Status ProviderType StatusEffectiveDate OrganizationName TIN FacilitySupplierName FirstName
MI LastName Degree Specialty PerformingSpecialty DOB SSN Gender ProviderNPI CAQHID PrimaryPractice
AcceptingNewPatients PCP ServiceLocationName LocationNPI LocationAddress LocationCity LocationState
LocationZip LocationPhone LocationFax LocationDigitalContact CredentialingContactEmail
OffersTelehealthServices TelehealthModalities TelehealthServicesOffered BillingNPI BillingAddress BillingCity
BillingState BillingZip BillingPhone BillingFax MailingBillingSameAddress MailingAddress MailingCity
MailingState MailingZip MailingPhone MailingFax
Instructions: This tab details all the data elements needed on the ProviderRosterTemplate tab.
Note: Providers must still be contracted and credentialed within the ProviDRs Care Network on status effective date
Field Name Example
Status Add
ProviderType Practitioner
StatusEffectiveDate 4/1/2022
OrganizationName Emergency Physicians of Wichita INC
TIN 123456789
FacilitySupplierName
FirstName John
MI F
LastName Smith
Degree MD
Specialty Family Medicine
PerformingSpecialty Emergency Medicine
DOB 1/23/1982
SSN 12345678X
Gender M
ProvderNPI 1234567890
CAQHID 12345678
PrimaryPractice Y
AcceptingNewPatients NA
PCP N
ServiceLocationName ICT Emergency Physicians
LocationNPI 1123456789
LocationAddress 238 N Waco
LocationCity Wichita
LocationState KS
LocationZip 67202
LocationPhone 3166834111
LocationFax 3166836255
LocationDigitalContact [Link]
CredentialingContactEmail cred@[Link]
OffersTelehealthServices N
TelehealthModalities
TelehealthServicesOffered
BillingNPI 1123456789
BillingAddress
BillingCity
BillingState
BillingZip
BillingPhone
BillingFax
MailingBillingSameAddress
MailingAddress
MailingCity
MailingState
MailingZip
MailingPhone
MailingFax
needed on the ProviderRosterTemplate tab.
ntialed within the ProviDRs Care Network on status effective date for any add or change requests.
Format Format Requirements
Add
Update
TermTIN
TermLocation
Attest
Practitioner
Facility
Supplier
MM/DD/YYYY
XXXXXXXXX (9 Digits - No Dashes)
X (1 Character)
No Special Characters
xxxxxx,xxxxxxxxx xxxxx,xxxxxxxxxx Multiple Specialties Allowed - Separate by comma
xxxxxx,xxxxxxxxx xxxxx,xxxxxxxxxx Multiple Specialties Allowed - Separate by comma
MM/DD/YYYY
XXXXXXXXX (9 Digits - No Dashes)
M/F (1 Character) M = Male
F = Female
XXXXXXXXXX (10 Digits)
XXXXXXXX (8 Digits)
Y/N Y = Indicates Primary Practice location for provider.
N = Indicates not the Primary Practice location for the provider.
Y/N/NA Y = Indicates Accepting New Patients at this service location.
N = Indicates not Accepting New Patients at this service location.
NA = Not Applicable for service location or provider type
Y/N Y = Indicates Provider is performing as a Primary Care Physician (PCP)
at this service location.
N = Indicates Provider is not performing as a Primary Care Physician
(PCP) at this service location.
Duplicate lines for multiple practice locations
XXXXXXXXXX (10 Digits) Duplicate lines for multiple practice locations
Duplicate lines for multiple practice locations
Duplicate lines for multiple practice locations
XX (2 characters) Duplicate lines for multiple practice locations
XXXXX (5 Digits) Duplicate lines for multiple practice locations
XXXXXXXXXX (10 Digits - No Special Charachters) Duplicate lines for multiple practice locations
XXXXXXXXXX (10 Digits - No Special Characters) Duplicate lines for multiple practice locations
Service Location URL, Main Website URL or Service Duplicate lines for multiple practice locations
Location Contact Email
Duplicate lines for multiple practice locations
Y/N Duplicate lines for multiple practice locations
RT/SAF/RPM/mHealth RT = Real-Time
SAF = Store-and-Forward
RPM = Remote Patient Monitoring
mHealth = Mobile Health
*Duplicate lines for multiple practice locations
xxxxxx,xxxxxxxxx xxxxx,xxxxxxxxxx Multiple Specialties Allowed - Separate by comma
XXXXXXXXXX (10 Digits) Duplicate lines for multiple practice locations
Duplicate lines for multiple practice locations
Duplicate lines for multiple practice locations
XX (2 characters) Duplicate lines for multiple practice locations
XXXXX (5 Digits) Duplicate lines for multiple practice locations
XXXXXXXXXX (10 Digits - No Special Charachters) Duplicate lines for multiple practice locations
XXXXXXXXXX (10 Digits - No Special Characters) Duplicate lines for multiple practice locations
Y/N Y = Indicates Mailing address is the same as billing address
N = Indicates Mailing address is different than billing address
Duplicate lines for multiple practice locations
Duplicate lines for multiple practice locations
XX (2 characters) Duplicate lines for multiple practice locations
XXXXX (5 Digits) Duplicate lines for multiple practice locations
XXXXXXXXXX (10 Digits - No Special Charachters) Duplicate lines for multiple practice locations
XXXXXXXXXX (10 Digits - No Special Characters) Duplicate lines for multiple practice locations
Notes
TermTin = When TermTin is selected all provider will be terminated from the TIN and active service, mailing
and billing addresses active under this TIN.
*Claims received for provider under this TIN with Dates of Service after Change Effective date will reject or
process as out of network.
TermLocation = Provider will only be terminated from Service, Billing and / or Mailing address listed on the
line.
*If this is the only service location active for the provider under this TIN this will terminate provider from the
TIN. Claims received for provider under this TIN with Dates of Service after Change Effective date will reject or
process as out of network.
Attest = Select Attest when submitting roster for attestation and there are no provider changes needed.
Date change should take effect
*Past effective dates entered will be honored when a Group Declaration is on file and provider within
credentialing dates
Legal Business Name
Federal Tax ID Number (aka EIN)
Example: MD, DO, PA, APRN, etc..
NPPES or Board Specialty
Specialty being performed at this service location
Date of Birth
Social Security Number
National Provider Identifier Type 1
Council for Affordable Quality Healthcare
Typically the DBA or the name you would want published in the directory for patients to find the practice
National Provider Identifier Type 2 that is used in HCFA box 32a
At this time we require this on all rosters to comply with the No Surprises Act Mandate
Text entered here is up to the provider's discretion.
National Provider Identifier Type 2 that is used in HCFA box 33a
*If left blank Service Location NPI will be used
If left blank Service Location address will be used
If left blank Service Location City will be used
If left blank Service Location State will be used
If left blank Service Location Zip will be used
If left blank Service Location Phone will be used
If left blank Service Location Fax will be used
If Y is selected Mailing address can be left blank
If left blank Service Location address will be used
If left blank Service Location City will be used
If left blank Service Location State will be used
If left blank Service Location Zip will be used
If left blank Service Location Phone will be used
If left blank Service Location Fax will be used
REQUIREMENTS
O = Optional
R = REQUIRED
C = CONDITIONAL; REQUIRED IF APPLICABLE
R
R
R
C = Required for ProviderType: Facility or Supplier
C = Required for ProviderType: Practitioner
O
C = Required for ProviderType: Practitioner
C = Required for ProviderType: Practitioner
C = Required for Status: Add, Update, Attest
C = Required for:
ProviderType: Practitioner
Status: Add, Update, Attest
C = Required for ProviderType: Practitioner
C = Required for ProviderType: Practitioner
C = Required for ProviderType: Practitioner
R
O
C = Required for:
ProviderType: Practitioner
Status: Add, Update, Attest
C = Required for:
ProviderType: Practitioner
Status: Add, Update, Attest
C = Required for:
ProviderType: Practitioner
Status: Add, Update, Attest
C = Required for Status: Add, Update, TermLocation, Attest
C = Required for Status: Add, Update, TermLocation, Attest
C = Required for Status: Add, Update, TermLocation, Attest
C = Required for Status: Add, Update, TermLocation, Attest
C = Required for Status: Add, Update, TermLocation, Attest
C = Required for Status: Add, Update, TermLocation, Attest
C = Required for Status: Add, Update, TermLocation, Attest
C = Required for Status: Add, Update, TermLocation, Attest
R
C = Required for Status: Add, Update, Attest
R
C = Required if Offers Telehealth Services = Y
C = Required if OffersTelehealthServices = Y
O
O
O
O
O
O
O
O
O
O
O
O
O
O
Frequently Asked Questions
How do I submit completed rosters?
Please email completed Rosters to our Provider Relations Department at ProviderRelations@[Link]
How do I receive an update on roster loading?
Our Provider Relations Department will respond to the roster request email once this roster has been loaded into o
How do I enter information for a provider who works at multiple practices?
Please add duplicate lines for a provider with multiple practice addresses to ensure each address is captured in the
What if a provider does not have a CAQH Profile/CAQH ID Number?
If a provider does not have a CAQH ID, we request the provider's Date of Birth (DOB) and Social Security Number (SS
tab.
What if a provider is billed under multiple TINs?
Please ensure each NPI, practice location and TIN combination are represented on the roster.
What if there are multiple providers practicing at the same location but with different TINS?
These providers should each be listed on a separate row with the appropriate TIN for the NPI and practice address.
What if our billing address is different from our mailing address?
Please include both in the appropriate fields on this roster
What specialty is displayed on the provider directory?
The specialty displayed in the provider directory is based on the provider's specialty listed in NPPES. ProviDRs Care u
specialty listings and displays. ProviDRs Care maps the specialties from NPPES to consumer-friendly specialties that
instance, instead of Otolaryngology, we use Ear, Nose and Throat.'