AP_CLAIM_IF_INFO_4
Description:
Overflow table for claim data that can be sent or received by prospective payment systems (PPS) Pricers.

Primary Key
Column Name Ordinal Position
CLAIM_ID 1
LINE 2

Column Information
Name Type Discontinued?
1 CLAIM_ID NUMERIC No
The unique identifier for the claim info record.
2 LINE INTEGER No
The line number for the information associated with this record. Multiple pieces of information can be associated with this record.
3 ADMIT_DX_FOR_HAC_PROCESSING VARCHAR No
The admit diagnosis code that was used during hospital-acquired condition adjusted diagnosis-related group processing.
4 ADMIT_MEDICAL_SURGICAL_DRG_FLG VARCHAR No
Medical/Surgical Flag assigned at admission.
5 ADMIT_RETURN_CODE VARCHAR No
Return code at admission.
6 BIRTH_WEIGHT_OPTION_USED VARCHAR No
Birth weight data entry method used during processing.
7 DISCHARGE_DRG_OPTION_USED VARCHAR No
The discharge diagnosis-related group (DRG) option used during processing.
8 HAC_ADJ_DRG VARCHAR No
Diagnosis Related Group (DRG) following Hospital-Acquired Condition (HAC) adjusted DRG processing.
9 HAC_ADJ_MDC VARCHAR No
The MDC following HAC-adjusted APR DRG Processing.
10 HAC_ADJ_MED_SURG_DRG_FLAG VARCHAR No
Medical or surgical DRG flag following HAC-adjusted DRG Processing.
11 HAC_ADJ_RETURN_CODE VARCHAR No
Return code following Hospital-Acquired Condition (HAC) adjusted Diagnosis Related Group (DRG) processing.
12 HAC_ADJ_ROM VARCHAR No
Risk of mortality (ROM) following HAC-adjusted DRG processing.
13 HAC_ADJ_SOI VARCHAR No
Severity of illness (SOI) following HAC-adjusted DRG processing.
14 HAC_VERSION_USED VARCHAR No
Hospital-acquired condition version used for processing.
15 HAC_PROCESSING_ICD_VERSION VARCHAR No
ICD version qualifier used for hospital-acquired condition adjusted diagnosis related group processing.
16 PAYER_LOGIC_INDICATOR_USED VARCHAR No
Type of payer logic applied during 3M APR DRG grouping.
17 USER_ID_IN VARCHAR No
Unique identifier for the user, required for processing the claim when using Super Certificates.
18 FINANCIAL_PAYER VARCHAR No
Classification of the financial payer of the claim.
19 MEMBER_BENEFIT_PLAN VARCHAR No
Classification of the member benefit plan.
20 PAT_RESPONSIBILITY VARCHAR No
Amount the patient is expected to pay for the claim.
21 GROUPER_ICD_VERSION_QUALIFIER VARCHAR No
Specifies the grouper ICD version to use for processing.
22 ACCESS_FEE_AMOUNT VARCHAR No
Portion of the total claim payment attributed to access fees.
23 AGE_ADJ VARCHAR No
The decimal representation of the adjustment rate to the claim due to agency defined age considerations.
24 BASE_DRG_ADJ_USED VARCHAR No
Max of the provider adjuster, age adjuster & service line adjuster.
25 COVERED_COST VARCHAR No
Portion of the total charges that is represented in cost dollars.
26 DRG_BASE_AMOUNT VARCHAR No
Initial estimate of portion of claim total payment qualifying as an inlier.
27 DRG_BASE_PAYMENT VARCHAR No
Portion of the claim total payment paid for claim qualifying as an inlier.
28 HAC_ADJ_PAYMENT_FLAG VARCHAR No
Indicates whether HAC-adjusted DRG and severity of illness (SOI) logic from the APR grouper was used.
29 OUTLIER_TRIM_POINT_USED VARCHAR No
Outlier trim point value used to determine outlier threshold.
30 SERVICE_ADJ VARCHAR No
Amount the relative weight is incremented for a facility.
31 TOTAL_ALLOWED_AMOUNT VARCHAR No
Payment before withholding & access payment adjustments.
32 TOTAL_NON_CVRD_AMOUNT_USED VARCHAR No
Non-covered charges used in determining cost of charges.
33 USER_DEFINED_ADJ_AMT VARCHAR No
Portion of total payment attributable to user-defined adjustment values.
34 VARIABLE_COST_FACTOR_USED VARCHAR No
Variable cost factor value used in cost outlier calculation.
35 WITHHOLDING_AMOUNT VARCHAR No
Reduction due to Pay for Performance adjustment.
36 CHARGE_OUTLIER_THRESHOLD VARCHAR No
The dollar amount, in charge dollars, that the claim charges must exceed to determine the claim eligibility for a high cost outlier payment.
37 ADMIT_MDC VARCHAR No
The Major Diagnostic Category (MDC) at admission.
38 ADJUSTED_EAPG_WEIGHT VARCHAR No
The Enhanced Ambulatory Payment Group weight after discounting and consolidation.
39 CLAIM_RECORD_TYPE VARCHAR No
The overall record type for the claim.
40 FULL_EAPG_WEIGHT VARCHAR No
Weight(s) obtained directly from the weight file before adjustment.
41 RURAL_ADJUSTMENT_FACTOR VARCHAR No
Line level rural adjustment factor
42 RURAL_ADJUSTMENT_FACT_SEP_BILL VARCHAR No
Line level, separately billable rural payment adjustment for adult ESRD beneficiaries utilizing ESRD facilities located in rural core-based statistical areas (CBSA) (that are non-urban CBSAs).
43 STATE_PRICING_INDICATOR VARCHAR No
Indicates the state rules that were used when pricing the claim.
44 STATE_IDENT VARCHAR No
State ID returned by Prospective Payment System pricer for diagnosis related group pricing.
45 TOTAL_ERRORS VARCHAR No
Total errors returned in PPS Medicare Code Editor (MCE) editor block.
46 TAXPAYER_IDENT VARCHAR No
Taxpayer ID Number from outgoing EasyGroup PPS Pricer
47 ALT_PDGM VARCHAR No
Alternate Patient-Driven Groupings Model (PDGM) from incoming Ambulatory Payment Classification (APC) grouper using EasyGroup PPS Pricer.
48 PDGM VARCHAR No
PDGM from incoming APC grouper using EasyGroup PPS Pricer
49 ADJUSTED_DRG_WT VARCHAR No
Adjusted Diagnosis Related Group (DRG) Weight from incoming DRG pricer using EasyGroup PPS Pricer.
50 VAL_CODE VARCHAR No
Payer Value Code from incoming Ambulatory Code Editor using EasyGroup PPS Pricer.
51 VAL_AMT VARCHAR No
Payer Value Code Amount from incoming Ambulatory Code Editor using EasyGroup PPS Pricer.
52 ER_REDUCT_FLAG VARCHAR No
Flag to determine to apply ER payment reduction from incoming APG Grouper using EasyGroup PPS Pricer
53 APL_FLAG VARCHAR No
Missing Ambulatory Procedures Listing (APL) Flag from incoming APG Pricer using EasyGroup PPS Pricer
54 NPI_USED VARCHAR No
National Provider Identifier (NPI) used for processing from incoming ECB2 block using EasyGroup PPS Pricer
55 TAXONOMY_USED VARCHAR No
Taxonomy used for processing from incoming ECB2 block using EasyGroup PPS Pricer
56 FACILITY_USED VARCHAR No
Facility used for processing from incoming ECB2 block using EasyGroup PPS Pricer
57 PAYSRC_USED VARCHAR No
Payer ID Used for processing from incoming ECB2 block using EasyGroup PPS Pricer
58 ADMIT_DX_USED_DESCRIPTION VARCHAR No
The description of the admission diagnosis used.
59 DRG_DESCRIPTION VARCHAR No
The description of the Diagnosis Related Group (DRG).
60 INITIAL_DRG_DESCRIPTION VARCHAR No
The description of the initial Diagnosis Related Group (DRG).
61 INITIAL_MDC_DESCRIPTION VARCHAR No
The description of the initial Major Diagnostic Category (MDC).
62 MDC_DESCRIPTION VARCHAR No
The description of the Major Diagnostic Category (MDC).
63 SUGGESTED_PRINCIPAL_PX_DESC VARCHAR No
Description of the suggested principal procedure.
64 ADMIT_DX_HAC_PROCESSING_DESC VARCHAR No
Description of admitting diagnosis code that was used during HAC Adjusted DRG processing.
65 ADMIT_DRG_DESCRIPTION VARCHAR No
Description of returned DRG assigned at admission.
66 ADMIT_MDC_DESC VARCHAR No
Description of the Major Diagnostic Category (MDC) assigned at admission
67 ADMIT_ROM_DESC VARCHAR No
Description of Risk of Mortality (ROM) assigned at admission.
68 ADMIT_SOI_DESC VARCHAR No
Description of Severity Of Illness (SOI) assigned at admission.
69 HAC_ADJ_DRG_DESC VARCHAR No
Description of the HAC adjusted Diagnosis Related Group.
70 HAC_ADJ_MDC_DESC VARCHAR No
Description of HAC adjusted Major Diagnostic Category.
71 HAC_ADJ_ROM_DESC VARCHAR No
Description of the HAC adjusted Risk of Mortality.
72 HAC_ADJ_SOI_DESC VARCHAR No
Description of HAC adjusted Severity of Illness.
73 RISK_OF_MORTALITY_DESC VARCHAR No
Description of the Risk of Mortality.
74 SEVERITY_OF_ILLNESS_DESC VARCHAR No
Description of the Severity of Illness.
75 PRICER_BASE_RATE VARCHAR No
Pricer data
76 OVERALL_CLAIM_TYPE VARCHAR No
The description of the overall claim type.
77 PAYMENT_ACTION VARCHAR No
The action for payment recommended by the pricer.
78 TOTAL_CUTBACK_PAYMENT VARCHAR No
Total cutback payment.
79 TOTAL_CUTBACK_PERCENT VARCHAR No
Total cutback percent.
80 TOTAL_EXCLUDING_OUTLIERS_PMT VARCHAR No
Total excluding outliers payment.
81 TTL_ITEM_PMT_SUBJ_TO_CUTBACK VARCHAR No
Total item payment subject to cutback.
82 PPS_ASSOC_VEN_CONTRACT_ID NUMERIC No
The unique ID of the vendor contract associated with one communication with a PPS pricer.
83 PPS_ASSOC_VEN_CONTRACT_ID_CONTRACT_NAME VARCHAR No
The name of the Vendor-Network contract.
84 PPS_USED_IN_PRICE_C_NAME VARCHAR No
Indicates whether a PPS data line is associated with the vendor contract that was used in the pricing of the claim at the time of adjudication. 1 indicates that the PPS data was used to price the claim. 2 indicates that the PPS data was not used to price the claim. Null indicates that there is no associated vendor contract or it is not known whether the PPS line was used for pricing.
May contain organization-specific values: No
Category Entries:
Used in Pricing
Not Used in Pricing
85 EDC_ANALYZER_FLAG VARCHAR No
Indicates whether the EDC Analyzer was run and results are available.
86 MOE_FLAG VARCHAR No
Indicates whether the Medicaid Outpatient Editor was run and results are available.
87 CALC_FLAG VARCHAR No
Indicates whether the Calculation Control program was run and results are available.
88 FILE_NOT_FOUND VARCHAR No
Name of the missing program file.
89 RAP_PENALTY_AMT VARCHAR No
Amount the total payment has been reduced by due to an untimely RAP submission.
90 RAP_PENALTY_AMT_ALT VARCHAR No
Amount the alternate total payment has been reduced by due to an untimely RAP submission.
91 PPR_ADJ_AMT VARCHAR No
Potentially Preventable Readmissions adjustment amount.
92 PPC_ADJ_AMT VARCHAR No
Potentially Preventable Complications adjustment amount.
93 EDITOR_RTN_TYPE VARCHAR No
Editor Return Code Type from incoming ACE editor using EasyGroup PPS Pricer.
94 DB_SERVER_AND_INST VARCHAR No
Database server and instance used for processing from incoming ECB2 block using EasyGroup PPS Pricer.
95 DB_NAME VARCHAR No
Database name used for processing from incoming ECB2 block using EasyGroup PPS Pricer.