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Plaintalk Blog: What is Actually in the CO APCD? Part 1: Health Insurance Medical Claims


This is the first in a series of blogs about what, exactly, is in the Colorado All Payer Claims Database (CO APCD). Today we’re looking at one of the most fundamental claims we receive - the medical claim. Medical claims include basic information about why you went to the doctor or hospital, who you visited, and what happened while you were there - all information which forms the basis for the facility (hospital or provider group) part of the cost of the visit. In the coming months we will explore additional claims that insurance companies send to the CO APCD like pharmacy claims, and professional claims (bills directly for the provider) and how that data is protected and incorporated in the database.

Sometimes really cool things are made up of really boring parts; take the Internet for example. When we log on to Facebook, we’re seeing a finished page that has pictures and text and lots of exciting ways to interact with the content. But, on the backside, Facebook is nothing more than a bunch of computer code:

Boring.

The CO APCD is pretty similar. To file a claim, providers fill out a form that has a bunch of tiny boxes and submit it to the insurance company. After processing by the payer, the claim ends up in the CO APCD, and is even more boring to look at than the form (how is that even possible?).
          
Really, really boring!

However, in the same way that each line of computer code gibberish translates to something cool, each of the boxes on an insurance claim contains information that can be used to do something pretty awesome. Let’s take a look at what goes into those boxes – and we promise to make it as interesting as possible.

Now, different types of facilities and providers fill out different versions of these forms so rather than explore a bunch of really boring forms, we’re going to use a general example to show what kind of information is provided in a typical medical claim. Additionally, we’re only focusing on what is collected by the CO APCD and not delving into any privacy or security concerns – all that stuff is coming, don’t worry, we want to take this step by step and not drop too much info on y’all all at once.

 Parts of a Medical Claim That Get Submitted to the CO APCD

Important Tidbits about You (De-identified for your protection!)

Name (converted to unique ID)

Address

Birth Date

Sex

Who Helped You and Who Should Get Paid?

Servicing Provider Name, National Provider Identifier (NPI)

(Note: CO APCD does not receive other provider information such as a surgeon or other providers who may have offered services)

Billing Provider Name, NPI, Address

What Happened?

If you got admitted to a Hospital

Type of Visit (emergency, elective, etc.)

Who Referred You (physician or other facility, if applicable)

Your Diagnosis (on arrival)

For Hospitals and all other types of visits

Date and Primary reason (diagnosis) for your visit

Additional reasons (diagnoses) that may have led to your condition

External Cause of Injury (if you got hurt by something)

How'd it Go and What Did They Do?

Primary and secondary procedure(s) and services you had done and when

Service Units (if applicable)

Units of service used (days in hospital, pints of blood, etc.)

When you left (if you were in a hospital), and where you went (home, skilled nursing facility, etc.)

Codes that ultimately help determine the cost

Condition Codes:

These codes provide information that might impact the processing of the claim, i.e. a correction or a change in dates.

Revenue Codes:

What happened and dollar amounts associated with the services you received

Description Codes for your visit:

ICD-10 Codes: What your diagnosis was

CPT Codes: What procedures you received

HCPC Codes:  Outpatient services (non-hospital); includes CPT codes and medical equipment

NDC Codes: drugs you may have received

Who Gets the Bill?

Who is insured and your relationship to that person

Unique identifier assigned to you by the insurance company

Group, Employer, and Health Insurance name and ID

How Much Did it Cost and How Much Gets Paid?

Total Charges: (Charged Amount): Amount that is being charged for each line of service by the provider as well as the total amount of all charges.

What Health Insurance Paid (Allowed Amount): How much of the total charges the health plan paid the provider based on their negotiated rate.

How Much You’re Supposed to Pay

(Member liability): How much of the bill you owe depending on your plan coverage, copays, deductibles, etc.  

(Note: The CO APCD doesn’t get information on whether or not you actually paid your portion to the provider.)

Additional Payments:

Any amounts paid by other insurance payers (if applicable)

Non-covered Charges:

Amount not covered by the primary payer for the service (if applicable).



 

 

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