Pla - Qua

Plan Formulary Code

A code that indicates whether or not the prescribed drug is on the plan's list of preferred pharmaceutical product.

Pharmacy Detail - Action Report

Plan Formulary description

A description that indicates whether or not the prescribed drug is on the plan's list of preferred pharmaceutical product.

Pharmacy Detail - Action Report

PMPM

Per member per month

General Definition

Population Readmit %

The percentage of admissions that resulted in a readmissions to an acute care facility (within 30 days) during the current period.

Readmit % -Population Measures

Practice / Group 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.

Patient Panel - Action Report

Practice / Group 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.

Patient Panel - Action Report

Practice/ Facility / Site 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.

Patient Opportunity Detail, Patient Opportunity Summary - Action Report

Prescribed NDC Description

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

Prescribing Pattern -Action Report

Prescribing Provider ID

The identifier for the provider that prescribed the pharmacy service/drug.

Pharmacy Detail - Action Report

Prescribing Provider name

The name of the provider that prescribed the pharmacy service/drug.

Pharmacy Detail - Action Report

Present on Admission

An indicator to denote whether that primary diagnosis was present upon admission.

Inpatient Admission - Action Report

Previous per 1000

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

Executive Detail - Action Report

Previous Period Cost

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

Executive Detail - Action Report

Previous PMPM

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

Executive Detail - Action Report

Previous Variance to Norm

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

Executive Detail - Action Report

Primary Care - Cost

The per member per month cost associated with 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

Primary Care - 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

Primary Care All PMPM

The per member per month primary 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 amp Utilization Summary by Cost Bucket -Action Report

Primary Care Index

The ratio of the target's per member per month risk adjusted primary care cost compared to the peer comparisons population's per member per month risk adjusted primary care cost.

Savings Opportunities - Dashlet

Primary Care Index Goal

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

Savings Opportunities - Dashlet

Primary Care Opportunity $

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

Savings Opportunities - Dashlet

Primary Care Outliers only PMPM

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

Cost amp Utilization Summary by Cost Bucket -Action Report

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

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

Variable Time Period Cost Overview -Dashlet

Primary Care Peer Time Period 2 (w/Outliers)

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

Variable Time Period Cost Overview -Dashlet

Primary Care PMPM Actual Time Period 1 (w/out Outliers)

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

Variable Time Period Cost Overview -Dashlet

Primary Care PMPM Actual Time Period 1 (w/Outliers)

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

Variable Time Period Cost Overview -Dashlet

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

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

Variable Time Period Cost Overview -Dashlet

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

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

Variable Time Period Cost Overview -Dashlet

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

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

Variable Time Period Cost Overview -Dashlet

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

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

Variable Time Period Cost Overview -Dashlet

Primary Care PMPM Variance %

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

Savings Opportunities - Dashlet

Primary Care Risk Adj PMPM Actual

The per member per month primary 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

Primary Care Risk Adj PMPM Actual (w/o Outliers)

The per member per month primary care 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

Primary Care Risk Adj PMPM Peer

The peer comparison population's per member per month primary 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

Primary Care Risk Adj PMPM Peer (w/out Outliers)

The peer comparison population's per member per month primary care 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

Primary Care Risk Adjusted Actual PMPM

The per member per month primary 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 amp Utilization Summary by Cost Bucket -Action Report

Primary Care Risk Adjusted Peer PMPM

The peer comparison population's per member per month primary 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 amp Utilization Summary by Cost Bucket -Action Report

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

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

Variable Time Period Utilization Overview -Dashlet

Primary Care Utilization/1000 Actual Time Period 1 (w/Outliers)

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

Variable Time Period Utilization Overview -Dashlet

Primary Care Utilization/1000 Actual Time Period 2 (w/Outliers)

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

Variable Time Period Utilization Overview -Dashlet

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

The selected population’s Utilization/1000 primary care utilization, excluding high Utilization claimants, for the previous period.

Variable Time Period Utilization Overview -Dashlet

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

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

Variable Time Period Utilization Overview -Dashlet

Primary Care Utilization/1000 Peer Time Period 1 (w/Outliers)

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

Variable Time Period Utilization Overview -Dashlet

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

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

Variable Time Period Utilization Overview -Dashlet

Primary Care Utilization/1000 Peer Time Period 2 (w/Outliers)

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

Variable Time Period Utilization Overview -Dashlet

Primary Care Visits/1000 Count

The total visit count per 1,000 members for primary care services.

Cost amp Utilization Summary by Cost Bucket -Action Report

Primary Care w/out Outliers PMPM

The per member per month primary care 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 amp Utilization Summary by Cost Bucket -Action Report

Primary Diagnosis Code

An International Classification for Diseases (ICD) code related to the primary diagnosis reported for the service.

Claim Detail, Claim Summary, Inpatient Admission -Action Report

Primary Diagnosis Description

An International Classification for Diseases (ICD) description related to the primary diagnosis reported for the service.

Claim Detail, Claim Summary, Inpatient Admission -Action Report

Primary Payer Indicator

An indicator to denote whether that claim processed under the member's primary medical coverage.

Claim Detail -Action Report

Procedure Code

A CPT-4 or Healthcare Common Procedure Coding System (HCPCS) codes normally reported on professional service claims that indicates the medical service provided.

Claim Detail -Action Report

Procedure Code Modifier

Used in conjunction with the procedure code to indicate additional information about the service provided.

Claim Detail -Action Report

Procedure Description

A description of the medical service provided.

Claim Detail -Action Report

Product Type

The category of product, as defined by the traditionally referenced types of insurance plans. (PPO, HMO, etc.)

Inpatient Admission - Action Report

Program

A description that indicates the medical care coordination program used to manage the member's care.

Program Summary - Action Report

Program Code

The code that indicates the name of the medical care coordination program used to manage the member's care.

Program Detail, Program Summary -Action Report

Program Description

The description that indicates the name of the medical care coordination program used to manage the member's care.

Program Detail, Program Summary -Action Report

Program End Date

The date on which the medical care coordination program was discontinued.

Program Detail -Action Report

Program Level

Indicates the intensity or duration of the medical care coordination program.

Program Detail, Program Summary -Action Report

Program Start Date

The date on which the medical care coordination program was initiated.

Program Detail -Action Report

Program Type

A code that indicates the medical care coordination program used to manage the member's care.

Program Detail -Action Report

Program Type Description

A description that indicates the medical care coordination program used to manage the member's care.

Program Detail -Action Report

Provider

The name of the attributed entity being displayed.

Cost amp Utilization Summary by Cost Bucket,Medical amp Pharmacy Cost Summary, Medical amp Pharmacy Financial Summary -Action Report

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.

Patient Profile - Action Report

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.

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

Provider Specialty

The primary practicing specialty of the provider.

Inpatient Admission - Action Report

Quality Deviations

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

Executive Summary - Action Report

Quality Opportunities

Instances defined by a set of standardized performance measures where actionable steps can be taken to achieve compliance or reduce non-compliance.

General Definition

Quality Opportunities

Instances defined by a set of standardized performance measures where actionable steps can be taken to achieve compliance or reduce non-compliance. 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