What is Theon Care Optimizer?

Theon Care Care Optimizer (Theon) is a data and analytics tool that focuses on the three domains of the Triple Aim.


Theon offers tools that can be used to improve the health of populations, e.g., identify preventive gaps in care opportunities.


Theon allow individuals to see healthcare cost and utilization trends over time. If use of the module is maximized, the user can find opportunities for reducing cost and utilization, and improving financial performance.

Patient experience of care

Theon highlights information about engagement in clinical programs and provides information that can be used to more effectively coordinate and close gaps in care.

Is Theon available to all providers contracted with Capital Blue Cross?

Theon is available to all contracted Capital Blue Cross primary care providers (PCP) and organizations.

When is the Theon Care Optimizer platform available to providers?

The Theon Care Optimizer platform is currently available to primary care providers. To obtain access to the platform, you must complete the user access form and fax it to your provider relations consultant.


Does attribution occur if a member receives services from a nurse practitioner? Would the attribution link back to the provider practice?

Yes, attribution can occur if a member received services from a nurse practitioner and other physician extenders. The attribution would link back to the provider practice.

The Theon tool includes a dashboard called savings opportunities. To whom does this refer, Capital Blue Cross or the provider?

This dashboard identifies potential opportunities that a provider may have to lower healthcare costs for a particular cost bucket if the provider is able to outperform its peers.

Does Theon show commercial and Medicare (Medicare Advantage) breakout?

Yes, you can view the breakout by using the line of business dropdown within the refine population filter.

How timely are the risk scores?

The risk scores are based on a monthly data refresh.

How often will the data in Theon be refreshed?

The data in Theon is generally refreshed monthly. However, the information appearing in the dashboard under the population measures headings called 'patients currently admitted' and 'discharged in the last ten (10) days' are updated daily.

How are we handling substance abuse, mental health and employee claims?

Substance abuse, mental health and employee claims are now masked for specific roles in Theon.

What data is included or excluded from Theon?

Federal Employee Program (FEP), Medicare supplement, and any members not attributed to PCP specialties are excluded from Theon. Attributed ITS host and out-of-area members were included in Theon as of July 2015 and CBC/Pinnacle payer data are included in payer refinement.

Can patients be attributed to a specialist such as an OBGYN?

No, patients cannot be attributed to specialists such as OBGYNs, however, that may be implemented in a future enhancement.

Could a provider be in both an accountable care arrangement and "no program"?

No. "No program" indicates that a provider is not contracted in a QualityFirst Accountable Care ArrangementSM or QualityFirst Medical Neighborhood and is also not in the QualityFirst Primary Care Recognition ProgramSM.

Why would Theon display zeros (0s) on the condition and demographic risk scores?

The condition risk and demographic risk will display a zero in the application after a member's Capital Blue Cross coverage has terminated.

When a patient's Capital Blue Cross coverage terminates, are their costs still reflected in the cost buckets?

When a patient's Capital Blue Cross coverage terminates, the costs incurred by the patient up through the date of termination will still remain in the cost buckets and on other reports. In due time, the patient will eventually cease to be attributed based on the time period used to determine attribution.

When a patient's Capital Blue Cross coverage terminates, will they continue to be listed on open gaps in care lists?

Capital Blue Cross follows the eligibility rules defined by HEDIS, and there is usually some gap of time during which the patient will continue to be listed, which can vary by HEDIS measure.

How is a member attributed to a practice?

Members are attributed to a provider practices in one of two ways. First, members within an HMO product, who are required to designate their primary care provider, are automatically assigned to the practice. Second, members within a PPO product are assigned a primary care provider through a process which uses the member's claim experience to determine the primary care provider that has provided the plurality of primary care services to the member. If the member received primary care services from two providers equally then tie-breaker logic is incorporated such as most recent E&M visit.

If a patient was recently hospitalized, can the provider tell they have been admitted?

Yes, that information is available in the dashboard under the population measure heading 'patients currently admitted'.

Will Theon ever have the capability to house more current data?

The data for the performance metrics in Theon are generally refreshed monthly. Recently, Capital reduced the claims run-out period from three months to two months, thus allowing for timelier reporting of the performance metrics. In addition, if your access grants permission to view the claim level detail this information is updated more frequently than monthly and is dependent upon when claims are received. The information appearing in the dashboard under the population measures headings called 'patients currently admitted' and 'discharged in the last ten (10) days' are updated daily. In addition, no additional changes are in discussion at this time.

Has Theon been updated to reflect ICD-10 diagnosis codes?

Yes. However, claims data is from the previous 12 months, thus data would be inclusive of ICD-9 diagnosis codes as well.

Can high dollar patient care data be retrieved separately?

Yes, that information is available in the dashboard under the population measure heading 'high cost patients'.

Are diagnosis/discharge reports sent to providers?

Providers should access Care Optimizer to view patient information for their patients. There are several reports available through the population bubbles to include; discharged in the last 10 days, high risk patient, or the ability to view the practices entire patient panel. Within the patient panel bubble providers can view a list of the patients and their diagnosis.


Can ranking/sorting be changed?

Yes, sorting can be changed.

Does the tool remember your filters from previous logins?

No, but the tool will save changes to rearranged columns and displayed dashlets.

How far back in time does the patient attribution logic look?

The first pass of the attribution logic looks at the latest twelve (12) months. If a patient fails to get attributed during that first twelve month time period, then the tool looks at the previous twelve (12) months. The attribution logic looks back two (2) years at most.

Are all of the prompts within the tool data driven?

Yes, depending on the underlying data the prompt filters will change. The tool is designed to accommodate different customer?s data as long as it follows certain data definitions.

Can providers export the data from Theon to Excel files?

Yes, up to a maximum of 50,000 records.

Can all graphs be exported as a PDF?

Yes, all graphs/visuals can be exported as a PDF. All detailed information can be exported to Excel.

Can providers export reports? Will report criteria information be reflected on any reports that are printed?

Action reports can be exported and printed. Timeframes and prompts are documented on the info tab of exported reports.

If providers click on patients currently in the hospital, will they be able to determine why a patient was in the hospital using such information as a diagnosis or procedure code?

Yes. If a provider clicks on a patient currently in the hospital, the provider will be taken to the Patient Panel. Original admitting diagnosis is reflected in the detail.

What does the up arrow in the performance overview represent?

An up arrow indicates that the PMPM is increasing when comparing the current 12-month period to the prior period.

Does an underline mean that 'drill down' is available?

Yes, if a data point is underlined, a 'drill down' to additional information is available. Drill paths will be included in the user documentation.

Will the Hierarchical Condition Code (HCC) categories within Theon be updated to accommodate ICD-10?


What is the visual queue to know a panel has been refined?

When a panel has been refined, the word "refine" will become italicized.

Is there any way to view trended risk scores?

Currently there is no way to view trended risk scores in Theon, but there has been functionality added to trend medical and pharmacy costs.

In the action reports, "medical and pharmacy financial summary" and "cost and utilization summary by cost bucket," is there any way to "expand all" so you can open all info to the practitioner level detail?

The Theon team is reviewing this as a future enhancement and Capital Blue Cross will provide an update in the near future.

Can providers easily get a readmit rate at the provider level and then trend these numbers?

Currently, the only way to get a readmit rate at the provider level is to refine the population to the provider of interest in the refine population section at the top of the initial log in page. Because this may involve small numbers overall, be cautious about small cell size and how that can influence this calculation.

Can Theon provide a PMPM for skilled nursing facilities (SNFs)?

This functionality does not currently exist in Theon, however, Theon is reviewing as a possible future enhancement.

When showing reports that break costs into the seven (7) cost categories, into which bucket do urgent care costs fall?

Urgent care centers costs generally fall into the specialty care, radiology and lab buckets.

Where are home health costs within the seven (7) cost categories?

The large majority of the costs and services related to home health costs fall into the specialty care bucket. However, some home health costs may get included into the lab, radiology and/or primary care buckets.

If fields within the reports are not needed, can they be moved and/or dropped.

Yes, fields within action reports can be moved, dropped and/or sorted in ascending or descending order. The user should hover to the right of a field header and they will receive an arrow which will display ascending, descending, and columns. The column function allows the selection or de-selection of columns.


The population measures included with the dashboard refers to 'new patients' – which identifies anyone newly attributed within the last ninety (90) days. Is there anything in the tool to identify who was lost?


The population measures included with the dashboard refers to patients 'not seen in the last 12 months' – does this mean not seen at all by any physician, including specialists, or by the PCP?

This population refers only to patients who have not seen their attributed PCP. The patient may have seen another PCP or physician extender in the same practice, but not their attributed PCP.

The population measures included with the dashboard refers to patients who were 'discharged in last 10 days' – does this mean on Day 11 the person falls off this category?

Yes, the person falls off this category when he/she has been discharged from the hospital more than 10 days from the current date. Information is based on authorizations – not claims based.

What does the trend on the main dashboard mean?

It is comparing the provider’s PMPM from the current 12-month period to the prior period.

Can providers sort fields on the patient panel?


What does 'readmission percentage' that appears on the population measures of the dashboard represent?

It represents all readmissions to an acute care facility within thirty (30) days of discharge from an admission of any kind e.g. acute or subacute.

Will the tool have the capability to enable users to change the benchmark/peer to which they are being compared?

The tool currently enables the user some flexibility to select a peer. Added flexibility to define a peer/benchmarks is being reviewed.

If a user does not have Excel can they export as a different type of file?

Currently, the user must have Excel installed on their computer in order to export the particular dataset. However, an enhancement has been requested to allow additional output types.

Is health reimbursement account (HRA) data used to calculate demographic risk?

No, but it is being considered for a future enhancement. Current demographic risk is based solely on age and gender.

Are the HEDIS measures that Capital Blue Cross uses in its value-based programs the same as the HEDIS measures used by CMS?

NCQA and measures utilized by CMS are often developed from input of the national quality forum, thus Capital’s use of NCQA’s HEDIS measures and the measures utilized by CMS may be very similar, but at times not exact.

Can a grid containing the HEDIS measures that are part of my contracted program with Capital Blue Cross be provided?

Yes. A grid of the various HEDIS measures that are part of your contracted program with Capital Blue Cross can be obtained from your Provider Service or ACA Representative.


Why was $125,000 chosen as cut off for outliers?

Capital Blue Cross selected $125,000 as the outlier cut point based on our internal data and experience, but this parameter is configurable by the system administration upon request.

Is it true that HMO selects PCP at the group level and not physician level?


Can a QualityFirst Accountable Care Arrangement provider find the definition of "peer" in the application?

The peer for a QualityFirst Accountable Care ArrangementSM provider is not specifically defined in the tool, but it can be found in the contract with the provider.

Have providers been approached by others with similar initiatives/products?

There are other products in the market that have certain pieces of what is included in Theon, however, we have not seen a product that has all the information that is included in Theon in one tool.

How can the "total members" field be lower than the "average member months" count?

The "total members" field posts a single tabulated count of 'one' for each unique member that had medical coverage with the group during the last month of coverage, but the "average member months" reflects the number of months or duration of time that the unique members had coverage.

Is there an incentive for providers to close gaps in care?

Currently, providers participating in one of our value-based program do have an incentive to close gaps in care. These incentives may be tied to a quality incentive payment, tiered program reimbursement, or shared savings calculations.

Care gap closures

Is there a limit to the number of patients a user can bring over from Care Optimizer into Care Collaborator?

No. there is no limit.

Is there a size limit to the uploaded file?

Each file has a 20 megabyte limit. If the file exceeds this amount, the user will receive an error message. Files over 20 megabytes should be broken down into separate files.

Can a user upload more than one file per measure?

Yes, a user can upload multiple attachments to support the measure. Note that each file is limited to 20 megabytes in size.

If a user filters on diabetes measures, why would patient explorer show other measures for the patient?

Patient explorer will show the user all of the patient's open opportunities, even if the user has selected just one measure.

Could a user just type 'diabetes' using control-F to find those patients?

Yes. This is browser functionality and not specific to the Theon application.

If a measure has sub-measures, does the uploaded documentation support the main measure, the specific sub-measure or both? (Example: immunizations)

The documentation will support both - however the status will not change until all sub-measures are satisfied.

Can you tell which HEDIS measures are part of the value based program?

A contracted measure is indicated by the symbol on the gap closure screen; the hover-over feature also informs the user if the measure is contracted.

Does the user receive a notification when documentation is rejected or returned?

No, the user does not receive a notification. The status will be updated in the patient opportunity summary report by the end of the following business day and will be displayed in the 'total returned opportunities' column. The user will need to monitor the patient opportunity summary report regularly.

Will there be a document that provides detail on what is acceptable documentation for submissions by measure?

Yes. See the supplemental HEDIS guide located in the supplemental data guide section above.

What measures are available for gap closure?

Open measures are included in Care Optimizer within the patient opportunity summary action report. The majority of these measures will be closed using the normal claims submission and adjudication process. There are currently 17 measures with actionable gap closure screens in which supplemental information is allowed for closure.

Is there a time stamp to inform the provider when the opportunity has been closed?

No, there is no time stamp at this time.

How long will it take to close an open opportunity using claim submission?

In general, a claim finalized by the first of the month would be included in the most recent data refresh and reflected as a closed opportunity. For instance, a claim finalized by June 1, 2020 would be included in the month Theon data refresh that occurs in mid-June.

What is the difference in the way opportunities in care are displayed now compared to how they were previously displayed?

To help you better identify Capital Blue Cross members in need of a service or screening, we made revisions to our former opportunities for recommended care reports in order to make this information more timely and actionable. This updated display of open care opportunities now includes a combined nine-month "look back" of claims data for missed opportunities and a prospective view for those measures that are not event driven which identifies services that your patients will be due for in the next three months.

What are my options for the information provided as an open opportunity?

You can do one of three things with the information:

  1. Perform a service that was past due and submit a claim.
  2. Submit supplemental data to identify that a service was performed for which a claim will not be received by Capital Blue Cross (e.g. colonoscopy performed 7 years ago under a different insurer).
  3. Perform outreach to a patient for which a service is about to be due to ensure they have access to a timely appointment.

How will I know the right time frame for which I may submit data?

As this display is a rolling twelve-month display, we recommend utilizing the supplemental data guide for closing opportunities in care found in the Theon Care Optimizer digital welcome kit in order to determine the proper time frame for submission. This document includes an introduction to the medical record submission process, a tool to calculate the acceptable supplemental dates per measure, and a description of each measure for which we are accepting supplemental data.

I am a provider participating in value based programs with Capital Blue Cross. How will this data submission tie to the performance period in my current quality program?

Any compliant data submitted during your performance period, whether it be calendar year (1/1/2020 - 12/31/2020), fiscal year (7/1/2019 - 6/30/2020), or any other time frame, may positively impact your contract year or performance period during that particular time.

How does the 'patient refused services' effect the HEDIS measures?

The use of the 'patient refused services' or another option under the 'service were not performed' option will result in the measure moving from an open to pend status. The measure will remain in a pend status for 2 months before it returns to open status. You can view the measure in a pend status by selecting 'pending opportunities' on the patient explorer screen under quality opportunities. The pend status has no effect on the HEDIS numerator and denominator and will not count as a measure closure, therefore we do not recommend that you choose this option.

When utilizing the patient opportunity summary report, is there a way to refine the report to show only actionable opportunities.

Yes, a new option, “patients with actionable opportunities” has been added to the refine dropdown. This allows you to refine based on actionable opportunities.

When I submit information to close a gap how will I know I have completed the submission successfully?

Once a record has successfully been submitted, you will receive a “record submitted” notice via a pop-up box that fades away 5 seconds after submission.

If, after successfully submitting a record, I realize it was incorrect or insufficient information, will I be able to access the submitted record and make corrections?

You will have the capability to alter opportunities in a pending status via an “edit” button on the pended recon screen until it is opened by an abstractor. Once the abstractor accesses the opportunity the edit button will become gray and you will no longer be able to make edits until the submitted opportunity is returned by the abstractor.

Our quality program includes deviations (HEDIS derived events which should not occur). These do not appear on the quality opportunity summary report. Is there a place in Care Optimizer that list my patients with deviations?

A new report, deviation opportunity summary report, has been added to Care Optimizer. This report behaves very similar to the quality opportunities summary report but will display only deviations. It hyperlinks to the patient opportunity detail report.

Are we able to submit supplemental data for a deviation?

Use of imaging studies for low back pain is the only deviation that has a supplemental data submission screen. You can submit supplemental data for this deviation through the manage opportunities button of the patient opportunity summary report.

What does the Capital Blue Cross ITS-HOST under the payer filters and columns mean?

ITS-HOST stands for our Blue Card members that may have an employer that is out of state but has Blue Cross Blue Shield coverage. As these members are attributed to your practice, you are still responsible for the management of their care.

What does the Capital Blue Cross/Pinnacle under the payer filters and columns mean?

Capital Blue Cross/Pinnacle represents a payer arrangement offered to some Capital Blue Cross employer groups. Members who have elected this option and have paid claims through this option will be included in the refinement.

Theon® provides health data informatics and analytical support.