risk transfer payment
risk_trans_pmtDefinition
ISO-11179 Definition
A payment made between health plans in the same market under the ACA risk adjustment program, transferring funds from plans with lower-than-average risk enrollees to plans with higher-than-average risk enrollees based on the relative risk scores of each plan enrolled population. Risk transfer payments are calculated by CMS and HHS using HHS-HCC risk adjustment models and are zero-sum within each market and state, designed to neutralize incentives for risk selection and ensure premiums reflect benefits rather than enrollee health status.
Standard Abbreviation
risk_trans_pmt
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