What is the difference between PRS 1.0 and PRS 2.0?
As the about section mentions; PRS is a repository of demographic information for hospital providers in the Centers for Medicare & Medicaid Services (CMS) System. PRS 2.0 will be the new version of PRS (which is now being referred to as PRS 1.0).
PRS 1.0 is the system that is currently used, PRS 2.0 is also available to all users.
Note that PRS 1.0 is still available for some time, post PRS 2.0 release.
What will be new in PRS 2.0?
- Improved Search
- Updated User Interface
- Customizable columns on search results and export
- View and compare provider details from PRS 1.0 and iQIES (PECOS coming soon)
- Daily data refresh
Why a PRS 2.0?
Major improvements are coming to the Program Resource System (PRS), and it’s thanks to feedback from its users. This updated system will bring new innovations, such as more reliable data, better reporting customization, and an improved user experience and accessibility.
PRS will continue to serve as the source to validate provider information for both CMS and its contractors and affiliated organizations, and the original system will continue to be operational while 2.0 rolls out. With releases planned in stages, the initial 2.0 release will offer view-only Health Service Provider information along with an improved user experience.
What is in PRS 2.0
- View only Health Service Provider category
- Provider Details
- Contact Information
- Customizable columns on the search results
- View and compare provider details from PRS 1.0 and iQIES (PECOS coming soon)
- Daily data refresh
What is in PRS 1.0
- HSP Details
- Contact Address & Phone
- Cross Reference
- HSP FI/Carrier/MAC
- Physician Acknowledgement Monitoring
- QIO Defined Field
- Unit Bed
- Vendor Contract
- Hospital OQR Contact
- Waiver
- Inpatient Discharges
- Validation Summary
- Hospital OQR Validation Summary
- Beneficiary
- Medicare Advantage Plan
- Physician
- Physician Group
- Physician Member Category
- FI/Carrier/MAC category
- Vendor
- QIO category
- QIO Defined Titles
- Code Table
- National Drug Code
- Prescription Drug Plan
- CDAC Tracking- Abstractions
- CDAC Tracking- Export
- CDAC Tracking- Master Sample
- CDAC Tracking- Medical Record
Resources:
Beneficiary
Beneficiary is a category in PRS 2.0 where users can search and view for beneficiary information. The users can view the beneficiary details, coverage information, cross reference information and entitlement reason when they access the beneficiary module
The Beneficiary module links to BIC (beneficiary information on cloud) via their APIs. The beneficiary data is available real time in PRS 2.0
Users can search for a beneficiary using MBI, HCIN, SSN or RRB via basic search. You can also search for the beneficiary using the advanced search by a combination of the below fields
First name, last name, state
First name, last name, birth date
First name, last name, zip code
The first name can be partial match.
Beneficiary details
Address 1 - 6
The mailing address where the beneficiary or the beneficiary's representative payee can be contacted. There are six address lines.
Birth Date
The birth date of the beneficiary.
City
The name of the city for the listed address.
Claim Account Number (CAN)
Number that identifies the primary Medicare beneficiary under the Social Security Administration (SSA) or Railroad Retirement Board (RRB) programs. This number along with the Beneficiary Identification Code (BIC) uniquely identifies a Medicare beneficiary.
County Number
The code for the county of residence for the beneficiary.
Death Date
The date of the beneficiary's death.
Extension
The telephone extension number for the beneficiary.
First Name
The first name of the Medicare Beneficiary.
Gender
The sex of the beneficiary.
Key | Description |
0 | Unknown |
1 | Male |
2 | Female |
Health Insurance Claim Number (HICN)
The Health Insurance Claim Number (HICN) is a Medicare beneficiary's identification number, used for paying claims and for determining eligibility for services across multiple entities (e.g. Social Security Administration (SSA), Railroad Retirement Board (RRB), States, Medicare providers and health plans, etc.)
Last Name
The last name of the Medicare beneficiary including any following titles.
Middle Name
The first position (letter) of a beneficiary's middle name.
Medicare Beneficiary Identifier (MBI)
Under the Social Security Number Removal Initiative (SSNRI), SSNs are being removed from all Medicare cards. A new Medicare Beneficiary Identifier (MBI), which uniquely identifies a Medicare beneficiary, is replacing the SSN-based Health Insurance Claim Number (HICN) on new Medicare cards being issued by CMS. The MBI is a randomly generated identifier that does not include a social security number or any personally identifiable information (PII). It is visibly different from the HICN and Railroad Retirement Board (RRB) numbers. The MBI is 11-characters in length and made up only of numbers and uppercase letters (no special characters), in a specified format.
Primary Payer Code
A code that indicates which other federal programs or insurance sources are required by law to pay their share of a Medicare beneficiary's medical claims before CMS funds can be used. These insurance sources are called 'primary payers'. When a Beneficiary has a primary payer, CMS becomes the 'secondary payer' of Medicare claims.
Note: Values C, M, N, Y, Z and BLANK indicate Medicare is primary payer
Key | Description |
| Medicare is Primary Payer |
1 | Potential Workers' Compensation |
2 | Potential Black Lung |
3 | Potential Department of Veterans Affairs |
A | Working aged Bene/spouse with employer group health plan (EGHP) |
B | End Stage Renal Disease (ESRD) Beneficiary in the 18 month coordination period with an employer group health plan |
C | Conditional payment by Medicare; future reimbursement expected |
D | Automobile no-fault or any liability |
E | Worker's compensation |
F | Public Health Service or other federal agency (other than Department of Veterans Affairs) |
G | Working disabled beneficiary (under age 65 with LGHP) |
H | Black Lung |
I | Department Of Veterans Affairs |
J | Any liability insurance |
M | Override code: EGHP services involved |
N | Override code: Non-EGHP Services involved |
X | MSP cost avoided override code |
Y | Other secondary payer investigation shows Medicare as primary payer |
Z | Medicare is primary payer |
Race
The race of a beneficiary.
Key | Description |
| N/A |
0 | Unknown |
1 | White |
2 | Black |
3 | Other |
4 | Asian |
5 | Hispanic |
6 | North American Native |
Railroad Retirement Board (RRB)
Identifier assigned by the Railroad Retirement Board (RRB) to the Railroad employee or retired Railroad Medicare beneficiary.
Repayee Indicator
The repayee flag that identifies the address as a representative payee of the beneficiary for cash benefit purposes. Indicates if a person other than the beneficiary is receiving the checks.
Social Security Number (SSN)
A nine-digit number issued to U.S. citizens, permanent residents, and temporary (working) residents under section 205(c)(2) of the Social Security Act, codified as 42 U.S.C. § 405(c)(2). The number is issued to an individual by the Social Security Administration, an independent agency of the United States government.
State
The two-character state abbreviation of residence for the beneficiary.
Telephone
The telephone number for the beneficiary.
ZIP Code
The ZIP Code for the listed address.
Coverage
Coverage Enrollment Date
The date the coverage became effective for this beneficiary.
Coverage Enrollment Reason
The reason for a beneficiary's enrollment to Medicare benefits.
Key | Description |
| Not applicable. Example: Part A data is generated at age 64 years, 8 months |
A | Attainment of age 65 |
B | Equitable relief |
D | Disability (under age 65 entitlement) |
G | General Enrollment Period (GEP) |
H | Entitled based on health hazard |
I | Initial Enrollment Period (IEP) |
J | Medicare Qualified Government Employee (MQGE) entitlement |
K | Renal disease was the reason for entitlement prior to age 65 or the 25th month of disability |
L | Late filing |
M | Termination based on renal entitlement, but disability based entitlement continues |
N | Age 65 and uninsured |
P | Potentially insured beneficiary is enrolled for Medicare coverage only |
Q | Quarters of coverage requirements are involved |
R | Residency requirements are involved |
T | Disabled working individual |
U | Unknown |
The current reason for a beneficiary's enrollment to Part B Medicare benefits.
Key | Description |
| Not applicable |
B | Equitable relief |
C | Good cause |
D | Deemed date of birth |
F | Working aged |
G | General Enrollment Period (GEP) |
H | Entitled based on health hazard |
I | Initial Enrollment Period (IEP) |
K | Renal disease was a reason for entitlement prior to age 65 or prior to the 25th month of disability |
M | Renal entitlement terminated, but disability based entitlement continues |
R | Residency requirements are involved |
S | State buy-in |
T | Disabled working individual.* (*future: current CMS program edits do not create this code) |
U | Unknown |
Coverage Termination Date
The date on which the beneficiary is no longer entitled to Medicare benefits.
Coverage Type
The type of coverage provided for the beneficiary.
Key | Description |
Disability | Disability insurance benefits |
ESRD | End stage renal desease |
HSPC | Hospice |
MA | Medicare Advantage Organization |
MCP A | Medicaid pays the Part A premium |
MCP B | Medicaid pays the Part B premium |
PTA | Part A |
PTB | Part B |
MA Contract Number
The identification number of the Medicare Advantage Organization issued by CMS.
MA Payment Option
Indicates who will process the Medicare Advantage claims.
Key | Description |
0 | Not a Member |
1 | CMS to Process all Provider Claims (Non-lock-in beneficiary) |
2 | MA to Process In-plan Part A and In-area Part B Claims (Non-lock-in beneficiary) |
4 | Chronic Care Disease Management Organizations - FFS Plan |
A | CMS to Process Provider Claims (Lock-in beneficiary) |
B | MA to Process In-plan Part A and In-area Part B Claims (Lock-in beneficiary) |
C | MA to Process All Claims (Part A and Part B) |
Cross Reference
Medicare Beneficiary Identifier (MBI)
Under the Social Security Number Removal Initiative (SSNRI), SSNs are being removed from all Medicare cards. A new Medicare Beneficiary Identifier (MBI), which uniquely identifies a Medicare beneficiary, is replacing the SSN-based Health Insurance Claim Number (HICN) on new Medicare cards being issued by CMS. The MBI is a randomly generated identifier that does not include a social security number or any personally identifiable information (PII). It is visibly different from the HICN and Railroad Retirement Board (RRB) numbers. The MBI is 11-characters in length and made up only of numbers and uppercase letters (no special characters), in a specified format.
Social Security Number (SSN)
A nine-digit number issued to U.S. citizens, permanent residents, and temporary (working) residents under section 205(c)(2) of the Social Security Act, codified as 42 U.S.C. § 405(c)(2). The number is issued to an individual by the Social Security Administration, an independent agency of the United States government.
Health Insurance Claim Number (HICN)
The Health Insurance Claim Number (HICN) is a Medicare beneficiary's identification number, used for paying claims and for determining eligibility for services across multiple entities (e.g. Social Security Administration (SSA), Railroad Retirement Board (RRB), States, Medicare providers and health plans, etc.)
Previous HICN
The previous HICN field will identify prior claim number. If the beneficiary has not had a change in claim numbers this section will not display any information.
Entitlement Reason
Reason
The reason for a beneficiary's entitlement to Medicare benefits.
Key | Description |
0 | Beneficiary insured due to age (OASI) |
1 | Beneficiary insured due to disability |
2 | Beneficiary insured due to End Stage Renal Disease (ESRD) |
3 | Beneficiary insured due to disability and current ESRD |
Reason Change Date
Date that the reason for entitlement was changed for a beneficiary. This is not the effective date of entitlement.
Medicare Status
The reason for a beneficiary's entitlement to Medicare benefits.
Key | Description |
10 | Aged without ESRD |
11 | Aged with ESRD |
20 | Disabled without ESRD |
21 | Disabled with ESRD |
31 | End stage renal disease (ESRD) only |
Status Change Date
The date on which the beneficiary's Medicare status code changed.
After 07/25/2023 user will be able to add/edit the below sections in the HSP module in PRS 2.0
- HSP Details (including add/edit new CCNs/Providers)
- Physical Location
- Cross Reference
- Unit bed
Users can add a new provider from the HSP module search page by clicking on the New provider button
When the users click on New provider they can add a new provider by updating the below screen
Users can also search for a providers based on the data source
On the HSP details page, users can toggle between community edits and iQIES using the data source dropdown to compare data between PRS and iQIES
Edit provider information by clicking on the edit button and updating the below information
Users can Add/edit physical location address
Add/edit cross reference information
Add/edit unit bed information
ISG Playbook
APIs
