line_item

Information about a line item for a health, dental, prescription drug, etc. claim

Primary Key:

• claim_id
• claim_line_item_index

Foreign Keys:

• ada_cdt_id => ada_cdt_lookup.ada_cdt_id
• claim_id => claim.claim_id
• cpt_id => cpt_lookup.cpt_id
• hcpcs_id => hcpcs_lookup.hcpcs_id

Indexes:

• line_item_ada_cdt_id_idx - ada_cdt_id
• line_item_claim_id_idx - claim_id
• line_item_cpt_id_idx - cpt_id
• line_item_hcpcs_id_idx - hcpcs_id

Column	Data Type	Nullable	Indexed	Description
claim_id	bigint	No	Yes	-
line_number	text	No	No	Number assigned for differentiation within a transaction set (from LX01)
rev_code	text	No	No	Service line revenue code (from SV201)
procedure_type	product_service_id_type	Yes	No	Describes the type of service such as HCPCS, ADA code, HIPPS code, etc. (From SV101_01, SV202_01, SV301_01)
procedure_code	text	No	No	Product or service identifier (from SV101_02, SV202_02, SV301_02)
procedure_modifier_list	text[]	Yes	No	Up to four modifiers. This identifies special circumstances related to the performance of the service, as defined by trading partners (from SV101_03-06, SV202_03-06, SV301_03-06)
procedure_description	text	No	No	Free form description of the procedure (from SV101_07, SV202_07, SV301_07)
billed_amount	numeric	Yes	No	Amount billed (from SV102, SV203, SV302)
quantity	numeric	Yes	No	Service unit count (from SV104, SV205 [with unit code UN], and SV306)
place_of_service	text	No	No	Place of service code (from SV105)
facility_non_covered_amount	numeric	Yes	No	Line item denied or non-covered charge amount (from SV207)
dental_oral_cavity_designation_list	text[]	Yes	No	Describes the quadrant or arch and area of the oral cavity when not uniquely defined by the procedure code (From SV304)
dme_length_of_medical_necessity	numeric	Yes	No	Length of medical treatment required (From SV503)
dme_rental_price	numeric	Yes	No	DME rental price (From SV504)
dme_purchase_price	numeric	Yes	No	DME purchase price (From SV505)
dme_rental_unit_frequency	text	No	No	DME rental billing frequency (From SV506)
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)
service_date_from	date	Yes	No	Service date start (from DTP qualifier 472)
service_date_through	date	Yes	No	Service date end (from DTP qualifier 472)
last_seen_date	date	Yes	No	Date last seen (From DTP 304)
initial_treatment_date	date	Yes	No	Date of initial treatment (From DTP 454)
line_item_provider_control_number	text	No	No	Provider's unique line item reference number (From REF 6R)
clia_number	text	No	No	Clinical Lab number (From REF X4)
drug_ndc	text	No	No	National Drug Code (From LIN02)
drug_units	unit_type	Yes	No	Drug measurement unit (From CTP05)
drug_quantity	numeric	Yes	No	Drug unit quantity (From CTP04)
drug_link_sequence_number	text	No	No	Provider assigned number for piecing together drug components (From REF VY)
drug_prescription_number	text	No	No	Prescription number which can be used to piece together all components of a drug (From REF XZ)
data_error_list	text[]	Yes	No	-
claim_line_item_index	smallint	No	Yes	Index of the line item within the claim. This may be used to differentiate between multiple line items within a claim when the line_number is not unique (non-EDI)
hcpcs_id	bigint	Yes	Yes	Links to the HCPCS code for the line item
cpt_id	bigint	Yes	Yes	Links to the CPT code for the line item
ada_cdt_id	bigint	Yes	Yes	Links to the ADA/CDT code for the line item
tpa_network_identifier	text	No	No	Network identifier assigned by the TPA (non-EDI)
tpa_network_name	text	No	No	Network name assigned by the TPA (non-EDI)
tpa_network_status	text	No	No	Network status according to the TPA (non-EDI)
adjudication_date	date	Yes	No	-
payment_limit	numeric	Yes	No	The max amount a provider can accept as payment for a line item. Under Medicare this is called the limiting charge (participating providers must accept Medicare as full payment, non-participating providers must accept 109.25% of Medicare, but opt-out providers have no limits on what they must accept as payment). A payment limit is usually enforced under a contract, but RBP and other baseline-based programs can also establish a payment limit through other means. A limiting charge is an important tool to protect patients from egregious charges even when a line item is denied coverage. See https://www.medicareresources.org/glossary/limiting-charge/. Payment Limit + Billed Adjustment = Billed
billed_adjustment	numeric	Yes	No	Adjustments to the billed charge to get to the established payment limit for the line item. Payment Limit + Billed Adjustment = Billed
allowed_amount	numeric	Yes	No	Amount covered by the plan for this line item. Note that this includes both plan and member responsibility portions (e.g. copay, coinsurance, deductible). Allowed + Not covered = Payment Limit
not_covered_amount	numeric	Yes	No	Amount not covered by the plan for this line item. Allowed + Not covered = Payment Limit
allowed_adjustment_amount	numeric	Yes	No	Adjustments to the allowed amount such as payment discounts, etc. Allowed Adjustment + Plan Payment + COB Paid + Copay + Coinsurance + Deductible = Allowed
plan_payment_amount	numeric	Yes	No	Amount to be paid by the plan for this line item. Allowed Adjustment + Plan Payment + COB Paid + Copay + Coinsurance + Deductible = Allowed
cob_paid_amount	numeric	Yes	No	Amount paid by another plan for this line item. Allowed Adjustment + Plan Payment + COB Paid + Copay + Coinsurance + Deductible = Allowed
copay_amount	numeric	Yes	No	A fixed out-of-pocket amount paid by a member for covered services. Allowed Adjustment + Plan Payment + COB Paid + Copay + Coinsurance + Deductible = Allowed
coinsurance_amount	numeric	Yes	No	The percentage of covered health costs that a member is responsible for paying after meeting their deductible. Allowed Adjustment + Plan Payment + COB Paid + Copay + Coinsurance + Deductible = Allowed
deductible_amount	numeric	Yes	No	The amount a member must pay for covered health services before their health plan begins to pay. Allowed Adjustment + Plan Payment + COB Paid + Copay + Coinsurance + Deductible = Allowed
payment_identification_code	text	Yes	No	Identifier for the payment transaction. This could be an EFT number, check number, etc.
payment_method_type	payment_method_type	Yes	No	The method used to make the payment. This could be EFT, check, etc.
payment_date	date	Yes	No	The date the payment was made
payment_to_provider	numeric	Yes	No	Payment made to a provider by the plan. A negative amount is a payment from the provider to the plan
payment_to_member	numeric	Yes	No	Payment made to a member by the plan. A negative amount is a payment from the member to the plan
anesthesia_minutes	numeric	Yes	No	Minutes of anesthesia administration (from SV104, SV205, SV306 with unit code MJ)
days	numeric	Yes	No	Number of days (from SV104, SV205, SV306 with unit code DA)
diagnosis_code_pointers	smallint[]	Yes	No	A 1-based array of diagnosis code pointers. Join to 0-based claim_diagnosis.claim_diagnosis_index for details (from SV107, SV311)
is_emergency_professional	boolean	Yes	No	Emergency-related indicator (from SV109)
is_epsdt_professional	boolean	Yes	No	Indicates whether claim is EPSDT referral (from SV111)
is_family_planning_professional	boolean	Yes	No	Family planning involvement indicator (from SV112)
is_copay_exempt	boolean	Yes	No	Patient is exempt from co-pay (from SV115, SV308)
dental_prosthesis_crown_or_inlay_placement	dental_prosthesis_crown_or_inlay_placement_type	Yes	No	Reports the placement type for the dental work (From SV305)
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, CRC03/4/5)
ambulance_conditions_not_applicable	text[]	Yes	No	Ambulance certification of not applicable patient conditions (From CRC01:07, CRC02:N, CRC03/4/5)
ambulance_patient_count	smallint	Yes	No	Number of patients transported by ambulance (From QTY PT)
dme_certification_type	certification_type	Yes	No	Type of DME certification (From CR301)
dme_months_needed	numeric	Yes	No	Time in months that DME equipment is needed (From CR303)
dme_conditions_applicable	text[]	Yes	No	DME certification of applicable patient conditions (From CRC01:07, CRC02:Y, CRC03/4)
dme_conditions_not_applicable	text[]	Yes	No	DME certification of non-applicable patient conditions (From CRC01:07, CRC02:N, CRC03/4)
dme_certification_date	date	Yes	No	Date of certification or recertification (From DTP 607)
is_provider_hospice_employed	boolean	Yes	No	Indicate whether provider is employed by a hospice (From CRC01:70, CRC02:Y)
prescription_date	date	Yes	No	Date of prescription (From DTP 471)
begin_therapy_date	date	Yes	No	Begin date of therapy (often DME related) (From DTP 463)
last_certification_date	date	Yes	No	Date of last certification (often DME related) (From DTP 461)
most_recent_hemoglobin_or_hematocrit_date	date	Yes	No	Date of most recent hemoglobin or hematocrit test (From DTP 738)
most_recent_serum_creatine_date	date	Yes	No	Date of most recent serum creatine test (From DTP 739)
shipped_date	date	Yes	No	Date shipped (From DTP 011)
last_x_ray_date	date	Yes	No	Date of last x-ray (From DTP 455)
estimated_prior_placement_date	date	Yes	No	Estimated date of prior dental work placement (From DTP 139)
prior_placement_date	date	Yes	No	Date of prior dental work placement (From DTP 441)
appliance_placement_date	date	Yes	No	Date of orthodontic applicance placement (From DTP 452)
replacement_date	date	Yes	No	Date of orthodontic applicance was replaced (From DTP 446)
treatment_start_date	date	Yes	No	Date of initial impression or preparation for a crown or denture (From DTP 196)
treatment_completion_date	date	Yes	No	Date of course of treatment was completed (From DTP 198)
obstetric_anesthesia_additional_units	numeric	Yes	No	Used to report additional complexity beyond the normal services (From QTY FL)
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)
repriced_line_item_number	text	No	No	Line number according to the repricing organization or other intermediary (from REF 9A or 9B)
adjusted_repriced_line_number	text	No	No	Adjusted line number according to the repricing organization or other intermediary (from REF 9C or 9D)
line_item_prior_authorization_number	text	No	No	Prior authorization number for primary payer [non-destination payer not supported] (from REF G1)
mammography_certification_number	text	No	No	Mammography certification number for a certified provider (from REF EW)
referring_clia_number	text	No	No	Referring clinical Lab number (From REF F4)
immunization_batch_number	text	No	No	Immunization batch number (From REF BT)
referral_number	text	No	No	Referral number for primary payer [non-destination payer not supported] (From REF 9F)
predetermination_identification	text	No	No	Predetermination of benefits identification for primary payer [non-destination payer not supported] (from REF G3)
sales_tax_amount	numeric	Yes	No	Sales tax (From AMT T)
service_tax_amount	numeric	Yes	No	Goods and services tax (From AMT GT)
facility_tax_amount	numeric	Yes	No	Facility tax (From AMT N8)
postage_amount	numeric	Yes	No	Postage amount (From AMT F4)
purchased_service_provider_identifier	text	Yes	No	Purchased service provider identifier (From PS101)
purchased_service_provider_charge_amount	numeric	Yes	No	Purchased service provider charge amount (From PS102)
reprice_methodology	text	No	No	From HCP01
reprice_allowed_amount	numeric	Yes	No	From HCP02
reprice_savings_amount	numeric	Yes	No	From HCP03
reprice_organization_id	text	No	No	From HCP04
reprice_per_diem_or_flat_rate_amount	numeric	Yes	No	From HCP05
reprice_approved_rev_code	text	No	No	From HCP06
reprice_approved_procedure_qualifier	text	No	No	From HCP09
reprice_approved_procedure_code	text	No	No	From HCP10
reprice_approved_service_units	text	No	No	-
reprice_approved_service_qty	numeric	Yes	No	From HCP12
reprice_reject_reason_code	text	No	No	From HCP13
reprice_policy_compliance_code	text	No	No	From HCP14
reprice_exception_code	text	No	No	From HCP15
medical_necessity_form_qualifier	code_list_qualifier_type	Yes	No	Industry code type (From LQ01)
medical_necessity_form_identifier	text	Yes	No	Industry code identifier (From LQ02)