Repository Model

This section describes the data model of the Claim Transaction Repository (or CTR). The claims transaction repository data model is based on the claims (working copy) data model. The main differences between the models are:

• The transaction model includes additional financial transaction data that is added when creating claim transactions (for example, allocations to payment receivers).

• The internal keys and references of the claims model are replaced with external meaningful values in the repository model.

• Some details of referenced entities are included in the repository model.

The repository claim transactions are in effect snapshots of claims and their referenced data at the time of finalization. Even though claims themselves are not versioned, claims transactions are versioned. Each time that a claim is finalized, a new claim transaction version is created in the repository.

See the Creation of a Transaction from a Claim - Example for an illustration of the differences between a claim transaction and a claim.

See the Claim Transaction Versioning Example for an illustration of versioning of claims in the transaction repository.

Design Principles

Minimal Validation

The transaction repository does not include referential integrity constraints other than those for internal use, for example, to implement internal primary-detail relationships. Likewise, it does not enforce any business rules. The intention is that claim transactions are an accurate representation of the claim and referenced data at the time of finalization, even if aspects of this information are incorrect.

Transactions are Self Contained

As part of the creation of a claim transaction internal references from a claim (and its details) to other 'non-claim' entities are replaced with externally meaningful values from the data that is referenced within Claims (for example, internal ids are replaced with codes).

Within the repository itself, foreign keys are used to implement internal primary / detail relationships. These are only used internally and are not included in any outbound messages. These internal foreign keys are resolved in the messages produced from the claims transaction repository by embedding the elements that represent the child objects within their parent elements. For example, even though coverages include a foreign key to their claim lines, the messages that deliver claims to external systems will have the coverages of a line as a list within the claim line element.

Included Referenced Data

In general, the referenced data that is included in the transaction repository is determined at the time that a transaction is created (that is, when the claim is finalized). For example, if some values are included in the repository from provider, the values would be as they are recorded for the provider at claim finalization time. If values are required as they were on another date (for example, claim service date), the dynamic logic of the transaction creation scenarios would need to specifically retrieve the value as it was at that the required time.

Multiple Language Considerations

Only the base language 'translation' of multi-language data will be included in the transaction repository. This is also the case with messages that can have substitution parameters. Messages will be included in the base language (with substitutions); however, the substitution parameters may also be stored with messages to provide the possibility for a downstream application to reconstruct the message in another language.

Basis of Entity Model

The data model of the transactions repository is based on the Claims entity model. The structure (attributes and associations between entities) are very similar to it. However, the transaction creation logic determines which attributes of the repository transactions are filled and the source of them. In general, it is expected that in most configurations the choice would be made to fill the transaction attributes directly from their corresponding Claims attributes. However, it is possible for different choices to be made. The 'Corresponding Claims Entity' column indicates the basis for repository fields and implicitly the expected / default source.

Preparation of the transaction creation logic is described in a separate section.

Dynamic Fields

Free fields and dynamic records can be added to each entity. Refer to the Repository Configuration section for more details.

Claim Unmatched Attributes

The Claims data model includes attributes for holding values of related entities needed to match a claim to a related entity. These 'unmatched' attributes are not included as native fields in the repository as it is expected that by the time claims reach finalization matching will have occurred. If for some reason an 'unmatched' attribute is needed, it could be defined as a dynamic field.

Claim Line Internal Details

In the Claims entity model claim lines have several detail entities that are very specific to claims processing. These detail entities are not included in the transaction repository model as they are not seen as having meaning once a claim has been finalized. These internal detail entities are:

• Limit Consumptions

• Rule Coverages

• Regime Consumptions

• Authorization Consumptions

• Case Details

These details could be added dynamic fields or records.

Data Types

In general, data types are carried through from the Claims data model. For example, dates will be stored as date fields even though they will primarily be sent out as strings.

Database Tables

The claim transaction repository is physically part of the Claims database. It is logically separate in the sense that it consists of an independent set of tables with no 'physical links' to the main claim tables (for example, they have no foreign keys to the main tables and no logic outside of the finalization step that accesses the repository tables directly).

Claim Versioning

Claims are considered to be a new version of an existing claim purely because they have the same claim code. The concept of claim versions is limited to the repository. Claims themselves do not have versions. Therefore, a claim version is in effect a 'count' of the number of times a claim with the same code has been finalized.

Versioning only applies at claim level. The claim lines (and other details) are not directly versioned by Claims. If claim lines need to be comparable between versions, it is up to the external components that send in new versions of claims to make sure that the claim lines can be recognized by their unique identification, that is, the combination of the claim code and the claim line code (unique within a claim).

Security

The downstream applications that receive / access information from the repository are treated as 'trusted' components in the overall SOA architecture. Security access restriction labels related to viewing claim information are included in the repository, and it is up to downstream applications to ensure that any restrictions that are needed based on them are implemented. Access restriction labels related to maintaining claim information (for example, adding and removing messages from claims or approving high-value claims) are not included as claims in the repository cannot be updated.

Data Model

The entities (and relationships) of the transaction repository are as illustrated here:

In addition to these entities, separate 'technical' entities are used to hold values of dynamic fields and records.

Corresponding Claims Entities

The details of each entity of the repository data model are described in the following sections. For each repository entity attribute, the corresponding Claims entity is indicated. For attributes that are from referenced entities where there is more than one relationship between the base entity and the referenced entity, the type of relationship is provided in italics. For example, Claimant Relation of Claim means that the attribute is from the relation with the 'claimant' relation type with the claim.

Descriptions of entities and attributes are not included. By default the meaning is the same as described for the corresponding Claims entities and attributes.

Dynamic logic determines the actual source of claim transaction values. Individual customers may choose different sources for claim transaction values than the indicated corresponding working copy entity.

Reversal Transactions

Reversal transactions are transactions with most amounts and numbers reversed (multiplied by -1). The Reverse? column in the table below indicates if a value is to be reversed in reversal transactions. Refer to Reversal Transactions section for more details.

Common Blocks of Attributes

Relation or Provider Details

Relation and provider details are included in the data model in several roles. For example, in claims, bills and claim lines relations are included in the 'payment receiver' role.

To reduce repetition, the inclusion of provider details is indicated in the format role + 'Provider Details'. This can be understood to mean that the following attributes are present prefixed with 'role name':

• Provider Name

• Provider Code

• Provider Code Definition

The inclusion of relation details is indicated in the format role
'Relation Details'. This can be understood to mean that the following attributes are present prefixed with 'role name':

• Relation Name

• Relation Code

CTR Claim

This entity is the 'header' of claim transactions.

Corresponding Entity	Attribute	Reverse?	Note
Claim	Code
None	Version		Set when transaction created. Simple increment of sequence within claim code.
None	Transaction Date		Set to current date / time when transaction created.
Claim	Authorization Code
Belongs to Brand of Claim	Brand Code
Belongs to Brand of Claim	Brand Description
has Access Restriction of Belongs to Brand of Claim	Brand Access Restriction Code
Belongs to Payer of Belongs to Brand of Claim	Brand Payer Name
has Access Restriction of Belongs to Payer of Belongs to Brand of Claim	Brand Payer Access Restriction Code
Grouped in Claim Set of Claim	Claim Set Code
Claim	Claim Date
Claimant Provider of Claim	Claimant 'Provider Details'
Claimant Relation of Claim	Claimant 'Relation Details'
has Access Restriction of Claimant Relation of Claim	Claimant Access Restriction Code
contact details Access Restriction of Claimant Relation of Claim	Claimant Contact Details Access Restriction Code
classified by Classification Scheme of Claim	Classification Scheme Code
has Classification of Claim	Classification Code
Claim	Due Date
Claim	Emergency Indicator
Claim	End Date
Claim	Entry Date
Claim	Expiration Date
Claim	External Remarks
Claim	Ignore History Indicator
Claim	Internal Remarks
Is of Claim Form	Form Code
Is of Claim Form	Form Description
Belongs to Data Access Group of Claim	Data Access Group
has Access Restriction of Belongs to Data Access Group of Claim	Data Access Group Access Restriction Code
Location Provider Provider of Claim	Location 'Provider Details'
Location Provider Provider of Claim	Location Provider Address
has Location Type of Claim	Location Type Code
has Location Type of Claim	Location Type Description
Claim	Manual Indicator
Claim	Next Payer Code		No look-up
Claim	Paid Date
Destination Payer Payer Code of Claim	Payer Code
Payment Beneficiary Provider of Claim	Payment Beneficiary 'Provider Details'
Payment Beneficiary Relation of Claim	Payment Beneficiary 'Relation Details'
Payment Receiver Provider of Claim	Payment Receiver 'Provider Details'
Payment Receiver Relation of Claim	Payment Receiver 'Relation Details'
Payment Specification Receiver Provider of Claim	Payment Specification Receiver 'Provider Details'
Payment Specification Receiver Relation of Claim	Payment Specification Receiver 'Relation Details'
Claim	Preceding Payer Code		No look-up.
Claim	Price Date
Claim	Process Type		C(laim) or R(eservation)
Claim	Provider Entity Reference
Claim	Provider Reference
Claim	Receipt Date
Referral Provider Provider of Claim	Referral 'Provider Details'
None	Reversal Indicator		This field indicates if the transaction is a reversal transaction.
Service Provider Provider of Claim	Service 'Provider Details'
Service Specialty Specialty of Claim	Service Specialty Code
Serviced Entity Relation of Claim	Serviced Entity 'Relation Details'
Serviced Entity Relation of Claim	Serviced Entity Date
Serviced Entity Relation of Claim	Serviced Entity Date Interpretation
has Access Restriction of Serviced Entity Relation of Claim	Serviced Entity Access Restriction Code
contact details Access Restriction of Serviced Entity Relation of Claim	Serviced Entity Contact Details Access Restriction Code
Claim	Start Date
Claim	Total Allowed Amount	Y
uses (total allowed amount) Currency	Total Allowed Amount Curr
Claim	Total Claimed Amount	Y
uses (total claimed amount) Currency	Total Claimed Amount Curr
Claim	Total Covered Amount	Y
uses (total covered amount) Currency	Total Covered Amount Curr
Claim	Type		P(rovider) or R(estitution)

CTR Transaction Labels

These labels provide additional information about a claim transaction that needs to be added after initial creation of a transaction. For now, they are only used to indicate that the claim of the transaction has been 'unfinalized'.

Corresponding Entity	Attribute	Note
None	Label Date
None	Label Type

CTR Status History

This entity holds the status history entries of claim transactions.

Corresponding Entity	Attribute	Note
Claim Status History	Status
Claim Status History	Status Date

CTR Pend Reason History

This entity holds the pend reason history entries for specific status history entries.

Corresponding Entity	Attribute	Note
Claim Pend Reason History	Sequence
Claim Pend Reason History	Bill Provider Reference
Claim Pend Reason History	Resolved Datetime
For Pend Reason of Claim Pend Reason History	Code
For Pend Reason of Claim Pend Reason History	External Code
For Pend Reason of Claim Pend Reason History	Alternative Text
For Pend Reason of Claim Pend Reason History	Provider Text
Resolved by User	User Login Name

CTR Callout History

This entity holds the callout history entries of claim transactions.

Corresponding Entity	Attribute	Note
Claim Callout History	Request Sent Datetime
Claim Callout History	Response Received Datetime
based on Callout Definition of Claim Callout Rule	Code
based on Callout Definition of Claim Callout Rule	Description

CTR Claim Un-finalize Reason

This entity holds the claim level unfinalize reasons of claim transactions.

Corresponding Entity	Attribute	Note
Claim Unfinalize Reason	Source Reference
Is unfinalized because of Unfinalize Reason of Claim Unfinalize Reason	Code
Is unfinalized because of Unfinalize Reason of Claim Unfinalize Reason	External Code

CTR Claim Diagnosis

This entity holds the claim level diagnoses of claim transactions.

Corresponding Entity	Attribute	Note
Applies To Diagnosis of Claim Diagnosis	Code
Applies To Diagnosis of Claim Diagnosis	Code Definition
Applies To Diagnosis of Claim Diagnosis	Description
Claim Diagnosis	Sequence
has Diagnosis Type of Claim Diagnosis	Type Code
has Diagnosis Type of Claim Diagnosis	Type Description
has Access Restriction of Applies To Diagnosis of Claim Diagnosis	Access Restriction Code

CTR Claim Message

This entry holds claim level messages of claim transactions.

Corresponding Entity	Attribute	Note
Knows Message of Claim Message of Claim	Code
Claim Message of Claim	Origin
None	Message text with substituted parameters
None	Provider Message text with substituted parameters
None	Alternative Message text with substituted parameters
Knows Message of Claim Message of Claim	Severity
Knows Message of Claim Message of Claim	Priority
Knows Message of Claim Message of Claim	External Code
Claim Message of Claim	Overturned Indicator
Knows User who overturned the Claim Message	Login Name
Claim Message of Claim	Value 0
Claim Message of Claim	Value 1
Claim Message of Claim	Value 2
Claim Message of Claim	Value 3
Claim Message of Claim	Value 4
Claim Message of Claim	Value 5
Claim Message of Claim	Value 6
Claim Message of Claim	Value 7
Claim Message of Claim	Value 8
Claim Message of Claim	Value 9

CTR Bill

This entity holds the bills of claim transactions.

Corresponding Entity	Attribute	Note
Bill	Provider Reference
Bill	Provider Entity Reference	Set when transaction created.
Bill	Bill Date
Bill	Authorization Code	No look-up
Bill	Emergency Indicator
Payment Receiver Provider of Bill	Payment Receiver 'Provider Details'
Payment Receiver Relation of Bill	Payment Receiver 'Relation Details'
Service Provider Provider of Bill	Service 'Provider Details'
Location _Provider _Provider of Bill	Location 'Provider Details'
has Location Type of Bill	Location Type Code
has Location Type of Bill	Location Type Description
Referral Provider Provider of Bill	Referral 'Provider Details'
Serviced Entity Relation of Bill	Serviced Entity 'Relation Details'
Serviced Entity Relation of Bill	Serviced Entity Date
Serviced Entity Relation of Bill	Serviced Entity Date Interpretation
has Access Restriction of Serviced Entity Relation of Bill	Serviced Entity Access Restriction Code
contact details Access Restriction of Serviced Entity Relation of Bill	Serviced Entity Contact Details Access Restriction Code
Service Specialty Specialty of Bill	Service Specialty Code

CTR Bill Diagnosis

This entity contains the diagnoses of bills.

Corresponding Entity	Attribute	Note
Applies To Diagnosis of Bill Diagnosis	Code
Applies To Diagnosis of Bill Diagnosis	Code Definition
Applies To Diagnosis of Bill Diagnosis	Description
Bill Diagnosis	Sequence
has Diagnosis Type of Bill Diagnosis	Type Code
has Diagnosis Type of Bill Diagnosis	Type Description
has Access Restriction of Applies To Diagnosis of Bill Diagnosis	Access Restriction Code

CTR Bill Message

This entity contains the messages of bills.

Corresponding Entity	Attribute	Note
Knows Message of Bill Message of Bill	Code
Bill Message of Bill	Origin
None	Message text with substituted parameters
None	Provider Message text with substituted parameters
None	Alternative Message text with substituted parameters
Knows Message of Bill Message of Bill	Severity
Knows Message of Bill Message of Bill	Priority
Knows Message of Bill Message of Bill	External Code
Claim Message of Claim	Value 0
Bill Message of Bill	Value 1
Bill Message of Bill	Value 2
Bill Message of Bill	Value 3
Bill Message of Bill	Value 4
Bill Message of Bill	Value 5
Bill Message of Bill	Value 6
Bill Message of Bill	Value 7
Bill Message of Bill	Value 8
Bill Message of Bill	Value 9

CTR Claim Policy Product

This entity holds the policy product details of the claim that is obtained through enrollment callout.

Corresponding Entity	Attribute	Note
Specifies Product of Policy Product	Code
has Insurable Entity of Policy Product	Serviced Entity Type
has Insurable Entity of Policy Product	Serviced Entity Code
is employed by Organization	Organization Code
Policy Product	Start Date
Policy Product	End Date
Policy Product	Subscription Date
Policy Product	Subscription End Date
	Group Account Code	Dynamic field on Policy Product
	Enrollment Product Code	Dynamic field on Policy Product
	Add-on Code	Dynamic field on Policy Product

During implementation, if policy product information is required in CTR for any downstream processing, then Claims recommends using this entity for that purpose. Also, note that for Product Profitability analysis (for example, covered amount vs premium paid for a group account), Oracle Health Insurance Analytics uses enrollment product, add-on and group account details from this entity.

CTR Claim Line

This entity holds the claim lines of claim transactions or bills.

Corresponding Entity	Attribute	Reverse?	Note
Claim Line	Code
Claim Line	Sequence
Claim Line	Allowed Amount	Y
uses (allowed amount) Currency	Allowed Amount Curr
Claim Line	Allowed Number of Units	Y
Claim Line	Authorization Code
Claim Line	Authorization Exception Type
Overriding Authorization Regime of Claim Line Override	Authorization Regime Code
Overriding Coverage Specification of Claim Line Override	Coverage Specification Code
Benefits Provider Provider of Claim Line	Benefits Provider 'Provider Details'
Claim Line	Benefits Age Input Date
Claim Line	Benefits Input Amount	Y
uses (benefits input amount) Currency	Benefits Input Amount Curr
Claim Line	Benefits Input Date
using reservation of Claim Line	Reservation Code
using reservation of Claim Line	Reservation Line Code
Claim Line	Claimed Amount	Y
uses (claimed amount) Currency	Claimed Amount Curr
Claim Line	Claimed Number Of Units	Y
has Classification of Claim Line	Classification Code
is classified on grounds of Authorization of Claim Line	Class Authorization Code
Overriding Coverage Regime of Claim Line	Coverage Regime Code
Overriding Coverage Regime (No auth. found) of Claim Line Override	Coverage Regime No Auth Code
Claim Line	Covered Amount	Y
uses (covered amount) Currency	Covered Amount Curr
Claim Line	Covered Number of Units	Y
Claim Line	Encounter Indicator
Claim Line	Emergency Indicator
Claim Line	End Date
Claim Line	Family Code
Overriding Funding Arrangement of Claim Line Override	Funding Arrangement Code
Location Provider Provider of Claim Line	Location 'Provider Details'
has Location Type of Claim Line	Location Type Code
has Location Type of Claim Line	Location Type Description
Payment Receiver Provider of Claim Line	Payment Receiver 'Provider Details'
Payment Receiver Relation of Claim Line	Payment Receiver 'Relation Details'
Overriding Post Benefit Regime of Claim Line Override	Post Benefit Regime Code
Claim Line	Preceding Payer Paid Amount	Y
uses (preceding payer paid amount) Currency	Preceding Payer Paid Amount Curr
Claim Line	Price Input Date
Claim Line	Price Input Number of Units	Y
Individual Price Provider Provider of Claim Line	Price Individual Provider 'Provider Details'
Organization Price Provider Provider of Claim Line	Price Organization Provider 'Provider Details'
Claim Line	Price Principal Proc1 Ind
Claim Line	Price Principal Proc2 Ind
Claim Line	Price Principal Proc3 Ind
Specifies Procedure of Claim Line	Procedure Code
Specifies Procedure of Claim Line	Procedure Definition
Specifies Procedure of Claim Line	Procedure Description
Specifies Procedure 2 of Claim Line	Procedure 2 Code
Specifies Procedure 2 of Claim Line	Procedure 2 Definition
Specifies Procedure 2 of Claim Line	Procedure 2 Description
Specifies Procedure 3 of Claim Line	Procedure 3 Code
Specifies Procedure 3 of Claim Line	Procedure 3 Definition
Specifies Procedure 3 of Claim Line	Procedure 3 Description
has Access Restriction of Specifies Procedure of Claim Line	Procedure Access Restriction Code
has Access Restriction of Specifies Procedure 2 of Claim Line	Procedure 2 Access Restriction Code
has Access Restriction of Specifies Procedure 3 of Claim Line	Procedure 3 Access Restriction Code
Claim Line	Process as IN
Overriding Product of Claim Line Override	Product Code
Overriding Product Family of Claim Line Override	Product Family Code
Overriding Product Line of Claim Line Override	Product Line Code
Claim Line	Provider Entity Reference
Claim Line	Provider Reference
Referral Provider Provider of Claim Line	Referral Provider 'Provider Details'
Claim Line	Replaced Indicator
Original For Claim Line of Claim Line	Replaced by Code
Replacement Of Claim Line of Claim Line	Replaces Code
Claim Line	Reservation Code
Service Provider Provider of Claim Line	Service 'Provider Details'
Service Specialty Specialty of Claim Line	Service Specialty Code
Serviced Entity Relation of Claim Line	Serviced Entity 'Relation Details'
_Serviced Entity _Relation of Claim Line	Serviced Entity Date
_Serviced Entity _Relation of Claim Line	Serviced Entity Date Interpretation
has Access Restriction of Serviced Entity Relation of Claim Line	Serviced Entity Access Restriction Code
contact details Access Restriction of Serviced Entity Relation of Claim Line	Serviced Entity Contact Details Access Restriction Code
Claim Line	Start Date
Claim Line	Status
Claim Line	Subscription Date
Claim Line	Waiting Period Input Date
_Overriding _ Waiting Period Regime of Claim Line Override	Waiting Period Regime Code

CTR Claim Line Diagnosis

This entity holds the diagnoses of claim lines.

Corresponding Entity	Attribute	Note
Applies To Diagnosis of Claim Line Diagnosis	Code
Applies To Diagnosis of Claim Line Diagnosis	Code Definition
Applies To Diagnosis of Claim Line Diagnosis	Description
Claim Line Diagnosis	Sequence
has Diagnosis Type of Claim Line Diagnosis	Type Code
has Diagnosis Type of Claim Line Diagnosis	Type Description
has Access Restriction of Applies To Diagnosis of Claim Line Diagnosis	Access Restriction Code

CTR Claim Line Message

This entity holds the messages of claim lines.

Corresponding Entity	Attribute	Note
Knows Message of Claim Line Message of Claim Line	Code
Claim Line Message of Claim Line	Origin
None	Message text with substituted parameters
None	Provider Message text with substituted parameters
None	Alternative Message text with substituted parameters
Knows Message of Claim Line Message of Claim Line	Severity
Knows Message of Claim Line Message of Claim Line	Priority
Knows Message of Claim Line Message of Claim Line	External Code
For Product of Claim Line Message of Claim Line	Product Code
Claim Line Message of Claim Line	Overturned Indicator
Knows User who overturned the Claim Line Message	Login Name
Claim Line Message of Claim Line	Value 1
Claim Line Message of Claim Line	Value 2
Claim Line Message of Claim Line	Value 3
Claim Line Message of Claim Line	Value 4
Claim Line Message of Claim Line	Value 5
Claim Line Message of Claim Line	Value 6
Claim Line Message of Claim Line	Value 7
Claim Line Message of Claim Line	Value 8
Claim Line Message of Claim Line	Value 9

CTR Claim Line Coverage

This line hold coverages of claim lines.

Corresponding Entity		Reverse?	Note
Claim Line Coverage	Action
Claim Line Coverage	Display Name
Claim Line Coverage	Amount	Y
uses for amount Currency	Amount Curr
Claim Line Coverage	Number	Y
By Product of Claim Line Coverage	Product Code
By Product of Claim Line Coverage	Product Description
By Product of Carried By Brand of Claim Line Coverage	Product Brand Code
By Product of Carried By Brand of Claim Line Coverage	Product Brand Description
By Product of Carried By Family of Claim Line Coverage	Product Family Code
Has Coverage Label of Claim Line Coverage	Coverage Label Code
Has Coverage Label of Claim Line Coverage	Coverage Label Display Sequence

CTR Claim Line Contract Reference

This entity holds contract references that apply to claim lines.

Corresponding Entity	Attribute	Note
has Claim Line Contract Reference	Code
has Claim Line Contract Reference	Description

CTR Claim Line Modifier

This entity holds modifiers of claim lines.

Corresponding Entity	Attribute	Note
Is Of Type Claim Line Modifier	Code
Is Of Type Claim Line Modifier	Description

CTR Claim Line Benefit Specification

This entity holds details about the benefit specifications that have been applied in the benefits calculation of claim lines.

Corresponding Entity	Attribute	Note
uses Benefit Specification of Claim Line Benefit Specification	Benefit Specification Code
_uses _ Benefit Specification of Claim Line Benefit Specification	Benefit Specification Subtype
uses Coverage Regime / Authorization Regime / Waiting Period Regime of Claim Line Benefit Specification	Regime Code
_for _ Product of Claim Line Benefit Specification	Product Code
Claim Line Benefit Specification	Product Provider Group Status
_uses product _ Provider Group of Claim Line Benefit Specification	Product Provider Group Code
Claim Line Benefit Specification	Specific Provider Group Status
_uses specific _ Provider Group of Claim Line Benefit Specification	Specific Provider Group Code
Claim Line Benefit Specification	Inherited Provider Group Status
Claim Line Benefit Specification	Processed as In

CTR Claim Line Provider Pricing Clause

This entity holds details about the provider pricing clauses that have been applied in the pricing of claim lines.

Corresponding Entity	Attribute	Reverse	Note
Claim Line Provider Pricing Clause	Sequence
uses Reimbursement Method / uses Pricing Rule	Type		Fee Schedule / Charged Amount / Payment System / Adjustment / Carve Out / Dynamic Field / Encounter / Lower Of / Message / Provider Limit / External Intervention
uses Provider Pricing Clause	Description
uses Provider Pricing Clause	Quantifier		The quantifier of the provider pricing clause, which can be either a percentage, maximum amount, maximum number of units or maximum service days
uses Reimbursement Method / uses Pricing Rule	Code
Claim Line Provider Pricing Clause	Amount	Y
uses for amount Currency	Amount Curr
Claim Line Provider Pricing Clause	Mark

For a claim line provider pricing clause, either the type and code of a reimbursement method are stored or the type and code of a pricing rule. This is because a provider pricing clause either uses a reimbursement method or a pricing rule.

CTR Claim Line Applied Parameter

This entity holds details about the parameter and limit values that were actually applied on the claim line during the claims flow.

Corresponding Entity	Attribute	Reverse	Note
Claim Line Applied Parameter	Percentage
Claim Line Applied Parameter	Amount per Unit
uses for amount	Amount per Unit Currency
in context of	Benefit Specification Code
in context of	Product Code
for	Cover Withhold Category Code
uses for max amount	Maximum Amount Currency
Claim Line Applied Parameter	Maximum Service Days
Claim Line Applied Parameter	Maximum Number
Claim Line Applied Parameter	Maximum Amount
Claim Line Applied Parameter	Alias Code
for Limit	Limit Code
Claim Line Applied Parameter	Reached Action

CTR Claim Sub Line

This entity holds claim sub lines of claim lines.

Corresponding Entity	Attribute	Reverse?	Note
Claim Sub Line	Sequence
Claim Sub Line	Claimed Number of Units	Y
Specifies Procedure of Claim Sub Line	Procedure Code
Specifies Procedure of Claim Sub Line	Procedure Code Definition
has Access Restriction of Specifies Procedure of Claim Sub Line	Procedure Access Restriction Code