Atomic Warehouse Model Data Model

Entity

Entity Claim Detail

Description

A request for reimbursement that a healthcare provider issues to a healthcare insurer in respect of services rendered to a patient who is a member of a health plan.

Attributes
Access Fee Amt
Accident Fault Attribution Code Sk
Adjusted Repriced Claim Reference Num
Administration Fee Amt
Advanced Technology Operating Allowance
Affiliated Claim Ind
Affiliated Plan Code Sk
Allowed Amt
Amount Applied to Benefit Limit
Amount Applied to Out-of-pocket Limit
Approved Amt
Attachment Transmission Code Sk
Attachment Type Code Sk
Audit Ind
Bill From Dt
Billing Form Code Sk
Bill To Dt
Capital Charge Amt
Claim Filing Indicator Code Sk
Claim Num
Claim Pricing Method Code Sk
Claim Recovery Strategy Code Sk
Claim Size Category Code Sk
Claim Sk
Claim Status Code Sk
Claim Status Reason Code Sk
Claim Status Ts
Claim Version Code Sk
Class Of Claim Code Sk
Clean Claim Receipt Dt
Clearinghouse Trace Num
CLIA Num
COB Amt
Contract Amt
Contract Code Num
Contract Pct
Contract Type Code Sk
Contract Version Num
Currency Code Sk
Decisions
Delay Reason Code Sk
Demonstration Project Num
Document Control Num
DRG Weighting
Dual Coverage Ind
Effective From Dt
Effective To Dt
EOB Requested Ind
Estimated Due Amt
Extraordinary Capital Allowance
Extreme Care Capital Allowance
Extreme Care Days Covered Cnt
Extreme Care Operating Allowance
FI Action Code Sk
Financial Intermediary Fee
Government Reduction Amt
HIPPS Code Sk
Home Plan Code Sk
Host Plan Code Sk
Incoming Ind
Incurred But Not Reported Ind
Indemnity Portion
In Plan Network Ind
Investigational Device Exemption Identifier Num
Last Worked Dt
Load Info Sk
Low Utilization Adjustment Code Sk
Medical Education Capital Allowance
Medical Education Operating Allowance
Medicare A Covered Months Cnt
Medicare B Covered Months Cnt
Medicare Buyin Months Covered Cnt
Medicare HMO Months Covered Cnt
Member Authorization Type Code Sk
Minimal Care Cost Capital Reduction
Minimal Care Cost Operating Reduction
National Capital Allowance
National Operating Allowance
One Pass Process Ind
Operating Charge Amt
Original Claim Num
Out of Area Financial Administration Fee Amt
Out of Area General Administration Fee Amt
Out of Area Surcharge Amt
Out-of-Network Reason Code Sk
Participation Agreement Code Sk
Patient Demographic Capital Allowance
Patient Demographic Operating Allowance
Patient Paid Amt
Payer Paid Amt
PPS Claim Code Sk
Pre-Authorization Exception Reason Code Sk
Prompt Payment Discount Amt
Property Casualty Claim Num
Provider Assignment Ind
Provider Capital Allowance
Provider Operating Allowance
Provider Signature Ind
Repriced Allowed Amt
Repriced Approved Ambulatory Patient Group Amt
Repriced Approved Ambulatory Patient Group Code Id
Repriced Claim Reference Num
Repriced Saving Amt
Reprice Exception Code Sk
Reprice Policy Compliance Code Sk
Reprice Rejection Reason Code Sk
Repricing Flat Rate Amt
Responsible Party Reason Code Sk
Retained Service Amt
Secondary Payer Pass-through Amt
Secondary Payment Ind
Service Authorization Exception Code Sk
Settlement Currency Code Sk
Signature Dt
Source Code Sk
Submission Clarification Type Code Sk
Subrogation Ind
Supporting Documentation Ind
Surcharge Amt
Tenant Sk
Term Discount Pct
Total Adjustment Units of Service
Total Claim Charge Amt
Total Cost
Total Member Liability Amt
Total Nonpayable Professional Fees Amt
Total Purchased Services Amt
Total Units of Services
Total Visits Rendered Cnt
Transaction Fee Amt
Type 4081 Claim Ind
Type Code Sk
Valid From Ts
Valid To Ts

Relationship
Claim Detail_Claim_FK

Primary Key
Claim Detail PK

Dependencies

Reverse Dependencies

Attribute Details

Access Fee Amt

Description	The fee charged by a host plan on a claim for making its negotiated provider fees available for out of area services that are rendered to a member of another health plan.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Accident Fault Attribution Code Sk

Description	Indicates how the blame for an accident related to a claim is allocated to the claimant.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Adjusted Repriced Claim Reference Num

Description	Identification number, assigned by a repricing organization, to identify an adjusted claim.
Data Type	Standards - Data Domains.ddm/Data Domains/Alphanumeric [VARCHAR(80)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Administration Fee Amt

Description	The administrative expense allowance for out-of-area claims that is based on the type of provider and group size.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Advanced Technology Operating Allowance

Description	The add-on operating payment amount paid to the healthcare provider in the context of this claim that is attributable to a treatment that uses new technologies.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Affiliated Claim Ind

Description	Indicates that the claim has been filed by a member for an out-of-area medical service such as a healthcare event rendered outside the service area of the healthcare insurer which enrolled the member. For example: 0 = In Area Claim 1 = Out-Of-Area Claim
Data Type	Standards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Affiliated Plan Code Sk

Description	A code that indicates the affiliation characteristics of the claim.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Allowed Amt

Description	The maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Amount Applied to Benefit Limit

Description	The portion of the claim health plan liability amount that is deductible from the member's benefit maximum amount.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Amount Applied to Out-of-pocket Limit

Description	The portion of the cost sharing amounts that are deductible from the member's out-of-pocket maximum amount.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Approved Amt

Description	Amount approved to be paid on claim.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Attachment Transmission Code Sk

Description	Indicates the timing, transmission method or format by which an attachment report is to be sent or has been sent. For example: Previously Submitted to Payer Certification Included in this Claim Narrative Segment Included in this Claim No Documentation is Required Not Specified
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Attachment Type Code Sk

Description	Specifies the type of attachment that is related to the claim.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Audit Ind

Description	Indicates whether the claim was audited. For example: 0 = Claim Not Audited 1 = Claim Audited
Data Type	Standards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Bill From Dt

Description	Earliest date of services billed for on the claim.
Data Type	Standards - Data Domains.ddm/Data Domains/Date [DATE]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Billing Form Code Sk

Description	NUBC 3 character Uniform Billing Claim Form Bill Type describing the type of medical facility and bill form.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Bill To Dt

Description	Last service date billed for on the claim.
Data Type	Standards - Data Domains.ddm/Data Domains/Date [DATE]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Capital Charge Amt

Description	Cost allocation against the claim in respect of the capital costs tied up in the organization's business.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Claim Filing Indicator Code Sk

Description	Identifies the type of claim or expected adjudication process. For example: Self-pay Central Certification Other Non-Federal Programs Preferred Provider Organization (PPO) Point of Service (POS) Exclusive Provider Organization (EPO) Indemnity Insurance Health Maintenance Organization (HMO) Medicare Risk Automobile Medical Blue Cross/Blue Shield Champus Commercial Insurance Co. Disability Health Maintenance Organization Liability Liability Medical Medicare Part B Medicaid Other Federal Program Title V Veteran Administration Plan Workers' Compensation Health Claim Mutually Defined
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Claim Num

Description	Number assigned by a processor to identify a claim.
Data Type	Standards - Data Domains.ddm/Data Domains/Alphanumeric [VARCHAR(80)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Claim Pricing Method Code Sk

Description	Classifies claim according to the method used to determine the allowed amounts relating to all medical services or products rendered.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Claim Recovery Strategy Code Sk

Description	Indicates in which way the modeled organization will try to recover the cost of the claim from a third party. For example: Legal action against third party.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Claim Size Category Code Sk

Description	A categorization of claims according to their monetary value. Typically, a banding approach is used to assign the claim to a claim size band, based on the amount of benefit that is requested, offered or paid.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Claim Sk

Description	Surrogate key for the anchor entity.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key Large [LONG]
Is Part Of PrimaryKey	true
Is Required	true
Is Derived	false
Is Surrogate Key	false

Claim Status Code Sk

Description	Indicates the state of the claim in the life cycle of adjudication.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Claim Status Reason Code Sk

Description	Indicates the reason for the current claim status.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Claim Status Ts

Description	The date and time the current claim status was established for this claim
Data Type	Standards - Data Domains.ddm/Data Domains/Timestamp [TIMESTAMP]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Claim Version Code Sk

Description	Classifies a submission cycle that a claim may have been involved in.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Class Of Claim Code Sk

Description	Categorization of claims according to the coverage component against which the claim belongs. It is used by the reservation department for determining the applicable reservation strategy.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Clean Claim Receipt Dt

Description	Date on which the complete and correct claim was received by the health plan. This date may reflect modifications and resubmissions by the claim filer and/or development (contacting the member or provider for required information) by a claims unit.
Data Type	Standards - Data Domains.ddm/Data Domains/Date [DATE]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Clearinghouse Trace Num

Description	Unique tracking number for the transaction assigned by a clearinghouse.
Data Type	Standards - Data Domains.ddm/Data Domains/Alphanumeric [VARCHAR(80)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

CLIA Num

Description	The CLIA Certificate of Waiver or the CLIA Certificate of Registration Identification Number assigned to the laboratory testing site that rendered the services on this claim. Used as a Pre-authorization number.
Data Type	Standards - Data Domains.ddm/Data Domains/Alphanumeric [VARCHAR(80)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

COB Amt

Description	The coordination of benefits amount.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount Large [DECIMAL(20,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Contract Amt

Description	A fixed monetary amount that pertains to the contract. It is required if the service amounts are different than the claim level amount.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Contract Code Num

Description	The specific insurance contract, established by the payer.
Data Type	Standards - Data Domains.ddm/Data Domains/Alphanumeric [VARCHAR(80)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Contract Pct

Description	The percentage of charges that are payable under the contract.
Data Type	Standards - Data Domains.ddm/Data Domains/Percentage [FLOAT(2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Contract Type Code Sk

Description	Indicates the contract type that is being claimed against. It is recommended that a contract type is always provided for capitated encounters. For example: Per Diem Variable Per Diem Flat Capitated Percent Other
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Contract Version Num

Description	Identification of additional or supplemental contract provisions or identification of a particular version or modification of payer contract.
Data Type	Standards - Data Domains.ddm/Data Domains/Alphanumeric [VARCHAR(80)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Currency Code Sk

Description	Indicates the currency used as the basis for all monetary amounts.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Decisions

Description	A free-text statement used to capture the decisions made by the healthcare insurer when assessing this claim. For example: A decision may be taken to grant coverage to a loyal customer, even though some of the coverage conditions are not fulfilled.
Data Type	Standards - Data Domains.ddm/Data Domains/Text Medium [VARCHAR(255)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Delay Reason Code Sk

Description	Indicates the cause of any discrepancy between planned and actual end dates.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Demonstration Project Num

Description	Identification number for a Medicare demonstration project.
Data Type	Standards - Data Domains.ddm/Data Domains/Alphanumeric [VARCHAR(80)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Document Control Num

Description	A reference number identifying this instance of the claim form.
Data Type	Standards - Data Domains.ddm/Data Domains/Alphanumeric [VARCHAR(80)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

DRG Weighting

Description	Factor applied to the standard cost for the diagnosis related group (DRG) with which the diagnosis is associated.
Data Type	Standards - Data Domains.ddm/Data Domains/Decimal 9 [DECIMAL(19,9)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Dual Coverage Ind

Description	Indicates that the claimed costs are covered by more than one insurance policy.
Data Type	Standards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Effective From Dt

Description	Establishes a period where a set of attributes are true according to the business.
Data Type	Standards - Data Domains.ddm/Data Domains/Date [DATE]
Is Part Of PrimaryKey	false
Is Required	true
Is Derived	false
Is Surrogate Key	false

Effective To Dt

Description	Ends a period of effectivity.
Data Type	Standards - Data Domains.ddm/Data Domains/Date [DATE]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

EOB Requested Ind

Description	Indicator of whether an explanation of benefits (EOB) is requested. For example: Yes No
Data Type	Standards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Estimated Due Amt

Description	Amount calculated to be owed by patient.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Extraordinary Capital Allowance

Description	The add-on amount paid in the context of this claim to the healthcare provider for extraordinary circumstances that require an unanticipated major capital expenditure.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Extreme Care Capital Allowance

Description	The add-on capital amount paid to the healthcare provider on this claim that relates to the exceptional nature of the claim case.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Extreme Care Days Covered Cnt

Description	The number of days that have been covered on this claim and that are attributable to the exceptional nature of the claim case.
Data Type	Standards - Data Domains.ddm/Data Domains/Number Integer [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Extreme Care Operating Allowance

Description	The add-on operating amount paid to the healthcare provider on this claim that relates to the exceptional nature of the claim case.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

FI Action Code Sk

Description	The type of action requested by the intermediary to be taken on an institutional claim.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Financial Intermediary Fee

Description	The amount that is charged by an intermediary for processing an out-of-area claim where the intermediary reconciles financial data between the home and host health plan products for the out-of-area claim.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Government Reduction Amt

Description	Reduction in payment as legally defined by the governmental authorities to prevent overspending.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

HIPPS Code Sk

Description	Health Insurance Prospective Payment System (HIPPS) rate codes represent the patient case mix groups on which payment determinations are made.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Home Plan Code Sk

Description	Identifies the health plan that enrolled the member who has received out-of-area medical services.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Host Plan Code Sk

Description	Identifies the health plan that serves the area where the out-of-area medical service was rendered. The host plan maintains provider contracts and issues payment for an affiliated healthcare claim.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Incoming Ind

Description	If true, indicates that the claim is an incoming claim i.e. the claim is made by another party against the modeled organization. If false, indicates that the claim is an outgoing claim i.e. the claim is made by the modeled organization against another party. The value is derived from the party role in the claim.
Data Type	Standards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Incurred But Not Reported Ind

Description	Incurred but not reported claim. Indicates that the claim is a provision for a cost that has been incurred but is not yet reported to the insurance company. For example: False True
Data Type	Standards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Indemnity Portion

Description	The part of the total cost of the claim that reimburses the loss. It excludes all fees and expenses.
Data Type	Standards - Data Domains.ddm/Data Domains/Percentage [FLOAT(2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

In Plan Network Ind

Description	A code that indicates whether or not a claim is for medical services performed by a healthcare provider who is within a network recognized by the insurer or out of network.
Data Type	Standards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Investigational Device Exemption Identifier Num

Description	Number or reference identifying exemption assigned to an investigational device referenced in the claim.
Data Type	Standards - Data Domains.ddm/Data Domains/Alphanumeric [VARCHAR(80)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Last Worked Dt

Description	The date upon which the patient last worked.
Data Type	Standards - Data Domains.ddm/Data Domains/Date [DATE]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Load Info Sk

Description	The surrogate key of the load information entry describing the details regarding the loading of the row.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key Large [LONG]
Is Part Of PrimaryKey	false
Is Required	true
Is Derived	false
Is Surrogate Key	false

Low Utilization Adjustment Code Sk

Description	Indicates an adjustment to estimated payment has occurred due to four or fewer visits being provided during a 60 day episode; Medicare therefore pays a per-visit amount.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Medical Education Capital Allowance

Description	The add-on capital amount paid to the healthcare provider on this claim that reflects the higher indirect patient care costs of a teaching healthcare provider relative to a non-teaching healthcare provider. The adjustment represented by the medical education capital allowance may be based on different factors, such as the measured effect of teaching intensity on hospitals' costs.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Medical Education Operating Allowance

Description	The add-on operating amount paid to the healthcare provider on this claim that reflects the higher indirect patient care costs of a teaching healthcare provider relative to a non-teaching healthcare provider. The adjustment represented by the medical education operating allowance may be based on different factors, such as the hospital's number of residents trained per inpatient bed.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Medicare A Covered Months Cnt

Description	Number of months covered by Medicare Part A.
Data Type	Standards - Data Domains.ddm/Data Domains/Small Counter [SHORT]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Medicare B Covered Months Cnt

Description	Number of months covered by Medicare Part B.
Data Type	Standards - Data Domains.ddm/Data Domains/Small Counter [SHORT]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Medicare Buyin Months Covered Cnt

Description	Number of months covered by Medicare buy-in coverage.
Data Type	Standards - Data Domains.ddm/Data Domains/Small Counter [SHORT]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Medicare HMO Months Covered Cnt

Description	Number of months covered by Medicare HMO.
Data Type	Standards - Data Domains.ddm/Data Domains/Small Counter [SHORT]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Member Authorization Type Code Sk

Description	Indicates how the patient/subscriber authorization signatures were obtained and how they are being retained by the provider.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Minimal Care Cost Capital Reduction

Description	Reduction in the capital payment amount paid to the healthcare provider on this claim that relates to different factors, such as a shorter inpatient stay than usually expected.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Minimal Care Cost Operating Reduction

Description	Reduction in the operating payment amount paid to the healthcare provider on this claim that relates to different factors, such as a shorter inpatient stay than usually expected.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

National Capital Allowance

Description	Add-on capital claim payment amount paid to the healthcare provider based on specific national factors, such as the cost-of-living factor.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

National Operating Allowance

Description	Add-on operating claim payment amount paid to the healthcare provider based on specific national factors, such as the cost-of-living factor.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

One Pass Process Ind

Description	Indicates whether or not the claim was processed in the 'first pass' without the need for human intervention to review, amend, or process the claim. For example: 0 = Unable To Process In A Single Pass 1 = Only One Pass Required
Data Type	Standards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Operating Charge Amt

Description	Cost allocation against the claim in respect of the operating cost directly attributable to the procedures and services provided.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Original Claim Num

Description	In the case where the payer had received the original claim and for some reason has asked the provider to resubmit the claim, giving the provider the payer's claim identification number. In this case the payer is expecting the provider to give them back the claim number so that the payer can match it in their adjudication system, avoiding a duplicate claim.
Data Type	Standards - Data Domains.ddm/Data Domains/Alphanumeric [VARCHAR(80)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Out of Area Financial Administration Fee Amt

Description	The amount that is charged for processing an out-of-area claim where the intermediary reconciles financial data between the home and host health plan products for the out-of-area claim.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Out of Area General Administration Fee Amt

Description	The administrative expense allowance for out-of-area claims that is based on the type of provider and group size. The fee charged for routing the claim transaction.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Out of Area Surcharge Amt

Description	A surcharge imposed on the claim because it was out of area.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Out-of-Network Reason Code Sk

Description	Indicates why a service was rendered outside the provider network.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Participation Agreement Code Sk

Description	Code indicating a participating claim submitted by a non-participating provider.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Patient Demographic Capital Allowance

Description	The add-on capital amount paid to the healthcare provider on this claim to compensate a high-percentage of low-income patients treated.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Patient Demographic Operating Allowance

Description	The add-on operating amount paid to the healthcare provider on this claim to compensate a high-percentage of low-income patients treated.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Patient Paid Amt

Description	The amount the provider has received from the patient (or insured) toward payment of a claim or claim line.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Payer Paid Amt

Description	The amount paid by the payer on this claim or claim line.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

PPS Claim Code Sk

Description	Prospective Payment System (PPS) Claim Code. A code indicating if the claim is being paid under a prospective payment system.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Pre-Authorization Exception Reason Code Sk

Description	Indicates why expected authorization is waived in a given context.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Prompt Payment Discount Amt

Description	The amount discounted from the health plan liability amount for prompt payment of the claim, as per provider agreement specifications.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Property Casualty Claim Num

Description	Identification number for property casualty claim associated with the services identified on the bill.
Data Type	Standards - Data Domains.ddm/Data Domains/Alphanumeric [VARCHAR(80)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Provider Assignment Ind

Description	An indicator showing whether or not the provider accepts assignment for the claim.
Data Type	Standards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Provider Capital Allowance

Description	The part of capital payment amount paid to the healthcare provider in the context of this claim that relates to labor costs.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Provider Operating Allowance

Description	The part of operating payment amount paid to the healthcare provider in the context of this claim that relates to labor costs.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Provider Signature Ind

Description	Indicates whether a signature is on file from the provider of the service acknowledging that they performed the service and therefore authorizing payment.
Data Type	Standards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Repriced Allowed Amt

Description	The maximum monetary amount determined by the repricer as being allowable under the provisions of the contract prior to the determination of the actual payment.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Repriced Approved Ambulatory Patient Group Amt

Description	The monetary amount of payment by the repricer for the referenced ambulatory patient group.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Repriced Approved Ambulatory Patient Group Code Id

Description	Identifier for ambulatory patient group assigned to the claim by the repricer.
Data Type	Standards - Data Domains.ddm/Data Domains/Identifier [VARCHAR(80)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Repriced Claim Reference Num

Description	Identification number, assigned by a repricing organization, to identify the claim.
Data Type	Standards - Data Domains.ddm/Data Domains/Alphanumeric [VARCHAR(80)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Repriced Saving Amt

Description	The monetary value of savings related to third party organization repricing of claims.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Reprice Exception Code Sk

Description	Exception code generated by the third party organization. Used only by repricers as needed. This information is specific to the destination payer.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Reprice Policy Compliance Code Sk

Description	Specifies facility's medical policy compliance.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Reprice Rejection Reason Code Sk

Description	A code assigned by issuer to identify reason for rejection.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Repricing Flat Rate Amt

Description	The amount used to determine the flat rate or per diem price by the repricing organization.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Responsible Party Reason Code Sk

Description	The reason why the insured cannot represent themselves and why assistance from a responsible party is required to authorize or enable the execution of the request for payment in respect of the claimed medical services.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Retained Service Amt

Description	Administered fee from payer.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount Large [DECIMAL(20,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Secondary Payer Pass-through Amt

Description	The amount resulting from, under special conditions, the payers primary to the modeled health insurer being exempt from fulfilling all the financial obligations of their primary payer role. This amount is derivable from the Amount in Money Provision Element Part and its Money Provision Element Part Type.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Secondary Payment Ind

Description	Secondary Payment Indicator.
Data Type	Standards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Service Authorization Exception Code Sk

Description	Indicates the reason or circumstances under which services were provided without prior authorization. For example: Immediate/Urgent Care Services Rendered in a Retroactive Period Emergency Care Client as Temporary Medicaid Request from County for Second Opinion to Recipient Request for Override Pending Special Handling
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Settlement Currency Code Sk

Description	Indicates the currency selected by the customer to be used for all benefit claim payments and all monetary information related to this claim.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Signature Dt

Description	Identifies the date on which the submitter signs the request for reimbursement from the payor.
Data Type	Standards - Data Domains.ddm/Data Domains/Date [DATE]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Source Code Sk

Description	The origin of the data identifying the actual load source, vendor, manual key entry, or context of the data in a specific row in the database.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	true
Is Derived	false
Is Surrogate Key	false

Submission Clarification Type Code Sk

Description	Indicates that the provider or practitioner is clarifying the submission.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Subrogation Ind

Description	Indicates whether or not there exist subrogation rights on the claim which may be used to recover money from a third party. For example: 0 = No subrogation 1 = Subrogation exists
Data Type	Standards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Supporting Documentation Ind

Description	Indicates whether necessary or expected claim supporting documentation has been submitted with the claim. For example: 1 documentation submitted 0 documentation not submitted
Data Type	Standards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Surcharge Amt

Description	A surcharge imposed on the claim transaction.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Tenant Sk

Description	The surrogate key of the entry identifying the legal owner of the data.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	true
Is Derived	false
Is Surrogate Key	false

Term Discount Pct

Description	The discount percentage available to the payer for payment within a specific time period.
Data Type	Standards - Data Domains.ddm/Data Domains/Percentage [FLOAT(2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Total Adjustment Units of Service

Description	The quantity of units of service being adjusted.
Data Type	Standards - Data Domains.ddm/Data Domains/Number Integer [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Total Claim Charge Amt

Description	The sum of all charges included within this claim.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Total Cost

Description	The total cost of this claim to the healthcare insurer.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Total Member Liability Amt

Description	The total amount on a healthcare claim that a member is liable for. This would include unpaid claim amounts and any claim amounts previously paid by the member.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Total Nonpayable Professional Fees Amt

Description	Total professional fees billed but not payable by the healthcare insurer.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Total Purchased Services Amt

Description	Amount of charges associated with the claim attributable to purchased services.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Total Units of Services

Description	The quantity of additional items associated with the claim.
Data Type	Standards - Data Domains.ddm/Data Domains/Number Integer [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Total Visits Rendered Cnt

Description	A count of visits on this bill rendered prior to re-certification date.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Transaction Fee Amt

Description	The fee charged for routing the claim transaction.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Type 4081 Claim Ind

Description	Indicating whether or not Medicare Section 4081 applies.
Data Type	Standards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Type Code Sk

Description	Identifies the actual type of the entry based on the entity type hierarchy defined in the business data model.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key [INTEGER]
Is Part Of PrimaryKey	false
Is Required	true
Is Derived	false
Is Surrogate Key	false

Valid From Ts

Description	Establishes a period where a set of attributes are true in the source system. This would be populated with the transaction timestamp and would be used for the snapshot date.
Data Type	Standards - Data Domains.ddm/Data Domains/Timestamp [TIMESTAMP]
Is Part Of PrimaryKey	true
Is Required	true
Is Derived	false
Is Surrogate Key	false

Valid To Ts

Description	Ends a period of validity.
Data Type	Standards - Data Domains.ddm/Data Domains/Timestamp [TIMESTAMP]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Relationship Details

Claim Detail_Claim_FK

Is Identifying Relationship	false
Child Table	Claim Detail
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Claim
Parent Multiplicity	ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Primary Key Details

Claim Detail PK

Key Attribute	Claim Sk
Key Attribute	Valid From Ts

Overview

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Package

Entity

Atomic Warehouse Model Data Model