URSA-PHF-902: Registry of Claim Financials (Reduced Fields)

  • Published on Apr 23, 2026
  • 6 minute(s) read
Prev Next

Measure Description

This measure is designed specifically for validation exercises in comparing patient counts to reports provided by the entity generating the source data (e.g., the payor) and has only critical and validation fields published. One record per pharmacy claim, medical claim, or medical claim service line item with a non-zero allowed or paid amount.

Metadata

  • Measure Identifier: URSA-PHF-902
  • Measure Type: Registry
  • Temporal Structure: Event
  • Component Class: Normal-Form
  • Denominator Case Field: Document ID
  • Target Direction: None

Published Fields

  • Data Model Keys

    • Document ID -- The internal database identifier (used, e.g., for joins and primary keys) for the document. (See also [URSA-CORE] Document)
    • 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)
    • 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.
    • Source ID -- The identifier for the original source data system from which the current record originated.
    • Primary Encounter ID

  • Date Fields

    • Document Effective Date -- The most appropriate single date that events associated with the document occurred. For documents spanning multiple calendar days, the earliest date is typically used; Document Effective Start Date and Document Effective End Date can be used for a more precise range of dates, if necessary.
    • Document Effective Date Text YYYYMM
    • Document Effective First of Quarter Date
    • Document Effective Year
    • 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)

  • Validation Only Fields

    • Is Plan Paid <= 0
    • Is Zero Dollar Plan Paid Amount
    • Is Negative Plan Paid Amount
    • Is Claim without Ursa Category
    • Is Non-Specific Ursa Service Type
    • Is Non-Specific Ursa Setting
    • Is Claim not associated with any Ursa Encounter

  • Encounter Fields

    • Ursa Encounter Type Tier 1 Category

  • Provider Fields

    • Billing Provider Description -- The natural language description of the billing provider. (See also [URSA-CORE] Billing Provider)
    • CMS Type of Bill Code -- The standard CMS 3-digit Type of Bill (TOB) Code; 111 = Hospital Inpatient Admit Through Discharge, etc.
    • 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)
    • Ursa Setting Tier 1 Description

  • Insurance Fields

    • Payor Description
    • Plan Description
    • Claim Financial Class Description -- The natural language description of the financial class of a claim or plan. (A claim's financial class is inherited from its associated plan.) (See also [URSA-CORE] Financial Class)
    • Medicare Benefit Type Category -- A categorical value identifying whether the claim is a Medicare FFS or Medicare Advantage claim and, if known, what Medicare program component -- i.e., Part A, Part B, or Part D -- it is associated with. (See also [URSA-CORE] Is Medicare Part A, [URSA-CORE] Is Medicare Part B, [URSA-CORE] Is Medicare Part D)

  • 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 -- The natural language description of a HCPCS code. (See also [URSA-CORE] HCPCS Code)
    • CMS Revenue Center Code -- The standard CMS 4-digit Revenue Center code; e.g., 0001 = Total charge, etc. CMS Revenue Center codes should include leading zeros.
    • CMS Revenue Center Description -- The natural language description of a CMS Revenue Center code (See also [URSA-CORE] CMS Revenue Center Code)
    • Ursa Service Type Tier 1 Description
    • HCPCS AHRQ CCS Single-Level Procedure Category Code
    • HCPCS AHRQ CCS Single-Level Procedure Category Description
    • HCPCS RBCS Code -- The Restructured BETOS Category System (RBCS) identifier which is comprised of 6 characters. The first character identifies the category; the second character identifies the subcategory; the third, fourth, and fifth characters identify the family, and the sixth character identifies whether the service is a major procedure.
    • HCPCS RBCS Category Code -- Identified as the first character of the RBCS code, categories are the highest level of the taxonomy and represent broad concepts such as “procedures,” “tests,” and “imaging.” These groupings give shape to the overall structure of the taxonomy and help guide subsequent code assignments. (See also [URSA-CORE] RBCS Code)
    • HCPCS RBCS Category Description
    • HCPCS RBCS Subcategory Code -- Identified by the combined first and second characters of the RBCS code, subcategories are the mid-level of the taxonomy, further dividing categories into specific service groups or organ 7 systems. For example, the “procedures” category contains subcategories specific to organ systems, such as “breast,” “cardiovascular,” or “skin.” The tests category contains subcategories that are specific to test type, such as “anatomic pathology” and “pulmonary function.” (See also [URSA-CORE] RBCS Code)
    • HCPCS RBCS Subcategory Description
    • HCPCS RBCS Family Code -- Families represent the lowest level of the hierarchy and subdivide the subcategories into groups of HCPCS codes based on the similarity of the procedural approach. For example, the “digestive/gastrointestinal” subcategory of the “procedures” category contains families such as “cholecystectomy – laparoscopic” and “upper GI endoscopy.” The “anatomic pathology” subcategory of the “tests” category contains families such as “immunohistochemistry” and “surgical pathology examination.” Clinical and coding experts, as well as AMA CPT section and subsection headings, are the primary means by which similar HCPCS codes are grouped. The 2022 RBCS taxonomy includes 172 named families. It is important to note that while all HCPCS codes in the RBCS taxonomy are given a category and subcategory, not all HCPCS codes are assigned to a family. The RBCS code family development process begins by identifying the highest spending among non-anesthesia HCPCS codes that, when combined, account for 90% of total allowed spending in the claims data being reviewed for the current year. These high-spend HCPCS codes (referred to below as “start codes”) are used as starting points to build RBCS code families. (See also [URSA-CORE] RBCS Code)
    • HCPCS RBCS Family Description

  • Medication Fields

    • NDC Code -- The standard 11-digit National Drug Code; e.g., 00045012400 = Tylenol 500 mg.
    • Label Description -- Supplies the name given to the product by the manufacturer.

  • Diagnosis Fields

    • Principal Diagnosis ICD-10-CM Code -- The ICD-10-CM diagnosis code documented as the principal diagnosis for a claim, bill, encounter, etc.

  • Billing and Claims Fields

    • Document Type Category
    • Claim Class Category -- Identifies a record as associated with a professional, institutional, or pharmacy claim.
    • Is Claim Class Institutional -- Indicates the record is associated with an institutional claim or bill.
    • Is Claim Class Professional -- Indicates the record is associated with a professional claim or bill.
    • Is Claim Class Pharmacy -- Indicates the record is associated with a pharmacy claim.

  • Financial Fields

    • Document Allowed Amount
    • Document Plan Paid Amount
    • Document Patient Responsibility Amount
    • Document Patient Paid Amount

  • Measure Fields