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

Column	Data Type	Nullable	Indexed	Description
claim_repricing_id	bigint	No	Yes	- Generated through expression:
medicare_amount	numeric	Yes	No	The amount Medicare would pay for the service Generated through expression:
allowed_amount	numeric	Yes	No	The allowed amount based on a contract or RBP pricing Generated through expression:
medicare_repricing_code	text	Yes	No	Explains the methodology used to calculate Medicare (MED or IFO) Generated through expression:
medicare_repricing_note	text	No	No	Note explaining approach for pricing or reason for error Generated through expression:
network_code	text	No	No	The network code used for pricing (is placed into HCP04) Generated through expression:
allowed_repricing_code	text	Yes	No	Explains the methodology used to calculate allowed amount (CON, RBP, SCA, or IFO) Generated through expression:
allowed_repricing_note	text	No	No	Note explaining approach for pricing or reason for error Generated through expression:
medicare_std_dev	numeric	Yes	No	Standard deviation of the estimated Medicare amount (estimates service only) Generated through expression:
medicare_source	text	Yes	No	Source of the Medicare amount (e.g. physician fee schedule, OPPS, etc.) Generated through expression:
pricer_result	text	No	No	Pricer return details Generated through expression:
inpatient_drg	text	No	No	Diagnosis Related Group (DRG) code used to price the claim Generated through expression:
inpatient_drg_amount	numeric	Yes	No	Amount Medicare would pay for the DRG Generated through expression:
inpatient_passthrough_amount	numeric	Yes	No	Per diem amount to cover capital-related costs, direct medical education, and other costs Generated through expression:
inpatient_outlier_amount	numeric	Yes	No	Additional amount paid for high cost cases Generated through expression:
inpatient_indirect_medical_education_amount	numeric	Yes	No	Additional amount paid for teaching hospitals Generated through expression:
inpatient_disproportionate_share_amount	numeric	Yes	No	Additional amount paid for hospitals with a high number of low-income patients Generated through expression:
inpatient_uncompensated_care_amount	numeric	Yes	No	Additional amount paid for patients who are unable to pay for their care Generated through expression:
inpatient_readmission_adjustment_amount	numeric	Yes	No	Adjustment amount for hospitals with high readmission rates Generated through expression:
inpatient_value_based_purchasing_amount	numeric	Yes	No	Adjustment for hospitals based on quality measures Generated through expression:
inpatient_wage_index	numeric	Yes	No	Wage index used for geographic adjustment Generated through expression:
outpatient_outlier_amount	numeric	Yes	No	Additional amount paid for high cost cases Generated through expression:
outpatient_first_passthrough_drug_offset_amount	numeric	Yes	No	Amount built into the APC payment for certain drugs Generated through expression:
outpatient_second_passthrough_drug_offset_amount	numeric	Yes	No	Amount built into the APC payment for certain drugs Generated through expression:
outpatient_third_passthrough_drug_offset_amount	numeric	Yes	No	Amount built into the APC payment for certain drugs Generated through expression:
outpatient_first_device_offset_amount	numeric	Yes	No	Amount built into the APC payment for certain devices Generated through expression:
outpatient_second_device_offset_amount	numeric	Yes	No	Amount built into the APC payment for certain devices Generated through expression:
outpatient_full_or_partial_device_credit_offset_amount	numeric	Yes	No	Credit for devices that are supplied for free or at a reduced cost Generated through expression:
outpatient_terminated_device_procedure_offset_amount	numeric	Yes	No	Credit for devices that are not used due to a terminated procedure Generated through expression:
outpatient_wage_index	numeric	Yes	No	Wage index used for geographic adjustment Generated through expression:
provider_ccn	text	No	No	CMS Certification Number for the facility Generated through expression:
provider_mac	integer	Yes	No	Medicare Administrative Contractor number Generated through expression:
provider_locality	smallint	Yes	No	Geographic locality number used for pricing Generated through expression:
provider_geographic_cbsa	bigint	Yes	No	The Core Based Statistical Area (CBSA) that the provider is located in Generated through expression:
provider_state_cbsa	integer	Yes	No	The Core Based Statistical Area (CBSA) that the provider's state is located in Generated through expression:
provider_rural_indicator	rural_indicator_type	Yes	No	Indicates whether provider is Rural, Super Rural, or Urban Generated through expression:
provider_specialty_type	text	No	No	Medicare provider specialty type Generated through expression:
provider_hospital_type	hospital_type	Yes	No	Type of hospital Generated through expression:
hcp_deny_code	text	Yes	No	The deny code that will be placed into the HCP13 data element for EDI 837 claims Generated through expression:
claim_edit_overall_disposition	text	No	No	Overall explanation of why the claim edit failed Generated through expression:
claim_edit_rejection_disposition	text	No	No	Explanation of why the claim was rejected Generated through expression:
claim_edit_denial_disposition	text	No	No	Explanation of why the claim was denied Generated through expression:
claim_edit_return_to_provider_disposition	text	No	No	Explanation of why the claim should be returned to provider Generated through expression:
claim_edit_suspension_disposition	text	No	No	Explanation of why the claim was suspended Generated through expression:
line_item_edit_rejection_disposition	text	No	No	Explanation of why the claim was rejected Generated through expression:
line_item_edit_denial_disposition	text	No	No	Explanation of why the claim was denied Generated through expression:
claim_edit_rejection_reasons	text[]	No	No	Detailed reason(s) describing why the claim was rejected Generated through expression:
claim_edit_denial_reasons	text[]	No	No	Detailed reason(s) describing why the claim was denied Generated through expression:
claim_edit_return_to_provider_reasons	text[]	No	No	Detailed reason(s) describing why the claim should be returned to the provider Generated through expression:
claim_edit_suspension_reasons	text[]	No	No	Detailed reason(s) describing why the claim was suspended Generated through expression:
line_item_edit_rejection_reasons	text[]	No	No	Detailed reason(s) describing why the line item was rejected Generated through expression:
line_item_edit_denial_reasons	text[]	No	No	Detailed reason(s) describing why the line item was denied Generated through expression:
edit_error	text	No	No	The details of a claim edit error that occurred Generated through expression:
price_config_price_zero_billed	boolean	No	No	Price claims with zero billed amounts (default is false) Generated through expression:
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) Generated through expression:
price_config_disable_cost_based_reimbursement	boolean	No	No	Disable cost-based reimbursement for line items paid as a percent of cost. Generated through expression:
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 Generated through expression:
price_config_use_drg_from_grouper	boolean	No	No	Always use the DRG from the inpatient grouper Generated through expression:
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 Generated through expression:
price_config_override_threshold	numeric	No	No	Allow the pricer flexibility to override NCCI edits and other overridable errors and return a price Generated through expression:
price_config_include_edits	boolean	No	No	Include edit details in the response Generated through expression:
price_config_continue_on_edit_fail	boolean	No	No	Continue to price the claim even if there are edit failures Generated through expression:
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 Generated through expression:
price_config_disable_machine_learning_estimates	boolean	No	No	Disable machine learning estimates (applies to estimates only) Generated through expression:
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) Generated through expression:
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) Generated through expression:
error	text	No	No	The details of an error that occurred Generated through expression:
price_config_contract_ruleset	text	No	No	The name of the ruleset used for contract pricing Generated through expression:
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) Generated through expression: