[NO/URSA-CORE] Institutional Claim Headers

Object Description

One record per non-reversed institutional claim header; includes denied claims.

Metadata

• Table Name: ursa.no_ursa_core_fin_001
• Layer: NATURAL_OBJECT
• Object Type: Single Stack
• Temporal Class: Event
• Case ID: Claim ID
• Event Date: Claim Covered Start Date
• Primary Key: Claim ID

Published Fields

• Data Model Keys

  • Claim ID -- The internal database identifier (used, e.g., for joins and primary keys) for the claim. (See also [URSA-CORE] 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)
  • Facility Provider ID
  • Attending Provider ID -- The internal database identifier (used, e.g., for joins and primary keys) for the attending provider. (See also [URSA-CORE] Attending Provider)
  • Operating Provider ID -- The internal database identifier (used, e.g., for joins and primary keys) for the operating provider. (See also [URSA-CORE] Operating 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.
  • Document ID
  • Source ID -- The identifier for the original source data system from which the current record originated.

• Source Local Keys

  • Source Local Claim ID -- The internal database identifier for the claim in the source data system this record originated from. (See also [URSA-CORE] Claim)
  • Source Local Patient ID -- The internal database identifier for the patient in the source data system this record originated from. (See also [URSA-CORE] Patient)

• Operations Support Fields

  • Claim Operational ID -- The identifier for an institutional, professional, or pharmacy claim used to identify a record in an operational or administrative system; i.e., the "real life" identifier for the record that might be used by staff or other operators.

• Date Fields

  • Claim Covered Start Date -- The start date of services covered by a claim.
  • Claim Covered End Date -- The end date of services covered by a claim.
  • Admit Date -- The date the patient was admitted to a care facility; note that "admission" typically implies the initiation of inpatient status, but not always, so this term should not necessarily be interpreted in that way.
  • Discharge Date -- The date the patient was discharged from a care facility.
  • Claim Received Date -- The date the claim was originally received for processing by the payor.
  • Claim Paid Date -- The date the claim was paid by the payor.
  • Payor Incurred Date -- The date the payor considers the services associated with the record to be incurred for accounting purposes.

• Provider Fields

  • Billing Provider Description
  • Billing Provider TIN -- The 9-digit federal Tax Identification Number for the billing provider. (See also [URSA-CORE] Billing Provider)
  • Billing Provider NPI -- The 10-digit National Provider Identifier for the billing provider. (See also [URSA-CORE] Billing Provider)
  • Is Billing Provider in Network -- Indicates whether the billing provider is considered to be in a plan's or payor's provider network. (See also [URSA-CORE] Billing Provider)
  • Facility Provider Description
  • Facility Provider NPI
  • Attending Provider Description
  • Attending Provider NPI -- The 10-digit National Provider Identifier for the attending provider. (See also [URSA-CORE] Attending Provider)
  • Operating Provider Description
  • Operating Provider NPI -- The 10-digit National Provider Identifier for the operating provider. (See also [URSA-CORE] Operating Provider)

• Insurance Fields

  • Is Medicare Part A
  • Is Medicare Part B

• Clinical Services Fields

  • MS-DRG Code -- The standard 3-digit Medicare Severity Diagnosis Related Group code; MS-DRG codes should include leading zeros.
  • MS-DRG Description
  • APR-DRG Code -- The standard 3-digit All Patient Refined Diagnosis Related Group code; APR-DRG codes should include leading zeros, and do not include the Severity of Illness or Risk of Mortality modifiers.
  • APR-DRG Severity of Illness Code -- The standard 1-digit Severity of Illness modifier for an All Patient Refined Diagnosis Related Group code; sometimes abbreviated as SOI.
  • APR-DRG Risk of Mortality Code -- The standard 1-digit Risk of Mortality modifier for an All Patient Refined Diagnosis Related Group code; sometimes abbreviated as ROM.
  • APR-DRG Description -- The natural language description of a standard 3-digit All Patient Refined Diagnosis Related Group code. (See also [URSA-CORE] APR-DRG Code)

• Diagnosis Fields

  • Admitting Diagnosis ICD-9-CM Code -- The ICD-9-CM diagnosis code documented as the admitting diagnosis for an encounter. (See also [URSA-CORE] Diagnosis ICD-9-CM Code)
  • Admitting Diagnosis ICD-9-CM Description
  • Admitting Diagnosis ICD-10-CM Code
  • Admitting Diagnosis ICD-10-CM Description

• Billing and Claims Fields

  • Is Non-FFS Encounter Record -- Indicates that the claim or bill is an administrative record of particular services not requiring payment. Used, for example, to document care delivered under capitated or other non-fee-for-service (FFS) contracts.
  • CMS Type of Bill Code -- The standard CMS 3-digit Type of Bill (TOB) Code; 111 = Hospital Inpatient Admit Through Discharge, etc.
  • CMS Type of Bill Description
  • CMS Admission Type Code -- The standard CMS 1-digit Admission Type code; 1 = Emergency, 2 = Urgent, etc.
  • CMS Admission Type Description -- The natural language description of a CMS Admission Type code (See also [URSA-CORE] CMS Admission Type Code)
  • CMS Admit Source Code -- The standard 1-character CMS Admit Source code; e.g., 1 = Physician Referral, 2 = Clinic Referral, etc.
  • CMS Admit Source Description -- The natural language description of a standard CMS Admit Source code. (See also [URSA-CORE] CMS Admit Source Code)
  • CMS Patient Discharge Status Code -- The standard 2-digit CMS Patient Discharge Status code; 01 = Discharged to Home or Self Care, etc. Patient Discharge Status codes should include leading zeros.
  • CMS Patient Discharge Status Description -- The natural language description of a standard CMS Patient Discharge Status code. (See also [URSA-CORE] CMS Patient Discharge Status Code)
  • Is Claim Processed Status Open -- Indicates that the claim has been received but not yet paid or denied.
  • Is Claim Processed Status Paid -- Indicates that the claim has completed processing without denial, with any outstanding balance paid.
  • Is Claim Processed Status Denied -- Indicates the claim has been denied.

• Financial Fields

  • Claim Charge Amount -- The amount charged for this claim on the original bill, before any contractual adjustments or other discounts were applied.
  • Claim Allowed Amount -- The amount determined by the payor to be the maximum allowed amount for all the billed services on a claim, often representing a negotiated contractual amount. (See also [URSA-CORE] Claim)
  • Claim Plan Paid Amount -- The amount paid by an insurance plan for all services on a claim.
  • Claim COB Paid Amount -- The amount paid for all services on a claim by other insurance plans as part of a "coordination of benefit" (COB) arrangement.
  • Claim Patient Responsibility Amount -- The amount determined by a plan to be owed by the patient for all services on a claim.
  • Claim Patient Paid Amount -- The amount paid by the patient for all services on a claim.

• Metadata Fields

  • Is Service Line Item Financial Data Coverage -- Indicates whether financial information associated with a bill or claim is available and generally accurate at the service line item level; a value of 0 indicates that line-level financials are not available or not reliably accurate, and that header-level financial information should be used despite its coarser grain.
  • Record Last Updated Datetime -- The date and time the current record was last updated in the original data source.
  • Source Data Effective Datetime -- The "as of" date and time of the original source data system at the moment the current record was extracted. For example, if a snapshot of the data in a production system is taken at 12:05 AM on the first of each month and used to generate a package of flat files that are eventually loaded into the Ursa Studio client database later that month, the Source Data Effective Datetime of all records in that month's package will be 12:05 AM on the first. Not to be confused with Record Last Updated Datetime. (See also [URSA-CORE] Record Last Updated Datetime)

Foreign Keys

• pat_id → ursa.no_ursa_core_pat_001.pat_id
• billing_prov_id → ursa.no_ursa_core_prov_001.prov_id
• facility_prov_id → ursa.no_ursa_core_prov_001.prov_id
• attending_prov_id → ursa.no_ursa_core_prov_001.prov_id
• operating_prov_id → ursa.no_ursa_core_prov_001.prov_id
• payor_id → ursa.no_ursa_core_struct_004.payor_id
• plan_id → ursa.no_ursa_core_struct_005.plan_id

Dedicated Precursors

• [NO/URSA-CORE] Institutional Claim Headers, Precursor 1 (All Source Records): One row per non-reversed institutional claim header; includes denied claims