AP_CLAIM_PROC_3

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 ID of the AP Claim procedure transaction.
2	ALWD_AMT_ADJ_RCR	VARCHAR	No
	The referral rules table used in determining the referral requirements which affect the allowed amount of the service line on the AP Claim. Join ALWD_AMT_ADJ_RCR and ALWD_AMT_ADJ_RCR_LN to REFERRAL_RCR_LINE.TABLE_ID and REFERRAL_RCR_LINE.LINE for information on the matched line.
3	ALWD_AMT_ADJ_FSC	NUMERIC	No
	The fee schedule that was used in determining the allowed amount of the service line on the AP Claim, if Regional Usual and Customary pricing was used.
4	ALWD_AMT_ADJ_FSC_FEE_SCHEDULE_NAME	VARCHAR	No
	The name of each fee schedule.
5	ALWD_AMT_ADJ_UC_HMU	VARCHAR	No
	The conversion factor table that was used in determining the allowed amount of the service line on the AP Claim, if Regional Usual and Customary pricing was used.
6	ALWD_AMT_ADJ_UC_HMU_TABLE_NAME	VARCHAR	No
	The name for the conversion factor table.
7	ALWD_AMT_ADJ_UC_ZIP	INTEGER	No
	The ZIP Code that was used in determining the allowed amount of the service line on the AP Claim, if Regional Usual and Customary pricing was used.
8	ALWD_AMT_ADJ_RCR_LN	INTEGER	No
	The line number of the referral rules table used in determining the allowed amount of the service line on the AP Claim. Join ALWD_AMT_ADJ_RCR and ALWD_AMT_ADJ_RCR_LN to REFERRAL_RCR_LINE.TABLE_ID and REFERRAL_RCR_LINE.LINE for information on the matched line.
9	ALWD_AMT_ADJ_CFR_RQ	VARCHAR	No
	The benefit referral classifier from the referral rules table that is used to determine the referral requirement for the allowed amount of the service line on the AP Claim.
10	ALWD_AMT_ADJ_CFR_RQ_CLASSIFIER_NAME	VARCHAR	No
	The title of the classifier record.
11	ALWD_AMT_ADJ_USE_UC	INTEGER	No
	Determines whether the Usual and Customary value in the contract was used. Join this column to ZC_IS_UC_APPLIED on INTERNAL_ID in order to translate values.
12	PROC_QTY_OVRRIDEN_C_NAME	VARCHAR	No
	Flag to indicate if the Procedure Quantity was manually overridden by the user. May contain organization-specific values: No Category Entries: User Overridden System Computed To Be Determined
13	PMT_INFO_RESP_ID	NUMERIC	No
	The responsibility class from the split definition table that was assigned to the service line on the AP Claim.
14	PMT_INFO_RESP_ID_RECORD_NAME	VARCHAR	No
	The name of the responsibility class record.
15	PMT_INFO_SPLIT_DATE	DATETIME	No
	The effective date of the split definition table used in determining the responsibility class of the service line on the AP Claim.
16	PMT_INFO_SPLIT_LINE	INTEGER	No
	The line of the split definition table used in determining the responsibility class of the service line on the AP Claim.
17	PMT_INFO_CPNT_ID	VARCHAR	No
	The component or component group of the split definition table used in determining the responsibility class of the service line on the AP Claim.
18	PMT_INFO_CPNT_ID_COMPONENT_INDEX_NAME	VARCHAR	No
	The name of the component index record
19	SERVICE_AREA_ID	NUMERIC	No
	The service area of the service line on the AP claim.
20	RX_POINTER_ID	NUMERIC	No
	The ID of medication file for the service line.
21	RX_TYPE_C_NAME	VARCHAR	No
	The medication type for this service line. May contain organization-specific values: No Category Entries: Acute Chronic PAT
22	START_TIME	DATETIME (Local)	No
	The start time of the procedure.
23	STOP_TIME	DATETIME (Local)	No
	The stop time of the procedure.
24	SERVICE_TIME	NUMERIC	No
	The elapsed time of the procedure in minutes.
25	PMT_RESP_OVER_ID	NUMERIC	No
	The override responsibility class that was assigned to the service line on the AP Claim.
26	PMT_RESP_OVER_ID_RECORD_NAME	VARCHAR	No
	The name of the responsibility class record.
27	VEN_CNTRCT_RFL_LST	VARCHAR	No
	The list of referrals satisfying the vendor contract authorization requirements. This column will be deprecated in a future release. Reporting content should use Clarity table AP_CLM_PX_VEN_CNTRCT_RFL going forward, which contains one row per linked referral record.
28	OPR_AUTH_RFL_LST	VARCHAR	No
	The list of referrals satisfying the operational authorization requirements. This column will be deprecated in a future release. Reporting content should use Clarity table AP_CLM_PX_OPR_AUTH_RFL going forward, which contains one row per linked referral record.
29	BEN_REQ_RFL_LST	VARCHAR	No
	The list of referrals satisfying the benefits authorization requirements. This column will be deprecated in a future release. Reporting content should use Clarity table AP_CLM_PX_BEN_AUTH_RFL going forward, which contains one row per linked referral record.
30	OPR_AUTH_CMP_CMG_ID	VARCHAR	No
	The unique identifier of the component or component group matched on the operational authorization table for this procedure. The operational authorization table is found in the Tapestry Profile.
31	OPR_AUTH_CMP_CMG_ID_COMPONENT_INDEX_NAME	VARCHAR	No
	The name of the component index record
32	OPR_AUTH_NET_C_NAME	VARCHAR	No
	The column stores the network status value as found by matching on the operational authorization table. The operational authorization table is found in the Tapestry Profile. The stored values can be translated using the ZC_NETWORK_LEVELS table. May contain organization-specific values: Yes Category Entries: In Out Out of Area N/A
33	OPR_AUTH_EFF_DATE	DATETIME	No
	The effective date column value of the matched row on the operational authorization table. The operational authorization table is found in the Tapestry Profile.
34	OPR_AUTH_TERM_DATE	DATETIME	No
	The termination date column value of the matched row on the operational authorization table. The operational authorization table is found in the Tapestry Profile.
35	OPR_AUTH_REQ_C_NAME	VARCHAR	No
	This column stores whether or not authorization is required as found by matching on the operational authorization table. The operational authorization table is found in the Tapestry Profile. The stored values can be translated using the ZC_AUTH_REC table. May contain organization-specific values: No Category Entries: No Yes-Internal Yes-External
36	OPR_AUTH_CFR_ID	VARCHAR	No
	The column stores the unique identifier of the referral classifier as found by matching on the operational authorization table. The operational authorization table is found in the Tapestry Profile.
37	OPR_AUTH_CFR_ID_CLASSIFIER_NAME	VARCHAR	No
	The title of the classifier record.
38	HR_AMOUNT	NUMERIC	No
	The healthcare reimbursement amount for the procedure.
39	OVERRIDE_HR_AMOUNT	NUMERIC	No
	The override healthcare reimbursement amount.
40	PMT_ORIG_RESP_ID	NUMERIC	No
	The responsibility class that was originally matched before it got overridden by the system.
41	PMT_ORIG_RESP_ID_RECORD_NAME	VARCHAR	No
	The name of the responsibility class record.
42	ALWD_AMT_ADJ_UC_FSM	NUMERIC	No
	The fee schedule map that was used in determining the allowed amount of the service line on the AP Claim, if Regional Usual and Customary pricing was used.
43	ALWD_AMT_ADJ_UC_FSM_FEE_SCHEDULE_MAP_NAME	VARCHAR	No
	The name for the fee schedule map record.
44	NETWORK_STATUS_C_NAME	VARCHAR	No
	Network status at the service level May contain organization-specific values: Yes Category Entries: In Network Out of Network N/A
45	OVRD_STOP_LOSS_YN	VARCHAR	No
	If set to 1-Yes, then the contractual stop loss threshold will not be evaluated when this service is adjudicated, and stop loss will therefore not be applied to this service. If set to 0-No, then stop loss will be applied to this service if applicable to the claim. If left blank, then the claim-level override (CLM 18132) will be used. May contain organization-specific values: No Category Entries: No Yes
46	PRIM_PAT_NOTCOV	NUMERIC	No
	For non-primary claims (e.g. secondary), the patient not covered amount adjudicated by the primary insurance company.
47	PRIM_PAT_DED	NUMERIC	No
	For non-primary claims (e.g. secondary), the patient deductible amount adjudicated by the primary insurance company.
48	PRIM_PAT_COPAY	NUMERIC	No
	For non-primary claims (e.g. secondary), the patient copay amount adjudicated by the primary insurance company.
49	PRIM_PAT_COINS	NUMERIC	No
	For non-primary claims (e.g. secondary), the patient co-insurance amount adjudicated by the primary insurance company.
50	ORIGINAL_TX_ID	NUMERIC	No
	Holds the original service line ID for claim line splitting.
51	ALWD_AMT_ADJ_DSLW_DSC_YN	VARCHAR	No
	This column stores a Y/N flag if the amount of this service line will route to patient responsibility as a disallowed amount. If Y, the discount amount on a service priced by the line was routed to patient responsibility as a disallowed amount. If N, means the system left the discount amount as provider responsibility.
52	ALWD_AMT_ADJ_NSL	NUMERIC	No
	This column stores the ID stop loss term record (NSL) that was used in determining the allowed amount of this service line.
53	ALWD_AMT_ADJ_NSL_RECORD_NAME	VARCHAR	No
	The name of the stop loss term record.
54	ALWD_AMT_ADJ_UBC	NUMERIC	No
	This column stores the ID of the revenue record (UBC) used in determining the allowed amount of this service line.
55	ALWD_AMT_ADJ_UBC_REVENUE_CODE_NAME	VARCHAR	No
	The name of the revenue code.
56	RESPONSIBLE_AMOUNT	NUMERIC	No
	Stores the responsible amount for this service line, as calculated by custom COB logic. If the payment method (AP_CLAIM.METH_TO_PAY_CLM_C) for the claim this service line is associated with is 1 (Primary Coverage), this column will be null.
57	NDC_PRICE	NUMERIC	No
	Holds the National Drug Code (NDC) price for the service.
58	NDC_FEE_SCHEDULE_ID	NUMERIC	No
	Holds the ID of the National Drug Code (NDC) fee schedule used.
59	NDC_FEE_SCHEDULE_ID_FEE_SCHEDULE_NAME	VARCHAR	No
	The name of each fee schedule.
60	NDC_PRICING_METHOD_C_NAME	VARCHAR	No
	Holds the category ID of the contract-level National Drug Code (NDC) pricing method for the service. May contain organization-specific values: No Category Entries: Percent of NDC Fee Schedule Minimum of NDC Fee Schedules Maximum of NDC Fee Schedules
61	NDC_PRICING_METHOD_ALLOWED_C_NAME	VARCHAR	No
	Holds the category ID of the National Drug Code (NDC) pricing method applied to the service allowed amount. May contain organization-specific values: No Category Entries: Use Only NDC Price Minimum of Amounts Maximum of Amounts Add to Service Allowed Amount Use NDC Price, but Fall Back to Contract
62	NDC_HANDLING_FEE	NUMERIC	No
	Holds the National Drug Code (NDC) handling fee used to price the service.
63	NDC_BASE_RATE	NUMERIC	No
	The National Drug Code (NDC) base rate used to price the service.
64	NDC_UNIT_PRICE	NUMERIC	No
	Holds the National Drug Code (NDC) unit price used to price the service.
65	NDC_PERCENT_OF_UNIT	NUMERIC	No
	Holds the National Drug Code (NDC) percent of unit charge used to price the service.
66	NDC_PERCENT_OF_FEE	NUMERIC	No
	Holds the National Drug Code (NDC) percent of fee schedule used to price the service.
67	NDC_CLAIM_THRESHOLD	NUMERIC	No
	Holds the National Drug Code (NDC) claim-level threshold used to price the service.
68	NDC_SERVICE_THRESHOLD	NUMERIC	No
	Holds the National Drug Code (NDC) service-level threshold used to price the service.
69	NDC_SERVICE_THRESHOLD_TYPE	NUMERIC	No
	Holds the National Drug Code (NDC) service-level threshold type.
70	NDC_CLAIM_THRESHOLD_MET_YN_NAME	VARCHAR	No
	A flag that stores whether or not the National Drug Code (NDC) claim-level threshold was met. If set to 0-No, the threshold was not met. If set to 1-Yes, the threshold was met. The category values for this column were already listed for column: OVRD_STOP_LOSS_YN
71	NDC_SERVICE_THRESHOLD_MET_YN_NAME	VARCHAR	No
	A flag that stores whether or not the National Drug Code (NDC) claim-level threshold was met. If set to 0-No, the threshold was not met. If set to 1-Yes, the threshold was met. The category values for this column were already listed for column: OVRD_STOP_LOSS_YN
72	NDC_PAYMENT_MECHANISM_PRICE	NUMERIC	No
	Holds the contractual payment mechanism price that the National Drug Code (NDC) price was compared with or added to during adjudication.
73	ADJ_TO_PAT_OOP	NUMERIC	No
	Amount that the patient out of pocket would have been on a capitated secondary service had the service not been capitated according to the contract. This amount gets displayed on the 835 in the CAS*CO*45 segment.
74	REDISTRIBUTED_TO_TX_ID	NUMERIC	No
	Specifies the line to which this line's primary factors (primary insurance and primary patient portion) were redistributed for the purposes of secondary claim adjudication, if applicable.
75	REPRESENTATIVE_LINE_YN	VARCHAR	No
	Specifies whether this line is used as a representative line for one or more other service lines for the purposes of secondary claim adjudication. The category values for this column were already listed for column: OVRD_STOP_LOSS_YN
76	OVERRIDE_RENTAL_RECORD_ID	NUMERIC	No
	Contains the rental record which this service should use when pricing by durable medical equipment (DME) rental.
77	DME_RENTAL_ID	NUMERIC	No
	Contains the rental linked to this service.
78	SYS_ADJUST_REASON_C_NAME	VARCHAR	No
	The category value of the system calculated 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
79	DME_PRICING_RECORD_ID	NUMERIC	No
	Holds the Durable Medical Equipment (DME) pricing record used during adjudication of the claim.
80	DME_PRICING_RECORD_ID_RECORD_NAME	VARCHAR	No
	The name of the pricing record.
81	MOOP_MET_C_NAME	VARCHAR	No
	Maximum Out-Of-Pockets (MOOPs) apply to this service. May contain organization-specific values: No Category Entries: No (Old) Yes (Old) N/A (Old) Yes No N/A
82	DEDUCTIBLE_MET_C_NAME	VARCHAR	No
	Displays whether the deductible limit was met, not met, or didn't apply to this service. 11 - Yes indicates that the deductible was met by this service or before the service was adjudicated. 12 - No indicates that a deductible applies to the service, but the limit was not met as of the time the service was adjudicated. 13 - N/A indicates that no deductibles apply to this service. The category values for this column were already listed for column: MOOP_MET_C_NAME
83	NOT_COVERED_YN	VARCHAR	No
	Stores Yes if the service is not covered, No if the service is covered, or NULL if the service was adjudicated prior to this calculation being available. The category values for this column were already listed for column: OVRD_STOP_LOSS_YN
84	SUBROGATION_DEMAND_AMT	NUMERIC	No
	This item stores the subrogation demand amount from another payer for a service.
85	SUBROGATION_ADJ_AMT	NUMERIC	No
	This item stores the amount for a service that was not paid due to subrogation demand being less than net payable.
86	LN_ITEM_CTRL_NUM	VARCHAR	No
	The line item control number from the submitted EDI claim. This is the ID of the service line in the submitter's system.
87	CLIA_NUMBER	VARCHAR	No
	Identification of a Clinical Laboratory Improvement Amendment (CLIA) certified facility that contrasts with the claim level.
88	REFERRING_CLIA_FACILITY_IDENT	VARCHAR	No
	Identification of a Clinical Laboratory Improvement Amendment (CLIA) certified facility that was referred to for qualifying tests.
89	HAS_UNMAPPED_CODE_YN	VARCHAR	No
	Indicates if there were procedure codes on the incoming claim that could not be mapped to internal records. The category values for this column were already listed for column: OVRD_STOP_LOSS_YN
90	PI_REDUCT_AMT	NUMERIC	No
	Payer Initiated Billed Amount Reduction from Emergency Department Claim (EDC) Analyzer as a result of down coding.
91	PI_REDUCT_OVRIDE_AMT	NUMERIC	No
	Override amount for Payer Initiated Reduction
92	ALWD_AMT_ADJ_UC_ZIP_FULL	VARCHAR	No
	The ZIP Code that was used in determining the allowed amount of the service line on the AP Claim, if Regional Usual and Customary pricing was used. This column can support both 5 and 9 digit zip codes.