EDGE_PROC_TABLE
Monthly aggregation of provider referrals and the procedures performed by the referred provider, both explicitly stated on the claim and inferred via patient pathways.
The "What Happened" of Provider Relationships
🤝 Provider relationships are at the core of provider networks, CareQuery® takes great care in defining metrics around provider relationships, what we call "edges."
🩺 EDGE_PROC_TABLE presents edges with procedure detail unlocks to better understand why a referral could have occurred, what was performed and who else could have performed it (recoverability).
Table Description
feature | description | example |
|---|---|---|
year | Year in which the primary encounter occured | 2023 |
month | Month in which the primary encounter occured | 2 |
ref_npi | National Provider Identifier (NPI) of the referring provider | 1447546585 |
ref_name | Full name of the referring provider | kellen benes |
ref_specialty | Primary specialty of the referring provider | therapy - physical medicine |
npi | National Provider Identifier (NPI) of the referred provider | 1003221029 |
name | Full name of the referred provider | gabriel jefferson |
specialty | Primary specialty of the referred provider | physician assistant |
inferred | Binary indicator of whether the relationship total was inferred.
| 1 |
proc_code | HCPCS or CPT procedural code performed by the referred provider. | 97039 |
proc_desc | Description of the procedure performed by the referred provider. | under constant attendance physical medicine |
proc_subcategory | Subcategory rollup of the procedure performed by the referred provider. | eval. and mgmt. - physical medicine |
proc_category | Category of the CPT or HCPCS | surgery |
num_patients | Number of unique patients referred within the explicit or inferred context of the relationship. | 4 |
num_encounters | Number of unique encounters referred within the explicit or inferred context of the relationship. | 14 |
total_line_charges | Total line-item provider charges for procedures rendered submitted to insurers by the referred provider (NPI). | 834.18 |
total_claim_charges | Line-item provider and facility charge for procedures and revenue codes rendered and submitted to insurers. | 1,250.39 |
total_smart_allowed | Total smart allowed made by the referred provider within the inferred context of the relationship. Smart Allowed is the line-item estimate of allowed amount, utilizing proprietary ML on actual adjudicated amounts to provide estimates, within an average of 5% variance from actuals. | 902.06 |
Updated about 2 months ago