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.

  • *True** indicates that the referral was explicitly stated on the claim
  • *False** indicates that the referral was inferred from the longitudinal journey of the individual patient.

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
procedure performed within the encounter

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