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Network and Insurance Plan Data File Specification

  • Updated

Version: 1.0
Date: April 26, 2021

Introduction

This document defines the file format for the electronic transfer of Network and Insurance Plan data to Ayin Health Solutions (Ayin). This file format provides the information needed for populating a provider directory API compliant with CMS Interoperability requirements.

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_networkplan_yyyymmdd.txt
  • Clientnm_networkplan_yyyymmdd.csv

File Delivery

File drop locations if using Ayin SFTP server will look similar to the following (individual client locations may differ):

  • Test Files : /home/entities/other/client name/to phtech/cms interoperability/provider data/testing
  • Production Files : /home/entities/other/client name/to phtech/cms interoperability/provider data/

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

Data Schema

Column Field Name Field Type Field Length Required Description
1 network_id varchar 20

No

 Unique identifier for the network - If value is not supplied Ayin will populate with an auto incremental value. NOTE: This value needs to align with the provider demographic file - see Linking to Provider Demographic Data
2 network_name varchar 100 Yes Short name for the network
3 network_description varchar 255 No Long name / description for the network - If value is not supplied the network_name value will be used
4 network_active varchar 5 Yes Is the network currently active.  Allowed values True / False
6 network_part_of varchar 50 Yes The organization that manages this network.  This likely matches the organization that the provider directory is representing. For assistance on this value please contact Ayin.
7 plan_id varchar 20 No Unique identifier for the plan - If value is not supplied Ayin will populate with an auto incremental value
8 plan_name varchar 100 Yes Short name for the plan
9 plan_description varchar 255 No

Long name / description for the plan - If value is not supplied the plan_name value will be used
10 plan_status varchar 10 Yes Current status of this plan. Allowed values are draft/active/retired/unknown
11 plan_type varchar 10 Yes Plan product type - see list of allowed values
12 plan_ownedby varchar 50 Yes Plan issuer. This likely matches the organization that the provider directory is representing. For assistance on this value please contact Ayin
13 plan_administeredby varchar 50 Yes Product administrator. This likely matches the organization that the provider directory is representing. For assistance on this value please contact Ayin
14 plan_plan_type varchar 15 No Categorization of the cost sharing for the plan - see list of allowed values

 

Example

network_id network_name network_description network_active network_part_of plan_id plan_name plan_description plan_status plan_type plan_ownedby plan_administeredby plan_plan_type
NET-001 Network 1 Network 1 TRUE ANOther Plan-001 Plan-001 Plan Marketing Name 1 active medihmo ANOther ANOther gold
NET-002

Network 2

 Network 2 TRUE ANOther Plan-002 Plan-002 Plan-002 active mediadvhmo ANOther ANOther  
NET-002 Network 2 Network 2 TRUE ANOther Plan-003 Plan-003 Plan Name Silver active mediadvhmo ANOther ANOther silver
NET-002 Network 2 Network 2 TRUE ANOther Plan-004 Plan-004 Plan-004 active mediadvhmo ANOther ANOther  

 

Linking to Provider Demographic Data

This file is meant as a complimentary file to the Provider Demographic Data File Specification which defines the format for provider data that is sent to Ayin. Specifically the Provider_Network value specified for a provider record in column 25 must match exactly with ONLY one network_id in the Network and Insurance Plan Data File specified here.

Example

In the following example a single provider (John Smith) is a part of two separate networks (NET-001 and NET-002) with a different specialty in each. Note: the sample below is condensed for simplicity and formatting.

Provider Demographic Data File 

Provider_Last_Name

Provider_First_Name

Address_Designation

Provider_NPI_Number

Practice_Address_1

Provider_Category

Provider_Network

Smith

John

Primary

123456789

123 Main Street NW

ph

NET-001

Smith

John

Second

123456789

595 West Morrison Street SE

ph

NET-001

Smith

John

Primary

123456789

123 Main Street NW

em

NET-002

Smith

John

Second

123456789

595 West Morrison Street SE

em

NET-002

 

Allowed Values

Plan_Type

Value Display Definition
commppo Commercial PPO Health insurance provided through a Preferred Provider Organization (PPO).
commhdhp Commercial HDHP Health insurance provided through a High Deductible Health Plan (HDHP).
commpos Commercial POS Health insurance provided through a Point-of-Service (POS) Plan.
commhmo Commercial HMO Health insurance provided through a Health Maintenance Organization (HMO).
commepo Commercial EPO Health insurance provided through a Exclusive Provider Organization(EPO).
medi Medicaid Health insurance provided to eligible adults and children under the Federal Medicaid program
medihmo Medicaid HMO Health insurance provided to eligible adults and children under the Federal Medicaid program through a Health Maintenance Organization (HMO).
mediadv Medicare Advantage Health insurance provided by a private company that contracts with Medicare to provide all Medicare Part A and Part B benefits.
mediadvhmo Medicare Advantage HMO Health insurance offered by a private company that contracts with Medicare to provide all Medicare Part A and Part B benefits through a Health Maintenance Organization (HMO).
media Medicare Part A Health insurance provided under the Federal Medicare program covering inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
medib Medicare Part B Health insurance provided under the Federal Medicare program covering certain doctors' services, outpatient care, medical supplies, and preventive services.
medid Medicare Part D Health insurance provided under the Federal Medicare program covering prescription drugs.
mediab Medicare A/B Health insurance provided under the Federal Medicare program covering inpatient hospital stays, care in a skilled nursing facility, hospice care, some home health care, certain doctors' services, outpatient care, medical supplies, and preventive services.
qhp Qualified Health Plan Health insurance provided through and certified by the Health Insurance Marketplace that provides essential health benefits (EHBs), follows established limits on cost sharing, and meets other requirements outlined within the application process.
ihs Indian Health Service Health care program provided to United States American Indians and Alaska Natives.
fep Federal Employee Program Health insurance provided to employees of the Federal government.
tri TRICARE Health care program provided to uniformed service members, retirees, and their families around the world.
va Veterans Affairs Plan Health care program provided to eligible veterans.
dent Dental Plan Health insurance provided to cover services related to the study, diagnosis, prevention, and treatment of diseases, disorders, and conditions of the oral cavity.
denthmo Dental HMO Health insurance provided to cover services related to the study, diagnosis, prevention, and treatment of diseases, disorders, and conditions of the oral cavity provided through a Health Maintenance Organization (HMO).
vis Vision Plan Health insurance provided to cover services related to the study, diagnosis, prevention, and treatment of diseases, disorders, and conditions of the eyes.
vishmo Vision HMO Health insurance provided to cover services related to the study, diagnosis, prevention, and treatment of diseases, disorders, and conditions of the eyes provided through a Health Maintenance Organization (HMO).

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

 

Plan_Plan_Type

Value Display Definition
platinum Platinum-QHP Plan with highest monthly premium and lowest costs when you need care A Qualified Health Plan with the highest monthly premiums and smallest out-of-pocket costs for the member in comparison to other metal-category plans
gold Gold-QHP Plan with high monthly premium and low costs when you need care A Qualified Health Plan with the higher monthly premiums and smaller out-of-pocket costs for the member in comparison to other metal-category plans
silver Silver-QHP Plan with moderate monthly premium and moderate costs when you need care A Qualified Health Plan with the lower monthly premiums and larger out-of-pocket costs for the member in comparison to other metal-category plans
bronze Bronze-QHP Plan with lowest monthly premium and highest costs when you need care A Qualified Health Plan with the lowest monthly premiums and largest out-of-pocket costs for the member in comparison to other metal-category plans
lowdeductible Low Deductible A plan that requires the insured to pay out of pocket a smaller proportion of incurred health care costs.
highdeductible High Deductible A plan that requires the insured to pay out of pocket a larger proportion of incurred health care costs than a traditional insurance plan.

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

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