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: 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
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.