Provider Demographic Data File Specification – Ayin Help Center

Version: 2.1
Date: June 13, 2024

Introduction

This document defines the file format for the electronic transfer of provider demographic data between a specific PLAN (or their designee) and Ayin Health Solutions (Ayin) required to configure Ayin’s claims administration platform or other data services.

File Format and Naming

Files should be delivered in one of the following formats

Pipe delimited text file with headers
Text Qualified CSV - with headers

File naming convention should be the following depending on file format above:

Clientnm_providerdemographics_yyyymmdd.txt
Clientnm_providerdemographics_yyyymmdd.csv

File Delivery

File drop locations if using Ayin SFTP server:

Test Files : /home/entities/other/client name/to ayin/providerdata/testing
Production Files : /home/entities/other/client name/to ayin/providerdata/

For more information regarding using Ayin SFTP please see: SFTP Data Transfer

Data Schema

Column	Field Name	Field Type	Field Length	Required	Default Value (Used if no value supplied)	Description
1	Provider_Last_Name	varchar	100	Yes		Provider's last name
2	Provider_First_Name	varchar	35	Yes		Provider's first name
3	Provider_Middle_Name	varchar	1	No		The first initial of the provider's middle name
4	Provider_Suffix	varchar	15	No		The suffix that would indicate providers MD, DO
5	Provider_Gender	varchar	1	Yes		Gender of the provider. M = male, F = female, O = other, U = unknown/unspecified
6	Provider_DOB	date	8	No		Provider's date of birth. MMDDYYYY
7	Provider_Category	varchar	50	No		For CMS Interop , all records should populate either Provider_Category or Facility_Type but NOT both. * See Provider Category and Facility Type for allowed values and additional information.
8	Address_Designation	varchar	10	Yes		Indicates if the office listed is the primary working office of the provider. A provider can only have one primary office.
9	Effective_Date_of_Office_Designation	date	8	No		Date the provider began work at the practice office MMDDYYYY
10	Termination_Date_of_Office_Designation	date	8	No		Date the provider left the practice office MMDDYYYY or blank if still active
11	Practice_Name	varchar	100	Yes		Physical Name of the practice office as could be seen from the street.
12	Practice_Address_1	varchar	55	Yes		Physical Address line for the practice
13	Practice_Address_2	varchar	55	No		Physical Address line for the practice
14	Practice_City	varchar	35	Yes		Physical City of the practice office
15	Practice_State	varchar	2	Yes		Physical State abbreviation of the practice office
16	Practice_Zip	varchar	10	Yes		Physical Zip code for the practice office; #####- ####
17	Practice_Phone	varchar	13	Yes		Phone number for the practice office ###-###-####. This will post a warning in the post load report file if not supplied.
18	Practice_Fax	varchar	13	No		Fax number for the practice office; ###-###-####. This will post a warning in the post load report file if not supplied.
19	Practice_NPI_Number	varchar	10	Yes		Practice Office registered National Provider ID. If sent this will greatly increase the ability to match the Practice Office being sent to the Practice Office in CIM.
20	Practice_Tax_ID	varchar	9	Yes		Practice Office Tax ID. If sent this will greatly increase the ability to match the Practice Office being sent to the Practice Office in CIM.
21	Provider_Tax_ID_SSN	varchar	9	No		SSN or TAX ID for the provider. If Ayin is completing provider enrollments this is required.
22	Provider_IS_PCP	varchar	1	Yes		Indicates if the provider is a PCP. Yes = Y No = N or blank. Utilized for member assignments and claims adjudication.
23	Provider_License_Number	varchar	35	No		State license number for the provider. If Ayin is completing provider enrollments this is required.
24	Provider_NPI_Number	varchar	10	Yes		Provider's registered National Provider ID
25	Provider_Taxonomy_Code	varchar	35	Yes		Provider's taxonomy code. The Taxonomy code is required for claims. If this value is unknown, obtain the value from relevant governing authority (ex. OHA, NPPES). Valid codes are defined at https://www.nucc.org/index.php/code-sets-mainmenu-41/provider-taxonomy-mainmenu-40/csv-mainmenu-57
26	Primary_Taxonomy	varchar	1	Yes		Indicates the taxonomy code provided is the primary taxonomy for the provider
27	Provider_Network	varchar	50	Yes		Name of the network that a provider can provide services in
28	Network_Effective_Date	date	8	No		Date the provider became effective on the network. MMDDYYYY
29	Network_Termination_Date	date	8	No		Date the provider became terminated from the network. MMDDYYYY or blank if still active.
30	Billing_Provider_Name	varchar	100	Yes		Name of the billing provider (provider group/network) for the provider
31	Billing_Provider_Doing_Business_As_Name	varchar	100	No		If the billing provider has a different name printed on a check than what is actually printed on the bill
32	Is_Billing_Provider_Facility	varchar	1	No	N	If the billing provider location should be considered a facility that patients are referred to then this value should be Y. The default value is N.
33	Billing_Provider_NPI_Number	varchar	10	Yes		The National Provider ID for the billing provider
34	Billing_Provider_Taxonomy	varchar	35	Yes		The primary taxonomy for the billing provider
35	Billing_Provider_Tax_ID	varchar	9	Yes		The Tax ID for the billing provider
36	Billing_Provider_Phone	varchar	13	Yes		The primary phone number for the billing provider; ###-###-####
37	Billing_Provider_Fax	varchar	13	No		The primary fax number for the billing provider; ###-###-####
38	Billing_Provider_Physical_Street_Address_1	varchar	55	Yes		The first line physical address location of the billing provider. This has to be a physical address, PO Boxes are not allowed.
39	Billing_Provider_Physical_Street_Address_2	varchar	55	No		The second line physical address location of the billing provider
40	Billing_Provider_Physical_City	varchar	35	Yes		The physical city of the billing provider
41	Billing_Provider_Physical_State	varchar	2	Yes		The physical state of the billing provider
42	Billing_Provider_Physical_Zip	varchar	15	Yes		The physical zip code of the billing provider; #####-####
43	Pay_To_Street_Address_1	varchar	55	No	Billing_Provider_Physical_Street_Address_1	The first line mailing address for the billing provider
44	Pay_To_Street_Address_2	varchar	55	No	Billing_Provider_Physical_Street_Address_2	The second line mailing address for the billing provider
45	Pay_To_City	varchar	35	No	Billing_Provider_Physical_City	The mailing city for the billing provider
46	Pay_To_State	varchar	2	No	Billing_Provider_Physical_State	The mailing state for the billing provider
47	Pay_To_Zip	varchar	15	No	Billing_Provider_Physical_Zip	The mailing zip code for the billing provider; #####-####
48	Panel_Open	varchar	1	Yes	Y	ONLY applicable for PCP. “Y” indicates that the provider is accepting new patients. “N” indicates that the provider is NOT accepting new patients. Default = “Y”. For compliance, it is very important that this data be as accurate as possible.
49	Include_in_Directory	varchar	1	Yes	Y	“Y” indicates that the provider is to be included in the directory. “N” indicates that the provider is NOT to be included in the directory. Default = “Y”.
50	Directory_Specialty	varchar	100	No		Recommended for Online and Printed Provider Directories. This is a friendly description that would be understood by a typical member. This is not intended to be populated with a taxonomy code description captured previously.
51	Language_1	varchar	100	Yes	English	This is the primary language of the provider as it will appear in the Provider Directory.
52	Language_2	varchar	100	No		This is the secondary language of the provider as it will appear in the Provider Directory.
53	Internal_Provider_ID	varchar	50	No		Optional identifier that is unique to the provider from the originating system that can be used for tracking and identification of that provider for downstream processes.
54	Facility_Type	varchar	100	No		This is for identifying the specific type of facility. For CMS Interop , all records should populate either Provider_Category or Facility_Type but NOT both. * See Provider Category and Facility Type for allowed values and additional information.
55	Non_Par_OnCall_Start	date	8	No		Indicates the start date that a provider is valid but non participating in the plan. Usually this is while contracting is pending.
56	Non_Par_OnCall_End	date	8	No		Indicates the end date that a provider is valid but non participating in the plan. Usually this is while contracting is pending.
57	Practice_Office_URL	varchar	255	No		Recommended for Online and Printed Provider Directories. Practice office website url if applicable
58	Practice_Office_Accessibility	varchar	1	No	N	Recommended for Online and Printed Provider Directories. Whether the provider's office/facility has accommodations for people with physical disabilities, including offices, exam room(s) and equipment. (Y=Yes, N=No)
59	Disability_Access	varchar	1	No	N	Recommended for Online and Printed Provider Directories. Indicates the Provider Office has disability access but that the Provider Office has not specified what that access is. Y = Yes, N = No.
60	Age_Restriction	varchar	20	No		Recommended for Online and Printed Provider Directories. Are there any age restrictions for this provider at this location (Adults Only, Pediatrics Only etc)
61	Cultural_Competency_Certification	varchar	1	No	N	Recommended for Online and Printed Provider Directories. Has the provider completed the Cultural Competency Certification course. (Y=Yes, N=No)
62	Provider_IS_Dental	varchar	1	No		Indicates if the provider is a dental provider. Yes = Y No = N or blank. Utilized for member assignments and claims adjudication.
63	Provider_IS_Mental_Health	varchar	1	No		Indicates if the provider is a mental health provider. Yes = Y No = N or blank. Utilized for member assignments and claims adjudication.
64	TeleHealth	varchar	1	No	N	Recommended for Online and Printed Provider Directories. Indicates if the Provider offers TeleHealth appointments. Y = TeleHealth Only, N = In-Person Only, B = Both TeleHealth and In-Person.
65	Auxiliary_Aids	varchar	1	No	N	Recommended for Online and Printed Provider Directories. Availability of auxiliary aids and services for all members with disabilities upon request and at no cost. Y = Yes, N = No.

Note: Exact required fields are dependent on client specific use case.

Duplicate Data Handling

Please note that in the event that a Provider Record has multiple practice offices and/or specialties Ayin would prefer that a unique record be sent for each situation. For example, if a Provider Record has three practice offices then three records would be delivered in the data file and one of these records needs to be marked as the primary practice office. Similarly, if a Provider Record has two specialties then two records would be delivered in the data file and one of these records needs to be marked as the primary specialty.

Sample Data for Multiple Practice Offices and Specialties
Transmit one provider row for each address and/or specialty (all of the other provider data would be the exact same except for the practicing address as follows). Note that the sample below is condensed for simplicity and formatting purposes.

Provider_Last_Name	Provider_First_Name	Address_Designation	Provider_NPI_Number	Practice_Address_1	Provider_Taxonomy_Code	Primary_Taxonomy
Smith	John	Primary	123456789	123 Main Street NW	207RR0500X	N
Smith	John	Second	123456789	595 West Morrison Street SE	207RR0500X	N
Smith	John	Primary	123456789	123 Main Street NW	207Q00000X	Y
Smith	John	Second	123456789	595 West Morrison Street SE	207Q00000X	Y

Provider Category and Facility Type

Provider_Category is used to identify individuals providing medical services such as doctors/nurses/pharmacists.

Facility_Type is used to identify the type of location where medical services are provided.

For CMS Interop, every record must contain either a Provider_Category or a Facility_Type but NOT both. If both values are specified the record will be rejected during import.

Provider_Category Allowed Values

http://hl7.org/fhir/us/davinci-pdex-plan-net/STU1/ValueSet-PractitionerRoleVS.html

Facility_Type Allowed Values

https://terminology.hl7.org/2.0.0/ValueSet-v3-ServiceDeliveryLocationRoleType.html