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