explanation of payment
eop_cdDefinition
ISO-11179 Definition
A coded value or document communicating how a health insurance payer calculated payment for a specific claim, providing the financial reconciliation detail needed for accurate payment posting and denial management. The explanation of payment includes the allowed amount, contractual adjustment, member cost-sharing amounts, payment amount, and any denial or adjustment reason codes for services that were not paid at the expected amount. For Medicare and Medicaid, the explanation of payment is delivered through the HIPAA 835 electronic remittance advice transaction using standardized CARC and RARC codes.
Commercial payers deliver explanation of payment through 835 transactions or proprietary remittance formats. Healthcare data teams build EOP processing pipelines that parse remittance transactions, map explanation codes to denial categories, automate payment posting from EOP data, identify underpayments by comparing EOP allowed amounts against contracted rates, and generate denial work queues from EOP denial reason codes.
Standard Abbreviation
eop_cd
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.
Related Content
Looking for more healthcare terms?
Browse our complete library of 100,000+ standardized healthcare data terms
Browse All Terms