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_TABLE_NAME VARCHAR No
The name of the referral rules table record.
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_LOC_NAME VARCHAR No
The name of the revenue location.
20 RX_POINTER_ID_MEDICATION_NAME VARCHAR No
The name of this medication record.
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.