claim_repricing

Results of a pricing request

Primary Key:

• claim_repricing_id

Foreign Keys:

• allowed_repricing_code => claim_repricing_code_lookup.repricing_code
• medicare_repricing_code => claim_repricing_code_lookup.repricing_code
• medicare_source => medicare_source_lookup.medicare_source

Indexes:

• claim_repricing_allowed_repricing_code_idx - allowed_repricing_code
• claim_repricing_medicare_repricing_code_idx - medicare_repricing_code
• claim_repricing_medicare_source_idx - medicare_source

Column	Data Type	Nullable	Indexed	Description
claim_repricing_id	bigint	No	Yes	-
medicare_amount	numeric	Yes	No	The amount Medicare would pay for the service
allowed_amount	numeric	Yes	No	The allowed amount based on a contract or RBP pricing
medicare_repricing_code	text	Yes	Yes	Explains the methodology used to calculate Medicare (MED or IFO)
medicare_repricing_note	text	No	No	Note explaining approach for pricing or reason for error
network_code	text	No	No	The network code used for pricing (is placed into HCP04)
allowed_repricing_code	text	Yes	Yes	Explains the methodology used to calculate allowed amount (CON, RBP, SCA, or IFO)
allowed_repricing_note	text	No	No	Note explaining approach for pricing or reason for error
medicare_std_dev	numeric	Yes	No	Standard deviation of the estimated Medicare amount (estimates service only)
medicare_source	text	Yes	Yes	Source of the Medicare amount (e.g. physician fee schedule, OPPS, etc.)
pricer_result	text	No	No	Pricer return details
inpatient_drg	text	No	No	Diagnosis Related Group (DRG) code used to price the claim
inpatient_federal_drg_amount	numeric	Yes	No	Federal DRG rate (excludes outliers and any hospital-specific adjustments)
inpatient_passthrough_amount	numeric	Yes	No	Per diem amount to cover capital-related costs, direct medical education, and other costs
inpatient_outlier_amount	numeric	Yes	No	Payment for high cost cases
inpatient_indirect_medical_education_amount	numeric	Yes	No	Payment for teaching hospitals
inpatient_disproportionate_share_amount	numeric	Yes	No	Payment for hospitals with a high number of low-income patients
inpatient_uncompensated_care_amount	numeric	Yes	No	Payment for patients who are unable to pay for their care
inpatient_readmission_adjustment_amount	numeric	Yes	No	Adjustment for hospitals with high readmission rates
inpatient_value_based_purchasing_adjustment_amount	numeric	Yes	No	Adjustment for hospitals based on quality measures
inpatient_wage_index	numeric	Yes	No	Wage index used for geographic adjustment
outpatient_outlier_amount	numeric	Yes	No	Adjustment for high cost cases
outpatient_first_passthrough_drug_offset_amount	numeric	Yes	No	Amount built into the APC payment for certain drugs
outpatient_second_passthrough_drug_offset_amount	numeric	Yes	No	Amount built into the APC payment for certain drugs
outpatient_third_passthrough_drug_offset_amount	numeric	Yes	No	Amount built into the APC payment for certain drugs
outpatient_first_device_offset_amount	numeric	Yes	No	Amount built into the APC payment for certain devices
outpatient_second_device_offset_amount	numeric	Yes	No	Amount built into the APC payment for certain devices
outpatient_full_or_partial_device_credit_offset_amount	numeric	Yes	No	Credit for devices that are supplied for free or at a reduced cost
outpatient_terminated_device_procedure_offset_amount	numeric	Yes	No	Credit for devices that are not used due to a terminated procedure
outpatient_wage_index	numeric	Yes	No	Wage index used for geographic adjustment
provider_ccn	text	No	No	CMS Certification Number for the facility
provider_mac	integer	Yes	No	Medicare Administrative Contractor number
provider_locality	smallint	Yes	No	Geographic locality number used for pricing
provider_geographic_cbsa	bigint	Yes	No	The Core Based Statistical Area (CBSA) that the provider is located in
provider_state_cbsa	integer	Yes	No	The Core Based Statistical Area (CBSA) that the provider's state is located in
provider_rural_indicator	rural_indicator_type	Yes	No	Indicates whether provider is Rural, Super Rural, or Urban
provider_specialty_type	text	No	No	Medicare provider specialty type
provider_hospital_type	hospital_type	Yes	No	Type of hospital
hcp_deny_code	text	Yes	No	The deny code that will be placed into the HCP13 data element for EDI 837 claims
claim_edit_overall_disposition	text	No	No	Overall explanation of why the claim edit failed
claim_edit_rejection_disposition	text	No	No	Explanation of why the claim was rejected
claim_edit_denial_disposition	text	No	No	Explanation of why the claim was denied
claim_edit_return_to_provider_disposition	text	No	No	Explanation of why the claim should be returned to provider
claim_edit_suspension_disposition	text	No	No	Explanation of why the claim was suspended
line_item_edit_rejection_disposition	text	No	No	Explanation of why the claim was rejected
line_item_edit_denial_disposition	text	No	No	Explanation of why the claim was denied
claim_edit_rejection_reasons	text[]	No	No	Detailed reason(s) describing why the claim was rejected
claim_edit_denial_reasons	text[]	No	No	Detailed reason(s) describing why the claim was denied
claim_edit_return_to_provider_reasons	text[]	No	No	Detailed reason(s) describing why the claim should be returned to the provider
claim_edit_suspension_reasons	text[]	No	No	Detailed reason(s) describing why the claim was suspended
line_item_edit_rejection_reasons	text[]	No	No	Detailed reason(s) describing why the line item was rejected
line_item_edit_denial_reasons	text[]	No	No	Detailed reason(s) describing why the line item was denied
edit_error	text	No	No	The details of a claim edit error that occurred
price_config_price_zero_billed	boolean	No	No	Price claims with zero billed amounts (default is false)
price_config_is_commercial	boolean	No	No	Use commercial code crosswalks from commercial codes Medicare won't pay for to substitute codes they do pay for (e.g. 99201 to G0463)
price_config_disable_cost_based_reimbursement	boolean	No	No	Disable cost-based reimbursement for line items paid as a percent of cost.
price_config_use_commercial_synthetic_for_not_allowed	boolean	No	No	Use a synthetic Medicare price for line-items that are not allowed by Medicare
price_config_use_drg_from_grouper	boolean	No	No	Always use the DRG from the inpatient grouper
price_config_use_best_drg_price	boolean	No	No	Use the best DRG price between the price on the claim and the price from the grouper
price_config_override_threshold	numeric	No	No	Allow the pricer flexibility to override NCCI edits and other overridable errors and return a price
price_config_include_edits	boolean	No	No	Include edit details in the response
price_config_continue_on_edit_fail	boolean	No	No	Continue to price the claim even if there are edit failures
price_config_continue_on_provider_match_fail	boolean	No	No	Continue with a average provider for the geographic area if the provider cannot be matched
price_config_disable_machine_learning_estimates	boolean	No	No	Disable machine learning estimates (applies to estimates only)
price_config_assume_impossible_anesthesia_units_are_minutes	boolean	No	No	Divide impossible anesthesia units by 15 (max of 96 anesthesia units per day) (default is false)
price_config_fallback_to_max_anesthesia_units_per_day	boolean	No	No	Fallback to the maximum anesthesia units per day (default is false which will error if there are more than 96 anesthesia units per day)
error	text	No	No	The details of an error that occurred
price_config_contract_ruleset	text	No	No	The name of the ruleset used for contract pricing
price_config_allow_partial_results	boolean	No	No	Return partially repriced claims. This can be useful to get pricing on non-erroring line items, but should be used with caution (default is false)
inpatient_new_technology_amount	numeric	Yes	No	Payment for new medical technologies
inpatient_hospital_acquired_condition_adjustment_amount	numeric	Yes	No	Adjustment for hospitals with high rates of hospital-acquired conditions
inpatient_low_volume_adjustment_amount	numeric	Yes	No	Adjustment for hospitals with low patient volumes
inpatient_electronic_health_record_adjustment_amount	numeric	Yes	No	Adjustment for hospitals that have adopted electronic health records
inpatient_bundle_adjustment_amount	numeric	Yes	No	Adjustment for bundled payments
rendering_provider_specialty_type	text	No	No	Medicare specialty type for the rendering provider