AP_CLAIM_PROC_4

Description: |
This table summarizes data for AP Claims service lines, with each service line given one row.
To link this table’s service line information back to a claim header, join this table to AP_CLAIM_PROC_IDS on the TX_ID column. If you need to report on claim service lines specific to Cost Sharing Reduction (CSR), join this table instead to AP_CLAIM_PROC_IDS_CSR on the TX_ID column.

Primary Key

Column Name | Ordinal Position |
--- | --- | ---
TX_ID | 1 |

Column Information

| Name | Type | Discontinued? |
--- | --- | --- | --- | ---
1 | TX_ID | NUMERIC | No |
The unique identifier for the transaction record.
2 | REPRICED_ALLOWED_AMT | NUMERIC | No |
The allowed amount for the procedure that was received from the most recent repricer.
3 | REPRICED_DISALLOWED_AMT | NUMERIC | No |
The disallowed amount for the procedure that was received from the most recent repricer.
4 | UPN_CODE | VARCHAR | No |
UPN (Universal Product Number) code for the procedure on a claim.
5 | UPN_QTY | INTEGER | No |
Quantity of UPN code for the procedure on a claim.
6 | UPN_DESC | VARCHAR | No |
Description of the UPN code for the procedure on a claim.
7 | UPN_QUAL_C_NAME | VARCHAR | No |
Qualifier code of the UPN code for the procedure on a claim.
May contain organization-specific values: No
Category Entries:
EAN/UCC-13
EAN/UCC-8
HIBC (Health Care Industry Bar Code)
Customer Order Number
GTIN-14
UCC-12
8 | UPN_UNIT_C_NAME | VARCHAR | No |
Unit of measurement for UPN code for the procedure on a claim.
May contain organization-specific values: No
Category Entries:
Milliliters
Milligrams
Grams
International Units
Units
9 | PAID_CLM_FILE_NOT_CVD_AMT | NUMERIC | No |
The not covered amount from the claim's source file. This is only populated for externally-paid claims loaded from claims files.
10 | PAID_CLM_FILE_DEDUCT_AMT | NUMERIC | No |
The deductible amount from the claim's source file. This is only populated for externally-paid claims loaded from claims files.
11 | PAID_CLM_FILE_COINS_AMT | NUMERIC | No |
The coinsurance amount from the claim's source file. This is only populated for externally-paid claims loaded from claims files.
12 | PAID_CLM_FILE_COPAY_AMT | NUMERIC | No |
The copay amount from the claim's source file. This is only populated for externally-paid claims loaded from claims files.
13 | PAID_CLM_FILE_INS_AMT | NUMERIC | No |
The insurance amount from the claim's source file. This is only populated for externally-paid claims loaded from claims files.
14 | PAT_ID | VARCHAR | No |
Patient associated with the transaction.
15 | RECORD_STATUS_C_NAME | VARCHAR | No |
This column displays the transaction record status.
May contain organization-specific values: No
Category Entries:
Active
Inactive
Deleted
Inactive and Deleted
Hidden
Inactive and Hidden
Deleted and Hidden
Inactive Deleted and Hidden
16 | QUAL_AMT | NUMERIC | No |
Amount used for computing benefits for limiting patient portion.
17 | QUAL_AMT_FEE_SCHEDULE_MAP_ID | NUMERIC | No |
Fee schedule map used for limiting patient portion.
18 | QUAL_AMT_FEE_SCHEDULE_MAP_ID_FEE_SCHEDULE_MAP_NAME | VARCHAR | No |
The name for the fee schedule map record.
19 | QUAL_AMT_FEE_SCHEDULE_ID | NUMERIC | No |
Fee schedule used for limiting patient portion.
20 | QUAL_AMT_FEE_SCHEDULE_ID_FEE_SCHEDULE_NAME | VARCHAR | No |
The name of each fee schedule.
21 | QUAL_AMT_NETWORK_LEVELS_C_NAME | VARCHAR | No |
Network level used for limiting patient portion.
May contain organization-specific values: Yes
Category Entries:
In Network - Not Leveled
22 | QUAL_AMT_SKIP_YN | VARCHAR | No |
Whether to skip this service for limiting the patient portion.
May contain organization-specific values: No
Category Entries:
No
Yes
23 | QUAL_AMT_NETWORK_ID | VARCHAR | No |
Network ID used for limiting patient portion.
24 | QUAL_AMT_NETWORK_ID_NETWORK_NAME | VARCHAR | No |
The name of the network.
25 | QUAL_AMT_OVERRIDE | NUMERIC | No |
Override for the qualifying amount for computing benefits for limiting patient portion.
26 | INVOICE_EXTERNAL_AMOUNT | NUMERIC | No |
The service line price that is manually entered by an end user based on an invoice or externally calculated amount.
27 | SUB_PEN_ADJ_DATE_TYPE_C | INTEGER | No |
The date type used when calculating timely filing (submission penalty).
28 | OVERRIDE_CONTRACTUAL_VALUE | NUMERIC | No |
The override contractual allowed amount. This is only used in Adjudication review for display and calculations in pricing card.
29 | HIPPS_PROC_CODE | VARCHAR | No |
Service-line HIPPS Code.
30 | HIPPS_CODE_PC_TYPE_C_NAME | VARCHAR | No |
Service-line HIPPS Code Type. This qualifies the HIPPS Code to a Prospective Payment System (PPS).
May contain organization-specific values: No
Category Entries:
Ambulatory Payment Classification
Home Health
CPT
Ambulatory Patient Grouping
MDS RUG Code
Inpatient Rehabilitation Facility
31 | PRICER_MSG_ID | NUMERIC | No |
The most recent Epic Pricer message record that was used to price the service.
32 | PRICER_DISTRIBUTION_AMT | NUMERIC | No |
For HIPPS-based pricing, Epic Pricer will return a claim-level allowed amount. This amount is then distributed to Room & Board service lines, based on the billed amount.
33 | ALWD_AMT_STOP_LOSS_CNCT_DATE | DATETIME | No |
This column stores the contact date associated with the stop loss term record (NSL) that was used in determining the allowed amount of this service line.
34 | ALWD_AMT_ADJ_CMP_CNCT_DATE | DATETIME | No |
The contact date of the component record used to calculate the allowed amount of the service line on the AP Claim.
35 | ALWD_AMT_TIERED_CMP_INDEX_ID | VARCHAR | No |
The CMP & CMG Index (CMI) record of the tiered component used to calculate the allowed amount of the service line on the AP Claim.
36 | ALWD_AMT_TIERED_CMP_INDEX_ID_COMPONENT_INDEX_NAME | VARCHAR | No |
The name of the component index record
37 | ALWD_AMT_TIERED_PX_LN | INTEGER | No |
The line of the matched tiered procedure used to calculate the allowed amount of the service line on the AP Claim.
38 | SUB_PEN_ADJ_PCT_USED | NUMERIC | No |
The reimbursement percentage used to calculate timely filing (submission penalty).
39 | SUB_PEN_ADJ_CNTRCT_OR_PRFL | VARCHAR | No |
Whether vendor contracts ("Contract") or the Tapestry Profile ("Profile") was used to calculate timely filing (submission penalty).
40 | SUB_PEN_ADJ_LAG_DAYS | INTEGER | No |
The difference in days between date received and date serviced for calculating timely filing (submission penalty).
41 | SUB_PEN_ADJ_DISCNT_AMT | NUMERIC | No |
The discounted amount used in calculating timely filing (submission penalty).
42 | SUB_PEN_ADJ_RULE_ID | VARCHAR | No |
The rule ID used if timely filing (submission penalty) setting was used and a rule was matched.
43 | SUB_PEN_ADJ_RULE_ID_RULE_NAME | VARCHAR | No |
The name of the rule.
44 | SUB_PEN_ADJ_TMLY_FILE_YN | VARCHAR | No |
Set to "Y" if timely filing (submission penalty) setting was used but no rule matched. Otherwise, set to "N".
45 | ALWD_AMT_ADJ_CMG_LN | INTEGER | No |
The line of the component group used to calculate the allowed amount of the service line on the AP Claim.
46 | ADDL_ADJ_AMT | NUMERIC | No |
Stores the total additional adjustments that apply to the allowed amount on a service.
47 | ORIGINAL_DOWNCODED_PROC_ID_PROC_NAME | VARCHAR | No |
The name of each procedure.
48 | ORIGINAL_DOWNCODED_QUAL_AMT | NUMERIC | No |
Qualifying payment amount for the original code before it went through EDC downcoding.
49 | AUTH_REQ_YN | VARCHAR | No |
Whether a service required authorization when it was last adjudicated.
The category values for this column were already listed for column: QUAL_AMT_SKIP_YN
50 | SUGGESTED_AUTH_FOUND_YN | VARCHAR | No |
Whether a service found a suggested authorization when it was last adjudicated.
The category values for this column were already listed for column: QUAL_AMT_SKIP_YN
51 | IS_CONTRACT_CAPITATED_YN | VARCHAR | No |
Whether the contract line matched to this service during adjudication has a service type of capitated.
The category values for this column were already listed for column: QUAL_AMT_SKIP_YN
52 | COMPUTED_PRIOR_INS_AMT | NUMERIC | No |
Prior insurance amount computed based on the claim-level prior insurance amount and allocated to this service.
53 | COMPUTED_PRIOR_PAT_PORTION | NUMERIC | No |
Prior patient portion computed based on the claim-level prior patient portion and allocated to this service.
54 | ORIG_CD_WORKFLOW_C_NAME | VARCHAR | No |
Workflow that changed the original code.
May contain organization-specific values: No
Category Entries:
EDC Analyzer
Epic Pricer
Generic Code Editor
55 | PAID_CLM_FILE_WITHHOLD_AMT | NUMERIC | No |
The withholding amount from the file for an externally paid claim.
56 | PAID_CLM_FILE_COB_AMT | NUMERIC | No |
The COB amount from the file for an externally paid claim.
57 | PAID_CLM_FILE_ADJ_AMT | NUMERIC | No |
The adjustment amount from the file for an externally paid claim.
58 | PAID_CLM_FILE_VEN_PENALTY_AMT | NUMERIC | No |
The vendor penalty amount from the file for an externally paid claim.
59 | PAID_CLM_FILE_DISCOUNT_AMT | NUMERIC | No |
The discount from the file for an externally paid claim.
60 | PAID_CLM_FILE_HRA_AMT | NUMERIC | No |
The HRA amount from the file for an externally paid claim.
61 | SECONDARY_NOT_COVERED_AMT | NUMERIC | No |
Patient responsibility for not-covered amounts on secondary claims.
62 | SECONDARY_DEDUCTIBLE | NUMERIC | No |
Deductible amount for secondary claims.
63 | SECONDARY_COINSURANCE | NUMERIC | No |
Coinsurance amount for secondary claims.
64 | SECONDARY_COPAY | NUMERIC | No |
Copay amount for secondary claims.
65 | SECONDARY_EXCEED_BENEFITS_AMT | NUMERIC | No |
Exceeded benefits amount for secondary claims.
66 | SECONDARY_DISALLOWED_AMT | NUMERIC | No |
Disallowed amount for secondary claims.
67 | BEN_TEMPLT_ID | NUMERIC | No |
The unique identifier for the benefits template used to adjudicate the procedure line.
68 | BEN_TEMPLT_ID_TEMPLATE_NAME | VARCHAR | No |
The name of the benefits template record.
69 | BENEFITS_DEFINITION_PROFILE_ID | NUMERIC | No |
The unique identifier for the benefit definitions used to adjudicate the procedure line.
70 | BENEFITS_DEFINITION_PROFILE_ID_PROFILE_NAME | VARCHAR | No |
The name of the configuration profile record.
71 | BENEFIT_GROUP_COMPON_INDEX_ID | VARCHAR | No |
The benefit grouping component/group that the procedure line matched to during patient payment adjudication.
72 | BENEFIT_GROUP_COMPON_INDEX_ID_COMPONENT_INDEX_NAME | VARCHAR | No |
The name of the component index record
73 | BENEFIT_GROUP_COMPON_LINE | INTEGER | No |
The benefit grouping component group line that the procedure line matched to during patient payment adjudication.
74 | SERVICE_COMPON_INDEX_ID | VARCHAR | No |
The service component/group that the procedure line matched to during patient payment adjudication.
75 | SERVICE_COMPON_INDEX_ID_COMPONENT_INDEX_NAME | VARCHAR | No |
The name of the component index record
76 | SERVICE_GROUP_COMPON_LINE | INTEGER | No |
The service component group line that the procedure line matched to during patient payment adjudication.
77 | ALTERNATE_NETWORK_RULE_ID | VARCHAR | No |
The ID of the alternate network criteria rule that the procedure line matched to during patient payment adjudication.
78 | ALTERNATE_NETWORK_RULE_ID_RULE_NAME | VARCHAR | No |
The name of the rule.
79 | BENEFIT_GROUP_CMP_CNCT_DT_REAL | FLOAT | No |
The date real contact of the benefit grouping component that the procedure line matched to during patient payment adjudication.
80 | SERVICE_COMPON_CONTACT_DT_REAL | FLOAT | No |
The date real contact of the service component that the procedure line matched to during patient payment adjudication.
81 | BENEFIT_GROUP_BEN_VAR_ID | NUMERIC | No |
The ID of the benefit grouping definition that the procedure line matched to during patient payment adjudication.
82 | BENEFIT_GROUP_BEN_VAR_ID_BEN_VAR_NAME | VARCHAR | No |
The name of the benefit variable.
83 | SERVICE_BEN_VAR_ID | NUMERIC | No |
The ID of the service definition that the procedure line matched to during patient payment adjudication.
84 | SERVICE_BEN_VAR_ID_BEN_VAR_NAME | VARCHAR | No |
The name of the benefit variable.
85 | BENEFIT_TIER_RULE_ID | VARCHAR | No |
The ID of the benefits tier rule record the service matches to.
86 | BENEFIT_TIER_RULE_ID_RULE_NAME | VARCHAR | No |
The name of the rule.
87 | BEN_GRP_DEF_OVR_BEN_VAR_ID | NUMERIC | No |
Stores the ID of the overridden benefit grouping definition to use for the service line in benefits calculations.
88 | BEN_GRP_DEF_OVR_BEN_VAR_ID_BEN_VAR_NAME | VARCHAR | No |
The name of the benefit variable.
89 | SVC_DEF_OVR_BEN_VAR_ID | NUMERIC | No |
Stores the ID of the override service definition to use for the service line in benefits calculations.
90 | SVC_DEF_OVR_BEN_VAR_ID_BEN_VAR_NAME | VARCHAR | No |
The name of the benefit variable.
91 | BEN_GRP_OVR_RSN_C_NAME | VARCHAR | No |
The override reason for the benefit grouping keyword if it is overridden.
May contain organization-specific values: Yes
No Entries Defined
92 | COPAY_WAIVE_BEN_VAR_ID | NUMERIC | No |
The ID of the copay waive group used when adjudicating this service
93 | COPAY_WAIVE_BEN_VAR_ID_BEN_VAR_NAME | VARCHAR | No |
The name of the benefit variable.
94 | COMPUTED_NETWORK_LEVEL_C_NAME | VARCHAR | No |
Contains the network level of a service, as computed during adjudication.
May contain organization-specific values: Yes
Category Entries:
In Network
Out of Network
N/A
95 | ADJUD_NETWORK_ID | VARCHAR | No |
The provider network record matched to the service during adjudication.
96 | ADJUD_NETWORK_ID_NETWORK_NAME | VARCHAR | No |
The name of the network.
97 | BEN_EXCEPTION_CLASSIFIER_ID | VARCHAR | No |
The ID of the benefit referral classifier that qualified this service as a benefit exception.
98 | BEN_EXCEPTION_CLASSIFIER_ID_CLASSIFIER_NAME | VARCHAR | No |
The title of the classifier record.
99 | WAIVE_AUTH_REQ_YN | VARCHAR | No |
If the service line's unified authorization requirement is waived.
The category values for this column were already listed for column: QUAL_AMT_SKIP_YN
100 | WAIVE_AUTH_RSN_C_NAME | VARCHAR | No |
The reason this service line's unified authorization requirement is waived.
May contain organization-specific values: Yes
No Entries Defined