AP_CLM_RX_2
Description:
This table contains information from pharmacy claims.

Primary Key
Column Name Ordinal Position
CLAIM_ID 1

Column Information
Name Type Discontinued?
1 CLAIM_ID NUMERIC No
The unique identifier for the claim info record
2 PRIM_PAYOR_ID NUMERIC No
The primary medical payer. This is only set when the primary medical payer is different than the primary pharmacy payer.
3 BCDA_GROUP_IDENT VARCHAR No
Claim group identifier provided by Beneficiary Claims Data API (BCDA)
4 TOT_PAT_PORTION NUMERIC No
Total patient portion
5 MOST_RECENT_INCOMING_CEV_ID NUMERIC No
The most recent incoming Claim External Values (CEV) record ID
6 CLAIM_HEADER_ID VARCHAR No
Holds the claim header ID for the claim received from raw data
7 ADJ_SEQUENCE VARCHAR No
Holds the adjustment sequence for the claim received from raw data
8 ADJ_TO_CLAIM_ID VARCHAR No
Holds the adjustment to claim ID for the claim received from raw data
9 REV_TO_CLAIM_ID VARCHAR No
Holds the reversal to claim ID for the claim received from raw data
10 IS_CLINICALLY_VALID_YN VARCHAR No
Stores whether a claim is considered valid for the purpose of clinical data derivation
May contain organization-specific values: No
Category Entries:
No
Yes
11 KLCTCEV_RECORD_ID NUMERIC No
Holds the CEV ID containing the KLCT metadata for a reversal claim.
12 WORKFLOW_PAYOR_ID NUMERIC No
The ID of the workflow payer associated with this claim
13 SOURCE_ORG_ID NUMERIC No
The source organization of the external record.
14 SOURCE_ORG_ID_EXTERNAL_NAME VARCHAR No
Organization's external name used as the display name on forms and user interfaces.
15 LOOP_OR_SPLIT_YN VARCHAR No
Indicates whether a claim is part of an adjustment sequence that contains a split claim or an adjustment sequence loop. This CLM does not have to be in the split or loop istelf, just a part of the adjustment sequence.
The category values for this column were already listed for column: IS_CLINICALLY_VALID_YN
16 EXTERNAL_DEMOG_ID NUMERIC No
Holds a pointer to the REQ record that holds the identifier and demographics that this claim was received with, linking this claim into an ID bundle.
17 BENEFIT_PLAN_ID NUMERIC No
This is the ID of the benefit plan used to adjudicate a claim.
18 CLM_LOB_ID VARCHAR No
Stores the unique identifier of the line of business associated with the claim. This is the LOB determined at adjudication.
19 CLM_LOB_ID_LOB_NAME VARCHAR No
The name of the line of business record.
20 IN_OUT_OF_NET_C_NAME VARCHAR No
Contains the network level of a claim.
May contain organization-specific values: Yes
Category Entries:
In Network
Out of Network
N/A
21 CLAIM_PAID_DATE DATETIME No
The date that the claim was paid, which is determined by the date the claim reaches the AP Status EOB Generated
22 CLAIM_NAT_KEY_HASH VARCHAR No
The hashed value of the mapped claim natural key.
23 CLAIM_NAT_KEY_ORDER VARCHAR No
The ordering value for the claim natural key.
24 CLM_ADJ_TYPE_C_NAME VARCHAR No
The Claim Adjustment Type Code
May contain organization-specific values: No
Category Entries:
Original
Adjustment
Reversal
25 NAT_KEY_FINAL_YN VARCHAR No
Indicates whether a claim is the final action of an adjustment sequence that is tracking adjustments via natural keys. Natural key adjustments are tracked using superitem CLM 18690. A claim is the final action of its natural key if it has the maximum order value (item 18692) for a given natural key (item 18691). If there is a tie, the claim with the largest claim header id (item 18681) is deemed the final action.
The category values for this column were already listed for column: IS_CLINICALLY_VALID_YN
26 CLAIM_SVC_CLASS_CTX_C_NAME VARCHAR No
Represents a high-level clinical classification context of the services billed for on this claim.
May contain organization-specific values: No
Category Entries:
Inpatient
Outpatient
Professional Services
Pharmacy
Lab Services
Hospice
Not Classified
27 CLAIM_SVC_CLASS_C_NAME VARCHAR No
Represents a clinical classification for the services billed on this claim.
May contain organization-specific values: No
Category Entries:
Acute Inpatient
Other Inpatient
Skilled Nursing
Inpatient Psychiatric Care
Inpatient Rehabilitation Care
Hospice
Home Health
Outpatient
Emergency
Specimen Only
Pharmacy
Observation
Urgent Care
Surgery
Nursing Facility
Residential Facility Services
Office Visit
Substance Abuse and Behavioral Health Services
Ambulance
Telemedicine
Home Visit
Outpatient Rehabilitation Services
Independent Laboratory
Inpatient Part B
Inpatient Part B Preventive Services
Skilled Nursing Part B
Skilled Nursing Part B Preventive Services
Not Classified
28 CLIN_FILTER_UTC_DTTM DATETIME (UTC) No
Last UTC instant clinical data derivation filters (I CLM 18625) were updated or calculated without changes for this claim.
29 CLIN_FILTER_DTTM DATETIME (Local) No
Last local instant clinical data derivation filters (I CLM 18625) were updated or calculated without changes for this claim. Calculated using EPIC_UTC_TO_LOCAL on I CLM 18626.
30 REGION_ID NUMERIC No
The attributed region on the member's coverage at the time of the claim service
31 MEDICAL_GROUP_ID NUMERIC No
The attributed medical group on the member's coverage at the time of the claim service
32 SERVICE_DATE_FROM_LINE_YN VARCHAR No
Indicates whether the service date was received at the header level, or was determined based on service lines.
The category values for this column were already listed for column: IS_CLINICALLY_VALID_YN