Provider Specific File

  The Provider Specific File contains data related to PPS payment such as number of beds and interns-to-bed ratio, for all PPS-eligible hospitals. This information is used along with the Diagnosis Related Group (DRG) by the PPS pricing mechanism software, called PRICER, to calculate Medicare PPS payment for inpatient hospital claims. Further discussion of PPS can be found in the Overview of the Health Care Financing Administration chapter in the Orientation Section.

File Creation

Fiscal Intermediaries (FIs) maintain provider specific information for the purpose of calculating inpatient hospital claim payment amounts under PPS. FIs obtain the values for some provider specific data elements such as number of beds from the hospitals and other data elements such as the case-mix index from CMS(previously HCFA). Every quarter, FIs send CMS a tape containing current and historic provider specific data. From these data CMS creates a file containing only the most recent data; data for previous quarters are stored in historical files. The Provider Specific File contains data for all PPS-eligible hospitals, including hospitals in waiver States. It does not include data for facilities that are specifically excluded from PPS, such as children's and cancer hospitals. The Provider Specific File has been created and maintained quarterly since October 1, 1983, the beginning of PPS. The file created for the fourth quarter of every fiscal year is referred to as an annual file.

File Maintenance

The Provider Specific File provides a snapshot of provider data at a certain point in time. All quarterly data submissions are maintained. When CMS receives a quarterly file from an FI, it performs completion checks and edits the record for conformity to provider number ranges, code ranges, minimum and maximum dollar amounts, and other data parameters. CMS also adds new information to the file such as changes in Metropolitan Statistical Area. FIs are alerted when submissions are incomplete or contain errors and are required to resubmit a corrected version of the file.

File Structure and Usage

The Provider Specific File contains provider specific information used by FIs to calculate PPS inpatient hospital claim payments. The information, which does not appear on the Medicare claims directly, includes intern-to-bed ratio; pass-through amounts for capital, direct medical education, and organ acquisition; and the number of hospital beds. The Provider Specific File is also used by the FIs to verify a provider's status against incoming claims. Providers can use provider specific data to calculate their own claim payment amounts, or to compare their pricing information to that of other PPS providers. The provider is the unit of analysis.

Data Structure and Usage

The Provider Specific File contains approximately 5,600 records: one record for each PPS-eligible hospital, including hospitals in waiver States. The records are ordered by provider number. Each fixed length record contains approximately 40 data elements including nine data elements that were added to the record when capital rates were incorporated into PPS in October of 1991.

Methods of Access

The Provider Specific File is available as a sequential flat file or SAS data set. A public use version of the Provider Specific File is described in the Public Use Files Data chapter.

Migration of Data

The Provider Specific File has not changed except to add capital rates data in 1991.

List of Data Elements

A list of the data elements contained in the Provider Specific File, along with brief definitions and coding schemes, will be included in the future on the CMS web site at www.cms.hhs.gov.  

POS Introduction | POS | Provider Specific | MPIER