AP_CLM_RX

Description: |
This table contains information from pharmacy claims. Each record represents one pharmacy claim in the managed care system's AP Claims module.

Primary Key

Column Name | Ordinal Position |
--- | --- | ---
CLAIM_ID | 1 |

Column Information

| Name | Type | Discontinued? |
--- | --- | --- | --- | ---
1 | CLAIM_ID | NUMERIC | No |
The unique identifier for the claim info record
2 | RX_BATCH_NUM | VARCHAR | No |
National Council for Prescription Drug Programs (NCPDP) file batch number
3 | RX_SUBMISSION_NUM | INTEGER | No |
NCPDP file submission number.
4 | RECORD_STATUS_EXT_CODE_LST_ID | NUMERIC | No |
Identifies the status of the pharmacy claim (paid, reversed, canceled, etc.). The record status code can be retrieved by joining this column to the EXT_CODE_LST_ID column in table FCL_EXTRNL_CDE_LST.
5 | RECORD_STATUS_EXT_CODE_LST_ID_EXT_CODE_LST_NAME | VARCHAR | No |
The name of the list value.
6 | REJECT_OVRIDE_EXT_CODE_LST_ID | NUMERIC | No |
Indicates reason for paying a pharmacy claim when override is used. The reject override code can be retrieved by joining this column to the EXT_CODE_LST_ID column in table FCL_EXTRNL_CDE_LST.
7 | REJECT_OVRIDE_EXT_CODE_LST_ID_EXT_CODE_LST_NAME | VARCHAR | No |
The name of the list value.
8 | PHARMACY_ID | NUMERIC | No |
Pharmacy associated to the claim.
9 | PHARMACY_ID_PHARMACY_NAME | VARCHAR | No |
The name of the pharmacy.
10 | PRESC_PROV_ID_PROV_NAME | VARCHAR | No |
The name of the service provider. This item may be hidden in a public view of the CLARITY_SER table.
11 | PRESC_PROV_TAXONOMY | VARCHAR | No |
Stores the prescribing provider's taxonomy code for pharmacy claims.
12 | TTL_INGRED_COST_PAID | NUMERIC | No |
Drug ingredient cost paid.
13 | TTL_DISPENSING_FEE_PAID | NUMERIC | No |
Dispensing fee paid.
14 | TTL_REG_TAX_AMT_PAID | NUMERIC | No |
Flat sales tax amount paid.
15 | TTL_PCT_TAX_AMT_PAID | NUMERIC | No |
Percentage tax amount paid.
16 | TTL_INCENTIVE_AMT_PAID | NUMERIC | No |
Incentive amount paid.
17 | TTL_PROF_SVC_FEE_PAID | NUMERIC | No |
Professional service fee paid.
18 | OTHER_AMT_RECOGNIZED | NUMERIC | No |
Total amount recognized by the processor of any payment from another source.
19 | ALTERNATE_CLM_IDENT | VARCHAR | No |
Alternate Claim ID
20 | REF_CLAIM_IDENT | VARCHAR | No |
Reference claim ID for the original claim
21 | WORKFLOW_C_NAME | VARCHAR | No |
Claim workflow type (AP claim, paid claim, estimate claim, etc.)
May contain organization-specific values: Yes
Category Entries:
AP claims
Reprice claims
Export only
Shadow claims
Externally paid claims
Externally paid claims with bucket update
Pre-adjudicated external claims
Estimate claims
Adjudicated external claims
22 | COVERAGE_ID | NUMERIC | No |
Coverage used to pay the claim
23 | PAYER_SEQ_NUMBER_C_NAME | VARCHAR | No |
Sequence number of the payer of the claim.
May contain organization-specific values: No
Category Entries:
Primary
Secondary
Tertiary
Quaternary
Quinary
Senary
Septenary
Octonary
Nonary
Denary
Undenary
24 | OWN_BUSINESS_SEGMENT_POS_ID_LOC_NAME | VARCHAR | No |
The name of the revenue location.
25 | CLM_SERV_AREA_ID_LOC_NAME | VARCHAR | No |
The name of the revenue location.
26 | CLM_STATUS_C_NAME | VARCHAR | No |
Claim status
May contain organization-specific values: No
Category Entries:
New
Pending
Denied
Clean
Void
27 | STATUS_SET_DATE | DATETIME | No |
Date when claim status was updated
28 | RECEIVED_DATE | DATETIME | No |
The date the claim was received
29 | ADJUD_DTTM | DATETIME (Local) | No |
Adjudication date and time
30 | SERVICE_START_DATE | DATETIME | No |
Service start date for the claim
31 | SERVICE_END_DATE | DATETIME | No |
Service end date for the claim
32 | TTL_DEDUCTIBLE | NUMERIC | No |
Total deductible
33 | TTL_COPAY | NUMERIC | No |
Total copay
34 | TTL_COINS | NUMERIC | No |
Total coinsurance
35 | TTL_PAT_AMT | NUMERIC | No |
Total patient amount
36 | TTL_PRIM_INS_AMT | NUMERIC | No |
Total prior insurance amount
37 | TTL_BILLED | NUMERIC | No |
Total billed amount
38 | TTL_ALLOWED_AMT | NUMERIC | No |
Total allowed amount
39 | TTL_NET_PAYABLE | NUMERIC | No |
Total net payable
40 | ORIG_OF_REV_CLAIM_ID | NUMERIC | No |
If this claim is a reversal claim, this column contains the ID of the claim reversed by this claim.
41 | ADJUST_BY_CLAIM_ID | NUMERIC | No |
If this claim has been adjusted, this column contains the ID of the claim which adjusts this claim.
42 | ORIG_OF_ADJUST_CLAIM_ID | NUMERIC | No |
If this claim adjusts another claim, this column contains the ID of the claim adjusted by this claim.
43 | TTL_PRIM_PAT_DEDUCTIBLE | NUMERIC | No |
Total prior patient deductible
44 | TTL_PRIM_PAT_COPAY | NUMERIC | No |
Total prior patient copay
45 | TTL_PRIM_PAT_COINS | NUMERIC | No |
Total prior patient coinsurance
46 | UNBALANCED_AMOUNTS_YN | VARCHAR | No |
Identifies whether the adjustment claim was received with credit/debit information that reflect the adjusted amount as opposed to new claim amounts.
May contain organization-specific values: No
Category Entries:
No
Yes
47 | INVALID_CLM_YN | VARCHAR | No |
If the system determined we cannot trust the claim's data for reporting or clinical purposes, this column will store Y (invalid). Otherwise it will be N (valid) or NULL (has not been evaluated by the system). This column's value can be overridden by AP_CLM_RX.OVERRIDE_INVALID_CLM_YN.
The category values for this column were already listed for column: UNBALANCED_AMOUNTS_YN
48 | OVERRIDE_INVALID_CLM_YN | VARCHAR | No |
Overrides the INVALID_CLM_YN column and determines if we cannot trust the claim's data for reporting or clinical purposes. This column will store Y if overridden to invalid, N if overridden to valid, or NULL if validity has not been overridden and the value in AP_CLM_RX.INVALID_CLM_YN will be used.
The category values for this column were already listed for column: UNBALANCED_AMOUNTS_YN
49 | IS_INVLD_ADJ_SEQ_RX_YN | VARCHAR | No |
Indicates whether a claim is part of an adjustment sequence that is not valid. An adjustment sequence can be invalid for a number of reasons, such as the sequence ending in a cancellation or the sequence having gaps.
The category values for this column were already listed for column: UNBALANCED_AMOUNTS_YN
50 | TOT_NOT_COVERED_AMT | NUMERIC | No |
Total not covered amount
51 | MEDICARE_DRUG_CVG_CODE_C_NAME | VARCHAR | No |
Code to distinguish if a claim was paid under Medicare Part B or Part D.
May contain organization-specific values: No
Category Entries:
None
Medicare Part D
Medicare Part B
52 | REC_OWN_BUSSEG_POS_ID_LOC_NAME | VARCHAR | No |
The name of the revenue location.
53 | CMS_NATURAL_KEY | VARCHAR | No |
The claim natural key for a CMS claim.