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Set #
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Extract claim
set control number. A unique reference to tie together a set of
potential duplicate claims.
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Match
Type
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Claim set match
criteria category: EXACT MATCH, NEAR MATCH, DATE OVERLAP, CPT-4,
CODE, OTHER. Determined during the initial extract and set construction.
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Claim
Match
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Claim match
criteria category. Same as claim set categories.
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M (match
type code for line item)
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Line item match
criteria category. Same as claim set categories.
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Risk
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Financially
underwritten, non-financially underwritten indicator for claim.
Please note that for the purposes of this system:
Financially
underwritten = Risk
Non-Financially
underwritten = Not at-risk.
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Mass Change
Level
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The latest MASS
CHANGE cluster rule applied to the claim.
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Patient
Region
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Patient health
service region code.
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Provider
Region
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Provider health
service region code.
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Owner
FI
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Owner
FI represents, for the claim set, the contractor that has
been assigned responsibility for resolving particular potential
duplicate claim sets. Typically, all claims within a set will have
the same responsible FI/contractor (Resp FI), in which
case the Owner FI will be the same as the responsible
FI/contractor. However, for “multi-contractor” claim sets where
the responsible FI/contractors are not the same for all claims within
the set, an Owner FI is originally assigned by the
system to be the responsible FI/Contractor from the claim within
the set having the latest PTC date.
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Resp FI
/ Rsp FI
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Resp
FI or Rsp FI represents, for the claim, the
contractor that is currently responsible for administering the claim.
When the claim is initially extracted from TED, the Resp FI is
identical to the Proc FI (Processing FI).
However, contract awarding and transitions may require claim administration
by a new contractor, in which case the system will assign a new Resp
FI for the claim.
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Owner
Region
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Owner
Region is a narrative descriptor of the contract number and represents,
for the claim set, the Owner FI/contractor region. Typically,
all claims within a set will have the same Responsible Contract,
in which case the Owner Region will be the same as
the Responsible Contract. However, for multi-contractor
claim sets where the contractors are not the same for all claims
within the set, an Owner Region is assigned by the
system to be the Responsible Contract from the claim
within the set having the latest processed-to-completion date. The
initial assignment is done in tandem with the assignment of Owner
FI.
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Responsible
Contract
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Responsible
Contract represents, for the claim, the contract under which
the claim is currently administered. When the claim is initially extracted
from TED, the Responsible Contract is identical to
the Processing Contract. However, contract awarding
and transitions may require claim administration under a new contract,
in which case the system will assign a new Responsible Contract for
the claim.
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Dupe?
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Dupe? is
an indicator to describe whether or not the claim or line item is
a duplicate. During the extract processes Dupe? will
be set to N (no) for the base claim within a set and
will be set to blank for the remaining claims and line items.
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Reason
Code
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Reason
Code is a code used for each claim within a set to designate why
the claim in the set is or is not a duplicate. During the initial loading
of a set into the system, the base claim within a set will be assigned
(in conjunction with Dupe? being set to N)
a reason code of BASE representing initial submission. The system
will provide an option list of valid codes intended to cover the
majority of possible conditions and a code for an “other” option
for the occasions when the condition cannot be classified. Some Reason
Code selections will require an additional explanation field
for further elaboration.
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TED Adjust?
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TED Adjust? is
a flag for the user to designate which adjustment or cancellation
corrects the duplicate condition. All adjustments and cancellations
that apply are checked Y (yes), and those that do not apply
can be left blank or checked N (no). The TED
Adjustment field is the sum (for the claim) of paid dollar
amounts for those that apply. Display screens enable TED Adjust? to
be checked for any institutional claim and any non-institutional
line item.
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Status
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Status indicates
the claim set life cycle phase from initial system loading to final
purging. Status is set by the system as a consequence of
specific user actions or periodic system functions.
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Identified
Recoup
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Identified
Recoup is a dollar amount that is entered by the user or
by the system upon initial determination that a claim or a line
item is a duplicate. It represents the amount of overpayment for
the claim or line item that has been identified for recoupment.
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Actual
Recoup
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Actual
Recoup is a dollar amount that is entered by the user upon completion
of recoupment for a duplicate claim. It represents the amount of
overpayment for the claim that has actually been recouped.
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TED Adjustment
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TED Adjustment is
a dollar amount that is maintained by the system (not by the user)
to accumulate TED adjustment or cancellations made during resolution
of a duplicate claim. It is calculated as the sum of all adjustment
and cancellation paid amounts that have been flagged by the user
as being associated with correcting the duplicate. This is the sum
of claim level paid amounts for institutional claims and line item
paid amounts for non-institutional claims.
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ID Recoup
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ID Recoup is
a dollar amount calculated by the system as the sum of Identified
Recoup amounts for all claims within a set. It represents the
total amount of overpayment for the claim set that has been identified
for recoupment.
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Actual
Recoup
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Actual
Recoup is a dollar amount calculated by the system as the sum
of claim level actual recoupment amounts for all claims within a set.
It represents the total amount of overpayment for the set that has actually
been recouped.
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Adjust
Amount
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Adjustment
Amount is a dollar amount calculated by the system as the
sum of TED Adjustment amounts for all claims within
a set. It represents the total amount of adjustments and cancellations
that have been flagged by the user as being associated with correcting
all duplicate claims within the set.
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Initial
Load Date
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Initial
Load Date represents the date the claim set was initially loaded
into the system. The LASTDATE reflects the most recent claim set
update date - for specific types of updates.
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Current
Load Date
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Current
Load Date represents the date the claim set was initially loaded
into the system or the date set ownership changed, or the date a
new claim was appended to the set, whichever is the latest date.
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Last Update
Date
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Last
Update Date represents the most recent date a claim set was updated.
Changes to the following will change the Last
Update Date: Status, Match Type, Multi-FI Indicator, Owner
FI, Owner Region, ID Recoup, Actual Recoup, Set Adjustment Amount,
and Adjust Indicator. The Last Update Date will not change
solely due to a change to: User Defined Codes, Dupe? field, Solicited
(S?) Indicator, TED Adjust?, Reason Code, Reason Code
Explanation, or Notepad.
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S?
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S? is
the Solicited Indicator.
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Set User Def
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