[DM/URSA-CORE] Data Mart for Claim Financials

Object Description

One record per pharmacy claim, medical claim, or medical claim service line item with a non-zero allowed or paid amount; this object contains line-level data for patient-source pairs in which claims data from that source include line-level paid amounts, and header-level data otherwise; only records (of any grain) with a non-zero allowed amount, plan paid amount, or patient paid amount field will be included.

Metadata

• Table Name: ursa.dm_ursa_core_020
• Layer: DATA_MART
• Object Type: Integrator
• Temporal Class: Event
• Case ID: Document ID
• Event Date: Document Effective Date
• Primary Key: Document ID

Published Fields

• Data Model Keys

  • Document ID -- The internal database identifier (used, e.g., for joins and primary keys) for the document. (See also [URSA-CORE] Document)
  • Claim ID -- The internal database identifier (used, e.g., for joins and primary keys) for the claim. (See also [URSA-CORE] Claim)
  • Claim Service Line Item ID -- The identifier for a service line item on an institutional or professional claim.
  • Patient ID -- The internal database identifier (used, e.g., for joins and primary keys) for the patient. This value is typically mastered, i.e., all records for the same patient, regardless of the source data system from which that record originated, should have the same Patient ID value. (Note that while the mastered Patient ID value might resemble a local identifier used in one of the upstream data sources, this does not indicate any special priority of that source system in determining the characteristics of the patient.) (See also [URSA-CORE] Patient)
  • Billing Provider ID -- The internal database identifier (used, e.g., for joins and primary keys) for the billing provider. (See also [URSA-CORE] Billing Provider)
  • Payor ID -- The identifier for the health insurance organization associated with the current record.
  • Plan ID -- The identifier for a particular health insurance plan product offered by a payor.
  • Source ID -- The identifier for the original source data system from which the current record originated.

• Date Fields

  • Document Effective Date -- The most appropriate single date that events associated with the document occurred. For documents spanning multiple calendar days, the earliest date is typically used; Document Effective Start Date and Document Effective End Date can be used for a more precise range of dates, if necessary.
  • Document Effective Date Text YYYYMM

• Encounter Fields

  • Ursa Encounter Type Tier 1 Category
  • Ursa Encounter Type Tier 2 Category
  • Ursa Surgery Encounter Type Category

• Provider Fields

  • Ursa Setting Tier 1 Description
  • Billing Provider Description -- The natural language description of the billing provider. (See also [URSA-CORE] Billing Provider)
  • CMS Type of Bill Code -- The standard CMS 3-digit Type of Bill (TOB) Code; 111 = Hospital Inpatient Admit Through Discharge, etc.
  • CMS Place of Service Code -- The standard CMS 2-digit Place of Service code; e.g., 01 = Pharmacy, 02 = Telehealth, etc.
  • CMS Place of Service Description -- The natural language description of a standard CMS Place of Service code (See also [URSA-CORE] CMS Place of Service Code)

• Insurance Fields

  • Claim Financial Class Description -- The natural language description of the financial class of a claim or plan. (A claim's financial class is inherited from its associated plan.) (See also [URSA-CORE] Financial Class)
  • Medicare Benefit Type Category -- A categorical value identifying whether the claim is a Medicare FFS or Medicare Advantage claim and, if known, what Medicare program component -- i.e., Part A, Part B, or Part D -- it is associated with. (See also [URSA-CORE] Is Medicare Part A, [URSA-CORE] Is Medicare Part B, [URSA-CORE] Is Medicare Part D)

• Clinical Services Fields

  • Ursa Service Type Tier 1 Description
  • HCPCS Code -- The Healthcare Common Procedure Coding System (HCPCS) code associated with a service. Includes both HCPCS Level I codes (commonly called CPT codes) and Level II codes (which includes products, supplies, and services not included in CPT). Level II codes consist of a letter followed by four numeric digits. Current Dental Terminology codes are included in the Level II codes as HCDT. (See also [URSA-CORE] HCPCS Description)
  • HCPCS Description -- The natural language description of a HCPCS code. (See also [URSA-CORE] HCPCS Code)
  • CMS Revenue Center Code -- The standard CMS 4-digit Revenue Center code; e.g., 0001 = Total charge, etc. CMS Revenue Center codes should include leading zeros.
  • CMS Revenue Center Description -- The natural language description of a CMS Revenue Center code (See also [URSA-CORE] CMS Revenue Center Code)

• Medication Fields

  • NDC Code -- The standard 11-digit National Drug Code; e.g., 00045012400 = Tylenol 500 mg.
  • Label Description -- Supplies the name given to the product by the manufacturer.
  • AHFS Therapeutic Class Tier 1 Description -- The natural language description of the first-tier category within the AHFS Therapeutic Classification System that the medication is assigned to. (See also [URSA-CORE] AHFS Pharmacologic-Therapeutic Classification System)
  • AHFS Therapeutic Class Tier 2 Description -- The natural language description of the second-tier category within the AHFS Therapeutic Classification System that the medication is assigned to. (See also [URSA-CORE] AHFS Pharmacologic-Therapeutic Classification System)

• Diagnosis Fields

  • Principal Diagnosis ICD-10-CM Code -- The ICD-10-CM diagnosis code documented as the principal diagnosis for a claim, bill, encounter, etc.
  • Principal Diagnosis ICD-10-CM Description -- The natural language description of the Principal Diagnosis ICD-10-CM Code. (See also [URSA-CORE] Principal Diagnosis ICD-10-CM Code)
  • Principal Diagnosis AHRQ CCS Diagnosis Category Tier 1 Description
  • Principal Diagnosis AHRQ CCS Diagnosis Category Tier 2 Description

• Billing and Claims Fields

  • Document Type Category
  • Claim Class Category -- Identifies a record as associated with a professional, institutional, or pharmacy claim.
  • Is Claim Class Institutional -- Indicates the record is associated with an institutional claim or bill.
  • Is Claim Class Professional -- Indicates the record is associated with a professional claim or bill.
  • Is Claim Class Pharmacy -- Indicates the record is associated with a pharmacy claim.

• Financial Fields

  • Document Allowed Amount
  • Document Plan Paid Amount
  • Document Patient Responsibility Amount
  • Document Patient Paid Amount

Foreign Keys

• plan_id → ursa.no_ursa_core_struct_005.plan_id
• payor_id → ursa.no_ursa_core_struct_004.payor_id
• pat_id → ursa.no_ursa_core_pat_001.pat_id
• billing_prov_id → ursa.no_ursa_core_prov_001.prov_id
• document_id → ursa.so_ursa_core_pat_001.document_id