Med - Opp

Medical Applying Stoploss

The per member per month medical cost for the after capping member total cost based on the pre-selected threshold. This data is presented for the current and previous period for the selected health system. Appropriate peer values are displayed. Variances are calculated for peer values as well as current to previous periods. Previous to Current variances have trend indicators. To aid in rapid identification of trend changes, increases of 5.0% or more are highlighted in red, while decreases of 5.0% or more are highlighted in green.

Executive Summary - Action Report

Medical Cost Health System Current PMPM Applying Stop Loss

The health system's per member per month medical cost for the current period after capping member total cost based on the pre-selected threshold.

Medical and Pharmacy Financial Summary - Action Report

Medical Cost Health System PMPM Applying Stop Loss

The change in the health system's per member per month medical cost from the prior to the current period after capping member total cost based on the pre-selected threshold.

Medical and Pharmacy Financial Summary - Action Report

Medical Cost Health System Previous PMPM Adjusted

The health system's per member per month medical cost for the current period after capping member total cost based on the pre-selected threshold and adjusted for the change in member risk from prior to current period.

Medical and Pharmacy Financial Summary - Action Report

Medical Cost Health System Previous PMPM Applying

The health system's per member per month medical cost for the prior period after capping member total cost based on the pre-selected threshold.

Medical and Pharmacy Financial Summary - Action Report

Medical Cost Peer Current PMPM Applying Stop Loss

The peer comparison population's per member per month medical cost for the current period after capping member total cost based on the pre-selected threshold.

Medical and Pharmacy Financial Summary - Action Report

Medical Cost Peer PMPM Applying Stop Loss % Change

The change in the peer comparison population's per member per month medical cost from the prior to the current period after capping member total cost based on the pre-selected threshold.

Medical and Pharmacy Financial Summary - Action Report

Medical Cost Peer Previous PMPM Adjusted for Change in Risk

The peer comparison population's per member per month medical cost for the current period after capping member total cost based on the pre-selected threshold and adjusted for the change in member risk from prior to current period.

Medical and Pharmacy Financial Summary - Action Report

Medical Cost Peer Previous PMPM Applying Stop Loss

The peer comparison population's per member per month medical cost for the prior period after capping member total cost based on the pre-selected threshold.

Medical and Pharmacy Financial Summary - Action Report

Medical Cost Risk Adjusted Peer PMPM w/o Outliers

The change in the peer comparison population's risk adjusted per member per month medical cost excluding high total claim cost members from the prior to the current period.

Medical and Pharmacy Cost Summary -Action Report

Medical Cost Risk Adjusted Peer PMPM w/o Outliers

The peer comparison population's per member per month medical cost excluding high total claim cost members during the current period adjusted for member risk. See the definition of Risk Adjusted Per Member Per Month (PMPM) for more information.

Medical and Pharmacy Cost Summary -Action Report

Medical Cost Risk Adjusted Peer PMPM w/o Outliers

The peer comparison population's per member per month medical cost excluding high total claim cost members during the prior period adjusted for member risk. See the definition of Risk Adjusted Per Member Per Month (PMPM) for more information.

Medical and Pharmacy Cost Summary -Action Report

Medical Cost Risk Adjusted PMPM w/o Outliers - Current

The per member per month medical cost excluding high total claim cost members during the current period adjusted for member risk. See the definition of Risk Adjusted Per Member Per Month (PMPM) for more information.

Medical and Pharmacy Cost Summary -Action Report

Medical Cost Risk Adjusted PMPM w/o Outliers - Previous

The per member per month medical cost excluding high total claim cost members during the prior period adjusted for member risk. See the definition of Risk Adjusted Per Member Per Month (PMPM) for more information.

Medical and Pharmacy Cost Summary -Action Report

Medical Cost Risk Adjusted PMPM w/o Outliers % Change

The change in the risk adjusted per member per month medical cost excluding high total claim cost members from the prior to the current period.

Medical and Pharmacy Cost Summary -Action Report

Medical Current Risk

A weighted measure of a population’s potential to incur expenses based on a combination of the population’s eligibility, age, gender, medical and pharmacy history. Weighting is based on each individual’s medical member months in relation to the population

Medical and Pharmacy Financial Summary - Action Report

Medical Current Rolling 12 with Runout PMPM

The per member per month medical cost for the current period.

Medical and Pharmacy Financial Summary - Action Report

Medical Current Rolling 12 with Runout PMPM Applying Stop Loss Dollars

The per member per month medical cost for the current period after capping member total cost based on the pre-selected threshold.

Medical and Pharmacy Financial Summary - Action Report

Medical Current Rolling 12 with Runout PMPM w/o Outliers

The per member per month medical cost excluding high total claim cost members during the current period.

Medical and Pharmacy Cost Summary -Action Report

Medical Current Rolling 12 with Runout PMPM With Outliers

The per member per month medical cost during the current period.

Medical and Pharmacy Cost Summary -Action Report

Medical Current Rolling 12 with Runout Risk Adjusted

The per member per month medical cost for the current period adjusted for member risk. See the definition of Risk Adjusted Per Member Per Month (PMPM) for more information.

Medical and Pharmacy Cost Summary -Action Report

Medical Current Rolling 12 with Runout Risk Adjusted

The per member per month medical cost excluding high total claim cost members during the current period adjusted for member risk. See the definition of Risk Adjusted Per Member Per Month (PMPM) for more information.

Medical and Pharmacy Cost Summary -Action Report

Medical Member Months

The number of months that members were enrolled in a medical product during the current period.

Cost and Utilization Summary by Cost Bucket -Action Report

Medical PMPM Applying Stop Loss Result

The per member per month medical cost that does not exceed the stop loss threshold during the current period.

Peer Comparison, Performance Overview - Dashlet

Medical PMPM Applying Stop Loss Trend

A directional arrow that indicates whether the change in cost was positive or negative.

Peer Comparison, Performance Overview - Dashlet

Medical PMPM Applying Stop Loss Variance

The change in risk adjusted per member per month medical cost from the prior to the current period after applying stop loss.

Peer Comparison, Performance Overview - Dashlet

Medical Previous PMPM

The per member per month medical cost for the prior period.

Medical and Pharmacy Financial Summary - Action Report

Medical Previous PMPM Applying Stop Loss Adjusted

The per member per month medical cost for the prior period after capping member total cost based on the pre-selected threshold and adjusted for the change in member risk from prior to current period.

Medical and Pharmacy Financial Summary - Action Report

Medical Previous PMPM Applying Stop Loss Dollars

The per member per month medical cost for the prior period after capping member total cost based on the pre-selected threshold.

Medical and Pharmacy Financial Summary - Action Report

Medical Previous PMPM w/o Outliers

The per member per month medical cost excluding high total claim cost members during the prior period.

Medical and Pharmacy Cost Summary -Action Report

Medical Previous PMPM With Outliers

The per member per month medical cost during the prior period.

Medical and Pharmacy Cost Summary -Action Report

Medical Previous Risk

A weighted measure of a population’s potential to incur expenses based on a combination of the population’s eligibility, age, gender, medical and pharmacy history. Weighting is based on each individual’s medical member months in relation to the population

Medical and Pharmacy Financial Summary - Action Report

Medical Previous Risk Adjusted PMPM w/o Outliers

The per member per month medical cost excluding high total claim cost members during the prior period adjusted for member risk. See the definition of Risk Adjusted Per Member Per Month (PMPM) for more information.

Medical and Pharmacy Cost Summary -Action Report

Medical Previous Risk Adjusted PMPM With Outliers

The per member per month medical cost for the previous period adjusted for member risk. See the definition of Risk Adjusted Per Member Per Month (PMPM) for more information.

Medical and Pharmacy Cost Summary -Action Report

Medicrel Adv Enrollment -Case Mgt

The number of Medicare Advantage members who were identified for a case management program during the current period.

Program Management - Dashlet

Medicrel Adv Enrollment -Disease Mgt

The number of Medicare Advantage members who were identified for a disease management program during the current period.

Program Management - Dashlet

Medicrel Advantage Patients

The number of members during the current period enrolled in a Medicare Advantage product.

Medicrel Advantage Risk Adjustment - Dashlet

Member ID

The member identifier from their original data source.

Program Detail -Action Report

Member Name

The member's full name.

Program Detail -Action Report

MHSA

Mental health substance abuse

General Definition

MHSA Admits - Utilization

The admission count per 1,000 members for MHSA Inpatient Admissions. This data is presented for the current and previous period for the selected health system. Appropriate peer values are displayed. Variances are calculated for peer values as well as current to previous periods.  Previous to Current variances have trend indicators. To aid in rapid identification of trend changes, increases of 5.0% or more are highlighted in red, while decreases of 5.0% or more are highlighted in green.

Executive Summary - Action Report

MHSA Flag

Indicates if the admission was for mental health or substance abuse care.

Inpatient Admission - Action Report

Mortality %

The percentage of admissions during the current period that resulted in the patient's death.

Inpatient Comparative - Dashlet

MRN

A tracking number (medical record number) for the patient.

Claim Detail, Claim Summary, Inpatient Admission, Patient Opportunity Detail, Patient Opportunity Summary, Patient Panel, Pharmacy Detail, Program Detail -Action Report

NDC

The National Drug Code (NDC) established by the Federal Food and Drug Administration (FDA) which serves as the universal product identifier for drugs.

Pharmacy Detail, Prescribing Pattern - Action Report

NDC Description

The description of the National Drug Code (NDC) as defined by the Federal Food and Drug Administration (FDA).

Pharmacy Detail - Action Report

New Patients

The number of members in the panel that are newly attributed to the clinician within the last 3 months.

New Patients -Population Measures

No PCP Visits

The number of members during the current period enrolled in a Commercial product, who have not had a primary care visit with their attributed practice in the previous twelve months.

Commercial Risk Adjustment - Dashlet

No PCP Visits

The number of members during the current period enrolled in a Medicare Advantage product, who have not had a primary care visit with their attributed practice in the previous twelve months.

Medicrel Advantage Risk Adjustment - Dashlet

Non-Attributed Members

Members who have not attributed to an in-network practice or physician. Attribution occurs when a member either selects a primary care provider (PCP) or imputes to one via claims history. If the member has not selected a PCP and has no evaluation and management services with a PCP during the current or prior time period, they will be demonstrated as non-attributed.

General Definition

Not Engaged Member Count

The number of identified members who are not actively participating in a medical care coordination program.

Program Summary - Action Report

Not Engaged Member Percentage

The percentage of identified members who are not actively participating in a medical care coordination program.

Program Summary - Action Report

Not Seen by PCP in 12 Months

The number of members in the panel during the current period who have not seen their attributed provider practice for an office visit within the last 12 months.

Not Seen by PCP in 12 Months -Population Measures

Number of Actionable Opportunities

The number of contracted care opportunities where there is no record of the member receiving the required service(s) and there is a reconsideration screen built to allow user input to close the opportunity. This includes opportunities in the following statuses: Open, Submitted, Pending and Snoozed. This DOES INCLUDE deviations.

Patient Opportunity Summary - Action Report

Number of Deviations

The number of selected services performed that do not follow widely accepted standards of care. This includes opportunities in the following statuses: Open, Submitted, Pending and Snoozed.

Patient Opportunity Summary - Action Report

Number of ED Visits

The number of emergency department visits that did not result in an inpatient visit.

Patient Panel - Action Report

Number of Interactions

The number of times an attempt was made to contact the member.

Program Detail -Action Report

Number of IP Admits

The number of inpatient admissions.

Patient Panel - 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). This includes opportunities in the following statuses: Open, Submitted, Pending and Snoozed.

Quality Opportunity Summary - Dashlet

Number of Open Care Opportunities

The number of care opportunities where there is no record of the member receiving the required service(s). This includes any opportunity in the following statuses: Open, Submitted, Pending and Snoozed. This DOES INCLUDE deviations.

Patient Opportunity Summary, Patient Panel - Action Report

Number of Open HCCs Missing

The number of situations where a retrospective review of the member's known medical history indicates the presence of a condition but that condition has yet to be reported in the last 12 months.

Patient Opportunity Summary, Patient Panel - Action Report

Number of Open HCCs Suspected

The number of situations where the presence of other factors observed in the member's claims data indicates that the member might have a serious undiagnosed medical condition.

Patient Opportunity Summary, Patient Panel - Action Report

Number of Open 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). This includes opportunities in the following statuses: Open, Submitted, Pending and Snoozed.

Patient Opportunity Summary - Action Report

Number of Prescriptions Filled

The number of 30 day equivalent prescriptions.

Patient Panel - Action Report

Number of Quality Deviations

The number of care opportunities where the member received treatment that did not follow widely accepted standards of care.

Quality Deviation Summary - Action Report

Number of Quality Non-Deviations

The number of care opportunities where the member received treatment that followed widely accepted standards of care.

Quality Deviation Summary - Action Report

Number of Quality Opportunities Met per Measure (Numerator)

The number of care opportunities where the member received the required service(s). This includes only opportunities in the Closed status.

Quality Opportunity Summary - Dashlet

Number of Quality Opportunities per Measure (Denominator)

The total number of care opportunities. This includes opportunities in all statuses.

Quality Deviation Summary, 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). This includes any opportunity in the following statuses: Open, Submitted, Pending and Snoozed.

Quality Opportunity Summary - Dashlet

Number of Specialist Visits

The number of visits a member had with a specialist providers in the last 14 months.

Patient Panel - Action Report

Observations - Utilization

The encounter count per 1,000 members for Primary Care services. This data is presented for the current and previous period for the selected health system. Appropriate peer values are displayed. Variances are calculated for peer values as well as current to previous periods.  Previous to Current variances have trend indicators. To aid in rapid identification of trend changes, increases of 5.0% or more are highlighted in red, while decreases of 5.0% or more are highlighted in green.

Executive Summary - Action Report

Open Care Opportunities

The number of times a member did not receive the recommended care for a quality care measure. This includes any opportunity in the following statuses: Open, Submitted, Pending and Snoozed.

Quality Opportunities - Dashlet

Open Coding Opportunities

The number of missing or suspected hierarchical Condition Categories (HCC) during the current period.

Quality Opportunities - Dashlet

Open 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). This includes any opportunity in the following statuses: Open, Submitted, Pending and Snoozed.

Quality Opportunities - Dashlet

Opportunities

The name of the quality opportunity.

Patient Opportunity Detail - Action Report

Opportunity

Opportunities includes Care, Coding – Missing, Coding – Suspect and Deviations. Refer to the opportunity type for definitions.

General Definition

Opportunity Due Date

The date when the care or coding gap must be closed in order to be compliant.

Patient Opportunity Detail - Action Report

Opportunity Status

Indicates how an opportunity is being managed and where in the supplemental data gathering cycle it currently is.

Patient Opportunity Detail - Action Report

Opportunity Type

Indicates the type of quality opportunity.

Patient Opportunity Detail - Action Report