In or Out Provider Network Information
This report enables users to identify claim submissions made by in-network or out-of-network providers of service. It provides detailed visibility into finalized claims that include at least one approved claim line, with details for each claim line and benefit specification.
| This report displays only claims whose last entry date falls within the last 90 days from the current system date. |
Objective
The Claims Operations team (including supervisors and managers) can use this report to:
-
Identify claim submissions for network versus non-network providers of service.
-
View claim line benefit specifications and the associated provider network status.
Reporting View Fields
The report is based on the view CLA_REP_CLA_NETWORK_COMPLIANCE_VW.
The following table lists the fields names. These fields support inheritance logic where applicable:
If a claim line field is unspecified, it assumes the value from the corresponding claim header field.
For details, see the Inherited Field Values.
| Field Name | Description | Searchable? |
|---|---|---|
Entry date |
The date when the claim was first entered into the system. |
Yes |
Claim ID |
A unique number assigned to the entire claim. |
Yes |
Claim Code |
A short code identifying the type or category of the claim such as, CLA0001. |
Yes |
Claim Service Provider Code |
The unique code for the main service provider (for example, hospital or doctor) on the claim. |
Yes |
Claim Service Provider Name |
The full name of the main service provider, displayed alongside the code. |
Yes |
Claim Service Speciality Code |
The code for the medical specialty (for example, CAR for cardiology) of the service on the claim. |
Yes |
Claim Member Code |
The unique code for the patient or insured member associated with the claim. |
Yes |
Claim Member Name |
The full name of the patient or member, shown with the code. |
Yes |
Claim Line Code |
A unique code for each individual service or procedure line within the claim. |
No |
Claim Line Sequence |
The order number of this line item in the claim (for example, 1st, 2nd). |
No |
Claim Line Status |
The current processing status of the line item, such as Approved or Denied. |
Yes |
Claim Line Claimed Amount |
The total amount billed by the provider for this specific service line, shown in the selected currency. |
No |
Claimed Amount Currency |
The currency code (for example, USD) for the claimed amount. |
No |
Claim Line Covered Amount |
The amount approved for payment by the insurance plan for this service line, after network adjustments. |
No |
Covered Amount Currency |
The currency code (for example, USD) for the covered amount. |
No |
Claim Line Member Code |
The code for the patient or member specific to this service line. |
Yes |
Claim Line Member Name |
The full name of the patient or member for this service line, shown with the code. |
Yes |
Claim Line Benefit Provider Code |
The code for the provider responsible for benefits (for example, reimbursement) on this line. |
Yes |
Claim Line Benefit Provider Name |
The full name of the benefit provider, displayed with the code. |
Yes |
Claim Line Service Provider Code |
The code for the service provider specific to this line (for example, doctor for a procedure). |
Yes |
Claim Line Service Provider Name |
The full name of the service provider for this line, shown with the code. |
Yes |
Claim Line Service Speciality Code |
The specialty code for the service on this line (for example, SUR for surgery). |
Yes |
Benefit Specification Code |
The code defining the specific benefit rules applied to this service line (for example, coverage limits). |
Yes |
Product Benefit Specification |
The identifier for how benefits are configured under the insurance product (plan) for this line. |
Yes |
Regime Code |
The code from the primary rule set (for example, coverage or authorization) applied to the line. |
Yes |
Regime Type |
The type of rule set for the regime code, such as, Coverage Regime or Authorization Regime. |
Yes |
Product |
The code for the insurance plan or product (for example, Gold Plan) covering this line. |
Yes |
Coverage Input Amount |
The base amount used to calculate coverage for this line (for example, eligible billed charges after adjustments). |
No |
Coverage Input Amount Currency |
The currency code (for example, USD) for the coverage input amount. |
No |
Product Provider Group Status |
The status of the provider group under the plan (for example, In-Network or Out-of-Network). |
Yes |
Provider Group Code |
The code for the group of providers affiliated with the plan. |
Yes |
Specific Provider Group Status |
The detailed status for this specific provider instance under the plan (for example, Eligible In-Network). |
Yes |
Specific Provider Group Code |
The code for the specific provider group for this line. |
Yes |