Guided Notes
Analyzing Claims Data
Claim headers and lines, billed vs allowed vs paid, claim status and adjustments, de-duplicating versions, and denial and payment analysis with SQL.
Claims data structure
Slide 1 / 5| Table | Grain | Key fields |
|---|---|---|
| Claim header | One claim | claim_id, member_id, provider, claim type (professional/institutional), dates, diagnoses, status |
| Claim line | One service line | line number, CPT/HCPCS or revenue code, units, billed, allowed, paid |
| Member/eligibility | Member × month (or span) | plan, product, enrollment dates, demographics |
| Provider | One provider | NPI, specialty, network status |
| Pharmacy claims | One fill | NDC, days' supply, quantity, paid |