Claims Data

Data dictionary fields for claims data in Payerset.

Payerset's claims data is sourced from various sources and normalized for ease of use. The level of detail of claims-related metrics, at the most granular representation, represent a granularity of Billing NPI | Payer | Billing Code & Modifiers | Year, along with other fields represented in the scope of your analysis (filters & dimensions). Information displayed here is aggregated for benchmarking & analysis and detail is available on the "Data Tab" within the Claims module.

_{Please note that the Claims data is only available with the upgraded Payerset Pricing Intelligence Solution. For more information, please contact [email protected].}

Provider

Field	Description
Parent Organization	High-level rollup of organizations that makes it easier to filter and group NPIs. These can represent large hospital systems, ownership groups, groups of facilities, and more. Note this can be separate from NPPES data and NPPES organizations should be used in conjunction with the Parent Organization in getting correct NPIs for analysis.
Organization	Indicates the healthcare organization or facility. Note there can be multiple NPIs per organization.
Billing NPI	Represents the National Provider Identifier, a unique 10-digit number assigned to healthcare providers from which the claim was submitted.
Facility NPI	Represents the National Provider Identifier, a unique 10-digit number assigned to healthcare providers where the services on the claim was performed. This is not always populated from claims data sources and may not match the Billing NPI (ex. Organization bills through a separate NPI from which the facility where the service is performed).
State	Indicates the U.S. state where the Billing NPI is registered in NPPES.
County	Indicates the U.S. county where the Billing NPI is registered in NPPES.
Zip Code	Indicates the U.S zip code where the Billing NPI is registered in NPPES.
City	Indicates the U.S. city where the Billing NPI is registered in NPPES.
Taxonomy Grouping	Represents the categorization of healthcare providers based on their specialties and services.
Taxonomy Display Name	User-friendly name to describe a provider’s specialty or service category. This is the display name of the Taxonomy Code.
Taxonomy Classification	Offers a detailed categorization of the provider’s area of expertise.
Taxonomy Specialization	Indicates a further level of specialization within a broader taxonomy classification.
Class of Trade	Provides a high-level grouping of related healthcare services to segment and analyze data across broad service domains (for example, Home Health and Hospice). This field is is commonly used for macro-level filtering to isolate relevant NPIs.
Trade Type	Additional layer of specificity within a trade category by describing the general nature of the services delivered (for example, in-home nursing care services).
Trade Subtype	The most granular classification within Trade Categories & Types, identifying the specific service focus within a trade type.

Health Plan

Field	Description
Channel	Commercial, Medicare, Medicaid, or Dual/Other
Payer Name	Identifies the insurance provider or entity responsible for reimbursement.

Service

Field	Description
Claim Type	Refers to the classification of billing codes based on service type or specialty. This field represents if a rate is Professional or Institutional. Note that the use of this field by individual Payers can be different based on their interpretation of CMS rules.
Procedure Code Type	Defines the type of billing code, such as CPT, HCPCS, or ICD.
Procedure Code Category	Groups billing codes into broader categories based on service or procedure characteristics to more easily identify services for analysis.
Procedure Code Subcategory	Provides a more detailed classification within a broader billing code category to further identify specific services or sets of services.
Procedure Code	The standardized code representing a specific medical service or procedure.
Procedure Code Description	Provides a descriptive name associated with the billing code.
Procedure Code Modifier	Adds additional context or specificity to a billing code, often indicating variations of a service. This can be additive to the original service or represent a different service variant depending on the code and payer.
Procedure Code Modifier Description	Additional description for the respective Procedure Code Modifier to provide more context on the modifier
Setting	High-level grouping of services for Inpatient, Outpatient, or Office
Place of Service Code	Codes that identify the physical location where the service was provided, such as an outpatient clinic or hospital. This field represents the actual codes as they show in the data.
Place of Service	Provides the descriptive name(s) corresponding to the place of service code(s).

Amounts

Field	Description
Total Claims	Number of claims submitted (from 837)
Total Remits	Count of remittance records (from 835).
Average Remit	Average allowed amount per remit. This is weighted by the # of units.
Attributed Charge Amount	Sum of charges across all claim submissions from the 837 for the given scope of filters & dimensions.
Attributed Total Units	Total number of billed units at the line-item level. Note: Codes can be billed multiple times on a single claim depending on the code type.
Average Claim Amount	Calculated as Attributed Charge Amount / Attributed Total Units.
Attributed Claim Count	This is the count of claims submitted per given scope of the data. This field is used to determine the "Total Claims" metric when viewing aggregates.
Min Per Unit Allowed	The lowest allowed amount observed for a single billed unit across all remittance records in the selected scope. Represents the lower bound of payer reimbursement at the unit level.
Max Per Unit Allowed	The highest allowed amount observed for a single billed unit across all remittance records in the selected scope. Represents the upper bound of payer reimbursement at the unit level.
Avg Per Unit Allowed	The average of allowed amounts per billed unit across all remittance records for given scope. This is often used in analysis to account for the impact of outliers and variation in reimbursements.
Median Per Unit Allowed	The median of allowed amounts per unit for the given scope. This is often used in conjunction with the Average Per Unit Allowed to better understand the variance of allowed amounts.
Count of Units	Total number of units reported on remittance records.
Total Claim Count	Count of remittance records (from 835).