community rating
comm_ratingDefinition
ISO-11179 Definition
An insurance premium rate-setting methodology that charges all members within a defined community or rating area the same premium rate regardless of individual health status, claims history, or demographic characteristics, required for ACA-compliant individual and small group market plans. Modified community rating allows variation by age and geographic area but prohibits premium variation based on health status. Community rating prevents adverse selection against sick individuals but may result in higher premiums for healthy young members.
Standard Abbreviation
comm_rating
Category
Production DDL — FACT_CLAIM_TRANSACTION
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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