[NO/URSA-CORE] Pharmacy Claims

Object Description

One row per non-reversed pharmacy claim; includes denied claims.

Metadata

• Table Name: ursa.no_ursa_core_fin_004
• Layer: NATURAL_OBJECT
• Object Type: Single Stack
• Temporal Class: Event
• Case ID: Claim ID
• Event Date: Filled 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)
  • Filling Provider ID -- The internal database identifier (used, e.g., for joins and primary keys) for the filling provider.
  • Prescribing Provider ID -- The internal database identifier (used, e.g., for joins and primary keys) for the prescribing provider. (See also [URSA-CORE] Prescribing 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

  • Prescription Number -- The unique, user-facing (“real-world”) identifier used by operational systems or staff to identify the medication order. (See also [URSA-CORE] Medication Order)

• Date Fields

  • Filled Date -- The date a prescription or medication order was filled, with medications dispensed.
  • Prescribed Date -- The date the prescription or medication order was signed.
  • 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

  • Prescribing Provider NPI -- The 10-digit National Provider Identifier for the prescribing provider. (See also [URSA-CORE] Prescribing Provider)
  • Prescribing Provider DEA Number -- The 9-character alphanumeric Drug Enforcement Agency (DEA) identifier for the prescribing provider. (See also [URSA-CORE] Prescribing Provider)
  • Prescribing Provider Description
  • Filling Provider NPI -- The 10-digit National Provider Identifier for the filling provider. (See also [URSA-CORE] Filling Provider)
  • Filling Provider TIN -- The 9-digit federal Tax Identification Number for the filling provider. (See also [URSA-CORE] Filling Provider)
  • Filling Provider DEA Number -- The 9-character alphanumeric Drug Enforcement Agency (DEA) identifier for the filling provider. (See also [URSA-CORE] Filling Provider)
  • Filling Provider Description
  • Filling Provider Practice Address State Abbreviation
  • Filling Provider Practice Address ZIP Code 5-Digit
  • Filling Provider Primary NUCC Provider Taxonomy Code
  • Filling Provider Primary NUCC Provider Taxonomy Description
  • Is Filling Provider in Network -- Indicates the filling provider is considered in network for the referenced plan. (See also [URSA-CORE] Filling Provider)
  • Is Filling Provider Mail Order Pharmacy -- Indicates the filling provider is a mail-order pharmacy. (See also [URSA-CORE] Filling Provider)

• Insurance Fields

  • Is Medicare Part B
  • Is Medicare Part D

• Medication Fields

  • NDC Code 11-Digit -- The standard 11-digit National Drug Code; e.g., 00045012400 = Tylenol 500 mg.
  • Label Description
  • Strength Description
  • Strength Numeric -- The numeric component of medication strength, expressed as a number, including non-integer values, if applicable. For medications with multiple strengths, this field should take the value of the first ingredient's numeric strength. (See also [URSA-CORE] Medication Strength)
  • Strength Unit Description -- The natural language description of the unit component of medication strength; e.g., mg, mg / 5 ml. (See also [URSA-CORE] Medication Strength)
  • Active Ingredients Description
  • Primary Agent Description
  • Manufacturer Description -- Identifies the name of the company that markets the product. The name appearing in this field corresponds to the FDA-registered labeler name identified by the five-digit labeler code on the NDC number. Therefore, names appearing in this field will include distributors and repackagers in addition to original manufacturers.
  • AHFS Therapeutic Class Code 6-Digit
  • AHFS Therapeutic Class Code 8-Digit -- The standard 8-digit AHFS Pharmacologic-Therapeutic Class Code, representing all 4 tiers of the AHFS Pharmacologic-Therapeutic Classification system. The code is expressed as 8 numbers, without special characters delimiting the tiers, with leading and trailing zeros as needed. (See also [URSA-CORE] AHFS Pharmacologic-Therapeutic Classification System)
  • AHFS Therapeutic Class Tier 1 Description
  • AHFS Therapeutic Class Tier 2 Description
  • AHFS Therapeutic Class Tier 3 Description
  • Red Book Generic Cross Reference Code
  • Red Book Generic Formulation Code
  • Medi-Span GPI Code 14-Digit -- The 14-digit Medi-Span Generic Product Identifier (GPI) for the medication. The GPI is a 7-level hierarchical classification, with each level represented by two digits in the GPI. The full 14-digit GPI describes a medication's class, ingredients, dosage form, and strength. GPI values should include leading and trailing zeros and should not include hyphens or other special characters.
  • FDA Dosage Form Code -- The standard Food and Drug Administration (FDA) dosage form code describing the medication form; e.g., C42887 = aerosol. (See also [URSA-CORE] Medication Form)
  • Form Description
  • Route of Administration Description
  • Quantity Dispensed -- The quantity of medication dispensed in the fill. For medications with discrete forms (e.g., tablets, capsules, etc.) this is the number of those discrete units dispensed. For non-discrete forms (e.g., solution, cream, etc.) this is some other measure of quantity, including (but not necessarily) the number of doses dispensed.
  • Days Supply -- The number of calendar days, including the date the medication was dispensed, the dispensed medication will last at the patient's intended dosage as defined in their prescription.
  • Is Refill -- Indicates the fill is not the first fill on a prescription.
  • Fill Number -- The ordinal number, chronologically ordered, of the fill among other fills made on the same prescription; with the first fill assigned a value of 1.
  • NCPDP Dispense as Written Code -- The standard 1-digit Dispense as Written (DAW) code developed and maintained by the National Council for Prescription Drug Programs (NCPDP), identifying the types of substitutions, if any, the pharmacy can make when filling the prescription; e.g., 1 = Substitution not allowed by prescriber.
  • Is in Formulary -- Indicates the medication is in the formulary of the relevant authority (e.g., plan). For formularies with multiple tiers, this field should be used to represent assignment to any formulary tier.
  • Formulary Tier Operational ID -- The "real-life" identifier for the formulary tier to which the medication is assigned, as defined by the relevant authority (e.g., plan).
  • Formulary Tier Description -- The natural language description of the formulary tier to which the medication is assigned, as defined by the relevant authority (e.g., plan).
  • Is Specialty Drug According to Plan -- Indicates the medication is considered by the plan to be a specialty drug.
  • Is Generic According to Plan -- Indicates the medication is considered by the plan to be a generic drug.
  • Is Brand According to Plan -- Indicates the medication is considered by the plan to be a brand name drug.
  • Is Generic According to Reference
  • Is Brand According to Reference
  • Is Single Source According to Reference
  • Is OTC
  • Is Compound Drug -- Indicates the medication is a mixture of two or more drugs, typically created individually for a particular patient.

• 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.
  • 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 Ingredient Cost Allowed Amount -- The portion of the allowed amount associated with the cost of the medication's ingredients. (See also [URSA-CORE] Claim Allowed Amount)
  • Claim Dispensing Fee Allowed Amount -- The portion of the allowed amount associated with the pharmacy's dispensing fee. (See also [URSA-CORE] Claim Allowed Amount)
  • Claim Sales Tax Allowed Amount -- The portion of the allowed amount associated with the sales tax on the fill. (See also [URSA-CORE] Claim Allowed Amount)
  • 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

  • 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
• filling_prov_id → ursa.no_ursa_core_prov_001.prov_id
• prescribing_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] Pharmacy Claims, Precursor 1 (All Source Records): One row per non-reversed pharmacy claim; includes denied claims