claim

Information about a healthcare or prescription drug claim

Primary Key:

• claim_id

Foreign Keys:

• ambulance_dropoff_address_id => address_seen.address_id
• ambulance_pickup_address_id => address_seen.address_id
• claim_member_id => claim_member.claim_member_id
• pay_to_plan_id => claim_pay_to_plan.pay_to_plan_id
• trading_partner_submission_id => trading_partner_submission.trading_partner_submission_id

Indexes:

• claim_trading_partner_submission_id_idx - trading_partner_submission_id

Column	Data Type	Nullable	Indexed	Description
claim_id	bigint	No	Yes	-
claim_transaction_type	text	No	No	Type of transaction (from BHT06)
tpa_adjudication_method	adjudication_method_type	Yes	No	Method used by TPA to adjudicate a claim (non-EDI)
tpa_claim_status	text	No	No	Status of the claim according to the TPA (non-EDI)
patient_control_number	text	No	No	Identifier used to track a claim from creation by the health care provider through payment (from CLM01)
claim_billed_amount	numeric	Yes	No	The total amount of all submitted charges of service segments for this claim (from CLM02)
facility_type	text	No	No	Code identifying where services were, or may be, performed (from CLM05_01)
claim_type	claim_type	Yes	No	Type of healthcare claim such as dental, medical, short-term disability, etc. (non-EDI)
form_type	form_type	No	No	Identifies the form the claim was submitted on such as UB-04 or HCFA (from CLM05_02)
claim_frequency_type	text	No	No	Code specifying the frequency (i.e. sequence of the claim in its billing/payment lifecycle) of the claim (from CLM05_03)
provider_accept_assignment	boolean	Yes	No	Code indicating whether the provider accepts assignment (from CLM07)
patient_assigned_benefits	boolean	Yes	No	A 'Y' value indicates insured or authorized person authorizes benefits to be assigned to the provider; an 'N' value indicates benefits have not been assigned to the provider. (from CLM08)
release_of_information	boolean	Yes	No	Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations (from CLM09)
patient_signature_source	text	No	No	[Professional claims only] Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider (from CLM10)
related_cause_list	text[]	Yes	No	[Professional claims only] To identify one or more related causes and associated state or country information (from CLM11_01 through CLM11_01-02)
auto_accident_state	text	No	No	State where the auto accident occured for property & casualty claims (From CLM11_05 + REF LU)
auto_accident_country	text	No	No	Country where the auto accident occured on property & casualty claims (From CLM11_06)
delay_reason	text	No	No	Code indicating the reason why a request was delayed (from CLM20)
earliest_service_date	date	Yes	No	Earliest service date among services, or statement date if not found
latest_service_date	date	Yes	No	Latest service date among services, or statement date if not found
statement_date_from	date	Yes	No	Begin statement date (From DTP 434)
statement_date_through	date	Yes	No	End statement date (From DTP 434)
admit_date	date	Yes	No	Date patient was admitted to the facility for treatment (From DTP 435)
discharge_date_or_hour	date	Yes	No	Date (HCFA) or hour (UB-04) patient was discharged from the facility after treatment (From DTP 096)
initial_treatment_date	date	Yes	No	Date of the first treatment for the same condition as this claim (From DTP 454)
onset_of_symptoms_or_illness_date	date	Yes	No	Date of initial medical service or visit performed when different than date of service (From DTP 431)
accident_date	date	Yes	No	Date of accident (From DTP 439)
last_seen_date	date	Yes	No	Date last seen for the same condition of the claim (From DTP 304)
repricer_received_date	date	Yes	No	Date repricer received claim (From DTP 050)
tpa_received_date	date	Yes	No	Date TPA received claim (non-EDI)
tpa_processed_date	date	Yes	No	Date TPA processed claim (non-EDI)
facility_admission_type	text	No	No	Indicates the type of admission (from CL101)
facility_admission_source	text	No	No	Indicates the source of admission (e.g. point of origin) (from CL102)
facility_patient_status	text	No	No	Indicates patient status at the time of discharge (e.g. discharge status) (from CL103)
patient_amount_paid	numeric	Yes	No	Amount paid by patient (From AMT F5)
claim_number	text	No	No	Claim number according to the clearing house, van, or other intermediary (from REF D9)
payer_claim_number	text	No	No	Claim number according to the payer or other intermediary (from REF F8)
repriced_claim_number	text	No	No	Claim number according to the repricing organization or other intermediary (from REF 9A)
medical_record_number	text	No	No	Medical record number for the patient (from REF EA)
icn_number	text	No	No	Internal control number (non-EDI)
its_number	text	No	No	ITS number (non-EDI)
prior_authorization_number	text	No	No	Prior authorization number (from REF G1)
clia_number	text	No	No	CLIA lab performing lab services (from REF X4)
ambulance_transport_reason	ambulance_transport_reason_type	Yes	No	Reason for ambulance transport (from CR104)
ambulance_pickup_address_id	bigint	Yes	No	Ambulance pickup location (From NM1 PW loop)
ambulance_dropoff_address_id	bigint	Yes	No	Ambulance dropoff location (From NM1 45 loop)
condition_list	text[]	Yes	No	NUBC condition codes (From HI BG)
treatment_code_list	text[]	Yes	No	NUBC treatment codes (From HI TC)
reprice_methodology	text	No	No	Code specifying pricing methodology at which the claim has been priced or repriced (from HCP01)
reprice_allowed_amount	numeric	Yes	No	Allowed amount (From HCP02)
reprice_savings_amount	numeric	Yes	No	Savings amount (From HCP03)
reprice_organization_id	text	No	No	Code identifying the organization that has repriced the claim (from HCP04)
reprice_per_diem_or_flat_rate_amount	numeric	Yes	No	Per diem or flat rate amount (From HCP05)
reprice_approved_drg_or_apg_code	text	No	No	Code specifying the approved Diagnosis Related Group or Ambulatory Patient Group (from HCP06)
reprice_approved_drg_or_apg_amount	numeric	Yes	No	Approved DRG or APG amount (From HCP07)
reprice_approved_inpatient_days	numeric	Yes	No	Approved inpatient days (From HCP12)
reprice_reject_reason	text	No	No	Code assigned by issuer to identify reason for rejection (from HCP13)
reprice_policy_compliance	text	No	No	Code specifying policy compliance (from HCP14)
reprice_exception	text	No	No	Code specifying the exception reason for consideration of out-of-network health care services (from HCP15)
data_error_list	text[]	Yes	No	-
property_and_casualty_claim_nbr	text	No	No	Property and Casualty Claim Number (from Subscribers's REF Y4)
claim_member_id	bigint	No	No	Information needed to identify the patient (from Loop 2000A and 2000B)
trading_partner_submission_id	bigint	No	Yes	Trading partner file submission details
pay_to_plan_id	bigint	Yes	No	Links to the plan requesting subrogation payment. Rarely used (From Loop 2010AC)
patient_death_date	date	Yes	No	Date of patient death (From PAT06)
patient_is_pregnant	yes_no_response_type	Yes	No	Indicates whether patient is pregnant (From PAT09)
acute_manifestation_date	date	Yes	No	Date of acute manifestation of a chronic condition (From DTP 453)
last_menstrual_period_date	date	Yes	No	Date of last menstrual period (From DTP 484)
last_x_ray_date	date	Yes	No	Date of last x-ray (From DTP 455)
prescription_date	date	Yes	No	Date of hearing or vision prescription (From DTP 471)
disability_date	date	Yes	No	Start and end date of disability (From DTP 314)
initial_disability_period_start_date	date	Yes	No	Date disability period began (From DTP 360)
initial_disability_period_end_date	date	Yes	No	Date disability period ended (From DTP 361)
last_worked_date	date	Yes	No	Date last worked (From DTP 297)
return_to_work_date	date	Yes	No	Date authorized to return to work (From DTP 296)
assumed_care_start	date	Yes	No	Date post-operative care began (From DTP 090)
relinquished_care_date	date	Yes	No	Date post-operative care ended (From DTP 091)
first_visit_or_consultation_date	date	Yes	No	Date of first visit to provider for this condition (From DTP 444)
orthodontic_treatment_months_total	numeric	Yes	No	Total months of orthodontic treatment (from DN101)
orthodontic_treatment_months_remaining	numeric	Yes	No	Remaining months of orthodontic treatment (from DN102)
contract_type	contract_type	Yes	No	Contract type (From CN101)
contract_amount	numeric	Yes	No	Contract amount (From CN102)
contract_billed_percentage	numeric	Yes	No	Contract billed percentage (From CN103)
contract_identification_code	text	Yes	No	Contract identification code (From CN104)
contract_term_discount_percent	text	Yes	No	Percentage discount available if paid before the discount due date (From CN105)
contract_version_identifier	text	Yes	No	Contract version identifier (From CN106)
estimated_patient_responsibility	numeric	Yes	No	Estimated patient responsibility (From AMT F3)
predetermination_identification	text	No	No	Predetermination of benefits identification number (from REF G3)
service_authorization_exception_code	text	No	No	Code to explain why authorization was not requested prior to care (from REF 4N)
mandatory_medicare_crossover_indicator	text	No	No	Describes when Medicare claim should crossover to Medigap or COB (from REF F5)
mammography_certification_number	text	No	No	Mammography certification number for a certified provider (from REF EW)
referral_number	text	No	No	Referral number (from REF 9F)
adjusted_repriced_claim_number	text	No	No	Adjusted claim number according to the repricing organization or other intermediary (from REF 9C)
investigational_device_exemption_number	text	No	No	FDA investigational device exemption number (from REF LX)
demonstration_project_identifier	text	No	No	Identifies demonstration or special project (from REF P4)
care_plan_oversight_number	text	No	No	Care plan oversight number (from REF 1J)
peer_review_organization_approval_number	text	No	No	Medical necessity approval from peer review organization (from REF G4)
ambulance_patient_weight_in_lbs	numeric	Yes	No	Weight of patient transported by ambulance (From CR101)
ambulance_transport_distance_in_miles	numeric	Yes	No	Distance patient was transported by ambulance (From CR105)
ambulance_round_trip_purpose_description	text	No	No	Describes why a round trip transport was required (from CR109)
ambulance_stretcher_purpose_description	text	No	No	Describes why a stretcher was required (From CR110)
ambulance_conditions_applicable	text[]	Yes	No	Ambulance certification of applicable patient conditions (From CRC01:07, CRC02:Y)
ambulance_conditions_not_applicable	text[]	Yes	No	Ambulance certification of non-applicable patient conditions (From CRC01:07, CRC02:N)
spinal_manipulation_condition	nature_of_condition_type	Yes	No	Spinal manipulation patient condition (From CR208)
spinal_manipulation_patient_condition_note1	text	Yes	No	Spinal manipulation patient condition description (From CR210)
spinal_manipulation_patient_condition_note2	text	Yes	No	Spinal manipulation patient condition description (From CR211)
is_homebound	boolean	Yes	No	Patient is homebound (From CRC01:75, CRC02:Y)
reprice_approved_revenue_code	numeric	Yes	No	Approved revenue code (From HCP08)
reprice_approved_service_quantity	numeric	Yes	No	Approved service quantity (From HCP12)
transaction_date	date	Yes	No	Date of the transaction (from BHT04)
patient_weight_in_kilograms	numeric	Yes	No	Patient Weight (from PAT08 or HI Value Code A8)
ambulance_patient_count	smallint	Yes	No	Number of patients in ambulance ride (From QTY PT)
ambulance_pickup_zip	text	Yes	No	Ambulance pickup ZIP code (From HI with HIxx_01=BE and HIxx_02=A0. This is the value required in CMS Internet Only Manual)
dme_certification_type	certification_type	Yes	No	Type of DME certification (From CR301)
dme_need_months	numeric	Yes	No	Length of time DME equipment is needed (From CR303)
dme_applicable_conditions	text[]	Yes	No	DME certification of applicable patient conditions (From CRC01:09, CRC02:Y)
dme_not_applicable_conditions	text[]	Yes	No	DME certification of not applicable patient conditions (From CRC01:09, CRC02:N)
rendering_provider_is_hospice_employee	boolean	Yes	No	Indicates whether rendering provider is an employee of the hospice (From CRC01:70, CRC02:Y or N)
vision_spectacle_lenses_applicable_conditions	text[]	Yes	No	Conditions that apply to spectacle lens claim (From CRC01:E1, CRC02:Y)
vision_spectacle_lenses_not_applicable_conditions	text[]	Yes	No	Conditions that do not apply to spectacle lens claim (From CRC01:E1, CRC02:N)
vision_spectacle_frames_applicable_conditions	text[]	Yes	No	Conditions that apply to spectacle frame claim (From CRC01:E3, CRC02:Y)
vision_spectacle_frames_not_applicable_conditions	text[]	Yes	No	Conditions that do not apply to spectacle frame claim (From CRC01:E3, CRC02:N)
vision_contacts_applicable_conditions	text[]	Yes	No	Conditions that apply to contact lens claim (From CRC01:E2, CRC02:Y)
vision_contacts_not_applicable_conditions	text[]	Yes	No	Conditions that do not apply to contact lens claim (From CRC01:E2, CRC02:N)
epsdt_referral_applicable_conditions	boolean	Yes	No	Conditions that apply to EPSDT referral claim (From CRC01:ZZ, CRC02:Y)
epsdt_referral_not_applicable_conditions	text[]	Yes	No	Conditions that do not apply to EPSDT referral claim (From CRC01:ZZ, CRC02:N)