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

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

Published Fields

• Data Model Keys

  • Document ID
  • Patient ID
  • Billing Provider ID
  • Payor ID
  • Plan ID
  • Source ID
  • Primary Encounter ID

• Date Fields

  • Document Effective Date
  • 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

  • Ursa Setting Tier 1 Description
  • Billing Provider Description
  • CMS Type of Bill Code
  • CMS Place of Service Code
  • CMS Place of Service Description

• Insurance Fields

  • Payor Description
  • Plan Description
  • Claim Financial Class Description
  • Medicare Benefit Type Category

• Clinical Services Fields

  • Ursa Service Type Tier 1 Description
  • HCPCS Code
  • HCPCS Description
  • CMS Revenue Center Code
  • CMS Revenue Center Description
  • HCPCS AHRQ CCS Single-Level Procedure Category Code
  • HCPCS AHRQ CCS Single-Level Procedure Category Description
  • HCPCS RBCS Code
  • HCPCS RBCS Category Code
  • HCPCS RBCS Category Description
  • HCPCS RBCS Subcategory Code
  • HCPCS RBCS Subcategory Description
  • HCPCS RBCS Family Code
  • HCPCS RBCS Family Description

• Medication Fields

  • NDC Code
  • Label Description

• Diagnosis Fields

  • Principal Diagnosis ICD-10-CM Code

• Billing and Claims Fields

  • Document Type Category
  • Claim Class Category
  • Is Claim Class Institutional
  • Is Claim Class Professional
  • Is Claim Class Pharmacy

• Financial Fields

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

• Measure Fields

  • Denominator