Business Data Model Data Model

Entity

Entity Claim Line

Description

A request for reimbursement that a healthcare provider issues in respect of an individual service or a single charge group of services. One or more claim lines make up a claim.

Attributes
Acute Manifestation Date
Adjusted Repriced Line Item Reference Num
Adjustment Amt
Admin Cost Amt
Allowed Amt
Ambulatory Payment Classification Code
Annual Maximum Benefit Amt
Applied To Out Of Pocket Limit Amt
Approved Amt
Attachment Copies Needed Cnt
Attachment Transmission
Attachment Type
Benefit Stage Amt
Benefit Stage Qualifier
Claim Base Payment Rt
Claim Data Source
Claim Item Num
Claim Line Item Code
Claim Line Item Code Type
Claim Line Received
Claim Line Status
Claim Line Status Reason
Claim Line Status Ts
Claim Line Type
Claim Pricing Methodology
Coinsurance Amt
Co-Insurance Pct
Compound Drug Code
Contract Amt
Contract Id
Contract Pct
Contract Type
Contract Version Id
Copay Deductible Amt
Copayment Amt
Co-Pay Status
Cost Sharing Ind
Currency
Days Supply Qty
Deductible Amt
Disallowed Amt
Discount Amt
Employer Cost Amt
EPSDT Ind
Expected CMS Payment Amt
Family Planning Ind
Fee For Service Equivalent Amt
Form Id Num
Initial Treatment Date
Interest Amt
Last X-Ray Date
Length Of Medical Necessity Cnt
Lifetime Maximum Benefit Amt
Line Item 80_100 Code
Line Item Charge Amt
Line Item Control Num
Line Item Unit Charge Amt
Line Note Txt
Local Sales Tax Amt
Low Income Cost Sharing Level
Member Penalty Amt
Network Access Fee Amt
Noncovered Charge Amt
Non-Covered Reason
Nonpayable Professional Fees Amt
Onset Date
Other Coverage Exists Ind
Out Of Area Claim Ind
Out-of-Pocket Maximum Amt
Packaging Status
Paid Amt
Patient Group Num
Patient Paid Amt
Patient Payment Amt
Patient Responsibility Amt
Payer Paid Amt
Payment Adjustment Type
Payment Due Prior to COB
Physician Assistant Discount Code
Place Of Service Type
Policy Compliance Code
Postage Claimed Amt
Preference Incentive Co-Payment Amt
Pricing Rt
Principal Procedure Ind
Prior Authorization Num
Prognosis
Provider Penalty Amt
Purchased Service Charge Amt
Purchase Price Amt
Rebate Amt
Reimbursement Action
Reimbursement Date
Reinsurance Amt
Reject Reason
Rental Price Amt
Repriced Allowed Amt
Repriced Approved Ambulatory Patient Group Amt
Repriced Approved Ambulatory Patient Group Code
Repriced Approved Service Unit Cnt
Repriced Line Item Reference Num
Repriced Saving Amt
Repricing Flat Rate Amt
Resident in CMS Qualified Facility Ind
Revenue Code
Revenue Code Num
Sales Tax Amount Submitted
Sales Tax Amt
Service Certification Type
Service Duration Cnt
Service State
Service Unit Cnt
Service Unit Type
Similar Illness Date
Term Discount Pct
Test Performed Date
Unit Price Amt
Universal Product Num
Usual And Customary Charge UCC
Write Off Amt

Relationship
Claim Line_Claim_FK
Claim Line_Diagnosis_FK
Claim Line_Practitioner_FK
Claim Line_Claim Line_FK
Claim Line_Healthcare Event_FK
Claim Line_Diagnosis_FK1
Claim Line_Accounting Structure Level_FK
Fee Schedule Item applies to Claim Line Item

Dependencies
NONE

Reverse Dependencies

Attribute Details

Acute Manifestation Date

Description	Date of acute manifestation of patient's condition.
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

Adjusted Repriced Line Item Reference Num

Description	Identification number of an adjusted repriced line item adjusted from an original amount.
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

Adjustment Amt

Description	The amount of an adjustment that is made to a claim line when an adjustment is processed after the initial claim adjudication.
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

Admin Cost Amt

Description	The monetary value of any administration charges.
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

Allowed Amt

Description	The maximum amount determined by the payer as allowable under the provisions of the contract before the determination of actual payment.
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

Ambulatory Payment Classification Code

Description	The Ambulatory Payment Classification (APC) code used for payment, which is the same as the assigned APC, for all situations except partial hospitalization. If partial hospitalization is billed in this visit, the assigned APC will differ from the APC used for payment. Partial hospitalization is the only time an assigned APC differs from the APC used for payment. The payment APC is used for billing and should be displayed in this field. The first component contains the APC identifier. The second component reports the text description for the APC group. For example: Dental procedures Excision/biopsy Level 1 skin repair.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Annual Maximum Benefit Amt

Description	The member liability arising on the claim line from the claimant exceeding their annual maximum benefit 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

Applied To Out Of Pocket Limit Amt

Description	The portion of the cost sharing amounts that is 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	The monetary value of the claim line approved by the payer.
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 Copies Needed Cnt

Description	The number of copies of the claim line attachments required for distribution.
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

Attachment Transmission

Description	Indicates the timing, transmission method or format by which an attachment 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/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Attachment Type

Description	Indicates the inherent nature of the claim line attachment.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Benefit Stage Amt

Description	The amount attributable to a particular benefit stage or coverage tier.
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

Benefit Stage Qualifier

Description	Qualifies the benefit stage amount by identifying the coverage tier under which a benefit is being paid.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Claim Base Payment Rt

Description	The per diem or fixed amount used to price the claim line payment in line with the pricing method.
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 Data Source

Description	The source of information for a claim or claim line. For claims and related data the source could be a patient administration system, lab system, claims system, or some other related system. This can indicate the relative data quality of the information represented.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	true
Is Derived	false
Is Surrogate Key	false

Claim Item Num

Description	A sequence number to uniquely identify this claim line within the context of the claim to which it belongs.
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

Claim Line Item Code

Description	A code identifying a procedure, medication, test, product or service specified on the claim line.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Claim Line Item Code Type

Description	Indicates the type of the item code such as procedure, medication, test, product or service.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Claim Line Received

Description	The date upon which the claim line was received by an administrator.
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

Claim Line Status

Description	The state of the claim line in the lifecycle of adjudication.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Claim Line Status Reason

Description	Indicates why the claim line is in its current state.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Claim Line Status Ts

Description	The date and time the current claim line status was established for this claim line.
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 Line Type

Description	Claim submitter is Institutional 'I' or Professional 'P'
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

Claim Pricing Methodology

Description	Indicates the pricing method by which the claim or line item has been priced or repriced. For example: Zero Pricing (Not Covered Under Contract) Priced as Billed at 100% Priced at the Standard Fee Schedule Priced at a Contractual Percentage Bundled Pricing Peer Review Pricing Per Diem Pricing Flat Rate Pricing Combination Pricing Maternity Pricing Other Pricing Lower of Cost Ratio of Cost Cost Reimbursed Adjustment Pricing
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Coinsurance Amt

Description	The monetary value of co-insurance applying to the claim line.
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

Co-Insurance Pct

Description	The percentage co-payment for which the member is liable that is applicable to a particular claim or medical service. The co-payment may depend on the type of service, the type of healthcare provider, the point of service where care was rendered, whether a healthcare provider is in the network, whether the care is an emergency, whether care was pre-certified or authorized by the health plan product, or other factors.
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

Compound Drug Code

Description	Indicates the compound nature of a drug. For example: 0 = Not specified 1 = Not a compound 2 = Compound
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
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 Id

Description	Identifies the specific contract, established by the payer.
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

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

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/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Contract Version Id

Description	The version or generation of an insurance coverage in force at the time of the claimed for service.
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

Copay Deductible Amt

Description	The combined monetary value of the copayment and deductible as reported by the 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

Copayment Amt

Description	The out-of-pocket amount to be paid by the member for the medical service. The co-payment may depend on the type of service, the type of healthcare provider, the point of service where care was rendered, whether a healthcare provider is in the network, whether the care is an emergency, whether care was pre-certified or authorized by the health insurer, or other factors.
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

Co-Pay Status

Description	Indicates the status of the co-payment requirements for this service.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Cost Sharing Ind

Description	Indicates whether co-payment or co-insurance requirements are applicable for this claim line. 0 No 1 Yes
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

Currency

Description	The currency that is used as the basis for all monetary amounts.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Days Supply Qty

Description	The number of days of supply, typically of medication that is represented on the claim line.
Data Type	Standards - Data Domains.ddm/Data Domains/Quantity Float [FLOAT(15)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Deductible Amt

Description	The portion of the allowed amount on a healthcare claim line that is to be applied as a deductible based on the provisions of the health plan product.
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

Disallowed Amt

Description	The portion of a claim line item charge amount that is for a non-covered service or exceeds the maximum charge allowed in the provider agreement or the applicable usual and customary charge (UCC).
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

Discount Amt

Description	An amount applied as a discount to a claim line item. The discount can be a percentage or set amount in accordance with the negotiated contract with the provider or supplier.
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

Employer Cost Amt

Description	The portion of the claim line amount that the employer health plan will pay.
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

EPSDT Ind

Description	An indicator of whether or not early and periodic screening for diagnosis and treatment (EPSDT) of children services are involved with this claim line.
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

Expected CMS Payment Amt

Description	The calculated dollar amount that CMS is expected to pay for the line item.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Family Planning Ind

Description	An indicator of whether or not family planning services are involved with this claim Line.
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

Fee For Service Equivalent Amt

Description	The amount paid to the provider for a medical service if the pricing methodology were Fee-for-Service. This fee generally applies to capitated services and can be used when analyzing provider payments and savings due to capitation, or calculating a reconciliation reimbursement to a capitated provider for total services rendered to members in excess of planned volumes.
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

Form Id Num

Description	A reference code or number identifying a specific 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

Initial Treatment Date

Description	The date upon which the patient initially sought treatment for this condition.
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

Interest Amt

Description	The amount of interest incurred by the insurer for late payment of a claim line item.
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

Last X-Ray Date

Description	The date upon which the patient most recently had an X-Ray.
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

Length Of Medical Necessity Cnt

Description	The number of days the durable medical equipment will be required for medical treatment.
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

Lifetime Maximum Benefit Amt

Description	The member liability on the claim line arising from the claimant exceeding their lifetime maximum benefit 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

Line Item 80_100 Code

Description	A code indicating that the amount shown in the payment field on the non-institutional line item represents either 80% or 100% of the allowed charges less any deductible, or 100% limitation of liability only.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Line Item Charge Amt

Description	The monetary value of charges related to this service.
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

Line Item Control Num

Description	An identifying reference number assigned by the submitter/provider to this line item.
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

Line Item Unit Charge Amt

Description	The per unit monetary charge for the procedure on the 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

Line Note Txt

Description	A free-form narrative text providing additional information related to the claim line.
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

Local Sales Tax Amt

Description	The amount of local sales tax applicable to the claim line charge 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

Low Income Cost Sharing Level

Description	Identifies and describes the low income cost sharing (LICS) level
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Member Penalty Amt

Description	A penalty incurred by the member on the claim line for failure to comply with health plan requirements regarding utilization management, prior authorization or other policy provisions.
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

Network Access Fee Amt

Description	The fee charged by another health plan, a provider network, preferred provider organization PPO, or other organization for granting access to its providers to the members of the health plan. This allows the members to have access to providers in locations or with specialties not covered in their own network and gives the health plan the benefit of discounted fees or other contracted pricing arrangements
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

Noncovered Charge Amt

Description	The monetary amount of the charge on this claim line that is not covered by the payer.
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

Non-Covered Reason

Description	Indicates why submitted charges were not covered.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Nonpayable Professional Fees Amt

Description	The monetary value of 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

Onset Date

Description	The date of the onset of the condition being treated.
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

Other Coverage Exists Ind

Description	Indicator that coverage exists under another coverage agreement or policy for this claim line.
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

Out Of Area Claim Ind

Description	Indicates whether or not the claimed procedure was rendered outside of the healthcare insurer's normal service area or geography in which they normally do business. 0 = In Area Treatment 1 = Out Of Area Treatment
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

Out-of-Pocket Maximum Amt

Description	The amount that the health plan is liable for on the claim line as a result of the claimant exceeding their annual 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

Packaging Status

Description	Indicates the packaging status of the service. For example: Not packaged Packaged service (status indicator N, or no HCPCS code and certain revenue codes) Packaged as part of partial hospitalization per diem or daily mental health service per diem
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Paid Amt

Description	The amount paid in total on this 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

Patient Group Num

Description	An identifier for the patient group assigned to the patient on this 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

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

Patient Payment Amt

Description	The amount the patient already paid for the claimed services or products.
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 Responsibility Amt

Description	The patient's total cost share, including co-payments, amounts applied to deductible, over maximum amounts, penalties and so on.
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

Payment Adjustment Type

Description	Indicates any payment adjustment due to drugs or medical devices. For example: No payment adjustment Designated current drug or biological payment adjustment applies to APC (status indicator G) Designated new device payment adjustment applies to APC (status indicator H) Designated new drug or new biological payment adjustment applies to APC (status indicator J) Deductible not applicable (specific list of HCPCS codes)
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Payment Due Prior to COB

Description	For a claim subject to coordination of benefits, the amount the healthcare insurer paid if the healthcare insurer were the primary payer. Where the healthcare insurer is not the primary payer, it can be necessary to first adjudicate the claim as if the healthcare insurer were the primary payer.
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

Physician Assistant Discount Code

Description	Indicates the discount given based on the fact that the service was provided by a medical assistant.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Place Of Service Type

Description	Indicates the type of facility where services were performed or may be performed.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Policy Compliance Code

Description	Indicates policy compliance. For example: Procedure Followed (Compliance) Not Followed - Call Not Made (Non-Compliance Call Not Made) Not Medically Necessary (Non-Compliance Non-Medically Necessary) Not Followed Other (Non-Compliance Other) Emergency Admit to Non-Network Hospital
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Postage Claimed Amt

Description	The monetary cost of postage used to provide a service or to process associated paper work.
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

Preference Incentive Co-Payment Amt

Description	The monetary amount of a patient's co-payment / cost share incentive for preferred product.
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

Pricing Rt

Description	The per diem or fixed amount used to price the claim in line with the claim pricing method 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

Principal Procedure Ind

Description	An indicator to show whether this claim line represents the most significant service in the treatment covered by this 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

Prior Authorization Num

Description	A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved.
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

Prognosis

Description	Indicates the outlook attributed to the patient for this service line based on condition and the diagnosis.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Provider Penalty Amt

Description	A penalty incurred by the healthcare provider for failure to comply with health benefits plan requirements regarding utilization management, prior authorization, referral, out-of-network or other policy or provider contract provisions applicable to a medical service charged on a 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

Purchased Service Charge Amt

Description	The monetary amount of the charge for a purchased service.
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

Purchase Price Amt

Description	The purchase price of the durable medical equipment.
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

Rebate Amt

Description	The monetary amount of the charge returned as rebate.
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

Reimbursement Action

Description	Indicates the action to be taken during reimbursement calculations. For example: OCE line item denial or rejection is not ignored OCE line item denial or rejection is ignored External line item denial. Line item is denied even if no OCE edits External line item rejection. Line item is rejected even if no OCE edits
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Reimbursement Date

Description	The date upon which the provider was reimbursed for the product or service.
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

Reinsurance Amt

Description	The monetary amount of the charge for this service that was ceded to a reinsurance partner.
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

Reject Reason

Description	The reason for rejection of the claim line. For example: Cannot Identify Provider as TPO (Third-party Organization) Participant Cannot Identify Payer as TPO (Third-party Organization) Participant Cannot Identify Insured as TPO (Third-party Organization) Participant Payer Name or Identifier Missing Certification Information Missing Claim does not contain enough information for repricing
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Rental Price Amt

Description	The monetary rental price of the durable medical equipment.
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 Allowed Amt

Description	The maximum monetary amount determined by the repricer as allowable under the provisions of the contract before 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

Description	Identifies the ambulatory patient group (APG) assigned to the claim by the repricer.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Repriced Approved Service Unit Cnt

Description	The number of service units approved by a pricing or repricing process.
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

Repriced Line Item Reference Num

Description	An identification number of a line item repriced by a third party or prior 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

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

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

Resident in CMS Qualified Facility Ind

Description	Indicates that the patient resides in a facility that qualifies for CMS benefits.
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

Revenue Code

Description	The field indicates the surrogate key for revenue codes that are 3-digit numbers that are used on hospital bills to tell the insurance companies either where the patient was when they received treatment, or what type of item a patient might have received as a patient.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Revenue Code Num

Description	Revenue codes are 3-digit numbers that are used on hospital bills to tell the insurance companies either where the patient was when they received treatment, or what type of item a patient might have received as a patient.
Data Type	Standards - Data Domains.ddm/Data Domains/Alphanumeric Small [VARCHAR(6)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Sales Tax Amount Submitted

Description	The amount of sales tax included in the amount submitted.
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

Sales Tax Amt

Description	The amount of sales tax attributable to the referenced service.
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

Service Certification Type

Description	Indicates the type of certification established for the service performed. For example: Initial Renewal Revised
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Service Duration Cnt

Description	The length of time a service takes or is in effect. For example: Length of time durable medical equipment (DME) is needed
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

Service State

Description	The state or province where the service was performed.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Service Unit Cnt

Description	The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS codes, revenue code or procedure code.
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

Service Unit Type

Description	Describes one unit of the service provided.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Similar Illness Date

Description	The date upon which a similar illness or symptom began.
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

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

Test Performed Date

Description	The date upon which a specific test is completed for a patient.
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

Unit Price Amt

Description	The price for one unit of goods or 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

Universal Product Num

Description	An industry standard code identifying supplies and materials.
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

Usual And Customary Charge UCC

Description	The amount specified by the health plan product as the maximum amount payable for healthcare service rendered in a particular service geographic area and service setting, whether it be an inpatient, outpatient, or ambulatory facility. The type of healthcare provider rendering the service, whether it be a physician, midlevel practitioner or registered nurse, is also a 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

Write Off Amt

Description	The total recoverable amount that has been written off. Claim recoveries may be written off in part or in total where the organization believes the cost of recovery will exceed the value to be recovered or where the amount is in dispute and the organization is not confident of a positive outcome.
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

Relationship Details

Claim Line_Claim_FK

Is Identifying Relationship	false
Child Table	Claim Line
Child Role Name	contained in
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

Claim Line_Diagnosis_FK

Is Identifying Relationship	false
Child Table	Claim Line
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	Diagnosis
Parent Multiplicity	ZERO_TO_ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Claim Line_Practitioner_FK

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

Claim Line_Claim Line_FK

Is Identifying Relationship	false
Child Table	Claim Line
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 Line
Parent Multiplicity	ZERO_TO_ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Claim Line_Healthcare Event_FK

Is Identifying Relationship	false
Child Table	Claim Line
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	Healthcare Event
Parent Multiplicity	ZERO_TO_MANY
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Claim Line_Diagnosis_FK1

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

Claim Line_Accounting Structure Level_FK

Is Identifying Relationship	false
Child Table	Claim Line
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	Accounting Structure Level
Parent Multiplicity	ZERO_TO_ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Fee Schedule Item applies to Claim Line Item

Is Identifying Relationship	false
Child Table	Claim Line
Child Role Name	is priced by
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	Fee Schedule Item
Parent Role Name	applies to
Parent Multiplicity	ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Overview

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