Adm - Dev

Admission

The total costs for the original admissions that had a readmission (within 30 days) in the current period.

Readmission Costs -Dashlet

Admission Status Code

A standardized code used primarily with census data to indicate the current status of an individual’s inpatient admission.

Inpatient Admission - Action Report

Admission Status Description

A standardized description used primarily with census data to indicate the current status of an individual’s inpatient admission.

Inpatient Admission - Action Report

Admission Type

A code that indicates whether the inpatient admission was elective, emergency, etc.

Inpatient Admission - Action Report

Admission Type Description

A description that indicates whether the inpatient admission was elective, emergency, etc.

Inpatient Admission - Action Report

Admit Date

The date of admission to an inpatient facility.

Inpatient Admission - Action Report

Admitting Diagnosis Code

The International Classification for Diseases (ICD) code related to the diagnosis upon admission to an inpatient facility.

Claim Summary, Inpatient Admission -Action Report

Admitting Diagnosis Description

The International Classification for Diseases (ICD) description related to the diagnosis upon admission to an inpatient facility.

Claim Summary, Inpatient Admission -Action Report

Admitting Provider Name

The name of the provider/facility that admitted the member.

Inpatient Admission - Action Report

Affiliated with Health System

An indicator that denotes whether the provider is associated with the health system reported.

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

Allowed Amount

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

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

ALOS

The average length of an inpatient episode of care. Calculated from the day of admission to the day of discharge.

Inpatient Comparative - Dashlet

Appropriate Treatment Rate

The percentage of care opportunities where the member received treatment that follows widely accepted standards of care.

Quality Deviation Summary -Action Report

Attributed PCP ID

The unique identifier for the provider who was selected by the member or appears to be managing the member's care, based on claims.

Patient Panel - Action Report

Attributed PCP Name

The name of the provider who was selected by the member or appears to be managing the member's care, based on claims.

Patient Panel - Action Report

Attributed Provider ID

The unique identifier for the provider who was selected by the member or appears to be managing the member's care, based on claims.

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

Attributed Provider Name

The name of the provider who was selected by the member or appears to be managing the member's care, based on claims.

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

Attributed Provider Practice ID

The unique identifier for the provider practice that was selected by the member or appears to be managing the member's care, based on claims.

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

Attributed Provider Practice Name

The name of the provider practice that was selected by the member or appears to be managing the member's care, based on claims.

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

Attribution

The assignment of a member to an individual provider or provider group based on the active selection made by the member according to plan rules, or inferred by analyzing the member’s claim history.

General Definition

Auth ID

The authorization number associated with the inpatient admission.

Inpatient Admission - Action Report

Average Age

The average age of the members in the panel during the current period.

Average Age -Population Measures

Average Wholesale Price Amount

The average price based on data obtained from manufacturers, distributers, and other suppliers. This can also be referred to as the list/sticker price.

Pharmacy Detail - Action Report

Average CRA

The average risk score (CRA) during the current period for commercial members based on the commercial HHS risk adjustment model.

Commercial Risk Adjustment - Dashlet

Average RAF

The average risk score (RAF) for Medicare Advantage members based on the CMS risk adjustment model.

Medicare Advantage Risk Adjustment - Dashlet

Biling Provider ID

The identifier for the entity that billed for the service.

Claim Detail, Claim Summary -Action Report

Biling Provider Name

The name of the entity that billed for the service.

Claim Detail, Claim Summary -Action Report

Brand Generic Description

Indicates whether the prescribed medication was filled with the generic or brand product.

Pharmacy Detail - Action Report

Brand Total Costs

The maximum amount on which payment is based for covered brand drug prescriptions.

Prescribing Pattern -Action Report

Brand Total Scripts

The number of 30 day equivalent prescription for a brand drug.

Prescribing Pattern -Action Report

Capture Rate

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

Quality Opportunity Summary -Dashlet

Care (Opportunity Type)

A measure that identifies widely accepted standards of care recommended for a member. These can be based on the member’s age, gender and/or disease state.

General Definition

Care Manager

The name of the medical care coordinator assigned to manage the member's care.

Program Detail -Action Report

Case Close Reason Code

A code that indicates the reason participation in the medical care coordination program was discontinued.

Program Detail -Action Report

Case Close Reason Description

A description that indicates the reason participation in the medical care coordination program was discontinued.

Program Detail -Action Report

CCS Multi Level 1 Code

A standard Health Cost and Utilization Project (HCUP) code that is based on the reported diagnosis and assigns a body systems or condition categories (e.g., Diseases of the Circulatory System, Mental Disorders, Injury, etc.). It can be used in conjunction with CCS Multi Level 2, 3 & 4 to assess very specific conditions and procedures.

Claim Detail -Action Report

CCS Multi Level 1 Description

A standard Health Cost and Utilization Project (HCUP) description that is based on the reported diagnosis and assigns a body systems or condition categories (e.g., Diseases of the Circulatory System, Mental Disorders, Injury, etc.). It can be used in conjunction with CCS Multi Level 2, 3 & 4 to assess very specific conditions and procedures.

Claim Detail -Action Report

CCS Multi Level 2 Code

A standard Health Cost and Utilization Project (HCUP) code that is based on the reported diagnosis and assigns a more detailed value under the body systems or condition categories (e.g., Hypertension, Bipolar Disorder, etc.). It can be used in conjunction with CCS Multi Level 1, 3 & 4 to assess very specific conditions and procedures.

Claim Detail -Action Report

CCS Multi Level 2 Description

A standard Health Cost and Utilization Project (HCUP) description that is based on the reported diagnosis and assigns a more detailed value under the body systems or condition categories (e.g., Hypertension, Bipolar Disorder, etc.). It can be used in conjunction with CCS Multi Level 1, 3 & 4 to assess very specific conditions and procedures.

Claim Detail -Action Report

CCS Multi Level 3 Code

A standard Health Cost and Utilization Project (HCUP) code that is based on the reported diagnosis and assigns a more detailed value under the body systems or condition categories (e.g., Hypertension with complications, etc.). It can be used in conjunction with CCS Multi Level 1, 2 & 4 to assess very specific conditions and procedures.

Claim Detail -Action Report

CCS Multi Level 3 Description

A standard Health Cost and Utilization Project (HCUP) description that is based on the reported diagnosis and assigns a more detailed value under the body systems or condition categories (e.g., Hypertension with complications, etc.). It can be used in conjunction with CCS Multi Level 1, 2 & 4 to assess very specific conditions and procedures.

Claim Detail -Action Report

CCS Multi Level 4 Code

A standard Health Cost and Utilization Project (HCUP) code that is based on the reported diagnosis and assigns a more detailed value under the body systems or condition categories (e.g., Other hypertensive complications, etc.). It can be used in conjunction with CCS Multi Level 1, 2 & 3 to assess very specific conditions and procedures.

Claim Detail -Action Report

CCS Multi Level 4 Description

A standard Health Cost and Utilization Project (HCUP) description that is based on the reported diagnosis and assigns a more detailed value under the body systems or condition categories (e.g., Other hypertensive complications, etc.). It can be used in conjunction with CCS Multi Level 1, 2 & 3 to assess very specific conditions and procedures.

Claim Detail -Action Report

CCS Single Level Code

A standard Health Cost and Utilization Project (HCUP) code that that is based on all reported diagnosis and assigns an illnesses category.

Claim Detail -Action Report

CCS Single Level Description

A standard Health Cost and Utilization Project (HCUP) description that is based on all reported diagnosis and assigns an illnesses category.

Claim Detail -Action Report

Center for Medicare and Medicaid Services (CMS)

The Centers for Medicare & Medicaid Services is an agency within the United States Department of Health & Human Services responsible for administration of several key federal health care programs including Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).

General Definition

Charged Amount

The total reported charges for service rendered. Also known as the billed amount.

Claim Detail, Claim Summary -Action Report

Chronic HCC's Missing Average

The average number of missing chronic HCCs during the current period for members who have a Commercial medical health insurance product.

Commercial Risk Adjustment - Dashlet

Chronic HCC's Missing Average

The average number of missing chronic HCCs during the current period for members who have a Medicare Advantage health insurance product.

Medicare Advantage Risk Adjustment - Dashlet

Chronic HCC's Missing Total #

The number of missing chronic HCCs during the current period for members who have a Commercial medical health insurance product.

Commercial Risk Adjustment - Dashlet

Chronic HCC's Missing Total #

The number of missing chronic HCCs during the current period for members who have a Medicare Advantage health insurance product.

Medicare Advantage Risk Adjustment - Dashlet

Claim ID

The code, coming from the source, used to identify the claim.

Claim Detail, Claim Summary, Pharmacy Detail -Action Report

Claim Line Number

The number used in conjunction with the claim ID to identify individual claim lines.

Claim Detail -Action Report

CMS

Centers for Medicare & Medicaid Services

General Definition

Coding - Missing (Opportunity Type)

A predicted medical condition {Hierarchical Condition Category} for a member based on the absence of a previously reported condition.

General Definition

Coding - Suspect (Opportunity Type)

The predicted medical condition {Hierarchical Condition Category} for a member based on the presence of other factors observed in the claims data.

General Definition

Cohort

A group of patients or members within a defined population sharing similar classifications, characteristics, or conditions.

General Definition

Commercial Enrollment -Case Mgt

The number of commercial members 18 years of age and older who were identified for a case management program during the current period.

Program Management - Dashlet

Commercial Enrollment -Disease Mgt

The number of commercial members 18 years of age and older who were identified for a disease management program during the current period.

Program Management - Dashlet

Commercial Patients

The number of members during the current period in a commercial product.

Commercial Risk Adjustment - Dashlet

Commercial Risk Adjustment Factor (CRA)

Related to Department of Health and Human Services Risk Adjustment Model; provides a numerical score of a commercial member’s potential for future cost and utilization.

General Definition

Co-Morbidity Managed Indicator

Indicates whether the member is participating in more than one medical care coordination program.

Program Detail -Action Report

Condition Hierarchy Amount

The total cost for the member's highest cost condition category based on a 12 month period.

Patient Panel - Action Report

Condition Hierarchy Code

A high level category code based on the primary diagnosis for the service line.

Claim Detail -Action Report

Condition Hierarchy Description

A high level category description based on the primary diagnosis for the service line.

Claim Detail, Patient Panel -Action Report

Condition Risk Score

A measure of a member's potential to incur expenses based on their age, gender and medical history. A risk greater than 1.0 indicates the potential for incurring higher than average cost. For example, a member with a risk score of 2.5 has the potential to cost 2.5 times the average member’s cost.

Patient Panel, Patient Profile - Action Report

Confinement

Represents a unique, uninterrupted inpatient stay within a single care facility. It summarizes the provider, diagnostic, procedural, and financial information associated with the member's stay.

General Definition

Confinement Number

An identifier assigned for each inpatient hospitalization that is also used to associate all services (professional & facility) performed during the inpatient stay.

Inpatient Admission - Action Report

Contract Flag

Indicates if a member has been included in a contract with the health system or practice.

Patient Opportunity Detail, Patient Profile, Quality Deviation Summary - Action Report; Quality Opportunity Summary -Dashlet

Cost Bucket

The categories of healthcare spend and utilization specific to Theon (e.g., including, but not limited to, Emergency Department, Hospital Services, Laboratory, Radiology, Pharmacy, Specialty Care, and Primary Care).

Claim Detail, Top 10 Performing Providers by Cost Bucket -Action Report

Cost Bucket Utilization

A number that represents the portion of the service that is billed on the service line. A value of one (1) indicates the entire service is covered by the line.

Claim Detail -Action Report

Coverage Status

This indicates if the members medical coverage is currently effective or terminated.

Patient Opportunity Detail, Patient Opportunity Summary, Patient Panel, Patient Profile, Program Detail - Action Report

Coverage Status

This indicates if the members medical coverage is currently effective or terminated.

Patient Opportunity Summary - Action Report

CRA

Commercial Risk Adjustment

General Definition

Current per 1000

The current reporting period utilization (per 1000) of the selected health system and practice. Refined to the Cost Bucket and Measure selected.

Executive Detail - Action Report

Current Period Cost

The current reporting period cost of the selected health system and practice. Refined to the Cost Bucket and Measure selected.

Executive Detail - Action Report

Current PMPM

The current reporting period cost PMPM of the selected health system and practice. Refined to the Cost Bucket and Measure selected.

Executive Detail - Action Report

Current Variance to Norm

The difference between the current period of the selected health system and practice.

Executive Detail - Action Report

Dashlet

A snapshot showing high level clinical, financial and utilization results.

General Definition

Date of Last Visit with ANY Primary Care Provider

The last date a service was performed by any primary care type provider (PCP) during the current period.

Patient Panel - Action Report

Date of Service

The date the service was performed.

Pharmacy Detail - Action Report

Date of Surgery

The surgical inpatient service date.

Inpatient Admission - Action Report

Days Supply Count

The number of days prescribed for the medication.

Pharmacy Detail - Action Report

Demographic Risk Score

A measure of a member's potential to incur expenses based on their age & gender. A risk greater than 1.0 indicates the potential for incurring higher than average cost. For example, a member with a risk score of 2.5 has the potential to cost 2.5 times the average member’s cost.

Patient Panel, Patient Profile - Action Report

Deviation (Opportunity Type)

An indicator identifying when a member received treatment that did not follow widely accepted standards of care.

General Definition

Deviations

The number of times a member received treatment that did not follow widely accepted standards of care.

Quality Opportunities -Dashlet