Measure Description
Among medical claims with line-level financials, the percentage with conflicting header-level and aggregate line-level amounts for any of the following: Allowed Amount, Plan Paid Amount, COB Paid Amount, Patient Responsibility Amount, and Patient Paid Amount.
Metadata
- Measure Identifier: URSA-CORE-915
- Measure Type: Rate Measure
- Temporal Structure: Event
- Component Class: Normal-Form
- Denominator Case Field: Claim ID
- Target Direction: Down
Denominator Description
One per medical claim with line-level financials.
Numerator Description
One per qualifying denominator observation with conflicting header-level and aggregate line-level amounts for any of the following: Allowed Amount, Plan Paid Amount, COB Paid Amount, Patient Responsibility Amount, and Patient Paid Amount.
Published Fields
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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)
- 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 -- The internal database identifier (used, e.g., for joins and primary keys) for the document. (See also [URSA-CORE] Document)
- Source ID -- The identifier for the original source data system from which the current record originated.
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Date Fields
- Claim Covered Start Date -- The start date of services covered by a claim.
- Segment Start Date -- The start date of the reporting segment. (See also [URSA-CORE] Reporting Segment)
- Segment End Date -- The end date of the reporting segment. (See also [URSA-CORE] Reporting Segment)
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Financial Fields
- 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.
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Numerator Fields
- Is Conflicting Service Line Item Financial Data Coverage
- Is Conflicting Allowed Amount
- Is Conflicting Plan Paid Amount
- Is Conflicting COB Paid Amount
- Is Conflicting Patient Responsibility Amount
- Is Conflicting Patient Paid Amount
- Claim Allowed Amount from Lines
- Claim Plan Paid Amount from Lines
- Claim COB Paid Amount from Lines
- Claim Patient Responsibility Amount from Lines
- Claim Patient Paid Amount from Lines
- Maximum Is Service Line Item Financial Data Coverage from Lines
- Minimum Is Service Line Item Financial Data Coverage from Lines
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Metadata Fields
- Is Service Line Item Financial Data Coverage from Header
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Measure Fields
- Denominator