Mem - Pha

Member Age

The age of the member as of the last day of the previous month.

Enrollment Detail, Member Opportunity Detail, Member Opportunity Summary, Member Summary, Program Detail -Action Report

Member Age at Service

The age of the member as of the date of service.

Claim Detail, Claim Summary, Inpatient Admission, Pharmacy Detail -Action Report

Member Birth Date

The date a member was born.

Member Opportunity Detail, Member Opportunity Summary -Action Report

Member Cost Share

The Total % Pharmacy cost that members are responsible for.

CE Executive Report – Pharmacy Cost Summary Page - Action Report

Member Cost Share % Dental

% of Total Dental Costs paid by the Member in the current year.

Member Cost Share Summary -Dashlet

Member Cost Share % Medical

% of Total Medical Costs paid by the Member in the current year.

Member Cost Share Summary -Dashlet

Member Cost Share % Pharmacy

% of Total Pharmacy Costs paid by the Member in the current year.

Member Cost Share Summary -Dashlet

Member Cost Share % Vision

% of Total Vision Costs paid by the Member in the current year.

Member Cost Share Summary -Dashlet

Member Count

Count of the members for whom the capitation payment was made.

Capitation Summary -Action Report

Member Count

Graphical representation of the number of unique members having each of the top 10 condition hierarchies (as determined by paid dollars).

Condition Hierarchy Summary - Action Report

Member Count - Non-Outliers

Count of the plan's members, who are not cost outliers, with the condition

Condition Hierarchy Summary - Action Report

Member Count - Outliers

Count of the plan's members, who are cost outliers, with the condition

Condition Hierarchy Summary - Action Report

Member Count - Total for Plan

Count of individual members with the condition

Condition Hierarchy Summary - Action Report

Member Gender

The member's gender.

Member Opportunity Summary -Action Report

Member ID

Identification number assigned to an individual enrolled in a group.

Claim Detail, Claim Summary, Enrollment Detail, Member Opportunity Detail, Member Opportunity Summary, Pharmacy Detail -Action Report

Member ID

The member identifier from their original data source.

Member Summary, Program Detail -Action Report

Member Months

Total Member Months for the appropriate month

Expense and Cost Summary by Incurred Date, Expense and Cost Summary by Paid Date -Action Report

Member Name

The name of the member.

Claim Detail, Claim Summary, Enrollment Detail, Inpatient Admission, Member Opportunity Detail, Member Opportunity Summary, Pharmacy Detail -Action Report

Member Name

The member's full name.

Member Summary, Program Detail -Action Report

Member Phone Number

The member's phone number as provided by the health plan.

Member Summary -Action Report

Member Responsibility $

The amount in dollars for which the member is responsible for payment.

Network Utilization Summary -Action Report

Member Responsibility Amount

The amount in dollars for which the member is responsible for payment.

Claim Detail, Claim Summary, Enrollment Summary, Pharmacy Detail -Action Report

Member Responsibility Amount Dental

Total Dental Costs that Members are responsible for in the current year.

Member Cost Share Summary -Dashlet

Member Responsibility Amount Medical

Total Medical Costs that Members are responsible for in the current year.

Member Cost Share Summary -Dashlet

Member Responsibility Amount Pharmacy

Total Pharmacy Costs that Members are responsible for in the current year.

Member Cost Share Summary -Dashlet

Member Responsibility Amount Vision

Total Vision Costs that Members are responsible for in the current year.

Member Cost Share Summary -Dashlet

Member Responsibility PMPM $

The per member per month representation of the dollars for which the member is responsible for payment.

Network Utilization Summary -Action Report

Members in Hospital

Number of members currently admitted to an inpatient facility which can be acute, SNF or rehab. This number is updated daily.

Members in Hospital - Population Measures

Members in Hospital

The percentage of admissions to acute care facilities where the member has been discharged from an acute care facility within 30 days of the current admission.

Members in Hospital - Population Measures

Members with Open Opportunities

The number of unique members with recommended care opportunities that remain open.

Quality Performance -Dashlet

Members with Opportunities

The number of unique members with recommended care opportunities identified.

Quality Performance -Dashlet

Membership Change %

% of Membership Change of total members.

Executive Report- Action Report

MHSA Admits/1000 - Actual

Admissions per 1000 members to a Mental Health Substance Abuse (MHSA) setting.

Inpatient Utilization -Dashlet

MHSA Admits/1000 - Norm

Admissions per 1000 members to a mental health substance abuse setting for the normative population.

Inpatient Utilization -Dashlet

MHSA Flag

A flag indicating if the admission is for Mental Health or Substance Abuse.

Inpatient Admission -Action Report

NDC

National Drug Code

Pharmacy Detail -Action Report

NDC

The National Drug Code associated with the prescribed drug.

Prescribing Pattern -Action Report

NDC Description

Description of the National Drug Code

Pharmacy Detail -Action Report

New Members

Number of members who have enrolled within 60 days prior to the end of the reporting period.

New Members - Population Measures

Non-Specialty % Paid

The percentage of the non-specialty claim payment amount during the current reporting period.

Pharmacy Utilization Summary -Dashlet

Non-Specialty % Scripts

Percentage of 30-day equivalent non-specialty scripts filled during the current reporting period.

Pharmacy Utilization Summary -Dashlet

Non-Specialty Paid

Total pharmacy cost during the current reporting period for non-specialty scripts.

Pharmacy Utilization Summary -Dashlet

Non-Specialty Scripts

30-day equivalent script count of non-specialty scripts filled the current reporting period.

Pharmacy Utilization Summary -Dashlet

Norm Dental /1000

Utilization per 1,000 members for dental services for the normative population. Completion factors are applied.

Utilization Overview -Dashlet

Norm ED/1000

Utilization per 1,000 members for emergency department services for the normative population. Completion factors are applied.

Utilization Overview -Dashlet

Norm Hospital Services/1000

Utilization per 1,000 members for hospital services for the normative population. Completion factors are applied.

Utilization Overview -Dashlet

Norm Lab/1000

Utilization per 1,000 members for laboratory services for the normative population. Completion factors are applied.

Utilization Overview -Dashlet

Norm Member Cost Share % Dental

% of Total Dental Costs paid by the Member in the current year for the Normative Population.

Member Cost Share Summary -Dashlet

Norm Member Cost Share % Medical

% of Total Medical Costs paid by the Member in the current year for the Normative Population.

Member Cost Share Summary -Dashlet

Norm Member Cost Share % Pharmacy

% of Total Pharmacy Costs paid by the Member in the current year for the Normative Population.

Member Cost Share Summary -Dashlet

Norm Member Cost Share % Vision

% of Total Vision Costs paid by the Member in the current year for the Normative Population.

Member Cost Share Summary -Dashlet

Norm Pharmacy/1000

Utilization per 1,000 members for pharmacy services for the normative population. Completion factors are applied.

Utilization Overview -Dashlet

Norm PMPM Pharmacy

Pharmacy cost per member per month for the normative population for the current rolling 12 month period. Capitation payments are included and completion factors are applied.

Norm Comparison - Dashlet

Norm Primary Care Visits/1000

Utilization per 1,000 members for primary care services for the normative population. Completion factors are applied.

Utilization Overview -Dashlet

Norm Radiology/1000

Utilization per 1,000 members for radiology services for the normative population. Completion factors are applied.

Utilization Overview -Dashlet

Norm Specialty/1000

Utilization per 1,000 members for specialty services for the normative population. Completion factors are applied.

Utilization Overview -Dashlet

Norm Vision /1000

Utilization per 1,000 members for vision services for the normative population. Completion factors are applied.

Utilization Overview -Dashlet

Not Engaged Member Count

Of those members enrolled in the program, the subset of individuals who have chosen not to participated (i.e. Those that are not engaged in the program).

Program Summary -Action Report

Not Engaged Member Percentage

The percentage of enrolled members who chose not to engage with the program.

Program Summary -Action Report

Not Seen in 12 Months

Number of members who have not seen their attributed provider practice for an office visit within the last 12 months.

Not Seen in 12 Months - Population Measures

Number of Deviations

Count of the number of deviations from care standards.

Member Opportunity Summary -Action Report

Number of ED Visits

The count of a member's visits to an Emergency Department in the last 14 months. Does not include ED visits that resulted in an admission.

Member Summary -Action Report

Number of Interactions

Number of interactions the plan's care staff have had with the member.

Program Detail -Action Report

Number of IP Admits

A member's count of inpatient admission in the last 14 months as sourced from both census and claims data.

Member Summary -Action Report

Number of Medicare Advantage Star Opportunities

The number of care opportunities that are part of the CMS STARS program and there is no record of the member receiving the required service(s).

Quality Opportunity Summary -Action Report

Number of Open Care Opportunities

The number of care opportunities that to date have not been addressed.

Member Opportunity Summary -Action Report

Number of Open Care Opportunities

The number of recommended care opportunities identified for a member that remain open.

Member Summary -Action Report

Number of Open HCCs Missing

The number of HCCs a member is suspected of having current claims history as compared to the previous period.

Member Opportunity Summary -Action Report

Number of Open HCCs Missing

For a given member, the total number of situations where a retrospective review of the member's coded history would likely indicate the presence of a condition unlikely to have resolved, and hence inadvertently and incidentally left out of their current claims coding.

Member Summary -Action Report

Number of Open HCCs Suspected

The number of HCCs a member is suspected of having based on Theon modeling algorithms.

Member Opportunity Summary -Action Report

Number of Open Star Opportunities

The number of Star Opportunities that to date have not been addressed.

Member Opportunity Summary -Action Report

Number of Prescriptions Filled

The count of 30-day equivalent pharmacy claims during the last 14 months.

Member Summary -Action Report

Number of Quality Opportunities Met per Measure (Numerator)

The number of care opportunities where the member received the required service(s).

Quality Opportunity Summary -Action Report

Number of Quality Opportunities per Measure (Denominator)

The number of care opportunities (open and closed) .

Quality Opportunity Summary -Action Report

Number of Quality Opportunities Unmet per Measure

The number of care opportunities where there is no record of the member receiving the required service(s).

Quality Opportunity Summary -Action Report

Number of Specialist Visits

The count of a member's visits to specialist providers in the last 14 months.

Member Summary -Action Report

Open Opportunities

The total number of recommended care opportunities identified for all members that remain open.

Quality Performance -Dashlet

Opportunities

Detailed description of the specific opportunity.

Member Opportunity Detail -Action Report

Opportunities Identified

The total number of recommended care opportunities identified for all members.

Quality Performance -Dashlet

Opportunity Type

A description of the type of opportunity present. Typically related to member care or coding omissions.

Member Opportunity Detail -Action Report

Opportunity Due Date

The latest date the opportunity can be addressed and carrier defined rules.

Member Opportunity Detail -Action Report

Opportunity Status

The current status of the opportunity.

Member Opportunity Detail -Action Report

Original Admit Date

For a readmission claim, the date of the original admission to a facility.

Inpatient Admission -Action Report

Original Admit Date

The original admission date is the member's last non-substance abuse admission date within the last 14 months, unless the patient experienced a readmission. If a patient was readmitted less than 30 days between discharge and readmission, then this is the start date of their pre-readmission confinement.

Member Summary -Action Report

Original Admitting Diagnosis Code

The original admitting diagnosis is the member's last non-substance abuse diagnosis at admission, for the last admission within the last 14 months, unless the patient experienced a readmission. If a patient was readmitted less than 30 days between discharge and readmission, then this is the diagnosis at admission of their pre-readmission confinement.

Inpatient Admission, Member Summary -Action Report

Original Admitting Diagnosis Description

The original admitting diagnosis is the member's last non-substance abuse diagnosis at admission, for the last admission within the last 14 months, unless the patient experienced a readmission. If a patient was readmitted less than 30 days between discharge and readmission, then this is the diagnosis at admission of their pre-readmission confinement.

Inpatient Admission, Member Summary -Action Report

Original Admitting Facility

The original admitting facility is the facility which hosted the member's last non-substance abuse admission within the last 14 months, unless the patient experienced a readmission. If a patient was readmitted less than 30 days between discharge and readmission, then this is the facility of their pre-readmission confinement.

Member Summary -Action Report

Original Discharge Date

For a readmission claim, the date of the original discharge from a facility.

Inpatient Admission -Action Report

Original Discharge Date

The original discharge date is the member's last non-substance abuse discharge date for an admission beginning within the last 14 months, unless the patient experienced a readmission. If a patient was readmitted less than 30 days between discharge and readmission, then this is the facility of their pre-readmission confinement.

Member Summary -Action Report

Original ICD Type Code

Code indicating if the ICD code is version 9 or 10.

Inpatient Admission -Action Report

Original ICD Type Code

Indicates if the diagnosis code is ICD-9 or ICD-10.

Member Summary -Action Report

Originated in ED Indicator

Flag indicating if the inpatient stay originated in the emergency department.

Claim Summary -Action Report

Outpatient Facility Average Paid Per Service - % Change

Average Paid per service for Outpatient Facility services % change from previous to current year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Outpatient Facility ED Cost/Visit - % Change

Outpatient Facility Emergency Department Costs per visit % change from previous to current year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Outpatient Facility ED Visits - % Change

Number of visits for Outpatient Facility Emergency Department services % change from previous to current year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Outpatient Facility ED Visits - % Change

Visits per 1,000 members for Outpatient Emergency Department services % change from previous to current year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Outpatient Facility Paid PMPM - % Change

Plan Paid Per Member Per Month for Outpatient Facility Services % change from previous to current year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Outpatient Facility Services/1000 Members - % Change

Outpatient Facility Services per 1000 member’s % change from previous to current year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Outpatient Hospital Current

The total adjusted paid amount for facility outpatient medical services in the current rolling 12 month period. Completion factors are applied then capitation payments are included.

Payment Summary -Dashlet

Outpatient Hospital Current

For each category driven service, the total adjusted paid amount for medical services in the current rolling 12 month period. Completion factors are applied then capitation payments are included.

Payment Summary -Dashlet

Outpatient Hospital Previous

The total adjusted paid amount for facility outpatient medical services in the previous rolling 12 month period. Completion factors are applied then capitation payments are included.

Payment Summary -Dashlet

Outpatient Hospital Previous

For each category driven service, the total adjusted paid amount for medical services in the previous rolling 12 month period. Completion factors are applied then capitation payments are included.

Payment Summary -Dashlet

Outpatient Hospital Variance

The variance in the total adjusted paid amount for facility outpatient medical services from the current period versus the previous one. Completion factors are applied then capitation payments are included.

Payment Summary -Dashlet

Outpatient Hospital Variance

The variance or percent change for the given data driven category from the current period versus the previous one. Completion factors are applied then capitation payments are included.

Payment Summary -Dashlet

Outpatient Professional Average Paid Per Service - % Change

Average Paid per service for Outpatient Professional Services % change from previous to current year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Outpatient Professional Paid PMPM - % Change

Plan Paid Per Member Per Month for Outpatient Professional services % change from current to previous year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Outpatient Professional Services - % Change

Number of Services that are for Outpatient Professional Services % change from previous to current year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Outpatient Professional Services/1000 Members - % Change

Number of Outpatient Professional Services per 1000 members % change from previous to current year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Paid

Total plan paid amount during the appropriate month.

Expense and Cost Summary by Incurred Date, Expense and Cost Summary by Paid Date -Action Report

Paid Amount

Sum of Adjusted Paid Amount by Incurred Month and Paid Month. Capitation Payments are included.

Lag Report -Action Report

Paid Date

The date the claim was paid.

Claim Summary, Pharmacy Detail - Action Report

Paid Month

Year and Month (CCYYMM) in which the expense was paid

Dental Payment Summary, Expense and Cost Summary by Incurred Date, Expense and Cost Summary by Paid Date, Vision Payment Summary -Action Report

Paid Month

The year and month (CCYYMM) in which the claim payment was made.

Lag Report -Action Report

Paid PMPM $

Plan paid per member per month.

Network Utilization Summary - Action Report

Paid PMPM Trend

Difference in trend between Actual and Norm Populations

CE Executive Report - Demographics Page -Action Report

Patient Paid

Total Patient Paid Amount during the appropriate month.

Expense and Cost Summary by Incurred Date, Expense and Cost Summary by Paid Date -Action Report

Payer Specialty Drug

Indicates if the payer considers the prescribed drug a 'Specialty drug'.

Pharmacy Detail -Action Report

Payer Specialty Drug Indicator

Indicates if the payer considers the prescribed drug a 'Specialty drug'.

Prescribing Pattern -Action Report

PBM Formulary Indicator

Indicates if the PBM includes the prescribed drug on one of its formulary listings.

Pharmacy Detail -Action Report

PBM Specialty Drug

Indicates if the PBM considers the prescribed drug a 'Specialty drug'.

Pharmacy Detail -Action Report

Percentage of Members with Condition - Comparison Population

The percentage of members in the plan's comparison population with the condition

Condition Hierarchy Summary - Action Report

Pharmacy - Current Year

Total Pharmacy cost in the current rolling 12 month period.

Executive Report- Action Report

Pharmacy - Prior Year

Total Pharmacy cost in the previous rolling 12 month period.

CE Executive Report - Action Report

Pharmacy - Variance %

Percentage change in Pharmacy cost in the current rolling 12 month period vs. previous rolling 12 month period.

Executive Report- Action Report

Pharmacy Actual PMPM

Pharmacy cost per member per month for the plan for the current rolling 12 month period. Completion factors are applied and capitation payments are included.

Cost Overview -Dashlet

Pharmacy Actual PMPM

Pharmacy cost per member per month for the plan for the current rolling 12 month period where the cost does not exceed a threshold. Capitation payments are included and completion factors are applied.

Cost Overview w/o Outliers -Dashlet

Pharmacy Actual PMPM

Pharmacy cost per member per month for the plan for the current rolling 12 month period where the cost exceeds a threshold. Capitation payments are included and completion factors are applied.

Cost Overview w/o Outliers -Dashlet

Pharmacy Costs Changed

The % and dollar amount that Total Pharmacy costs have changed from previous to current Year

CE Executive Report – Pharmacy Cost Summary Page - Action Report

Pharmacy Current

The total adjusted paid amount for pharmacy services in the current rolling 12 month period. Completion factors are applied then capitation payments are included.

Payment Summary -Dashlet

Pharmacy Detail – Brand/Generic

Indicates if the generic or brand version of the prescribed drug was dispensed.

CE Executive Report – Pharmacy Cost Summary Page - Action Report

Pharmacy Detail - Plan Cost (Sum)

The Total Plan costs for the 30 day equivalent (prescription) in the current year.

CE Executive Report – Pharmacy Cost Summary Page - Action Report

Pharmacy Detail - Plan Cost (Sum)

% of Total Pharmacy Costs paid by the Plan in the current year.

CE Executive Report – Pharmacy Cost Summary Page - Action Report

Pharmacy Detail – Prescribed Drug Name

The name of the prescribed drug

CE Executive Report – Pharmacy Cost Summary Page - Action Report

Pharmacy Detail – Prescriptions – 30 Day Equivalent Count

A calculated measure that provides for a consistent per month comparison of pharmacy Utilization and costs.

CE Executive Report – Pharmacy Cost Summary Page - Action Report

Pharmacy ID

Unique identifier of the pharmacy filling the prescription.

Pharmacy Detail -Action Report

Pharmacy Member Months

Average number of member months for the current rolling 12 month period for the pharmacy plan.

Cost and Utilization Summary by Cost Bucket - Action Report

Pharmacy Name

Name of the pharmacy filling the prescription.

Pharmacy Detail -Action Report

Pharmacy Norm PMPM

Pharmacy cost per member per month for the normative population for the current rolling 12 month period. Completion factors are applied and capitation payments are included.

Cost Overview -Dashlet

Pharmacy Norm PMPM

Pharmacy cost per member per month for the normative population for the current rolling 12 month period where the cost does not exceed a threshold. Capitation payments are included and completion factors are applied.

Cost Overview w/o Outliers -Dashlet

Pharmacy Norm PMPM

Pharmacy cost per member per month for the normative population for the current rolling 12 month period where the cost exceeds a threshold. Capitation payments are included and completion factors are applied.

Cost Overview w/o Outliers -Dashlet

Pharmacy PMPM Changed - %

The % that Total Pharmacy per member per month cost has changed from previous to current year.

CE Executive Report – Pharmacy Cost Summary Page - Action Report

Pharmacy PMPM Changed – dollar ($) amount

The dollar amount that Total Pharmacy per member per month cost has changed from previous to current year.

CE Executive Report – Pharmacy Cost Summary Page - Action Report

Pharmacy Previous

The total adjusted paid amount for pharmacy services in the previous rolling 12 month period. Completion factors are applied then capitation payments are included.

Payment Summary -Dashlet

Pharmacy Utilization Summary – Mail Order Scripts

Number 30-day equivalent scripts (prescriptions) filled through the mail order channel during the current period.

CE Executive Report – Pharmacy Cost Summary Page - Action Report

Pharmacy Utilization Summary – Retail Scripts

Number of 30-day equivalent pharmacy scripts (prescriptions) filled through the retail channel during the current period.

CE Executive Report – Pharmacy Cost Summary Page - Action Report

Pharmacy Utilization Summary Mail Order– % of Scripts

% of 30-day equivalent scripts (prescriptions) that are filled through mail order channel during the current period.

CE Executive Report – Pharmacy Cost Summary Page - Action Report

Pharmacy Utilization Summary Mail Order– % Paid

The % of the plan paid amount for 30-day equivalent scripts (prescriptions) that are filled through mail order channel during the current period.

CE Executive Report – Pharmacy Cost Summary Page - Action Report

Pharmacy Utilization Summary Mail Order– Paid

The total plan paid amount for 30-day equivalent scripts (prescriptions) that are filled through mail order channel during the current period.

CE Executive Report – Pharmacy Cost Summary Page - Action Report

Pharmacy Utilization Summary Retail– % of Scripts

% of 30-day equivalent scripts (prescriptions) that are filled through retail channel during the current period.

CE Executive Report – Pharmacy Cost Summary Page - Action Report

Pharmacy Utilization Summary Retail– % Paid

The % of the paid amount for 30-day equivalent scripts (prescriptions) that are filled through retail channel during the current period.

CE Executive Report – Pharmacy Cost Summary Page - Action Report

Pharmacy Utilization Summary Retail– Paid

The total plan paid amount for 30-day equivalent scripts (prescriptions) that are filled through retail channel during the current period.

CE Executive Report – Pharmacy Cost Summary Page - Action Report

Pharmacy Variance

The variance in the total adjusted paid amount for pharmacy services from the current period versus the previous one. Completion factors are applied then capitation payments are included.

Payment Summary -Dashlet

Pharmacy Visits/1000 Count

Utilization per 1,000 members for Pharmacy services for the plan population. Completion factors are applied.

Cost and Utilization Summary by Cost Bucket - Action Report

Pharmacy-All PMPM

Pharmacy services cost per member per month for the plan for the current rolling 12 month period. Completion factors are applied and capitation payments are included.

Cost and Utilization Summary by Cost Bucket - Action Report

Pharmacy-Outliers Only PMPM

Pharmacy services cost per member per month for the plan for the current rolling 12 month period. This measure includes only those members who have exceeded a client configured threshold. Completion factors are applied and capitation payments are included

Cost and Utilization Summary by Cost Bucket - Action Report

Pharmacy-w/o Outliers PMPM

Pharmacy services cost per member per month for the plan for the current rolling 12 month period. This measure excludes those members who have exceeded a client configured threshold. Completion factors are applied and capitation payments are included.

Cost and Utilization Summary by Cost Bucket - Action Report