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Medical Claim Dataset Specification

Updated over a month ago

Medical Claim Dataset Specification

Medical Claim Dataset Specification

The Medical Claim Dataset Specification contains information on medical claims (Professional and Institutional claims are differentiated via the discriminator field Claim_Type) received with customer files, including simple enrichment using procedure, diagnosis, and other lookups. It also includes the calculation of visit type indicators.

Its unique key is Claim_Number. It references Members by Member_ID and Owning Providers by Provider_ID, and it is referenced from Admissions and Episodes. This dataset plays a pivotal role in enhancing the efficiency and accuracy of medical claim management, ensuring healthcare organizations can effectively handle billing and administrative duties while complying with relevant regulations.

Key Components

Claim Details

  • Captures comprehensive data on each medical claim, including claimant information, date of service, and other relevant details necessary to process the claim.

Claim Lines

  • Records specific items or services claimed, providing a detailed breakdown of each claim which is essential for accurate billing and reimbursement.

Claim Modifiers

  • Includes information on any adjustments or special circumstances that affect how a claim is processed, ensuring all factors are considered in the adjudication process.

Diagnoses

  • Documents the medical diagnoses associated with each claim, linking clinical data with billing information, which is vital for health record management and compliance.

Procedures

  • Captures details about the medical procedures performed, which are essential for coding and billing accuracy.

Raw Claim Data

  • Contains unprocessed, detailed data related to claims. This data is crucial for conducting in-depth analyses and audits, providing a comprehensive view for compliance checks and process improvements.

Table: Medical_Claim

Column Name

Is Nullable

Data Type

Description

Claim_Number

YES

STRING

Unique identifier or number assigned to the medical claim.

Claim_Type

YES

STRING

Claim type discriminator: "PROF" vs "INST".

Claim_Type_Description

YES

STRING

Description of the type or category of the medical claim.

Member_ID

YES

STRING

Unique identifier for the member associated with the medical claim.

Membership_ID

YES

STRING

Identifier for the membership linked to the medical claim.

Subscriber_ID

YES

STRING

Identifier for the subscriber linked to the medical claim.

Client_ID

YES

STRING

Identifier for the client or organization associated with the medical claim.

Subclient_ID

YES

STRING

Identifier for the subclient or division associated with the medical claim.

Is_Subscriber

YES

BOOL

Indicator that the claim owner is also the subscriber.

Adjustment_Type

YES

STRING

Adjustment type code (New/Adjusted/Voided).

Adjustment_Type_Description

YES

STRING

Description of the type of adjustment applied to the medical claim.

Provider_ID

YES

STRING

Unique identifier for the provider associated with the medical claim.

Provider_NPI

YES

STRING

National Provider Identifier (NPI) of the provider associated with the medical claim.

Provider_Specialty_Code

YES

STRING

Claim’s provider specialty (Medecision_Specialty_Code).

Provider_Taxonomy

YES

STRING

Taxonomy code assigned to the provider associated with the medical claim.

Provider_Taxonomy_Description

YES

STRING

Description of the taxonomy code assigned to the provider associated with the medical claim.

In_Network_Provider_Indicator

YES

BOOL

Indicator specifying whether the provider is in-network or out-of-network for the medical claim.

Admission_Source_Category

YES

STRING

Category indicating the source of admission for the medical claim.

Admission_Source_Code

YES

STRING

Code representing the source of admission for the medical claim.

Admission_Source_Description

YES

STRING

Description of the source of admission for the medical claim.

Admission_Type_Code

YES

STRING

Code indicating the type of admission for the medical claim.

Admission_Type_Description

YES

STRING

Description of the type of admission for the medical claim.

Bill_Code_Type

YES

STRING

Type of billing code used for the medical claim.

Place_of_Service

YES

STRING

Code indicating the place of service for the medical claim. See Dictionary Place Of Service table in the Dictionary Dataset Specification.

Place_of_Service_Description

YES

STRING

Description of the place of service for the medical claim. See Dictionary Place Of Service table in the Dictionary Dataset Specification.

Diagnosis_Related_Group

YES

STRING

Code representing the diagnosis-related group for the medical claim.

Diagnosis_Related_Group_Description

YES

STRING

Description of the diagnosis-related group for the medical claim.

Patient_Status_Code

YES

STRING

Code indicating the status of the patient for the medical claim.

Patient_Status_Description

YES

STRING

Description of the status of the patient for the medical claim.

Deductible_Amount

YES

NUMERIC

Amount of deductible applied to the medical claim.

Coinsurance_Amount

YES

NUMERIC

Amount of coinsurance applied to the medical claim.

Copay_Amount

YES

NUMERIC

Amount of copayment applied to the medical claim.

Billed_Amount

YES

NUMERIC

Total amount billed for the medical claim.

Paid_Amount

YES

NUMERIC

Amount paid for the medical claim.

Allowed_Amount

YES

NUMERIC

Amount allowed or approved for the medical claim.

Total_Adjustment_Amount

YES

NUMERIC

Total amount of adjustments made to the medical claim.

Medical Claim Dataset Specification

Medical Claim

Columns and Descriptions

  • Paid_Date

  • Is Nullable: YES

  • Data Type: DATE

  • Description: Date on which the medical claim was paid.

  • Statement_Start_Date

  • Is Nullable: YES

  • Data Type: DATE

  • Description: Start date of the statement or billing period for the medical claim.

  • Statement_End_Date

  • Is Nullable: YES

  • Data Type: DATE

  • Description: End date of the statement or billing period for the medical claim.

  • Visibility_Level

  • Is Nullable: YES

  • Data Type: INT64

  • Description: Level of visibility or access to the claim data.

  • Office_Visit_Indicator

  • Is Nullable: YES

  • Data Type: BOOL

  • Description: Indicator specifying if the claim is related to an office visit.

  • ER_Visit_Indicator

  • Is Nullable: YES

  • Data Type: BOOL

  • Description: Indicator specifying if the claim is related to an emergency room visit.

  • Behavioral_Health_Admission_Indicator

  • Is Nullable: YES

  • Data Type: BOOL

  • Description: Indicator specifying if the claim is related to a behavioral health admission.

  • Encounter_Indicator

  • Is Nullable: YES

  • Data Type: BOOL

  • Description: Indicator specifying if the claim is related to a general encounter.

Medical Claim Claim Line

Columns and Descriptions

  • Claim_Number

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Unique identifier or number assigned to the medical claim.

  • Member_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Unique identifier for the member associated with the medical claim.

  • Membership_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the membership linked to the medical claim.

  • Subscriber_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the subscriber linked to the medical claim.

  • Client_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the client or organization associated with the medical claim.

  • Subclient_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the subclient or division associated with the medical claim.

  • Claim_Line_Number

  • Is Nullable: YES

  • Data Type: INT64

  • Description: Unique identifier or number assigned to the claim line within the medical claim.

  • Claim_Line_From_Date

  • Is Nullable: YES

  • Data Type: DATE

  • Description: Start date for the service or treatment provided in the claim line.

  • Claim_Line_To_Date

  • Is Nullable: YES

  • Data Type: DATE

  • Description: End date for the service or treatment provided in the claim line.

  • Claim_Line_Revenue_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Code representing the revenue category for the service in the claim line.

  • Claim_Line_Revenue_Code_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the revenue category for the service in the claim line.

  • Claim_Line_Service_Units

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Number of service units or quantity for the service in the claim line.

  • Claim_Line_Unit_Type

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Service units type code:

    • "UN" - Units

    • "DA" - Days

    • "MJ" - Minutes

  • Claim_Line_Unit_Type_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the type of units or measurement for the service in the claim line.

  • Claim_Line_Deductible_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Amount of deductible applied to the claim line.

  • Claim_Line_Coinsurance_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Amount of coinsurance applied to the claim line.

  • Claim_Line_Copay_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Amount of copayment applied to the claim line.

  • Claim_Line_Billed_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Total amount billed for the service in the claim line.

  • Claim_Line_Paid_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Amount paid for the service in the claim line.

  • Claim_Line_Allowed_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Amount allowed or approved for the service in the claim line.

  • Claim_Line_Total_Adjustment_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Total amount of adjustments made to the claim line.

  • Claim_Line_Place_of_Service_Group

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Group or category indicating the place of service for the claim line.

  • Claim_Line_Procedure_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Code representing the procedure performed in the claim line.

  • Claim_Line_Procedure_Code_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the procedure performed in the claim line.

  • Claim_Line_Procedure_Code_Type

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Type or category of the procedure code in the claim line.

  • Claim_Line_Procedure_Code_Type_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the type or category of the procedure code in the claim line.

  • Claim_Line_Procedure_Scheme_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Scheme or coding system for the procedure code in the claim line.

  • Claim_Line_Procedure_Code_Set

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Code set or category for the procedure code in the claim line.

  • Claim_Line_Procedure_Code_Set_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the code set or category for the procedure code in the claim line.

  • Claim_Line_Claim_Line_Procedure_Code_Set_Type

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Type or category of the code set for the procedure code in the claim line.

  • Claim_Line_Procedure_Code_Set_Type_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the type or category of the code set for the procedure code in the claim line.

Medical Claim Claim Line Claim Modifiers

Columns and Descriptions

  • Claim_Number

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Unique identifier or number assigned to the medical claim.

  • Member_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Unique identifier for the member associated with the medical claim.

  • Membership_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the membership linked to the medical claim.

  • Subscriber_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the subscriber linked to the medical claim.

  • Client_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the client or organization associated with the medical claim.

  • Subclient_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the subclient or division associated with the medical claim.

  • Claim_Line_Number

  • Is Nullable: YES

  • Data Type: INT64

  • Description: Unique identifier or number assigned to the claim line within the medical claim.

  • Claim_Line_Claim_Modifiers_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Code representing the modifiers applied to the claim line.

Medical Claim Dataset Specification

Medical Claim Claim Line Modifiers

Fields

  • Claim_Line_Claim_Modifiers

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Code representing the modifier applied to the claim line within the medical claim.

  • Claim_Line_Claim_Modifiers_Description

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Description of the modifier applied to the claim line within the medical claim.

Medical Claim Diagnoses

Fields

  • Claim_Number

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Unique identifier or number assigned to the medical claim.

  • Member_ID

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Unique identifier for the member associated with the medical claim.

  • Membership_ID

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Identifier for the membership linked to the medical claim.

  • Subscriber_ID

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Identifier for the subscriber linked to the medical claim.

  • Client_ID

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Identifier for the client or organization associated with the medical claim.

  • Subclient_ID

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Identifier for the subclient or division associated with the medical claim.

  • Diagnoses_Code

  • Data Type: STRING

  • Is Nullable: YES

  • Description: ICD9/ICD10 diagnosis code.

  • Diagnoses_Code_Description

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Description of the diagnosis code used in the medical claim.

  • Diagnoses_Scheme_Code

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Diagnosis Scheme: ICD9 or ICD10.

  • Diagnoses_Code_Type

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Diagnosis code type:

    • ABK: Principal

    • ABJ: Admitting

    • ABF: Other

    • BK: Principal

    • BJ: Admitting

    • BF: Other

  • Diagnoses_Code_Type_Description

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Description of the diagnosis code type used in the medical claim.

  • Diagnoses_Type_Code

  • Data Type: STRING

  • Is Nullable: YES

  • Description:

    • Principal => P

    • Admitting => A

    • Otherwise => S

  • Diagnoses_Type_Description

  • Data Type: STRING

  • Is Nullable: YES

  • Description:

    • Principal => Primary

    • Admitting => Admitting

    • Otherwise => Secondary

Medical Claim Procedures

Fields

  • Claim_Number

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Unique identifier or number assigned to the medical claim.

  • Member_ID

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Unique identifier for the member associated with the medical claim.

  • Membership_ID

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Identifier for the membership linked to the medical claim.

  • Subscriber_ID

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Identifier for the subscriber linked to the medical claim.

  • Client_ID

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Identifier for the client or organization associated with the medical claim.

  • Subclient_ID

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Identifier for the subclient or division associated with the medical claim.

  • Procedures_Code

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Service code. ICD10 code (for institutional). HCPCS or CPT code (for professional).

  • Procedures_Code_Description

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Description of the medical procedure code used in the medical claim.

  • Procedures_Code_Type

  • Data Type: STRING

  • Is Nullable: YES

  • Description:

    • BO: HCPCS code

    • BP: Principal HCPCS code

    • HC: CPT4 code

    • BBQ: ICD10 code

    • BBR: Principal ICD10 code

    • BQ: ICD9 code

    • BR: Principal ICD9 code

  • Procedures_Code_Type_Description

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Description of the medical procedure code type used in the medical claim.

  • Procedures_Scheme_Code

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Service code scheme: HCPCS, CPT4, ICD10, ICD9.

  • Procedures_Code_Set

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Code representing the set or group of related medical procedure codes.

  • Procedures_Code_Set_Description

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Description of the set or group of related medical procedure codes used in the medical claim.

  • Procedures_Code_Set_Type

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Code representing the type or category of the procedure code set (e.g., primary, secondary, etc.).

  • Procedures_Code_Set_Type_Description

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Description of the type or category of the procedure code set used in the medical claim.

  • Procedures_Type_Code

  • Data Type: STRING

  • Is Nullable: YES

  • Description:

    • Principal => "P"

    • Anesthesia => "A"

    • Otherwise => "S"

  • Procedures_Type_Description

  • Data Type: STRING

  • Is Nullable: YES

  • Description:

    • Principal => "Principal"

    • Anesthesia => "Anesthesia"

    • Otherwise => "Other"

Medical Claim Raw

Fields

  • Claim_Number

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Unique identifier or number assigned to the medical claim.

  • Claim_Type

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Claim type discriminator: "PROF" vs "INST".

  • Claim_Type_Description

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Description of the claim type.

  • Claim_Line

  • Data Type: ARRAY

  • Is Nullable: NO

  • Description: Identifier or number of the claim line within the claim.

Claim Line Fields

  • Claim_Line_Number

  • Data Type: INT64

  • Is Nullable: YES

  • Description: Unique identifier or number assigned to the claim line within the medical claim.

  • Claim_Line_From_Date

  • Data Type: DATE

  • Is Nullable: YES

  • Description: Start date for the service or treatment provided in the claim line.

  • Claim_Line_To_Date

  • Data Type: DATE

  • Is Nullable: YES

  • Description: End date for the service or treatment provided in the claim line.

  • Claim_Line_Revenue_Code

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Code representing the revenue category for the service in the claim line.

  • Claim_Line_Revenue_Code_Description

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Description of the revenue category for the service in the claim line.

  • Claim_Line_Service_Units

  • Data Type: NUMERIC

  • Is Nullable: YES

  • Description: Number of service units or quantity for the service in the claim line.

  • Claim_Line_Unit_Type

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Service units type code:

    • UN: Units

    • DA: Days

    • MJ: Minutes

  • Claim_Line_Unit_Type_Description

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Description of the type of units or measurement for the service in the claim line.

Procedure Fields

  • Claim_Line_Procedure_Code

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Code representing the procedure performed in the claim line.

  • Claim_Line_Procedure_Code_Description

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Description of the procedure performed in the claim line.

  • Claim_Line_Procedure_Code_Type

  • Data Type: STRING

  • Is Nullable: YES

  • Description: Type or category of the procedure code in the claim line.

Medical Claim Dataset Specification

Claim Line

Procedure

  • Description

  • Type: STRING

  • Description of the type or category of the procedure code in the claim line.

  • Claim_Line_Procedure_Scheme_Code

  • Type: STRING

  • Scheme or coding system for the procedure code in the claim line.

  • Claim_Line_Procedure_Code_Set

  • Type: STRING

  • Code set or category for the procedure code in the claim line.

  • Claim_Line_Procedure_Code_Set_Description

  • Type: STRING

  • Description of the code set or category for the procedure code in the claim line.

  • Claim_Line_Procedure_Code_Set_Type

  • Type: STRING

  • Type or category of the code set for the procedure code in the claim line.

  • Claim_Line_Procedure_Code_Set_Type_Description

  • Type: STRING

  • Description of the type or category of the code set for the procedure code in the claim line.

Claim Modifiers

  • Claim_Modifiers

  • Type: ARRAY

  • Claim modifiers related to the medical claim.

  • Claim_Line_Claim_Modifiers_Code

  • Type: STRING

  • Code representing the modifier applied to the claim line within the medical claim.

  • Claim_Line_Claim_Modifiers_Description

  • Type: STRING

  • Description of the modifier applied to the claim line within the medical claim.

Financial Details

  • Deductible_Amount

  • Type: NUMERIC

  • Amount of deductible applied to the claim.

  • Coinsurance_Amount

  • Type: NUMERIC

  • Amount of coinsurance applied to the claim.

  • Copay_Amount

  • Type: NUMERIC

  • Amount of copay applied to the claim.

  • Billed_Amount

  • Type: NUMERIC

  • Total amount billed for the claim.

  • Paid_Amount

  • Type: NUMERIC

  • Amount paid for the claim.

  • Allowed_Amount

  • Type: NUMERIC

  • Amount allowed for the claim.

  • Total_Adjustment_Amount

  • Type: NUMERIC

  • Total amount of adjustments applied to the claim.

Other Details

  • Claim_Line_Place_of_Service_Group

  • Type: STRING

  • Group or category indicating the place of service for the claim line.

  • Visibility_Level

  • Type: INT64

  • Level of visibility or access to the claim data.

Medical Claim Raw

Member Information

  • Member_ID

  • Type: STRING

  • Unique identifier for the member associated with the claim.

  • Membership_ID

  • Type: STRING

  • Identifier for the membership linked to the claim.

  • Subscriber_ID

  • Type: STRING

  • Identifier for the subscriber linked to the claim.

  • Client_ID

  • Type: STRING

  • Identifier for the client or organization associated with the claim.

  • Subclient_ID

  • Type: STRING

  • Identifier for the subclient or division associated with the claim.

  • Is_Subscriber

  • Type: BOOL

  • Indicator that the claim owner is also the subscriber.

Adjustment Details

  • Adjustment_Type

  • Type: STRING

  • Adjustment type code (New/Adjusted/Voided).

  • Adjustment_Type_Description

  • Type: STRING

  • Description of the adjustment type.

Provider Information

  • Provider_ID

  • Type: STRING

  • Identifier for the provider associated with the claim.

  • Provider_NPI

  • Type: STRING

  • National Provider Identifier (NPI) for the provider.

  • Provider_Specialty_Code

  • Type: STRING

  • Claim’s provider specialty (Medecision_Specialty_Code).

  • Provider_Taxonomy

  • Type: STRING

  • Code representing the taxonomy of the provider.

  • Provider_Taxonomy_Description

  • Type: STRING

  • Description of the provider taxonomy.

  • In_Network_Provider_Indicator

  • Type: BOOL

  • Indicator specifying if the provider is in-network or not.

Diagnoses

  • Diagnoses

  • Type: ARRAY

  • Diagnoses related to the medical claim.

  • Diagnoses_Code

  • Type: STRING

  • ICD9/ICD10 diagnosis code.

  • Diagnoses_Code_Description

  • Type: STRING

  • Description of the diagnosis code used in the medical claim.

  • Diagnoses_Scheme_Code

  • Type: STRING

  • Diagnosis Scheme: ICD9 or ICD10.

  • Diagnoses_Code_Type

  • Type: STRING

  • Diagnosis code type:

    • ABK - Principal

    • ABJ - Admitting

    • ABF - Other

    • BK - Principal

    • BJ - Admitting

    • BF - Other

  • Diagnoses_Code_Type_Description

  • Type: STRING

  • Description of the diagnosis code type used in the medical claim.

  • Diagnoses_Type_Code

  • Type: STRING

  • Principal => P

  • Admitting => A

  • Otherwise => S

  • Diagnoses_Type_Description

  • Type: STRING

  • Principal => Primary

  • Admitting => Admitting

  • Otherwise => Secondary

Procedures

  • Procedures

  • Type: ARRAY

  • Element holding procedures associated with the claim. It includes principal procedures for institutional claims and anesthesia procedures for professional claims.

  • Procedures_Code

  • Type: STRING

  • Service code. ICD10 code (for institutional). HCPCS or CPT code (for professional).

  • Procedures_Code_Description

  • Type: STRING

  • Description of the medical procedure code used in the medical claim.

  • Procedures_Code_Type

  • Type: STRING

  • Code types:

    • BO - HCPCS code

    • BP - Principal HCPCS code

    • HC - CPT4 code

    • BBQ - ICD10 code

    • BBR - Principal ICD10 code

    • BQ - ICD9 code

    • BR - Principal ICD9 code

  • Procedures_Code_Type_Description

  • Type: STRING

  • Description of the medical procedure code type used in the medical claim.

  • Procedures_Scheme_Code

  • Type: STRING

  • Service code scheme: HCPCS, CPT4, ICD10, ICD9.

  • Procedures_Code_Set

  • Type: STRING

  • Code representing the set or group of related medical procedure codes.

  • Procedures_Code_Set_Description

  • Type: STRING

  • Description of the set or group of related medical procedure codes used in the medical claim.

  • Procedures_Code_Set_Type

  • Type: STRING

  • Code representing the type or category of the procedure code set (e.g., primary, secondary, etc.).

  • Procedures_Code_Set_Type_Description

  • Type: STRING

  • Description of the type or category of the procedure code set used in the medical claim.

  • Procedures_Type_Code

  • Type: STRING

  • Principal => "P"

  • Anesthesia => "A"

  • Otherwise => "S"

  • Procedures_Type_Description

  • Type: STRING

  • Principal => "Principal"

  • Anesthesia => "Anesthesia"

  • Otherwise => "Other"

Admission Source

  • Admission_Source_Category

  • Type: STRING

  • Category of the admission source (e.g., emergency, elective, etc.).

  • Admission_Source_Code

  • Type: STRING

  • Code representing the admission source.

Medical Claim Dataset Specification

Overview

This document outlines the specifications for the Medical Claim dataset, detailing the structure, descriptions, and data types of each field. The dataset captures comprehensive information related to medical claims, including claimant details, billing information, diagnoses, procedures, and more.

Medical Claim Raw Fields

Admission Details

  • Admission_Source_Description

  • Data Type: STRING

  • Nullable: YES

  • Description: Description of the admission source.

  • Admission_Type_Code

  • Data Type: STRING

  • Nullable: YES

  • Description: Code representing the admission type.

  • Admission_Type_Description

  • Data Type: STRING

  • Nullable: YES

  • Description: Description of the admission type.

Billing Information

  • Bill_Code_Type

  • Data Type: STRING

  • Nullable: YES

  • Description: Type of billing code used in the claim.

  • Bill_Type_Description

  • Data Type: STRING

  • Nullable: YES

  • Description: Description of the billing code type.

Place of Service

  • Place_of_Service

  • Data Type: STRING

  • Nullable: YES

  • Description: Code representing the place of service. See Dictionary Place Of Service table in the Dictionary Dataset Specification.

  • Place_of_Service_Description

  • Data Type: STRING

  • Nullable: YES

  • Description: Description of the place of service. See Dictionary Place Of Service table in the Dictionary Dataset Specification.

Diagnosis and Patient Status

  • Diagnosis_Related_Group

  • Data Type: STRING

  • Nullable: YES

  • Description: Code representing the diagnosis-related group.

  • Diagnosis_Related_Group_Description

  • Data Type: STRING

  • Nullable: YES

  • Description: Description of the diagnosis-related group.

  • Patient_Status_Code

  • Data Type: STRING

  • Nullable: YES

  • Description: UB-92 patient status code. Also known as discharge disposition code.

  • Patient_Status_Description

  • Data Type: STRING

  • Nullable: YES

  • Description: Patient status (discharge disposition) description.

Financial Details

  • Deductible_Amount

  • Data Type: NUMERIC

  • Nullable: YES

  • Description: Amount of deductible applied to the claim.

  • Coinsurance_Amount

  • Data Type: NUMERIC

  • Nullable: YES

  • Description: Amount of coinsurance applied to the claim.

  • Copay_Amount

  • Data Type: NUMERIC

  • Nullable: YES

  • Description: Amount of copay applied to the claim.

  • Billed_Amount

  • Data Type: NUMERIC

  • Nullable: YES

  • Description: Total amount billed for the claim.

  • Paid_Amount

  • Data Type: NUMERIC

  • Nullable: YES

  • Description: Amount paid for the claim.

  • Allowed_Amount

  • Data Type: NUMERIC

  • Nullable: YES

  • Description: Amount allowed for the claim.

  • Total_Adjustment_Amount

  • Data Type: NUMERIC

  • Nullable: YES

  • Description: Total amount of adjustments applied to the claim.

Dates

  • Paid_Date

  • Data Type: DATE

  • Nullable: YES

  • Description: Date when the claim was paid.

  • Statement_Start_Date

  • Data Type: DATE

  • Nullable: YES

  • Description: Start date of the claim statement period.

  • Statement_End_Date

  • Data Type: DATE

  • Nullable: YES

  • Description: End date of the claim statement period.

Metadata

  • Type

  • Data Type: STRING

  • Nullable: YES

  • Description: Type of the claim or record.

  • Tenant

  • Data Type: STRING

  • Nullable: YES

  • Description: Identifier for the tenant or organization.

  • Active_Version

  • Data Type: BOOL

  • Nullable: YES

  • Description: Version number of the active record.

  • Date

  • Data Type: DATE

  • Nullable: YES

  • Description: Date of the claim or record.

  • Sequence

  • Data Type: INT64

  • Nullable: YES

  • Description: Sequence number of the claim or record.

  • Source_System_Name

  • Data Type: STRING

  • Nullable: YES

  • Description: Name of the source system that generated the claim.

  • Source_Timestamp

  • Data Type: TIMESTAMP

  • Nullable: YES

  • Description: Timestamp indicating when the claim was sourced.

  • Source_File_Name

  • Data Type: STRING

  • Nullable: YES

  • Description: Name of the source file containing the claim information.

  • Schema_Version

  • Data Type: FLOAT64

  • Nullable: YES

  • Description: Version of the schema used for the claim data.

  • Visibility_Level

  • Data Type: INT64

  • Nullable: YES

  • Description: Level of visibility or access to the claim data.

Indicators

  • Office_Visit_Indicator

  • Data Type: BOOL

  • Nullable: YES

  • Description: Indicator specifying if the claim is related to an office visit.

  • ER_Visit_Indicator

  • Data Type: BOOL

  • Nullable: YES

  • Description: Indicator specifying if the claim is related to an emergency room visit.

  • Behavioral_Health_Admission_Indicator

  • Data Type: BOOL

  • Nullable: YES

  • Description: Indicator specifying if the claim is related to a behavioral health admission.

  • Encounter_Indicator

  • Data Type: BOOL

  • Nullable: YES

  • Description: Indicator specifying if the claim is an encounter record.

Partition and Updates

  • Member_Partition

  • Data Type: INT64

  • Nullable: YES

  • Description: Identifier for the member partition or segment.

  • _updated

  • Data Type: STRING

  • Nullable: YES

  • Description: Indicator specifying if the claim record has been updated.

Claim Data Tables

Claim Details

This table captures comprehensive data on each medical claim, including claimant information, date of service, and other relevant details necessary to process the claim.

Claim Lines

Records specific items or services claimed, providing a detailed breakdown of each claim which is essential for accurate billing and reimbursement.

Claim Modifiers

Includes information on any adjustments or special circumstances that affect how a claim is processed, ensuring all factors are considered in the adjudication process.

Diagnoses

Documents the medical diagnoses associated with each claim, linking clinical data with billing information, which is vital for health record management and compliance.

Procedures

Captures details about the medical procedures performed, which are essential for coding and billing accuracy.

Raw Claim Data

Contains unprocessed, detailed data related to claims. This data is crucial for conducting in-depth analyses and audits, providing a comprehensive view for compliance checks and process improvements.

Table Content

Table Name

Column Name

Is Nullable

Data Type

Description

Medical_Claim

Claim_Number

YES

STRING

Unique identifier or number assigned to the medical claim.

Medical_Claim

Claim_Type

YES

STRING

Claim type discriminator: "PROF" vs "INST".

Medical_Claim

Claim_Type_Description

YES

STRING

Description of the type or category of the medical claim.

Medical_Claim

Member_ID

YES

STRING

Unique identifier for the member associated with the medical claim.

Medical_Claim

Membership_ID

YES

STRING

Identifier for the membership linked to the medical claim.

Medical_Claim

Subscriber_ID

YES

STRING

Identifier for the subscriber linked to the medical claim.

Medical_Claim

Client_ID

YES

STRING

Identifier for the client or organization associated with the medical claim.

Medical_Claim

Subclient_ID

YES

STRING

Identifier for the subclient or division associated with the medical claim.

Medical_Claim

Is_Subscriber

YES

BOOL

Indicator then claim owner is also subscriber.

Medical_Claim

Adjustment_Type

YES

STRING

Adjustment type code (New/Adjusted/Voided).

Medical_Claim

Adjustment_Type_Description

YES

STRING

Description of the type of adjustment applied to the medical claim.

Medical_Claim

Provider_ID

YES

STRING

U

Medical Claim Dataset Specification

Medical Claim

Provider Information

  • Provider_NPI

  • Is Nullable: YES

  • Data Type: STRING

  • Description: National Provider Identifier (NPI) of the provider associated with the medical claim.

  • Provider_Specialty_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Claim’s provider specialty (Medecision_Specialty_Code).

  • Provider_Taxonomy

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Taxonomy code assigned to the provider associated with the medical claim.

  • Provider_Taxonomy_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the taxonomy code assigned to the provider associated with the medical claim.

  • In_Network_Provider_Indicator

  • Is Nullable: YES

  • Data Type: BOOL

  • Description: Indicator specifying whether the provider is in-network or out-of-network for the medical claim.

Admission Information

  • Admission_Source_Category

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Category indicating the source of admission for the medical claim.

  • Admission_Source_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Code representing the source of admission for the medical claim.

  • Admission_Source_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the source of admission for the medical claim.

  • Admission_Type_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Code indicating the type of admission for the medical claim.

  • Admission_Type_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the type of admission for the medical claim.

Billing Information

  • Bill_Code_Type

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Type of billing code used for the medical claim.

  • Place_of_Service

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Code indicating the place of service for the medical claim. See Dictionary Place Of Service table in the Dictionary Dataset Specification.

  • Place_of_Service_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the place of service for the medical claim. See Dictionary Place Of Service table in the Dictionary Dataset Specification.

Diagnosis Information

  • Diagnosis_Related_Group

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Code representing the diagnosis-related group for the medical claim.

  • Diagnosis_Related_Group_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the diagnosis-related group for the medical claim.

Patient Information

  • Patient_Status_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Code indicating the status of the patient for the medical claim.

  • Patient_Status_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the status of the patient for the medical claim.

Financial Information

  • Deductible_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Amount of deductible applied to the medical claim.

  • Coinsurance_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Amount of coinsurance applied to the medical claim.

  • Copay_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Amount of copayment applied to the medical claim.

  • Billed_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Total amount billed for the medical claim.

  • Paid_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Amount paid for the medical claim.

  • Allowed_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Amount allowed or approved for the medical claim.

  • Total_Adjustment_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Total amount of adjustments made to the medical claim.

Dates

  • Paid_Date

  • Is Nullable: YES

  • Data Type: DATE

  • Description: Date on which the medical claim was paid.

  • Statement_Start_Date

  • Is Nullable: YES

  • Data Type: DATE

  • Description: Start date of the statement or billing period for the medical claim.

  • Statement_End_Date

  • Is Nullable: YES

  • Data Type: DATE

  • Description: End date of the statement or billing period for the medical claim.

Miscellaneous

  • Visibility_Level

  • Is Nullable: YES

  • Data Type: INT64

  • Description: Level of visibility or access to the claim data.

  • Office_Visit_Indicator

  • Is Nullable: YES

  • Data Type: BOOL

  • Description: Indicator specifying if the claim is related to an office visit.

  • ER_Visit_Indicator

  • Is Nullable: YES

  • Data Type: BOOL

  • Description: Indicator specifying if the claim is related to an emergency room visit.

  • Behavioral_Health_Admission_Indicator

  • Is Nullable: YES

  • Data Type: BOOL

  • Description: Indicator specifying if the claim is related to a behavioral health admission.

  • Encounter_Indicator

  • Is Nullable: YES

  • Data Type: BOOL

  • Description: Indicator specifying if the claim is related to a general encounter.

Medical Claim Claim Line

Claim Line Information

  • Claim_Number

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Unique identifier or number assigned to the medical claim.

  • Member_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Unique identifier for the member associated with the medical claim.

  • Membership_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the membership linked to the medical claim.

  • Subscriber_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the subscriber linked to the medical claim.

  • Client_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the client or organization associated with the medical claim.

  • Subclient_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the subclient or division associated with the medical claim.

  • Claim_Line_Number

  • Is Nullable: YES

  • Data Type: INT64

  • Description: Unique identifier or number assigned to the claim line within the medical claim.

Dates

  • Claim_Line_From_Date

  • Is Nullable: YES

  • Data Type: DATE

  • Description: Start date for the service or treatment provided in the claim line.

  • Claim_Line_To_Date

  • Is Nullable: YES

  • Data Type: DATE

  • Description: End date for the service or treatment provided in the claim line.

Revenue Information

  • Claim_Line_Revenue_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Code representing the revenue category for the service in the claim line.

  • Claim_Line_Revenue_Code_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the revenue category for the service in the claim line.

Service Units

  • Claim_Line_Service_Units

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Number of service units or quantity for the service in the claim line.

  • Claim_Line_Unit_Type

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Service units type code:

    • "UN" - Units

    • "DA" - Days

    • "MJ" - Minutes

Medical Claim Dataset Specification

Medical Claim Claim Line

Claim Line Fields

  • Claim_Line_Deductible_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Amount of deductible applied to the claim line.

  • Claim_Line_Coinsurance_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Amount of coinsurance applied to the claim line.

  • Claim_Line_Copay_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Amount of copayment applied to the claim line.

  • Claim_Line_Billed_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Total amount billed for the service in the claim line.

  • Claim_Line_Paid_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Amount paid for the service in the claim line.

  • Claim_Line_Allowed_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Amount allowed or approved for the service in the claim line.

  • Claim_Line_Total_Adjustment_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Total amount of adjustments made to the claim line.

  • Claim_Line_Place_of_Service_Group

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Group or category indicating the place of service for the claim line.

  • Claim_Line_Procedure_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Code representing the procedure performed in the claim line.

  • Claim_Line_Procedure_Code_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the procedure performed in the claim line.

  • Claim_Line_Procedure_Code_Type

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Type or category of the procedure code in the claim line.

  • Claim_Line_Procedure_Code_Type_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the type or category of the procedure code in the claim line.

  • Claim_Line_Procedure_Scheme_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Scheme or coding system for the procedure code in the claim line.

  • Claim_Line_Procedure_Code_Set

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Code set or category for the procedure code in the claim line.

  • Claim_Line_Procedure_Code_Set_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the code set or category for the procedure code in the claim line.

  • Claim_Line_Claim_Line_Procedure_Code_Set_Type

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Type or category of the code set for the procedure code in the claim line.

  • Claim_Line_Procedure_Code_Set_Type_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the type or category of the code set for the procedure code in the claim line.

Medical Claim Claim Line Claim Modifiers

Claim Modifiers Fields

  • Claim_Number

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Unique identifier or number assigned to the medical claim.

  • Member_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Unique identifier for the member associated with the medical claim.

  • Membership_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the membership linked to the medical claim.

  • Subscriber_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the subscriber linked to the medical claim.

  • Client_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the client or organization associated with the medical claim.

  • Subclient_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the subclient or division associated with the medical claim.

  • Claim_Line_Number

  • Is Nullable: YES

  • Data Type: INT64

  • Description: Unique identifier or number assigned to the claim line within the medical claim.

  • Claim_Line_Claim_Modifiers_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Code representing the modifier applied to the claim line within the medical claim.

  • Claim_Line_Claim_Modifiers_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the modifier applied to the claim line within the medical claim.

Medical Claim Diagnoses

Diagnoses Fields

  • Claim_Number

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Unique identifier or number assigned to the medical claim.

  • Member_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Unique identifier for the member associated with the medical claim.

  • Membership_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the membership linked to the medical claim.

  • Subscriber_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the subscriber linked to the medical claim.

  • Client_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the client or organization associated with the medical claim.

  • Subclient_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the subclient or division associated with the medical claim.

  • Diagnoses_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description: ICD9/ICD10 diagnosis code.

  • Diagnoses_Code_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the diagnosis code used in the medical claim.

  • Diagnoses_Scheme_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Diagnosis Scheme: ICD9 or ICD10.

  • Diagnoses_Code_Type

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Diagnosis code type:

    • ABK: Principal

    • ABJ: Admitting

    • ABF: Other

    • BK: Principal

    • BJ: Admitting

    • BF: Other

  • Diagnoses_Code_Type_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the diagnosis code type used in the medical claim.

  • Diagnoses_Type_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description:

    • Principal: P

    • Admitting: A

    • Otherwise: S

  • Diagnoses_Type_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description:

    • Principal: Primary

    • Admitting: Admitting

    • Otherwise: Secondary

Medical Claim Procedures

Procedures Fields

  • Claim_Number

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Unique identifier or number assigned to the medical claim.

  • Member_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Unique identifier for the member associated with the medical claim.

  • Membership_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the membership linked to the medical claim.

  • Subscriber_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the subscriber linked to the medical claim.

  • Client_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the client or organization associated with the medical claim.

  • Subclient_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the subclient or division associated with the medical claim.

Medical Claim Dataset Specification

Medical Claim Procedures

Membership_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the membership linked to the medical claim.

Subscriber_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the subscriber linked to the medical claim.

Client_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the client or organization associated with the medical claim.

Subclient_ID

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Identifier for the subclient or division associated with the medical claim.

Procedures_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Service code. ICD10 code (for institutional). HCPCS or CPT code (for professional).

Procedures_Code_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the medical procedure code used in the medical claim.

Procedures_Code_Type

  • Is Nullable: YES

  • Data Type: STRING

  • Description:

  • "BO" for HCPCS code

  • "BP" for Principal HCPCS code

  • "HC" for CPT4 code

  • "BBQ" for ICD10 code

  • "BBR" for Principal ICD10 code

  • "BQ" for ICD9 code

  • "BR" for Principal ICD9 code

Procedures_Code_Type_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the medical procedure code type used in the medical claim.

Procedures_Scheme_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Service code scheme: HCPCS, CPT4, ICD10, ICD9.

Procedures_Code_Set

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Code representing the set or group of related medical procedure codes.

Procedures_Code_Set_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the set or group of related medical procedure codes used in the medical claim.

Procedures_Code_Set_Type

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Code representing the type or category of the procedure code set (e.g., primary, secondary, etc.).

Procedures_Code_Set_Type_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the type or category of the procedure code set used in the medical claim.

Procedures_Type_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description:

  • Principal => "P"

  • Anesthesia => "A"

  • Otherwise => "S"

Procedures_Type_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description:

  • Principal => "Principal"

  • Anesthesia => "Anesthesia"

  • Otherwise => "Other"

Medical Claim Raw

Claim_Number

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Unique identifier or number assigned to the medical claim.

Claim_Type

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Claim type discriminator: "PROF" vs "INST".

Claim_Type_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the claim type.

Claim_Line

  • Is Nullable: NO

  • Data Type: ARRAY

  • Description: Identifier or number of the claim line within the claim.

Claim Line

Claim_Line_Number

  • Is Nullable: YES

  • Data Type: INT64

  • Description: Unique identifier or number assigned to the claim line within the medical claim.

Claim_Line_From_Date

  • Is Nullable: YES

  • Data Type: DATE

  • Description: Start date for the service or treatment provided in the claim line.

Claim_Line_To_Date

  • Is Nullable: YES

  • Data Type: DATE

  • Description: End date for the service or treatment provided in the claim line.

Claim_Line_Revenue_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Code representing the revenue category for the service in the claim line.

Claim_Line_Revenue_Code_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the revenue category for the service in the claim line.

Claim_Line_Service_Units

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Number of service units or quantity for the service in the claim line.

Claim_Line_Unit_Type

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Service units type code:

  • "UN" - Units

  • "DA" - Days

  • "MJ" - Minutes

Claim_Line_Unit_Type_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the type of units or measurement for the service in the claim line.

Procedure

Claim_Line_Procedure_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Code representing the procedure performed in the claim line.

Claim_Line_Procedure_Code_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the procedure performed in the claim line.

Claim_Line_Procedure_Code_Type

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Type or category of the procedure code in the claim line.

Claim_Line_Procedure_Code_Type_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the type or category of the procedure code in the claim line.

Claim_Line_Procedure_Scheme_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Scheme or coding system for the procedure code in the claim line.

Claim_Line_Procedure_Code_Set

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Code set or category for the procedure code in the claim line.

Claim_Line_Procedure_Code_Set_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the code set or category for the procedure code in the claim line.

Claim_Line_Procedure_Code_Set_Type

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Type or category of the code set for the procedure code in the claim line.

Claim_Line_Procedure_Code_Set_Type_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the type or category of the code set for the procedure code in the claim line.

Claim Modifiers

Claim_Line_Claim_Modifiers_Code

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Code representing the modifier applied to the claim line within the medical claim.

Claim_Line_Claim_Modifiers_Description

  • Is Nullable: YES

  • Data Type: STRING

  • Description: Description of the modifier applied to the claim line within the medical claim.

Financial Details

Deductible_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Amount of deductible applied to the claim.

Coinsurance_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Amount of coinsurance applied to the claim.

Copay_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Amount of copay applied to the claim.

Billed_Amount

  • Is Nullable: YES

  • Data Type: NUMERIC

  • Description: Total amount billed for the claim.

Medical Claim Dataset Specification

Claim Line Fields

Claim_Line.Paid_Amount

  • Required: YES

  • Type: NUMERIC

  • Description: Amount paid for the claim.

Claim_Line.Allowed_Amount

  • Required: YES

  • Type: NUMERIC

  • Description: Amount allowed for the claim.

Claim_Line.Total_Adjustment_Amount

  • Required: YES

  • Type: NUMERIC

  • Description: Total amount of adjustments applied to the claim.

Claim_Line.Claim_Line_Place_of_Service_Group

  • Required: YES

  • Type: STRING

  • Description: Group or category indicating the place of service for the claim line.

Claim_Line.Visibility_Level

  • Required: YES

  • Type: INT64

  • Description: Level of visibility or access to the claim data.

Medical Claim Raw Fields

Member_ID

  • Required: YES

  • Type: STRING

  • Description: Unique identifier for the member associated with the claim.

Membership_ID

  • Required: YES

  • Type: STRING

  • Description: Identifier for the membership linked to the claim.

Subscriber_ID

  • Required: YES

  • Type: STRING

  • Description: Identifier for the subscriber linked to the claim.

Client_ID

  • Required: YES

  • Type: STRING

  • Description: Identifier for the client or organization associated with the claim.

Subclient_ID

  • Required: YES

  • Type: STRING

  • Description: Identifier for the subclient or division associated with the claim.

Is_Subscriber

  • Required: YES

  • Type: BOOL

  • Description: Indicator that the claim owner is also the subscriber.

Adjustment_Type

  • Required: YES

  • Type: STRING

  • Description: Adjustment type code (New/Adjusted/Voided).

Adjustment_Type_Description

  • Required: YES

  • Type: STRING

  • Description: Description of the adjustment type.

Provider_ID

  • Required: YES

  • Type: STRING

  • Description: Identifier for the provider associated with the claim.

Provider_NPI

  • Required: YES

  • Type: STRING

  • Description: National Provider Identifier (NPI) for the provider.

Provider_Specialty_Code

  • Required: YES

  • Type: STRING

  • Description: Claim’s provider specialty (Medecision_Specialty_Code).

Provider_Taxonomy

  • Required: YES

  • Type: STRING

  • Description: Code representing the taxonomy of the provider.

Provider_Taxonomy_Description

  • Required: YES

  • Type: STRING

  • Description: Description of the provider taxonomy.

In_Network_Provider_Indicator

  • Required: YES

  • Type: BOOL

  • Description: Indicator specifying if the provider is in-network or not.

Diagnoses Fields

Diagnoses

  • Required: NO

  • Type: ARRAY

  • Description: Diagnoses related to the medical claim.

Diagnoses.Diagnoses_Code

  • Required: YES

  • Type: STRING

  • Description: ICD9/ICD10 diagnosis code.

Diagnoses.Diagnoses_Code_Description

  • Required: YES

  • Type: STRING

  • Description: Description of the diagnosis code used in the medical claim.

Diagnoses.Diagnoses_Scheme_Code

  • Required: YES

  • Type: STRING

  • Description: Diagnosis Scheme: ICD9 or ICD10.

Diagnoses.Diagnoses_Code_Type

  • Required: YES

  • Type: STRING

  • Description: Diagnosis code type:

  • ABK - principal

  • ABJ - admitting

  • ABF - other

  • BK - principal

  • BJ - admitting

  • BF - other

Diagnoses.Diagnoses_Code_Type_Description

  • Required: YES

  • Type: STRING

  • Description: Description of the diagnosis code type used in the medical claim.

Diagnoses.Diagnoses_Type_Code

  • Required: YES

  • Type: STRING

  • Description:

  • Principal => P

  • Admitting => A

  • Otherwise => S

Diagnoses.Diagnoses_Type_Description

  • Required: YES

  • Type: STRING

  • Description:

  • Principal => Primary

  • Admitting => Admitting

  • Otherwise => Secondary

Procedures Fields

Procedures

  • Required: NO

  • Type: ARRAY

  • Description: Element holding procedures associated with the claim. It includes principal procedures for institutional claims and anesthesia procedures for professional claims.

Procedures.Procedures_Code

  • Required: YES

  • Type: STRING

  • Description: Service code. ICD10 code (for institutional). HCPCS or CPT code (for professional).

Procedures.Procedures_Code_Description

  • Required: YES

  • Type: STRING

  • Description: Description of the medical procedure code used in the medical claim.

Procedures.Procedures_Code_Type

  • Required: YES

  • Type: STRING

  • Description:

  • “BO” for HCPCS code

  • “BP” for Principal HCPCS code

  • “HC” for CPT4 code

  • “BBQ” for ICD10 code

  • “BBR” for Principal ICD10 code

  • “BQ” for ICD9 code

  • “BR” for Principal ICD9 code

Procedures.Procedures_Code_Type_Description

  • Required: YES

  • Type: STRING

  • Description: Description of the medical procedure code type used in the medical claim.

Procedures.Procedures_Scheme_Code

  • Required: YES

  • Type: STRING

  • Description: Service code scheme:

  • HCPCS

  • CPT4

  • ICD10

  • ICD9

Procedures.Procedures_Code_Set

  • Required: YES

  • Type: STRING

  • Description: Code representing the set or group of related medical procedure codes.

Procedures.Procedures_Code_Set_Description

  • Required: YES

  • Type: STRING

  • Description: Description of the set or group of related medical procedure codes used in the medical claim.

Procedures.Procedures_Code_Set_Type

  • Required: YES

  • Type: STRING

  • Description: Code representing the type or category of the procedure code set (e.g., primary, secondary, etc.).

Procedures.Procedures_Code_Set_Type_Description

  • Required: YES

  • Type: STRING

  • Description: Description of the type or category of the procedure code set used in the medical claim.

Procedures.Procedures_Type_Code

  • Required: YES

  • Type: STRING

  • Description:

  • Principal => "P"

  • Anesthesia => "A"

  • Otherwise => "S"

Procedures.Procedures_Type_Description

  • Required: YES

  • Type: STRING

  • Description:

  • Principal => "Principal"

  • Anesthesia => "Anesthesia"

  • Otherwise => "Other"

Admission Fields

Admission_Source_Category

  • Required: YES

  • Type: STRING

  • Description: Category of the admission source (e.g., emergency, elective, etc.).

Admission_Source_Code

  • Required: YES

  • Type: STRING

  • Description: Code representing the admission source.

Admission_Source_Description

  • Required: YES

  • Type: STRING

  • Description: Description of the admission source.

Admission_Type_Code

  • Required: YES

  • Type: STRING

  • Description: Code representing the admission type.

Admission_Type_Description

  • Required: YES

  • Type: STRING

  • Description: Description of the admission type.

Billing Fields

Bill_Code_Type

  • Required: YES

  • Type: STRING

  • Description: Type of billing code used in the claim.

Bill_Type_Description

  • Required: YES

  • Type: STRING

  • Description: Description of the billing code type.

Place of Service Fields

Place_of_Service

  • Required: YES

  • Type: STRING

  • Description: Code representing the place of service. See Dictionary Place Of Service table in the Dictionary Dataset Specification.

Place_of_Service_Description

  • Required: YES

  • Type: STRING

  • Description: Description of the place of service. See Dictionary Place Of Service table in the Dictionary Dataset Specification.

  • Required: YES

  • Type: STRING

  • Description: Code representing the diagnosis-related group.

  • Required: YES

  • Type: STRING

  • Description: Description of the diagnosis-related group.

Medical Claim Dataset Specification

Medical Claim Raw Fields

Patient Status Code

  • Field Name: Patient_Status_Code

  • Required: YES

  • Type: STRING

  • Description: UB-92 patient status code. Also known as discharge disposition code.

Patient Status Description

  • Field Name: Patient_Status_Description

  • Required: YES

  • Type: STRING

  • Description: Patient status (discharge disposition) description.

Deductible Amount

  • Field Name: Deductible_Amount

  • Required: YES

  • Type: NUMERIC

  • Description: Amount of deductible applied to the claim.

Coinsurance Amount

  • Field Name: Coinsurance_Amount

  • Required: YES

  • Type: NUMERIC

  • Description: Amount of coinsurance applied to the claim.

Copay Amount

  • Field Name: Copay_Amount

  • Required: YES

  • Type: NUMERIC

  • Description: Amount of copay applied to the claim.

Billed Amount

  • Field Name: Billed_Amount

  • Required: YES

  • Type: NUMERIC

  • Description: Total amount billed for the claim.

  • Field Name: Paid_Amount

  • Required: YES

  • Type: NUMERIC

  • Description: Amount paid for the claim.

Allowed Amount

  • Field Name: Allowed_Amount

  • Required: YES

  • Type: NUMERIC

  • Description: Amount allowed for the claim.

Total Adjustment Amount

  • Field Name: Total_Adjustment_Amount

  • Required: YES

  • Type: NUMERIC

  • Description: Total amount of adjustments applied to the claim.

  • Field Name: Paid_Date

  • Required: YES

  • Type: DATE

  • Description: Date when the claim was paid.

Statement Start Date

  • Field Name: Statement_Start_Date

  • Required: YES

  • Type: DATE

  • Description: Start date of the claim statement period.

Statement End Date

  • Field Name: Statement_End_Date

  • Required: YES

  • Type: DATE

  • Description: End date of the claim statement period.

Type

  • Field Name: Type

  • Required: YES

  • Type: STRING

  • Description: Type of the claim or record.

Tenant

  • Field Name: Tenant

  • Required: YES

  • Type: STRING

  • Description: Identifier for the tenant or organization.

Active Version

  • Field Name: Active_Version

  • Required: YES

  • Type: BOOL

  • Description: Version number of the active record.

Date

  • Field Name: Date

  • Required: YES

  • Type: DATE

  • Description: Date of the claim or record.

Sequence

  • Field Name: Sequence

  • Required: YES

  • Type: INT64

  • Description: Sequence number of the claim or record.

Source System Name

  • Field Name: Source_System_Name

  • Required: YES

  • Type: STRING

  • Description: Name of the source system that generated the claim.

Source Timestamp

  • Field Name: Source_Timestamp

  • Required: YES

  • Type: TIMESTAMP

  • Description: Timestamp indicating when the claim was sourced.

Source File Name

  • Field Name: Source_File_Name

  • Required: YES

  • Type: STRING

  • Description: Name of the source file containing the claim information.

Schema Version

  • Field Name: Schema_Version

  • Required: YES

  • Type: FLOAT64

  • Description: Version of the schema used for the claim data.

Visibility Level

  • Field Name: Visibility_Level

  • Required: YES

  • Type: INT64

  • Description: Level of visibility or access to the claim data.

Office Visit Indicator

  • Field Name: Office_Visit_Indicator

  • Required: YES

  • Type: BOOL

  • Description: Indicator specifying if the claim is related to an office visit.

ER Visit Indicator

  • Field Name: ER_Visit_Indicator

  • Required: YES

  • Type: BOOL

  • Description: Indicator specifying if the claim is related to an emergency room visit.

Behavioral Health Admission Indicator

  • Field Name: Behavioral_Health_Admission_Indicator

  • Required: YES

  • Type: BOOL

  • Description: Indicator specifying if the claim is related to a behavioral health admission.

Encounter Indicator

  • Field Name: Encounter_Indicator

  • Required: YES

  • Type: BOOL

  • Description: Indicator specifying if the claim is an encounter record.

Member Partition

  • Field Name: Member_Partition

  • Required: YES

  • Type: INT64

  • Description: Identifier for the member partition or segment.

Updated

  • Field Name: _updated

  • Required: YES

  • Type: STRING

  • Description: Indicator specifying if the claim record has been updated.

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