Claims

Categorizes the adjustment (e.g., CO = Contractual Obligation, PR = Patient Responsibility).

The specific code (CARC) explaining why the full charge was not paid (e.g., 45 = Charge exceeds fee schedule).

The primary key assigned by the submitter to track the claim record (CLM01).

Identifies the type of insurance plan (e.g., MC=Medicaid, HM=HMO, CI=Commercial).

Indicates the final status of the claim (1=Processed as Primary, 2=Processed as Secondary, 4=Denied).

The fixed amount a patient pays for a prescription covered by insurance.

The unique identifier assigned to the claim by the payer (ICN/DCN).

The date the funds were issued by the payer (BPR segment).

The sum of all line item charges submitted on the claim.

The claim submission date for a condition severity level. Used to track temporal information related to acuity claim date. This field is commonly used in electronic health records (EHR), healthcare information systems (HIS), and clinical data warehouses for acuity management and reporting.

The claim adjudication state for a condition severity level. Used to track the current state or condition of the acuity. This field is commonly used in electronic health records (EHR), healthcare information systems (HIS), and clinical data warehouses for acuity management and reporting.