

to calculate and report the Cost-to-Charge Ratio.

Does not apply to ESRD Facilities.

80-84 X(5) Actual

Geographic

Location CBSA

00001-89999, or the rural area, (blank) (blank)

(blank) 2 digit numeric State code such as _ _ _ 3

6 for Ohio, where the facility is physically located.

85-89 X(5) Wage Index

Location CBSA

Enter the appropriate code for the CBSA,

0000189999, or the rural area,

(blank)(blank)(blank) (2 digit numeric State code)

such as _ _ _ 3 6 for Ohio, to which a hospital has

been reclassified due to its prevailing wage rates.

Leave blank or enter the Actual Geographic

Location CBSA, if not reclassified. Pricer will

automatically default to the actual location CBSA

if this field is left blank. Does not apply to ESRD

Facilities.

90-95 9(2)

V9(4)

Special Wage

Index

Enter the special wage index that certain

providers may be assigned. Enter zeroes unless

the Special Payment Indicator equals a “1” or “2.”

96 X(1) Special Payment

Indicator

The following codes indicate the type of special

payment provision that applies.

Blank = not applicable

Y = reclassified

1 = special wage index indicator

2 = both special wage index indicator and

reclassified

D = Dual Reclassified

97-100 9(4) Reduced

Coinsurance

Trailer Count

Enter the number of APCs the provider has

elected to reduce coinsurance for. The number

cannot be greater than 999.

101 X(1) Quality Indicator

ESRD Children’s

Hospitals

Children’s Hospitals for End Stage Renal Disease

(ESRD) Facilities:

Enter the code applicable to the ESRD Quality

Incentive Program (QIP):

Blank = no reduction

1 = ½ percent payment reduction

2 = 1 percent payment reduction

3 = 1 ½ percent payment reduction

4 = 2 percent payment reduction

102-105 9V9(3) Device

department’s

Cost-to-Charge

Ratio

Derived from the latest available cost report data.

Does not apply to ESRD Facilities.

106-112 X(7) Carrier/Locality

code

The carrier/locality code for the provider service

facility. The first five positions represent the

carrier code and the last two positions represent

the locality code.

113-117 9(5) County Code Enter the County Code.

Must be 5 numbers.

118-122 X(5) Payment CBSA Enter the appropriate code for the CBSA,

0000189999, or the rural area,

(blank)(blank)(blank) (2 digit numeric State code)

such as _ _ _ 3 6 for Ohio, to which a hospital has

been reclassified due to its prevailing wage rates.

Leave blank or enter the Actual Geographic

Location CBSA, if not reclassified. Pricer will

automatically default to the actual location CBSA

if this field is left blank. Does not apply to ESRD

Facilities.

123-128 9V9(5)

Payment Model

Adjustment (PMA)

Derived from payment model Technical Direction

Letter.

129-133

9V9999

Medicare

Performance

Adjustment (MPA)

Enter the MPA percentage calculated and

published by the Centers for Medicare & Medicaid

Services (CMS).

134-139 9(2)

V9(4)

Supplemental

Wage Index

Enter the supplemental wage index that certain

providers may be assigned. Enter zeroes if it does

not apply.

140-140 X(1) Supplemental

Wage Index Flag

Enter the supplemental wage index flag:

1=Prior Year Wage Index

2=Future use

3=Future use

Enter blank if it does not apply.

141-162 X(22) FILLER

The contractor enters the number of APCs for which the provider has elected to reduce

coinsurance. Cannot be greater than 999. Reduced Coinsurance Trailer Record - Occurs 0-

999 times depending on the reduced Coinsurance Trailer Count in positions 97-100. Due to

system’s capacity limitations the maximum number of reduced coinsurance trailers allowable

is 999 at this time.