[SO/URSA-CORE] Claim Aggregator

Object Description

One record per institutional, professional, or pharmacy claim (header) record. Includes open, paid, and denied claims.

Metadata

• Table Name: ursa.so_ursa_core_fin_001
• Layer: SYNTHETIC_OBJECT
• Object Type: Integrator
• Temporal Class: Event
• Case ID: Claim ID
• Event Date: Claim Covered Start Date
• Primary Key: Claim 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)
  • 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.
  • 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.

• 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.
  • 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.
  • Claim Calendar Year Start Date
  • Claim Calendar Quarter Start Date
  • Claim Calendar Month Start Date

• Provider Fields

  • Billing Provider Description -- The natural language description of the billing provider. (See also [URSA-CORE] Billing Provider)

• Insurance Fields

  • 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)
  • Is Claim Financial Class Commercial -- Indicates the financial class of the claim or plan is commercial. (See also [URSA-CORE] Financial Class)
  • Is Claim Financial Class Medicare FFS -- Indicates the financial class of the claim or plan is Medicare fee-for-service (FFS). (See also [URSA-CORE] Financial Class)
  • Is Claim Financial Class Medicare Advantage -- Indicates the financial class of the claim or plan is Medicare Advantage. (See also [URSA-CORE] Financial Class)
  • Is Claim Financial Class Medicaid -- Indicates the financial class of the claim or plan is Medicaid (See also [URSA-CORE] Financial Class)
  • Is Claim Financial Class Other -- Indicates the financial class of the claim or plan is something other than commercial, Medicare FFS (fee-for-service), Medicare Advantage, or Medicaid. (See also [URSA-CORE] Financial Class)
  • Is Medicare Part A -- Indicates that the coverage for this claim or bill is provided by Medicare Part A.
  • 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.
  • Is Medicare Part D -- Indicates that the coverage for this claim or bill is provided by Medicare Part D.
  • Medicare Benefit Type Category

• Clinical Services Fields

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

• 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.
  • AHFS Therapeutic Class Tier 1 Description -- The natural language description of the first-tier category within the AHFS Therapeutic Classification System that the medication is assigned to. (See also [URSA-CORE] AHFS Pharmacologic-Therapeutic Classification System)
  • AHFS Therapeutic Class Tier 2 Description -- The natural language description of the second-tier category within the AHFS Therapeutic Classification System that the medication is assigned to. (See also [URSA-CORE] AHFS Pharmacologic-Therapeutic Classification System)

• Diagnosis Fields

  • Principal Diagnosis ICD-9-CM Code -- The ICD-9-CM diagnosis code documented as the principal diagnosis for a claim, bill, encounter, etc. (See also [URSA-CORE] Diagnosis ICD-9-CM Code)
  • Principal Diagnosis ICD-9-CM Description -- The natural language description of the Principal Diagnosis ICD-9-CM Code. (See also [URSA-CORE] Principal Diagnosis ICD-9-CM Code)
  • Principal Diagnosis ICD-10-CM Code -- The ICD-10-CM diagnosis code documented as the principal diagnosis for a claim, bill, encounter, etc.
  • Principal Diagnosis ICD-10-CM Description -- The natural language description of the Principal Diagnosis ICD-10-CM Code. (See also [URSA-CORE] Principal Diagnosis ICD-10-CM Code)
  • Principal Diagnosis AHRQ CCS Diagnosis Category Tier 1 Description
  • Principal Diagnosis AHRQ CCS Diagnosis Category Tier 2 Description

• Billing and Claims Fields

  • Claim Class Category
  • 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.
  • Is Claim Processed Status Open -- Indicates that the claim has been received but not yet paid or denied.
  • Is Claim Processed Status Denied -- Indicates the claim has been denied.
  • Is Claim Processed Status Paid -- Indicates that the claim has completed processing without denial, with any outstanding balance paid.

• 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.

• 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
• payor_id → ursa.no_ursa_core_struct_004.payor_id
• plan_id → ursa.no_ursa_core_struct_005.plan_id
• document_id → ursa.so_ursa_core_pat_001.document_id