Core 5.2 Model | Unified | claim

claim

The claim table is related to the Claim resource that is available via the FHIR API.
Claims are used by providers and insurers to exchange the financial information, and supporting clinical information, regarding the provision of health care services and for reporting to regulatory bodies and firms which provide data analytics.
The claim table combines all claims from all sources for a HIEBus person (recordgroup) into a consolidated structure.

Additional References:

Overview of the Unified Model
Using Terminology Concepts Mapped By Rosetta for columns represented with Rosetta-mapped terms.
Galileo Encounter Reconciliation for computed columns related to primary care setting.
Refer to the condition table for diagnoses associated with the claim. Refer to the procedure table for procedures and services associated with the claim.

Table Schema

Name	Type	Description
personid	VARCHAR	GUID. An internal identifier representing a unique `person` that may include data from several sources that have been linked. This identifier is the person_id of a HIEBus recordgroup.
claimid	VARCHAR	GUID. An internal identifier representing a unique `claim`. This identifier is the id of the row in the HIEBus claim table.
identifier	VARCHAR	External identifier used by the source system to uniquely identify the claim.
datasource	VARCHAR	The name of the data source. Commonly determined from the HIEBus record authority name of the source patient record.
status	VARCHAR	Mapped by Rosetta. The administrative state of the claim. For example: Pended, Final, Canceled. This is the preferred mapped concept determined by the Rosetta Terminology Service.
statuscode	VARCHAR	Mapped by Rosetta. Coded value. The administrative state of the claim. For example: Pended, Final, Canceled. This is the preferred mapped concept determined by the Rosetta Terminology Service.
statustermid	INTEGER	Reference to HIEBus terminology properties for the claim.
type	VARCHAR	Mapped by Rosetta. Category or discipline. This is the preferred mapped concept determined by the Rosetta Terminology Service.
typecode	VARCHAR	Mapped by Rosetta. Coded value. Category or discipline. This is the preferred mapped concept determined by the Rosetta Terminology Service.
typetermid	INTEGER	Reference to HIEBus terminology properties for the claim.
subtype	VARCHAR	Mapped by Rosetta. More granular claim type; represents claim bill class. CMS Bill Type Code, described here. This is the preferred mapped concept determined by the Rosetta Terminology Service.
subtypecode	VARCHAR	Mapped by Rosetta. Coded value. More granular claim type; represents claim bill class. CMS Bill Type Code, described here. This is the preferred mapped concept determined by the Rosetta Terminology Service.
subtypetermid	VARCHAR	Reference to HIEBus terminology properties for the claim.
facilitytype	VARCHAR	Mapped by Rosetta. Primary place of service for the claim. See CMS POS Codes, described here. This is the preferred mapped concept determined by the Rosetta Terminology Service.
facilitytypecode	VARCHAR	Mapped by Rosetta. Coded value. Primary place of service for the claim. See CMS POS Codes, described here. This is the preferred mapped concept determined by the Rosetta Terminology Service.
facilitytypetermid	INTEGER	Reference to HIEBus terminology properties for the claim.
program	VARCHAR	Values: Facility (i.e. CMS Part A, or Institutional), Professional (i.e. CMS Part B, or Professional Service), Pharmacy (i.e. CMS Part D, or Medications).
startdate	TIMESTAMP	The start date for the claim.
enddate	TIMESTAMP	The end date for the claim.
admitdate	TIMESTAMP	If the claim is related to a bed-assigned inpatient encounter, the admit date of the encounter.
dischargedate	TIMESTAMP	If the claim is related to a bed-assigned inpatient encounter, the discharge date of the encounter.
total	DECIMAL	Total claim cost.
drg	VARCHAR	DRG for the claim.
provideridentifier	VARCHAR	The identifier assigned to the primary provider associated with the claim.
providername	VARCHAR	The name of the primary provider associated with the claim.
primarycaresetting	VARCHAR	Computed. A normalized description of the primary place of service for the claim.
primarycaresettingreason	VARCHAR	Computed. For traceability, an explanation for the primarycaresetting assignment.
isderivedencounteranchor	BOOLEAN	Computed. Claim will be used as a primary claim to constructed derived encounters.
secondarycaresettings	VARCHAR	Computed. A comma delimited string of other care settings (for example ED or observation activity on an inpatient claim) determined for the claim.
primaryspecialty	VARCHAR	Computed. The specialty associated with the claim or the primary provider.
annotations	VARCHAR	Computed. A comma delimited set of strings that represent computed features of the claim.
lastupdated	TIMESTAMP	System generated timestamp indicating the most recent change to this data row. Used for differential operations. Managed in UTC.

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