Adding Providers, Codes, Payers, Networks
Providers and Provider Types
To add a new provider or provider type, follow this decision tree:
Does a Spine exist for the Provider Type?
❌ No
A Spine does not exist for the Provider Type. We'll will need to create one.
Next Step: Consult the Spines team to create a new Spine for this provider type.
✅ Yes
Continue below ⬇️
Is the Provider already in the Spine?
❌ No
The Spine exists for the Provider Type, but the Provider is missing.
Next Step: Consult the Spines team to add the provider to the existing Spine.
✅ Yes
Continue below ⬇️
Does the provider type already exist in CLD?
✅ Yes
The provider type already exists in CLD. The provider will be added in the next refresh automatically.
Next Step: No action needed - wait for the next refresh.
❌ No
The provider type exists in Spines but has not yet been added to CLD.
Next Step: The CLD team will need to add the provider type. In order to do this, we will need a list of plausible codes for that provider_type. Whether the list is provider_id specific is optional.
Codes
| Provider Type | Bill Type | Codes |
|---|---|---|
| Hospital | Inpatient | ALL MS-DRGs, ALL APR-DRGs, except Transplant, ECMO, CAR-T |
| Hospital | Outpatient | Most OPPS codes, Lab template codes, manual additions |
| ASC | Outpatient | top 5000 codes by revenue from ASC reference prices |
| Physician Groups | Professional | top 2000 MPFS codes by revenue, Anesthesia codes, manual additions |
| Imaging Centers | Professional | limited to codes in Consumer SSPs |
| Infusion Centers | Outpatient | Drugs |
To edit the codeset or request manual additions, please contact the CLD team.
Payers and Networks
-
Do we need have labelled payer MRF files for the payer/network? (e.g. for Exchange plans, we might only need hospital MRF data). If so, Contact the Ryan K / Maya N / Derivative Assets to label payer MRF files.
-
To add the payer/network to CLD, contact the CLD team with the following information, here's an example:
| Payer | Network Display Name | Payer File Labels (Array) | States |
|---|---|---|---|
| 76 | NATIONAL OAP | NATIONAL OAP,NATIONAL PPO | National |
| 42 | NY PPO | NY PPO | NY |
- If possible, it's also helpful to do some research in hospital data to flag plan names that definitely should not be considered. Our plan bridge logic likely already has logic to exclude plans if they are Medicare plans mislabeled as Commercial, indemnity plans, international plans, behavioral health plans, etc.. but there may be other plans that should be excluded as well.
As an example:
SELECT plan_name, count(*) as n
FROM tq_production.hospital_data.hospital_rates
WHERE payer_id = XX
AND payer_class_name = 'Commercial'
GROUP BY plan_name
ORDER BY n DESC
LIMIT 100