AP_CLAIM_PROC

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. If you care about neither distinguishing CSR-related service lines nor the ordering of service lines on a claim, you can join back to the claim header on this table's CLAIM_ID column.

Primary Key

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

Column Information

| Name | Type | Discontinued? |
--- | --- | --- | --- | ---
1 | TX_ID | NUMERIC | No |
The unique ID of the AP Claim procedure transaction.
2 | PROC_ID_PROC_NAME | VARCHAR | No |
The name of each procedure.
3 | SVC_FROM_DATE | DATETIME | No |
The beginning service date for the procedure on the accounts payable claim record.
4 | SVC_TO_DATE | DATETIME | No |
The ending service date for the procedure on the accounts payable claim record.
5 | MODIFIERS | VARCHAR | No |
A list of modifiers used with the procedure on the accounts payable claim record.
6 | BILLED_AMT | NUMERIC | No |
The amount billed for the procedure on the accounts payable claim record.
7 | ALLOWED_AMT | NUMERIC | No |
The allowed amount calculated for the procedure on the accounts payable claim record.
8 | NET_PAYABLE | NUMERIC | No |
The net payable amount for the procedure on the accounts payable claim record.
9 | POS_TYPE_C_NAME | VARCHAR | No |
The category value associated with the place of service type of the procedure on the accounts payable claim record.
May contain organization-specific values: Yes
Category Entries:
Telehealth - Provided in Patient's Home
Office
Home
Assisted Living Facility
Group Home
Mobile Unit
Temporary Lodging
Walk-in Retail Health Clinic
Place of Employment - Worksite
Off Campus - Outpatient Hospital
Urgent Care Facility
Inpatient Hospital
On Campus - Outpatient Hospital
Emergency Room - Hospital
Ambulatory Surgical Center
Birthing Center
Military Treatment Facility
Outreach Site/Street
Skilled Nursing Facility
Nursing Facility
Custodial Care Facility
Hospice
Adult Living Care Facility
Ambulance - Land
Ambulance - Air or Water
Independent Clinic
Federally Qualified Health Center
Inpatient Psychiatric Facility
Psychiatric Facility - Partial Hospitalization
Community Mental Health Center
Intermediate Care Facility/ Individuals with Intellectual Disabilities
Residential Substance Abuse Treatment Facility
Psychiatric Residential Treatment Center
Non-residential Substance Abuse Treatment Facility
Non-residential Opioid Treatment Facility
Mass Immunization Center
Comprehensive Inpatient Rehabilitation Facility
Comprehensive Outpatient Rehabilitation Facility
End-Stage Renal Disease Treatment Facility
Programs of All-Inclusive Care for the Elderly (PACE) Center
Public Health Clinic
Rural Health Clinic
Independent Laboratory
Other Place of Service
Pharmacy
Telehealth - Provided Other than in Patient's Home
School
Homeless Shelter
Indian Health Service Free-standing Facility
Indian Health Service Provider-based Facility
Tribal 638 Free-standing Facility
Tribal 638 Provider-based Facility
Prison/Correctional Facility
10 | OVERRIDE_ALLD_AMT | NUMERIC | No |
The override allowed amount for the procedure on the accounts payable claim record.
11 | OVERRIDE_REASON_C_NAME | VARCHAR | No |
The category value associated with the reason for the override.
May contain organization-specific values: Yes
12 | TYPE_OF_SERVICE_C_NAME | VARCHAR | No |
The category ID of the type of service associated with the procedure on the accounts payable claim record.
May contain organization-specific values: Yes
Category Entries:
Medical Care
Surgery
Consultation
Diagnostic Radiology
Diagnostic Laboratory
Therapeutic Radiology
Anesthesia
Assistant at Surgery
Other Medical Items or Services
Whole Blood
Used Durable Medical Equipment (DME)
Ambulatory Surgical Center (Facility usage for Surgical Services)
Hospice (Obsolete, Discontinued 1/95)
ESRD Supplies
Monthly Capitation Payment for Dialysis
Kidney Donor
Pneumococcal/Flu Vaccine
Second Opinion on Elective Surgery (Obsolete)
Third Opinion on Elective Surgery (Obsolete)
Diagnostic Medical (Obsolete)
Ancillaries, Hospital and Nursing Home (Obsolete)
Drug Services (Obsolete)
Accommodations, Hospital and Nursing Home (Obsolete)
Dental (Obsolete)
Vision Care and Cataract Lens (Obsolete)
Nuclear Medicine (Obsolete)
Diagnostic X-Ray (Professional) (Obsolete)
Rental of DME
Radiation Therapy (Professional) (Obsolete)
Diagnostic Lab (Professional) (Obsolete)
Diagnostic Medical (Professional) (Obsolete)
DME Purchase (Obsolete)
CRD Equipment (Obsolete)
Pre-Admission Testing (Obsolete)
EPSDT
High Risk Screening Mammography
Low Risk Screening Mammography
Ambulance
Enteral/Parenteral Nutrients/Supplies
Immunosuppressive Drugs
Diabetic Shoes
Hearing Items and Services
Lump Sum Purchase of DME, Prostethics, Orthotics
Vision Items or Services
Surgical Dressings or Other Medical Supplies
Psychological Therapy
Occupational Therapy
Physical Therapy
Medication (Obsolete)
Chiropractic Care
DME Prescription
13 | PRIM_INS_AMOUNT | NUMERIC | No |
For non-primary claims (e.g. secondary), the sum of the insurance amounts paid by previous payors.
14 | PRIM_PAT_PORTION | NUMERIC | No |
For non-primary claims (e.g. secondary), the sum of all patient portion amounts specified by previous payors.
15 | PROC_INSURANCE_AMT | NUMERIC | No |
The calculated insurance amount for the procedure on the accounts payable claim record.
16 | NET_INSURANCE_AMT | NUMERIC | No |
The net insurance amount for this procedure on the accounts payable claim record.
17 | WITHHOLD_METHOD_C_NAME | VARCHAR | No |
The category value representing the method of withholding an amount for this procedure.
May contain organization-specific values: No
Category Entries:
Percentage of Net Insurance
Fixed Amount
Extension
None
Percentage of Allowed Amount
18 | WITHHOLD_RATE | NUMERIC | No |
The rate to be withheld for this procedure.
19 | COMP_WITHHOLDING | NUMERIC | No |
The computed withholding amount for the procedure on the accounts payable claim record.
20 | COMP_ADJUSTMENT | NUMERIC | No |
The computed adjustment amount for the procedure on the accounts payable claim record.
21 | ACTUAL_ADJUSTMENT | NUMERIC | No |
The actual adjustment taken for this procedure on the accounts payable claim record.
22 | ADJUST_REASON_C_NAME | VARCHAR | No |
The category value of the reason for the adjustment to this procedure on the accounts payable claim record.
May contain organization-specific values: Yes
Category Entries:
Procedure is capitated
Coordination of Benefits
Maintenance of Benefits
Allowed exceeds amount patient paid
Pay by DRG
23 | ADJ_BILLED_AMT | NUMERIC | No |
The adjusted billed amount after refund for the procedure on the accounts payable claim record.
24 | ADJ_ALLOWED_AMT | NUMERIC | No |
The adjusted allowed amount after refund for the procedure on the accounts payable claim record.
25 | ADJ_PAT_PORTION | NUMERIC | No |
The adjusted patient portion after refund for the procedure on the accounts payable claim record.
26 | ADJ_INS_AMT | NUMERIC | No |
The adjusted insurance amount after refund for the procedure on the accounts payable claim record.
27 | ADJ_ADJUSTMENT | NUMERIC | No |
The adjusted adjustment amount after refund for the procedure on the accounts payable claim record.
28 | ADJ_NET_INS | NUMERIC | No |
The adjusted net insurance amount after refund for the procedure on the accounts payable claim record.
29 | ADJ_WITHHOLDING | NUMERIC | No |
The adjusted withholding amount after refund for the procedure on the accounts payable claim record.
30 | ADJ_NET_PAYABLE | NUMERIC | No |
The adjusted net payable amount after refund for the procedure on the accounts payable claim record.
31 | PAT_PORTION | NUMERIC | No |
The patient portion for the procedure on the accounts payable claim record.
32 | REVENUE_CODE_ID_PROC_NAME | VARCHAR | No |
The name of each procedure.
33 | QUANTITY | NUMERIC | No |
The quantity (number of units, procedures, etc.) billed on this service line.
34 | REFUND_REVERSAL_ID | NUMERIC | No |
The unique ID of the reversal procedure transaction for refund.
35 | REFUND_ADJT_ID | NUMERIC | No |
The unique ID of the adjustment procedure transaction for refund.
36 | EOB_COMMENT | VARCHAR | No |
The claim code (explanation of benefit code) comment on the procedure.
37 | UC_VALUE | NUMERIC | No |
The usual and customary amount for the procedure.
38 | CONTRACT_ALLOWED | NUMERIC | No |
The contractual allowed amount for the procedure.
39 | OVRD_DISALW_RSN_C_NAME | VARCHAR | No |
The category ID of the reason for overriding the disallowed amount on the procedure.
May contain organization-specific values: Yes
40 | OVRD_DISALW_AMT | NUMERIC | No |
The override disallowed amount for the procedure.
41 | DISALW_AMT | NUMERIC | No |
The disallowed amount for the procedure.
42 | OVRD_NOT_CVD | NUMERIC | No |
The override not covered amount for the procedure.
43 | OVRD_DEDUCTIBLE | NUMERIC | No |
The override deductible amount for the procedure.
44 | OVRD_COINS | NUMERIC | No |
The override coinsurance amount for the procedure.
45 | OVRD_COPAY | NUMERIC | No |
The override copay amount for the procedure.
46 | NON_CVD_AMT | NUMERIC | No |
The non-covered amount for the procedure.
47 | DEDUCTIBLE | NUMERIC | No |
The deductible amount for the procedure.
48 | COPAYMENT | NUMERIC | No |
The copayment amount for the procedure.
49 | COINSURANCE | NUMERIC | No |
The coinsurance amount for the procedure.
50 | PATIENT_TOT | NUMERIC | No |
The total patient portion for the procedure.
51 | OVRD_PAT_RSN_C_NAME | VARCHAR | No |
The category ID of the reason for overriding the patient portion on the procedure.
May contain organization-specific values: Yes
52 | OVRD_PAT_PORT | NUMERIC | No |
The override patient portion amount for the procedure.
53 | PRICING_ATTR_C_NAME | VARCHAR | No |
The category ID of the pricing attribute for the procedure (used in conjunction with the vendor contract).
May contain organization-specific values: Yes
Category Entries:
PCP
Specialist
54 | PENALTY_BEF_BEN | NUMERIC | No |
The before benefits provider penalty amount for the procedure.
55 | PENALTY_AFT_BEN | NUMERIC | No |
The after benefits provider penalty amount for the procedure.
56 | EXCEEDED_BEN_AMT | NUMERIC | No |
The amount on the procedure that exceeds benefits.
57 | COB_SAVING_AMT | NUMERIC | No |
The Coordination of Benefits (COB) savings amount for the procedure.
58 | PAT_OUT_OF_POCKET | NUMERIC | No |
The total patient out-of-pocket amount for the procedure.
59 | SUB_PEN_ADJ_STR | VARCHAR | No |
The submission penalty adjudication string for the procedure.
60 | ALLOWED_CODE_C_NAME | VARCHAR | No |
The allowed code for the procedure (e.g., claim denied, procedure denied, contracted rate payment).
May contain organization-specific values: No
Category Entries:
Contracted Rate Payment
Payment as per Appeals Review Committee
Payment as per Duality Review Committee
Claim Denied
Procedure Denied
Secondary Claim Rate
61 | WITHHOLDING | NUMERIC | No |
The withholding amount for the procedure.
62 | TX_TYPE_C_NAME | VARCHAR | No |
The category ID that indicates the type of procedure. Only AP claim types should appear in this table (e.g. AP claim, AP claim refund, AP claim DRG).
May contain organization-specific values: No
Category Entries:
Charge
Payment
Adjustment
AP Claim Tx
AP Claim Refund Tx
AP Claim DRG Tx
Pharmacy Claim Tx
63 | DRG_ID | VARCHAR | No |
The unique ID of Diagnosis Related Group (DRG) code for the procedure.
64 | DRG_ID_DRG_NAME | VARCHAR | No |
The name of the Diagnoses Related Group name.
65 | PAT_PORT_CODE_C_NAME | VARCHAR | No |
The category ID of the type of patient payment for the procedure (e.g., coinsurance, copay, not covered).
May contain organization-specific values: No
Category Entries:
Co-ins
Copay
Not Covered
No Patient Payment
66 | DISCOUNT | NUMERIC | No |
The discount amount for the procedure.
67 | SECONDARY_DISC_AMT | NUMERIC | No |
The amount of additional discount on a secondary claim.
68 | PRIMARY_FACTORS | NUMERIC | No |
The amount on a non-primary (e.g. secondary) claim that was paid/handled by the primary payor.
69 | SEC_PROV_RESP | NUMERIC | No |
The secondary denied amount if the service is denied to provider responsibility.
70 | UNCVRD_EOB_CODE_ID_EOB_CODE_NAME | VARCHAR | No |
The name of the processing code.
71 | DISC_EOB_CODE_ID_EOB_CODE_NAME | VARCHAR | No |
The name of the processing code.
72 | PRICE_USING_C_NAME | VARCHAR | No |
The category ID of the method used to price the service (e.g. Revenue code, HCPCS code, DRG code). This is set only for UB claims.
May contain organization-specific values: No
Category Entries:
HCPCS CODE
REVENUE CODE
DRG CODE
73 | STATUS_C_NAME | VARCHAR | No |
The category ID of the procedure's status.
May contain organization-specific values: No
Category Entries:
Denied
Deleted
74 | CVG_ID | VARCHAR | No |
The ID of the coverage used to pay the procedure on the claim.
75 | APC_CODE_ID | VARCHAR | No |
The unique ID of the Ambulatory Payment Classification (APC) code that mapped to the procedure.
76 | APC_PRICE | NUMERIC | No |
The Ambulatory Payment Classification (APC) price for the procedure.
77 | OVRD_EXCD_BEN_AMT | NUMERIC | No |
The override exceeded benefit amount for the procedure.
78 | COB_SAVINGS_PAYOUT | NUMERIC | No |
The Coordination of Benefits (COB) savings member payout.
79 | PAT_PAY_ADJ_STR | VARCHAR | No |
The patient payment adjudication string.
80 | ALWD_AMT_ADJ_STR | VARCHAR | No |
The allowed amount adjudication string.
81 | CMG_MATCHED_ID | VARCHAR | No |
Stores the matched component group for referral bed days for this service.
82 | CMG_MATCHED_ID_COMPONENT_GRP_NAME | VARCHAR | No |
The name of the component group
83 | NPR_BDTABLE_LINE | NUMERIC | No |
The line number of the bed days mapping table in the Tapestry Profile (I NPR 41040) on which the procedure matched.
84 | REL_WT_BED_DAY | NUMERIC | No |
Relative weight of the bed day type mapped to this service.
85 | RFL_MATCHED_ID | NUMERIC | No |
Referral matched for service.
86 | TOD_MATCHED_ID | NUMERIC | No |
Bed day type matched for service.
87 | TOD_MATCHED_ID_BED_DAY_TYPE_NAME | VARCHAR | No |
The name of the bed day type record (i.e. ICU or non-authorized.)
88 | WEIGHT_BED_DAYS | NUMERIC | No |
Weight of bed days for service.
89 | UBC_REVENUE_CODE_ID | NUMERIC | No |
The unique identifier of the revenue code/procedure associated with the accounts payable claim record.
90 | UBC_REVENUE_CODE_ID_REVENUE_CODE_NAME | VARCHAR | No |
The name of the revenue code.
91 | CLAIM_ID | NUMERIC | No |
The claim to which this service associated. For most claim services, this column is equivalent to joining this table's TX_ID column to AP_CLAIM_PROC_IDS.TX_ID and retrieving AP_CLAIM_PROC_IDS.CLAIM_ID. For services related to Cost Sharing Reduction (CSR), this column is equivalent to joining this table's TX_ID column to AP_CLAIM_PROC_IDS_CSR.TX_ID and retrieving AP_CLAIM_PROC_IDS_CSR.CLAIM_ID. To retrieve the ordering of service lines on a claim, join to AP_CLAIM_PROC_IDS or AP_CLAIM_PROC_IDS_CSR as appropriate and retrieve the LINE column.
92 | PEN_AFT_BEN_COMPUTED | NUMERIC | No |
The after benefits provider penalty amount for the procedure, as computed by the system.
93 | PEN_AFT_BEN_OVRIDE | NUMERIC | No |
The after benefits provider penalty amount for the procedure, as overridden by the user.
94 | PEN_AFT_BEN_OVRIDE_RSN_C_NAME | VARCHAR | No |
The reason given for setting the provider penalty after benefits override, if any. This should be translated using ZC_PEN_AFT_BEN_OVRIDE_RSN.
May contain organization-specific values: Yes
95 | POS_TYPE_SRC_C_NAME | VARCHAR | No |
Source of the procedure's Place of Service type
May contain organization-specific values: No
Category Entries:
Profile
User
Batch Type Definition
96 | OVERRIDE_UC_VALUE | NUMERIC | No |
The amount that overrides the usual and customary amount for the procedure.