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compliance audit

cmplnc_audit
finance·Updated Jun 23, 2026

Definition

ISO-11179 Definition

A systematic review of healthcare billing, coding, and documentation practices conducted by internal compliance staff, external consultants, or government agencies to evaluate adherence to applicable laws, regulations, payer policies, and coding guidelines and identify areas of financial and compliance risk. Compliance audits may be prospective reviewing records before claim submission, concurrent reviewing active inpatient cases, or retrospective reviewing previously submitted claims. OIG Work Plans, MAC probe audits, RAC audits, and ZPIC reviews represent external compliance audit activities that healthcare organizations must be prepared to respond to.

Internal compliance audit programs are a core element of effective healthcare compliance programs under OIG guidance. Healthcare data teams build compliance audit analytics that support statistical sampling, track audit findings by error type and provider, calculate financial exposure from identified compliance issues, measure error rate trends over time to evaluate compliance program effectiveness, and produce audit documentation demonstrating systematic compliance monitoring.

Standard Abbreviation

cmplnc_audit

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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