[NO/URSA-CORE] Professional Claim Service Line Items

Object Description

One record per non-reversed professional claim service line item; includes denied line items; includes header-level fields.

Metadata

• Table Name: ursa.no_ursa_core_fin_003
• Layer: NATURAL_OBJECT
• Object Type: Single Stack
• Temporal Class: Event
• Case ID: Claim Service Line Item ID
• Event Date: Claim Covered Start Date
• Primary Key: Claim Service Line Item 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)
  • Claim Service Line Item ID -- The identifier for a service line item on an institutional or professional claim.
  • Service Line Number -- The integer-valued ordinal representing the position of a service line item in a claim, bill, encounter, or other master record. May not necessarily match the analogous value in the source data for the same record.
  • 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)
  • Service Provider ID -- The internal database identifier (used, e.g., for joins and primary keys) for the service provider. (See also [URSA-CORE] Service 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.
  • Header Document ID
  • Service Line Item 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 Claim Service Line Item ID -- The identifier for the institutional or professional service line item in the original source data system.
  • Source Local Service Line Number -- The integer-valued ordinal for a service line item in the original source data system.
  • 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)

• 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.
  • Service Start Date
  • Service End Date
  • 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 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)
  • Billing Provider Description
  • 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)
  • Service Provider NPI -- The 10-digit National Provider Identifier for the service provider. (See also [URSA-CORE] Service Provider)
  • Service Provider Description

• Insurance Fields

  • Is Medicare Part B -- Indicates that the coverage for this claim or bill is provided by Medicare Part B. Note that some institutional claims and pharmacy claims may be designated Part B.

• Clinical Services Fields

  • 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
  • HCPCS Modifier 1 Code -- The 2-character code modifying a HCPCS code.
  • HCPCS Modifier 1 Description -- The natural language description of a HCPCS code modifier. (See also [URSA-CORE] HCPCS Modifier Code)
  • HCPCS Modifier 2 Code
  • HCPCS Modifier 2 Description
  • HCPCS Modifier 3 Code
  • HCPCS Modifier 3 Description
  • HCPCS Modifier 4 Code
  • HCPCS Modifier 4 Description
  • HCPCS Modifier 5 Code
  • HCPCS Modifier 5 Description
  • Anesthesia Surgical HCPCS Code -- The HCPCS code associated with the surgical procedure performed on a patient receiving anesthesia; sometimes included as a second HCPCS code on an anesthesia claim or bill. (See also [URSA-CORE] HCPCS Code)
  • Anesthesia Surgical HCPCS Description

• Billing and Claims 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.
  • Is Anesthesia Billing Format -- Indicates that the claim or bill should include values in fields associated with anesthesia billing, e.g., anesthesia base unit count, physical status unit count, and time unit count.
  • 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 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)
  • CMS Type of Service Code -- The standard CMS 1-character Type of Service (TOS) code; 0 = Whole Blood, 1 = Medical Care, etc.
  • CMS Type of Service Description -- The natural language description of a CMS Type of Service (TOS) code (See also [URSA-CORE] CMS Type of Service Code)
  • Service Unit Count -- The number of units of a service delivered to the patient; includes non-integer values, if appropriate.
  • Anesthesia Base Unit Count -- The base units (or base factor) associated with the service documented on an anesthesia claim or bill.
  • Anesthesia Physical Status Unit Count -- The numeric physical status units associated with the service documented on an anesthesia claim or bill, representing the patient's physical condition. (NB: not the same as, but often derived from, the physical status modifier, e.g., P1, P2, etc.)
  • Anesthesia Time Unit Count -- The time units associated with the service documented on an anesthesia claim or bill.
  • Claim Service Line Item Operational ID -- The identifier for an institutional or professional claim service line item 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.
  • 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.
  • Is Claim Service Line Item Processed Status Open -- Indicates that the claim service line item has been received but not yet paid or denied.
  • Is Claim Service Line Item Processed Status Paid -- Indicates that the claim service line item has completed processing without denial, with any outstanding balance paid.
  • Is Claim Service Line Item Processed Status Denied -- Indicates the claim service line item 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.
  • Claim Service Line Item Charge Amount -- The amount charged for this claim service line item on the original bill, before any contractual adjustments or other discounts were applied.
  • Claim Service Line Item Allowed Amount -- The amount determined by the payor to be the maximum allowed amount for all the a claim service line item, representing, for example, negotiated contractual amounts.
  • Claim Service Line Item Plan Paid Amount -- The amount paid by an insurance plan for a claim service line item.
  • Claim Service Line Item COB Paid Amount -- The amount paid for a claim service line item by other insurance plans as part of a "coordination of benefit" (COB) arrangement.
  • Claim Service Line Item Patient Responsibility Amount -- The amount determined by a plan to be owed by the patient for a claim service line item.
  • Claim Service Line Item Patient Paid Amount -- The amount paid by the patient for a claim service line item.

• 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
• service_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] Professional Claim Service Line Items, Precursor 1 (All Source Records): One record per non-reversed professional claim service line item