managed care contract
mgd_care_cntrctDefinition
ISO-11179 Definition
A provider agreement with a managed care organization such as an HMO, PPO, or ACO that establishes network participation terms, negotiated reimbursement rates, utilization management requirements, quality metrics, and value-based payment arrangements governing how the provider is compensated for delivering care to the managed care plan members. Managed care contracts may include fee-for-service rate schedules, capitation arrangements, bundled payment provisions, shared savings opportunities, and quality bonus incentives tied to performance on defined metrics. Contract negotiation leverage depends on provider market position, specialty type, quality reputation, and the payer network adequacy needs in the service area.
Healthcare data teams support managed care contracting through analytics that calculate current reimbursement rates as a percentage of Medicare, model proposed rate changes against current volumes to project revenue impact, analyze service line profitability under different rate scenarios, and track contract performance against quality and utilization benchmarks.
Standard Abbreviation
mgd_care_cntrct
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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