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claim adjudication

clm_adjud
finance·Updated Jun 13, 2026

Definition

ISO-11179 Definition

The process by which a health insurance payer reviews a submitted claim, applies benefit plan rules and contract terms, and determines the amount to be paid to the provider. Claim adjudication involves multiple sequential steps including eligibility verification confirming the member was covered on the date of service, medical necessity review validating that the billed services were clinically appropriate, coordination of benefits processing when multiple payers are involved, contract rate application calculating the allowed amount based on the provider network contract, and member cost-sharing calculation determining deductible, copay, and coinsurance obligations. The adjudication result is communicated to providers through the HIPAA 835 electronic remittance advice transaction.

Healthcare data teams build adjudication analytics that track claim processing times, adjudication accuracy rates, payment variance between billed and allowed amounts, and adjudication outcome distributions across payer and service type combinations.

Standard Abbreviation

clm_adjud

Category

finance

Production DDL — FACT_CLAIM_TRANSACTION

FACT_CLAIM_TRANSACTION.sql
CREATE OR REPLACE TABLE FACT_CLAIM_TRANSACTION (
    clm_txn_key     INTEGER        NOT NULL  -- surrogate key,
    clm_id          VARCHAR(50)    NOT NULL  -- claim identifier,
    mbr_key         INTEGER        NOT NULL  -- FK to DIM_MEMBER,
    prvdr_key       INTEGER        NOT NULL  -- FK to DIM_PROVIDER,
    clm_typ_cd      VARCHAR(10)              -- claim type code,
    tot_chrg_amt    DECIMAL(18,2)            -- total charged amount,
    tot_alwd_amt    DECIMAL(18,2)            -- total allowed amount,
    tot_pd_amt      DECIMAL(18,2)            -- total paid amount,
    cntrct_adj_amt  DECIMAL(18,2)            -- contractual adjustment,
    denial_ind      CHAR(1)                  -- denial indicator,
    denial_rsn_cd   VARCHAR(10)              -- denial reason code,
    prior_auth_nbr  VARCHAR(30)              -- authorization number,
    clm_lag_days    SMALLINT                 -- claim lag days,
    days_ar         SMALLINT                 -- days in AR,
    load_dt         TIMESTAMP_NTZ  NOT NULL  -- load timestamp
);

Standard Snowflake DDL for the canonical finance table. Convert to BigQuery or Databricks →

Why This Term Matters

Healthcare data terminology is foundational for any data engineer working in this industry. Precise understanding of standard terms enables accurate schema design, reduces downstream data quality issues, and ensures pipelines meet the regulatory and interoperability requirements imposed by HIPAA, HL7 FHIR, and CMS reporting frameworks. Without this foundation, even technically well-built pipelines produce data that fails validation when it reaches payers or regulators.

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