URSA-CORE-915: Conflicting Claim Header and Line Financials

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 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

• Data Model Keys

  • Claim ID
  • Patient ID
  • Payor ID
  • Plan ID
  • Document ID
  • Source ID

• Date Fields

  • Claim Covered Start Date
  • 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)

• Financial Fields

  • Claim Allowed Amount
  • Claim Plan Paid Amount
  • Claim COB Paid Amount
  • Claim Patient Responsibility Amount
  • Claim Patient Paid Amount

• 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

• Metadata Fields

  • Is Service Line Item Financial Data Coverage from Header

• Measure Fields

  • Denominator