Provider Network Batch Load Layout

About

• The provider network batch process allows the user to create/update/modify the provider networks within a PBM.
• File Format: Tab-delimited Text File
• File Naming Format : *_PROVIDERNETWORK_*.txt   Example -ACNEPBM_PROVIDERNETWORK_FILE1.txt
• Provider network batch process driven by Record types. Every row will start with a record type and be followed by data. Based on the record type, the system will automatically identify the data and load accordingly. 

Records Types

Provider network records in the batch file will one or more of the following record types

Code	Record Type Description	Mandatory	Additional Info
GN	General data of Provider Network	Yes	This field has general information like Provider network ID, name effective dates, etc. Every provider network record in the batch file starts will this record type. This field is required because the details given in this row will be used to identify the provider network in the system.
PR	Provider	No	The record type is used for giving provider details There can be more than one PR record type within a single provider network record
PG	Provider Group	No	The record type is used for giving Provider Group details There can be more than one PG record type within a single provider network record
PP	Provider Parent	No	The record type is used for giving Provider Parent details There can be more than one PP record type within a single provider network record This is currently not supported. Future enhancement
NB	Network Baseline Pricing	No	This record type is used to provide base pricing of the network Standard pricing rules  -Ingredient cost edit, dispensing fee edit, Incentive fee edits etc can be provided in this row
NE	Network Exception - Financial Exceptions	No	This record type is used to provide Exception rules for the network

• A single provider network record in the batch file may look like this.
  • Each row starts with a record type
  • The yellow highlight indicates the tab space between each field in the row

• A single batch file can contain multiple provider network records. The record type (GN) is always the start of a Provider Network record. Each and every record layout is explained in detail below.

Action Code

Every Provider Network record in the file starts with the GN (General Details) record type, which contains the Action Code. There are three action codes. Each action code defines the action performed on the Provider Network data.

Action Code	Description	Additional Info
A	Add	Used when creating a new provider network. (If the given provider network id already exists in the system, then no network will be created. This record is skipped by the system) Use this Action code when you want to create a Provider Network through batch, but you will review and activate through UI
U	Update / Append	This action code can be used if you want to update specific data in the existing provider network. For eg., Adding new providers/groups in the network. Use this action code to update existing active provider network record.
M	Modify / Replace	This action code can be used if you want to replace the data of the existing provider network. For eg., Remove all existing Providers/ Provider groups in the network and add new ones. Use this action code to replace the existing active provider network record.

Note

• To perform Update / Modify actions on a Provider Network, there should be an active version of the provider network existing in the system. 
• Action code U/M does not work on the draft provider network in the system. You may see this error if you try to perform the update/ modify action on a provider network if it is in draft status.

  Error Code: VAL_PROVIDER_NETWORK_ID_SHOULD_BE_VALID

• Certain fields are Mandatory/optional based on the Action Code in the GN record.
• As Provider Networks may be frequently updated,
  
  • To make the update process easier (Action Code - U), It is enough to provide ONLY the updates of the Provider Network, along with basic information. Basic informations are the data's is required to identify the provider network in the PBM. Provider Network ID, Provider Network Name, Effective start date, and Effective end date in the GN record are required to perform the update. 
  • For example, Let's say there is an existing active Provider Network in the PBM with 50 providers and 10 provider groups. If you want to add 3 more providers to the Provider Network, then you will have to Provider Network ID, Provider Network Name, Effective start date, Effective end date, and just the three providers that need to be added.

• 
  

• • Similarly, if it is a pricing update in the provider network, you will have to required details in GN record and NB or NE record based on the pricing update.
• It is important to understand the difference between the Update and Modify Action code

Update	Modify
This takes the latest active version of the Provider Network available in the system. Copies all the details from this active version along with the updates provided in the batch file to create a new provider network version	Create a new provider network version by replacing all the data in the Provider network with data provided in the batch file.
Can be used to update Providers / Provider Groups Can you be used to update Network baseline edits (For example, Old Ingredient cost will be replaced with new Ingredient cost from the batch file)	Can be used if you want to replace all provider/provider groups in the network

Layout 

• The record type and the value in each position are important when preparing the provider network batch file. 
• This is a record-based file, so each row should start with a record type.
• Each and every field in a row should be separated by a Tab
• If you are not providing a value. For eg., Let's say you are not providing 'Lesser of Gross Amount Due(GAD), then remember to leave a Tab space for position 12
• There can be ONLY one GN record per provider network in the file.

Record Type - GN

Field Name	Position	Maximum Length Allowed	Value	Mandatory	Description
Record Type	1	2	GN	Yes	GN identifies the record type as General Details
Action Code	2	1	A/U/M	Yes	As explained in the Action Code section
Provider Network ID	3	15		Yes	This position should contain the provider network ID.  Alphanumeric value is allowed. Should NOT contain space or special characters. Example: CVSNETWORK01 When you are creating a NEW provider network, provider Network ID should be unique (It should not be an existing ID in the PBM)  When you are updating/modifying a provider network data, make sure you provide this ID accurately (as available in the system). Because this ID is used to identify the Provider Network in the system.
Provider Network Name	4	60		Yes	This position should contain the Provider Network Name. Examples: CVS Network 01 CVS B24 G20 BW8.8 GW4
Effective Start Date	5	8	Format: YYYYMMDD	Yes	This position should contain the effective start date of the Provider Network Should be less than the Effective End date
Effective End Date	6	8	Format: YYYYMMDD	Yes	This position should contain the effective end date of the Provider Network Should be greater than the Effective start date
Status	7	1	A/D	Yes	A -> denotes status Active. An active Provider network will be created D -> denotes draft. Draft Provider Network will be created
Provider Network Reimbursement ID	8	10		Yes (For action code A & M) No (For action code U)	Provider Network Reimbursement ID
Health Plan Network ID	9	10		Yes (For action code A & M) No (For action code U)	Health Plan Network ID
Payment Group ID	10	6		Yes (For action code A & M) No (For action code U)	This should be an existing Payment group ID in the PBM. (Not the payment group name) The Payment Group should be in active status
Remittance Group ID	11	6		Yes (For action code A & M) No (For action code U)	This should be an existing remittance group ID from the system. (Not the remittance group name) The Remittance group should be in active status
Lesser of Gross Amount Due (GAD)	12		Y/N	No	If not provider, N will be taken as the default value
Lesser of Submitted Ingredient Cost	13		Y/N	No	If not provider, N will be taken as the default value
Lesser of U&C	14		Y/N	No	If not provider, N will be taken as the default value
Any Willing Provider	15		Y/N	No	If not provider, N will be taken as the default value If the value is Y, it means all providers. So it is not required to provide PR (Provider), PG (Provider Group), PP (Provider Parent) for the Provider Network record

Example 1 - All 15 fields are provided with value. Yellow color denotes tab-space

Example 2 - A few fields left blank (Please note tab needs to be provided when you are leaving certain fields blank). Remember to leave a tab even if you are leaving the last field blank

Record Type - PR

• This record type is NOT mandatory within a provider network record.
  • This record type can be skipped if you are creating the Provider Network with Any Willing Provider.
  • This record type can be skipped if you are NOT adding any providers to the network
• There can be more than one PR record type within a single provider network. 
• For example, if you want to add three providers within a network, then the provider network record would look like this

Field Name	Position	Maximum Length Allowed	Value	Mandatory	Description
Record Type	1	2	PR	Yes	PR identifies the record type as Provider Record
Service Provider ID	2	20		Yes	Service Provider ID - This can be NCPDP Provider Identification Number or National Provider Identifier (NPI)
Service Provider ID Qualifier	3	2	01 or 07	Yes	Service Provider ID qualifier to identify the value provided

Service Provider ID and Service Provider Qualifier can be found in the Benefit Manager / Provider Manager / Providers

Record Type - PG

• This record type is NOT mandatory within a provider network record.
  • This record type can be skipped if you are creating the Provider Network with Any Willing Provider.
  • This record type can be skipped if you are NOT adding any provider group to the network
• There can be more than one PG record type within a single provider network. 
• For example, if you want to add three providers and three provider groups within a network, then the provider network record would look like this in the batch file

Field Name	Position	Maximum Length Allowed	Value	Mandatory	Description
Record Type	1	2	PG	Yes	PG identifies the record type as the Provider Group record
Provider Group ID	2	20		Yes	Service Provider ID - This can be NCPDP Provider Identification Number or National Provider Identifier (NPI)

Provider Group ID can be found in the Benefit Manager / Provider Manager / Provider Group

Record Type - PP

Currently, this is not supported.

Record Type - NB

• There can be multiple NB records within a single provider network record. 
• The edit categories cannot repeat in the Network baseline rule within a provider network.  For example, Two NB records cannot have the same category, like 2 ingredient costs or 2 dispensing fee edits. When you create a provider network through UI, only one edit rule can be provided per category. The same is applicable for batch as well.

Field Name	Position	Maximum Length Allowed	Value	Mandatory	Description
Record Type	1	2	NB	Yes	NB identifies the record type as the Network Baseline rules where you can define base pricing like Ingredient Cost, Dispensing Fee, Incentive Fee, Program admin fee, Other services fee and overrides
Edit ID	2	20		Yes	The Edit ID is the system ID for the Edits. It can be found in Benefit Manager / Edit Manager
Edit Name	3	30		No	This is just used in the batch file for readability. The edit name is not used to identify the edit in the system

• Edit ID can be found in Benefit Manager / Edit Manager

• Provider network record with an Ingredient cost and Dispensing fee edits defined in Network baseline rules would look like this

• Example of Invalid data. It is invalid to provide multiple edits of the same category in the Network Baseline rules

Record Type - NE

• The Network Exception (NE) record is used to define the financial exceptions of the Provider Network.
• There could be more than one Network Exception NE record within a provider network record
• Every NE record starts with Criteria ID and is followed by Edits. The Edits category CANNOT repeat within a single NE record. For eg., you cannot provide two ingredient cost edits within a single NE record
• The financial exception rules are added in the order that is provided in the Provider Network record.
• Criteria ID and Edit ID must be valid and should exist in the PBM. The criteria and edit should be in active status

• Refer Benefit Manager / Criteria Manager to get the Criteria ID. (Use the Criteria ID and not the Criteria version ID from the Criteria history screen)

Field Name	Position	Maximum Length Allowed	Value	Mandatory	Description
Record Type	1	2	NE	Yes	NE identifies the record type as the Network Exception rules where you can define Network exception pricing like Ingredient Cost, Dispensing Fee, Incentive Fee, Program admin fee, Other services fee and overrides for specific criteria
Criteria ID	2	20		Yes	Criteria ID has to be given here for the exception rule.  Criteria should be active and the criteria ID should exist within the PBM
Edit ID1	3	20		Yes	The Edit ID is the system ID for the Edits. It can be found in Benefit Manager / Edit Manager
Edit Name1	4	30		Yes	This is just used in the batch file for readability. The edit name is not used to identify the edit in the system
Edit ID2	5	20		No
Edit Name2	6	30		No
....
.....
Edit ID_7		20		No
Edit Name_7		30		No

Example 

For more details on the provider network batch process and error handling, Please refer to this article Provider Network Batch Load

A Sample Provider Network Batch file is attached for reference.