Claims — volume, dollars, and network status

fct_claim is one row per adjudicated claim. The in-network determination is not recomputed here — it is read straight from claim_network_status, the platinum mart that realizes the in-network business rule (eligibility active at the service date and the servicing provider inside the member's network).

Claim volume over time

Dollars paid over time

In-network status

Surfaced exactly as claim_network_status states it — in = servicing provider inside the member's network with active eligibility, out = out-of-network. The app displays the determination; it does not re-derive it.

Why so many are "not determinable." A claim only gets an in/out answer when both the member's eligibility is active on the service date and the servicing provider resolves to a directory provider inside a network. The "not determinable" claims split into two honest, distinct reasons — and the split is the point, not a defect:

• Uninsured / lapsed coverage — no active eligibility span at the service date. Real: not every care event happens under active coverage.
• Unidentifiable provider — the servicing provider can't be resolved to a single directory provider, because the synthetic payer directory (like real ones) has genuine MDM ambiguity: multiple distinct provider IDs sharing the same name + specialty + state. The same-as resolver (cs_provider_same_as, rule PSA-5) refuses to guess — it will not fabricate a match it can't prove. So these claims are honestly unidentifiable, not silently mis-assigned. This is the vault's MDM discipline made visible: a data platform that won't invent a determination it can't defend.

Claims by adjudication status