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recoupment

recoup_amt
finance·Updated Jun 23, 2026

Definition

ISO-11179 Definition

The process by which a health insurance payer or government program recovers previously paid claim amounts determined to have been overpaid, typically by offsetting future claim payments to the provider rather than requiring a direct refund check. Medicare and Medicaid recoupments are common following RAC audit findings, MAC post-payment reviews, and RADV audit settlements where CMS has determined that prior payments exceeded the correct amount. Providers have the right to request an extended repayment schedule for large recoupment amounts and may suspend recoupment by filing a timely appeal.

Commercial payer recoupments are governed by provider contract terms and applicable state prompt payment and recoupment regulations. Healthcare data teams track recoup_amt in accounts receivable systems as a reduction to expected cash receipts, monitor recoupment activity by payer and audit type, manage cash flow projections that account for pending recoupment offsets, and ensure appeal rights are exercised before recoupment deadlines to preserve the ability to challenge disputed findings.

Standard Abbreviation

recoup_amt

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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