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.