Ser - Wei

Servicing Provider ID

The identifier for the provider/facility that performed the service.

Claim Detail, Claim Summary -Action Report

Servicing Provider Name

The name of the provider/facility that performed the service.

Claim Detail, Claim Summary, Inpatient Admission -Action Report

Servicing Provider Practice ID

The identifier for the provider practice that performed the service.

Claim Detail, Claim Summary -Action Report

Servicing Provider Practice Name

The name of the provider practice that performed the service.

Claim Detail, Claim Summary -Action Report

SNF

Skilled nursing facility

General Definition

SNF Admits - Utilization

The admission count per 1,000 members for Skilled Nursing Facility 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

SNF Flag

Indicates if the admission was for skilled nursing care.

Inpatient Admission - Action Report

Source System

A value that indicates the client source for the data.

Inpatient Admission - Action Report

Specialty

The medical discipline the provider is practicing.

Top 10 Performing Providers by Specialty - Action Report

Specialty All PMPM

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

Cost and Utilization Summary by Cost Bucket -Action Report

Specialty Care - Cost

The per member per month cost associated with Specialty 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

Specialty Care - Utilization

The encounter count per 1,000 members for Specialty 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

Specialty Care Outliers only PMPM

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

Cost and Utilization Summary by Cost Bucket -Action Report

Specialty Care Peer Time Period 2 (w/out Outliers)

The peer comparison population's per member per month specialty cost, excluding high cost claimants, for the previous period.

Variable Time Period Cost Overview -Dashlet

Specialty Care Peer Time Period 2 (w/Outliers)

The peer comparison population's per member per month specialty cost, including high cost claimants, for the previous period.

Variable Time Period Cost Overview -Dashlet

Specialty Care PMPM Actual Time Period 2 (w/out Outliers)

The per member per month specialty cost, excluding high cost claimants, for the previous period.

Variable Time Period Cost Overview -Dashlet

Specialty Care PMPM Actual Time Period 2 (w/Outliers)

The per member per month specialty cost, including high cost claimants, for the previous period.

Variable Time Period Cost Overview -Dashlet

Specialty Care PMPM Peer Time Period 1 (w/out Outliers)

The peer comparison population's per member per month specialty cost, excluding high cost claimants, for the current period.

Variable Time Period Cost Overview -Dashlet

Specialty Care PMPM Peer Time Period 1 (w/Outliers)

The peer comparison population's per member per month specialty cost, including high cost claimants, for the current period.

Variable Time Period Cost Overview -Dashlet

Specialty Care Visits/1000 Count

The total visit count per 1,000 members for specialty service.

Cost and Utilization Summary by Cost Bucket -Action Report

Specialty Care w/o Outliers PMPM

The per member per month specialty 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.

Cost and Utilization Summary by Cost Bucket -Action Report

Specialty Index

The ratio of the target's per member per month risk adjusted specialty cost compared to the peer comparison population's per member per month risk adjusted specialty cost.

Savings Opportunities - Dashlet

Specialty Index Goal

The savings opportunity goal set for comparing the target's risk adjusted emergency department per member per month to the peer comparison population's risk adjusted specialty per member per month.

Savings Opportunities - Dashlet

Specialty Opportunity $

The cost savings amount for specialty services if the index goal had been met. (Lost savings)

Savings Opportunities - Dashlet

Specialty PMPM Actual Time Period 1 (w/out Outlier)

The per member per month specialty cost, excluding high cost claimants, for the current period.

Variable Time Period Cost Overview -Dashlet

Specialty PMPM Actual Time Period 1 (w/Outliers)

The per member per month specialty cost, including high cost claimants, for the current period.

Variable Time Period Cost Overview -Dashlet

Specialty PMPM Actual Time Period 2 (w/out Outliers)

The per member per month specialty cost, excluding high cost claimants, for the previous period.

Variable Time Period Cost Overview -Dashlet

Specialty PMPM Actual Time Period 2 (w/Outliers)

The per member per month specialty cost, including high cost claimants, for the previous period.

Variable Time Period Cost Overview -Dashlet

Specialty PMPM Peer Time Period 1 (w/out Outliers)

The peer comparison population's per member per month specialty cost, excluding high cost claimants, for the current period.

Variable Time Period Cost Overview -Dashlet

Specialty PMPM Peer Time Period 1 (w/Outliers)

The peer comparison population's per member per month specialty cost, including high cost claimants, for the current period.

Variable Time Period Cost Overview -Dashlet

Specialty PMPM Peer Time Period 2 (w/out Outliers)

The peer comparison population's per member per month specialty cost, excluding high cost claimants, for the previous period.

Variable Time Period Cost Overview -Dashlet

Specialty PMPM Peer Time Period 2 (w/Outliers)

The peer comparison population's per member per month specialty cost, including high cost claimants, for the previous period.

Variable Time Period Cost Overview -Dashlet

Specialty PMPM Variance %

The change in per member per month risk adjusted specialty cost from the prior to the current period.

Savings Opportunities - Dashlet

Specialty Risk Adj PMPM Actual

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

Risk Adjusted Cost Overview -Dashlet

Specialty Risk Adj PMPM Actual (w/o Outliers)

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

Risk Adjusted Cost Overview w/o Outliers - Dashlet

Specialty Risk Adj PMPM Peer

The peer comparison population's per member per month specialty risk cost for the current period adjusted for member risk. See the definition of Risk Adjusted Per Member Per Month (PMPM) for more information.

Risk Adjusted Cost Overview -Dashlet

Specialty Risk Adj PMPM Peer (w/o Outliers)

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

Risk Adjusted Cost Overview w/o Outliers - Dashlet

Specialty Risk Adjusted Actual PMPM

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

Cost and Utilization Summary by Cost Bucket -Action Report

Specialty Risk Adjusted Peer PMPM

The peer comparison population's per member per month specialty risk cost for the current period adjusted for member risk. See the definition of Risk Adjusted Per Member Per Month (PMPM) for more information.

Cost and Utilization Summary by Cost Bucket -Action Report

Specialty Utilization/1000 Actual Time Period 1 (w/out Outliers)

The selected population’s Utilization/1000 specialty utilization, excluding high utilization claimants, for the current period.

Variable Time Period Utilization Overview -Dashlet

Specialty Utilization/1000 Actual Time Period 1 (w/Outliers)

The selected population’s Utilization/1000 specialty utilization, including high utilization claimants, for the current period.

Variable Time Period Utilization Overview -Dashlet

Specialty Utilization/1000 Actual Time Period 2 (w/out Outliers)

The selected population Utilization/1000 specialty utilization, excluding high utilization claimants, for the previous period.

Variable Time Period Utilization Overview -Dashlet

Specialty Utilization/1000 Actual Time Period 2 (w/Outliers)

The selected population’s Utilization/1000 specialty utilization, including high utilization claimants, for the previous period.

Variable Time Period Utilization Overview -Dashlet

Specialty Utilization/1000 Peer Time Period 1 (w/out Outliers)

The peer comparison population's Utilization/1000 specialty utilization, excluding high utilization claimants, for the current period.

Variable Time Period Utilization Overview -Dashlet

Specialty Utilization/1000 Peer Time Period 1 (w/Outliers)

The peer comparison population's Utilization/1000 specialty utilization, including high utilization claimants, for the current period.

Variable Time Period Utilization Overview -Dashlet

Specialty Utilization/1000 Peer Time Period 2 (w/out Outliers)

The peer comparison population's Utilization/1000 specialty utilization, excluding high utilization claimants, for the previous period.

Variable Time Period Utilization Overview -Dashlet

Specialty Utilization/1000 Peer Time Period 2 (w/Outliers)

The peer comparison population's Utilization/1000 specialty utilization, including high utilization claimants, for the previous period.

Variable Time Period Utilization Overview -Dashlet

Star Measure

Indicates if the quality opportunity is part of the CMS STARS program for Medicare enrollees.

Patient Opportunity Detail - Action Report

Star Opportunities

CMS quality measures, based on Healthcare Effectiveness Data and Information Set (HEDIS), that evaluate compliance with specific treatment protocols and adoption of best practices for preventive care.

General Definition

Status

Indicates whether the service needed has been performed in the required time frame. Close indicated the service was performed. Open indicates the service has not been performed.

Patient Profile - Action Report

Status Loss

A pre-selected threshold at which member total costs are capped for reporting .

General Definition

Target

For the target, the number of members who selected a provider to manage their care or, based on claims, a provider was determined to be managing the member's care.

Attributed Population -Dashlet

Therapeutic Class Code

The American Society of Health-System Pharmacists (ASHP) code that groups drugs with similar chemical, pharmacological, or therapeutic characteristics.

Prescribing Pattern -Action Report

Therapeutic Class Description

The definition for the therapeutic class code.

Prescribing Pattern -Action Report

Total Applying Stoploss

The sum of Medical Applying Stop Loss and Pharmacy Applying Stop Loss. 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 cu

Executive Summary - Action Report

Total Cost

The total medical cost for the current period.

Top 10 Performing Providers by Cost Bucket,Top 10 Performing Providers by Specialty - Action Report

Total Cost Amount

The maximum amount on which payment is based for covered services. This can also be referred to as “payment allowance or “eligible expense”.

Prescribing Pattern -Action Report

Total Member Cost Amount

The total medical and pharmacy cost incurred by the member during the current period.

Patient Panel - Action Report

Total Member Medical Cost Amount

The total medical cost incurred by the member during the current period.

Patient Panel - Action Report

Total Member Pharmacy Cost Amount

The total pharmacy cost incurred by the member during the current period.

Patient Panel - Action Report

Total Number of Open HCCs

The number of suspect and missing Hierarchical Condition Category (HCC) codes.

Patient Opportunity Summary, Patient Panel - Action Report

Total Open Opportunities

The total number of open suspect HCCs, missing HCCs and care opportunities. This includes opportunities in the following statuses: Open, Submitted, Pending and Snoozed. This DOES INCLUDE deviations.

Patient Opportunity Summary - Action Report

Total Returned Opportunities

The number of opportunities where the submitted information about the performed service or exclusion was not acceptable for addressing the opportunity and was returned for correction. This includes only opportunities in the Open: Returned status. This DOES INCLUDE deviations.

Patient Opportunity Summary - Action Report

Total Submitted Opportunities

The number of opportunities where an attachment has been submitted about a performed service or exclusion.

Patient Opportunity Summary - Action Report

Total Visits

The total count of distinct visits in the current period.

Top 10 Performing Providers by Cost Bucket,Top 10 Performing Providers by Specialty - Action Report

Trend

The trend of the cost from previous to current period. Color coded green or red if the trend plus or minus five percent or more.

Executive Detail - Action Report

Type of Bill

A CMS code that indicates the type of facility, the type of care (inpatient, out patient, subacute etc..) and frequency of claim submission.

Claim Summary -Action Report

Type of Facility

A grouping of the type of facility where a patient or member receives care.

General Definition

Type of Service

A grouping of the type of procedure or treatment that is rendered to the patient or member.

General Definition

Type of Service Level 2

The highest level description of the medical service category. (Office Visit, OP Facility, DME, etc.)

Claim Detail, Inpatient Admission -Action Report

Type of Service Level 3

The moderate level description of the medical service category. Used in conjunction with the type of service level 2 for more detail on the service performed. (Established Patient, Cardiology, Wheelchair, etc.)

Claim Detail -Action Report

Type of Service Level 4

The final level description of the medical service category. Used in conjunction with the type of service levels 2 and 3 for more detail on the service performed. (Immunization, Other, Accessory, etc.)

Claim Detail -Action Report

Urgent Care Visits - Utilization

The encounter count per 1,000 members for Urgent 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

Utilization

A measure of the number of care services consumed by the patient or member, typically expressed in services per thousand members or inpatient admissions per thousand members.

General Definition

Variance

The percentage change of the cost from previous to current period.

Executive Detail - Action Report

Weighted Risk Score

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.

Weighted Risk Score -Population Measures

Weighted Risk Score

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.

Executive Summary - Action Report

Weighted Risk Score

The enrollment weighted risk score of the patients in the selected health system and practice.

Executive Detail - Action Report