Medida

Definición

Acontecimiento

Provider Group

Group the servicing provider is associated with.

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

Provider Specialty (Especialidad del proveedor)

La especialidad principal del proveedor.

Claim Detail, Inpatient Admission - Action Report (Detalle de la reclamación, Admisión de paciente hospitalizado - Informe de acción)

Provider Specialty Code

Code describing the primary practicing Specialty of the provider.

Claim Summary - Action Report (Resumen de la reclamación - Informe de acción)

Provider Specialty Description

The primary practicing specialty of the provider.

Claim Summary - Action Report (Resumen de la reclamación - Informe de acción)

Provider Type Code

Code indicating the type of provider.

Claim Summary - Action Report (Resumen de la reclamación - Informe de acción)

Provider Type Description

Description of the type of provider.

Claim Summary - Action Report (Resumen de la reclamación - Informe de acción)

Quantity Dispensed

A measure of the quantity of the prescribed drug that was dispensed to the patient.

Pharmacy Detail -Action Report

Radiology Actual PMPM

Radiology cost per member per month for the plan for the current rolling 12 month period. Completion factors are applied and capitation payments are included.

Cost Overview -Dashlet

Radiology Actual PMPM

Radiology cost per member per month for the plan for the current rolling 12 month period where the cost does not exceed a threshold. Capitation payments are included and completion factors are applied.

Cost Overview w/o Outliers -Dashlet

Radiology Actual PMPM

Radiology cost per member per month for the plan for the current rolling 12 month period where the cost exceeds a threshold. Capitation payments are included and completion factors are applied.

Cost Overview w/o Outliers -Dashlet

Radiology Norm PMPM

Radiology cost per member per month for the normative population for the current rolling 12 month period. Completion factors are applied and capitation payments are included.

Cost Overview -Dashlet

Radiology Norm PMPM

Radiology cost per member per month for the normative population for the current rolling 12 month period where the cost does not exceed a threshold. Capitation payments are included and completion factors are applied.

Cost Overview w/o Outliers -Dashlet

Radiology Norm PMPM

Radiology cost per member per month for the normative population for the current rolling 12 month period where the cost exceeds a threshold. Capitation payments are included and completion factors are applied.

Cost Overview w/o Outliers -Dashlet

Radiology Visits/1000 Count

Utilization per 1,000 members for Radiology services for the plan population. Completion factors are applied.

Cost and Utilization Summary by Cost Bucket - Action Report

Radiology-All PMPM

Radiology services cost per member per month for the plan for the current rolling 12 month period. Completion factors are applied and capitation payments are included.

Cost and Utilization Summary by Cost Bucket - Action Report

Radiology-Outliers Only PMPM

Radiology services cost per member per month for the plan for the current rolling 12 month period. This measure includes only those members who have exceeded a client configured threshold. Completion factors are applied and capitation payments are include

Cost and Utilization Summary by Cost Bucket - Action Report

Radiology-w/o Outliers PMPM

Radiology services cost per member per month for the plan for the current rolling 12 month period. This measure excludes those members who have exceeded a client configured threshold. Completion factors are applied and capitation payments are included.

Cost and Utilization Summary by Cost Bucket - Action Report

RAF/CRA

The CRA is the member's risk scores commercial risk score. It is displayed if the member has a commercial insurance product. It is calculated using the current HCC risk model as defined in Affordable Care Act.

Member Summary -Action Report

RAF/CRA

The RAF is the member's Medicare risk score if they have a Medicare Advantage insurance product. The risk score is determined using the CMS risk adjustment model.

Member Summary -Action Report

Readmit Date

For a readmission claim, the date of the readmission.

Inpatient Admission -Action Report

Readmit Date

The start date of a patient's inpatient readmission confinement. The readmission must be less than 30 days after the discharge date of the previous inpatient admission. Substance abuse admissions are not considered as an original or readmission confinemment.

Member Summary -Action Report

Readmit Discharge Date

For a readmission claim, the date of the discharge from the readmission.

Inpatient Admission -Action Report

Readmit Discharge Date

If a patient was readmitted less than 30 days between discharge and readmission, then this is the end date of their readmission confinement. It will be null if the patient is still inpatient or the final bill closing the confinement has not been processed.

Member Summary -Action Report

Readmit Flag

A flag indicating if the claim was for a readmission.

Claim Summary - Action Report (Resumen de la reclamación - Informe de acción)

Readmits/1000 - Actual

Readmissions per 1000 members for the plan.

Inpatient Utilization -Dashlet

Readmits/1000 - Norm

Readmissions per 1000 members for the plan for the normative population.

Inpatient Utilization -Dashlet

Readmitting Diagnosis Code

If a patient was readmitted less than 30 days between discharge and readmission, then this is the admitting diagnosis of their readmission confinement.

Inpatient Admission, Member Summary -Action Report

Readmitting Diagnosis Description

If a patient was readmitted less than 30 days between discharge and readmission, then this is the admitting diagnosis description of their readmission confinement.

Inpatient Admission -Action Report

Readmitting Facility

Carrier assigned identifier for the facility.

Inpatient Admission -Action Report

Readmitting Facility

If a patient was readmitted less than 30 days between discharge and readmission, then this is the facility of their readmission confinement.

Member Summary -Action Report

Readmitting ICD Type Code

A code indicating what type of ICD code is used (9 or 10).

Inpatient Admission -Action Report

Referral Close Reason Code (Código del motivo de cierre de la derivación)

Un código que indica el motivo por el que se interrumpió la participación en el programa de coordinación de atención médica del miembro.

Program Detail - Action Report (Detalle del programa - Informe de acción)

Referral Close Reason Description (Descripción del motivo de cierre de la derivación)

Una descripción que indica el motivo por el que se interrumpió la participación en el programa de coordinación de atención médica del miembro.

Program Detail - Action Report (Detalle del programa - Informe de acción)

Referred from Another Program Count

The count of members who were identified from another program's engagement or enrollment process.

Program Summary -Action Report

Referred From Another Program Indicator

Indicates the source that referred the member to the medical care coordination program.

Program Detail - Action Report (Detalle del programa - Informe de acción)

Rehab Admits/1000 - Norm

Admissions per 1,000 members to a rehabilitation setting for the normative population.

Inpatient Utilization -Dashlet

Rehab Flag

A flag indicating if the admission is for a Rehabilitation Facility.

Inpatient Admission -Action Report

Rehab/1000 - Actual

Admissions per 1,000 members to a rehabilitation setting.

Inpatient Utilization -Dashlet

Relationship Code

Code indicating the member's relationship to the subscriber.

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

Relationship Code

A code describing the member's relationship to the subscriber.

Member Opportunity Detail, Member Opportunity Summary -Action Report

Relationship Code

Code indicating the member's relationship to the subscriber.

Member Summary, Pharmacy Detail, Program Detail -Action Report

Relationship Description

Description of the member's relationship to the subscriber.

Claim Detail, Claim Summary, Enrollment Detail, Inpatient Admission, Member Opportunity Detail, Member Opportunity Summary, Member Summary, Pharmacy Detail, Program Detail -Action Report

Retail % Paid

The percentage of retail channel pharmacy claim payment amount during the current reporting period.

Pharmacy Utilization Summary -Dashlet

Retail % Scripts

Percentage of scripts filled in the current reporting period through the retail channel. The script count is based on a 30-day equivalent calculation.

Pharmacy Utilization Summary -Dashlet

Retail Paid

Total retail channel pharmacy claim paid amount during the current reporting period.

Pharmacy Utilization Summary -Dashlet

Retail Scripts

Number of 30-day equivalent pharmacy scripts (prescriptions) filled through the retail channel during the current reporting period.

Pharmacy Utilization Summary -Dashlet

Revenue Code

The description of the types of persons covered under the subscribers contract.

Claim Detail - Action Report (Detalle de la reclamación - Informe de acción)

Revenue Code Description

Description of the revenue code.

Claim Detail - Action Report (Detalle de la reclamación - Informe de acción)

Service From Date

The earliest date associate with the billed service.

Claim Detail, Claim Summary - Action Report (Detalle de la reclamación, Resumen de la reclamación - Informe de acción)

Service To Date

The latest date associated with a billed service.

Claim Detail, Claim Summary - Action Report (Detalle de la reclamación, Resumen de la reclamación - Informe de acción)

Servicing Provider ID

Unique identifier for the provider who actually provides the service(s) billed on a claim.

Claim Detail, Claim Summary - Action Report (Detalle de la reclamación, Resumen de la reclamación - Informe de acción)

Servicing Provider Name

The name of the provider who actually provides the service(s) billed on a claim.

Claim Detail, Claim Summary - Action Report (Detalle de la reclamación, Resumen de la reclamación - Informe de acción)

Servicing Provider Name

The name of the provider who actually provides the service(s) billed on a claim.

Inpatient Admission -Action Report

Servicing Provider Practice ID

Unique identifier for practice of the provider who actually provides the service(s) billed on a claim.

Claim Detail, Claim Summary - Action Report (Detalle de la reclamación, Resumen de la reclamación - Informe de acción)

Servicing Provider Practice Name

The name of the practice of the provider who actually provides the service(s) billed on a claim.

Claim Detail, Claim Summary - Action Report (Detalle de la reclamación, Resumen de la reclamación - Informe de acción)

SNF Admits/1000 - Actual

Admissions per 1,000 members to Skilled Nursing Facility (SNF) setting.

Inpatient Utilization -Dashlet

SNF Admits/1000 - Norm

Admissions per 1,000 members to skilled nursing facility setting for the normative population.

Inpatient Utilization -Dashlet

SNF Flag

A flag indicating if the admission is for a Skilled Nursing Facility.

Inpatient Admission -Action Report

Especialidad

Description of provider Specialty.

Top 10 Performing Providers by Specialty - Action Report (Los diez principales proveedores de servicios por especialidad - Informe de acciones)

Specialty % Paid

The percentage of the specialty claim payment amount during the current reporting period.

Pharmacy Utilization Summary -Dashlet

Specialty % Scripts

Percentage of 30-day equivalent specialty scripts filled during the current reporting period.

Pharmacy Utilization Summary -Dashlet

Specialty Actual PMPM

Specialty services cost per member per month for the plan for the current rolling 12 month period. Completion factors are applied and capitation payments are included.

Cost Overview -Dashlet

Specialty Actual PMPM

Specialty services cost per member per month for the plan for the current rolling 12 month period where the cost does not exceed a threshold. Capitation payments are included and completion factors are applied.

Cost Overview w/o Outliers -Dashlet

Specialty Actual PMPM

Specialty services cost per member per month for the plan for the current rolling 12 month period where the cost exceeds a threshold. Capitation payments are included and completion factors are applied.

Cost Overview w/o Outliers -Dashlet

Specialty Care Visits/1000 Count

Utilization per 1,000 members for Specialty Care services for the plan population. Completion factors are applied.

Cost and Utilization Summary by Cost Bucket - Action Report

Specialty Care-All PMPM

Specialty Care services cost per member per month for the plan for the current rolling 12 month period. Completion factors are applied and capitation payments are included.

Cost and Utilization Summary by Cost Bucket - Action Report

Specialty Care-Outliers Only PMPM

Specialty Care services cost per member per month for the plan for the current rolling 12 month period. This measure includes only those members who have exceeded a client configured threshold. Completion factors are applied and capitation payments are in

Cost and Utilization Summary by Cost Bucket - Action Report

Specialty Care-w/o Outliers PMPM

Specialty Care services cost per member per month for the plan for the current rolling 12 month period. This measure excludes those members who have exceeded a client configured threshold. Completion factors are applied and capitation payments are include

Cost and Utilization Summary by Cost Bucket - Action Report

Specialty Drugs Account For - % of Plan Costs

% that Specialty Drugs account in Total Plan Paid costs.

CE Executive Report – Pharmacy Cost Summary Page - Action Report

Specialty Drugs Account For - % of Prescriptions

% of Prescriptions that are Specialty Drugs that are Specialty Drugs.

CE Executive Report – Pharmacy Cost Summary Page - Action Report

Specialty Norm PMPM

Specialty services cost per member per month for the normative population for the current rolling 12 month period. Completion factors are applied and capitation payments are included.

Cost Overview -Dashlet

Specialty Norm PMPM

Specialty services cost per member per month for the normative population for the current rolling 12 month period where the cost does not exceed a threshold. Capitation payments are included and completion factors are applied.

Cost Overview w/o Outliers -Dashlet

Specialty Norm PMPM

Specialty services cost per member per month for the normative population for the current rolling 12 month period where the cost exceeds a threshold. Capitation payments are included and completion factors are applied.

Cost Overview w/o Outliers -Dashlet

Specialty Paid

Total pharmacy cost during the current reporting period for specialty scripts.

Pharmacy Utilization Summary -Dashlet

Specialty Scripts

30-day equivalent script count of specialty scripts filled the current reporting period.

Pharmacy Utilization Summary -Dashlet

Spouse Membership Count

Membership Count of all members who are spouses of employees.

Executive Report- Action Report

Star Measure

Indicates if the opportunity is related to a STAR measure.

Member Opportunity Detail -Action Report

Sub Group

A concatenation of Sub-Group Name and Sub-Group Number

Cost and Utilization Summary by Cost Bucket, Financial Summary - Action Report

Subgroup Description

The Subgroup Name associated with the Subgroup Number.

Capitation Summary -Action Report

Subgroup ID

The Subgroup Number assigned by the carrier.

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

Subgroup Number

The Subgroup Number assigned by the carrier.

Capitation Summary, Expense and Cost Summary by Incurred Date, Expense and Cost Summary by Paid Date -Action Report

Subscriber Count

Count of subscribers.

Enrollment Summary -Action Report

Subscriber Member Month

Total member months for subscribers.

Enrollment Summary -Action Report

Subscriber Paid Amount

Total plan paid dollars made on behalf of subscribers.

Enrollment Summary -Action Report

Therapeutic Class Code

Hierarchical code grouping like drugs together.

Pharmacy Detail, Prescribing Pattern-Action Report

Therapeutic Class Description

Description of the Therapeutic Class Code.

Pharmacy Detail, Prescribing Pattern-Action Report

Top 10 Facilities by Payment

Total dollars of the Top 10 Facilities (as determined by paid dollars).

Executive Report- Action Report

Top 3 MDC Categories

Top 3 Major Diagnosis categories by cost.

Executive Report- Action Report

Total

Total dollars paid by the plan.

Network Utilization Summary -Action Report

Total Cost Amount

Total dollars paid by the plan.

Prescribing Pattern - Action Report (Patrón de prescripción - Informe de acción)

Total Current Count

The total count of subscribers (contract holder) across all contract benefit coverage type and enrolled in the last month in the reporting period.

Subscriber Enrollment by Contract Type -Dashlet

Total Dental

Total Dental Costs that Members are responsible for in the current year.

Member Responsibility Overview -Dashlet

Total Medical

Total Medical Costs that Members are responsible for in the current year.

Member Responsibility Overview -Dashlet

Total Member Cost Amount

Total plan paid dollars for a member in the current rolling 12 month period.

Member Summary -Action Report

Total Member Cost Amount

Sum of medical and pharmacy cost for members for the current rolling 12 month period. Capitation payments are included and completion factors are applied.

Member Summary -Action Report

Total Member Cost Share - Dental

% of Total Dental Costs paid by the Member in the current year. Capitation Payments are included and Completion Factors are applied.

Member Responsibility Overview -Dashlet

Total Member Cost Share - Medical

% of Total Medical Costs paid by the Member in the current year. Capitation Payments are included and Completion Factors are applied.

Member Responsibility Overview -Dashlet

Total Member Cost Share - Pharmacy

% of Total Pharmacy Costs paid by the Member in the current year. Capitation Payments are included and Completion Factors are applied.

Member Responsibility Overview -Dashlet

Total Member Cost Share - Vision

% of Total Vision Costs paid by the Member in the current year. Capitation Payments are included and Completion Factors are applied.

Member Responsibility Overview -Dashlet

Total Member Count

Total number of members.

Enrollment Summary -Action Report

Total Member Medical Cost Amount

Total adjusted paid amount for medical services received by the member in the current rolling 12 month period. Completion factors are applied and capitation payments are included when applicable.

Member Summary -Action Report

Total Member Month

Total number of member months.

Enrollment Summary -Action Report

Total Member Paid Amount

Total dollars paid by the members.

Enrollment Summary -Action Report

Total Member Pharmacy Cost Amount

Total adjusted paid amount for pharmacy services received by the member in the current rolling 12 month with Completion factors applied.

Member Summary -Action Report

Total Member Responsibility Amount

Total dollars the member was responsible for in the current period.

Member Summary -Action Report

Total Members

Number of unique members covered under the plan (contract holder, spouse, and/or dependent(s)) as of the last month in the reporting period.

Total Members - Population Measures

Total Number of Open HCCs

The number of HCCs a member is suspected of having or are missing based on Theon modeling algorithms and claims history.

Member Opportunity Summary -Action Report

Total Number of Open HCCs

For a given member the total number of suspect and missing Hierarchical Condition Category (HCC) codes, or chances where existing coding may indicate a gap in coding may exist.

Member Summary -Action Report

Total Number of Open HCCs Suspected

For a given member, the total number of situations where advanced algorithms have predicted a member may have a condition not present in their claims coding, due to the presence of other factors observed in the claims data and often seen with the suspected condition.

Member Summary -Action Report

Total Paid

Total dollars paid by the plan.

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

Total Pharmacy

Total Pharmacy Costs that Members are responsible for in the current year.

Member Responsibility Overview -Dashlet

Total Vision

Total Vision Costs that Members are responsible for in the current year.

Member Responsibility Overview -Dashlet

Total Visits

Total number of visits.

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

Type of Bill

Uniform Billing Committee defined bill type. Applies only to Facility claims.

Claim Summary - Action Report (Resumen de la reclamación - Informe de acción)

Type of Service Level 2

Theon assigned classification of services performed.

Claim Detail, Inpatient Admission - Action Report (Detalle de la reclamación, Admisión de paciente hospitalizado - Informe de acción)

Type of Service Level 3

Theon assigned classification of services performed.

Claim Detail - Action Report (Detalle de la reclamación - Informe de acción)

Type of Service Level 4

Theon assigned classification of services performed.

Claim Detail - Action Report (Detalle de la reclamación - Informe de acción)

Utilization Per K

A per thousand representation of service utilization.

Network Utilization Summary - Action Report

Utilization Per K In-Network

A per thousand representation of service utilization.

Network Utilization Summary - Action Report

Utilization Per K Out of Network

A per thousand representation of service utilization.

Network Utilization Summary -Action Report

Variance Avg Dental Member Months

Percentage change between Average number of member months for the current vs. previous rolling 12 month period for the Dental plan.

Enrollment Overview -Dashlet

Variance Avg Dental Member Months - Norm

Percentage change between Average number of member months for the current vs. previous rolling 12 month period for the Dental plan normative population.

Norm Enrollment Overview -Dashlet

Variance Avg Medical Member Months

Percentage change between Average number of member months for the current vs. previous rolling 12 month period for the medical plan.

Enrollment Overview -Dashlet

Variance Avg Medical Member Months - Norm

Percentage change between Average number of member months for the current vs. previous rolling 12 month period for the medical plan normative population.

Norm Enrollment Overview -Dashlet

Variance Avg Pharmacy Member Months

Percentage change between Average number of member months for the current vs. previous rolling 12 month period for the Pharmacy plan.

Enrollment Overview -Dashlet

Variance Avg Pharmacy Member Months - Norm

Percentage change between Average number of member months for the current vs. previous rolling 12 month period for the Pharmacy plan normative population.

Norm Enrollment Overview -Dashlet

Variance Avg Vision Member Months

Percentage change between Average number of member months for the current vs. previous rolling 12 month period for the Vision plan.

Enrollment Overview -Dashlet

Variance Avg Vision Member Months - Norm

Percentage change between Average number of member months for the current vs. previous rolling 12 month period for the Vision plan normative population.

Norm Enrollment Overview -Dashlet

Variance Dental PMPM

Percentage change in Dental Cost per member per month in the current rolling 12 month period vs. previous rolling 12 month period for the Normative Population. Capitation Payments are included and Completion Factors are applied.

Norm Comparison - Dashlet

Variance Dental PMPM

Percentage change in Dental Cost per member per month in the current rolling 12 month period vs. previous rolling 12 month period for the plan.

Payment Overview - Dashlet

Variance Medical PMPM

Percentage change in medical cost per member per month in the current rolling 12 month period vs. previous rolling 12 month period for the normative population.

Norm Comparison - Dashlet

Variance Medical PMPM

Percentage change in medical cost per member per month in the current rolling 12 month period vs. previous rolling 12 month period for the plan.

Payment Overview - Dashlet

Variance Pharmacy PMPM

Percentage change in pharmacy cost per member per month in the current rolling 12 month period vs. previous rolling 12 month period for the normative population.

Norm Comparison - Dashlet

Variance Pharmacy PMPM

Percentage change in pharmacy cost per member per month in the current rolling 12 month period vs. previous rolling 12 month period for the plan.

Payment Overview - Dashlet

Variance Vision PMPM

Percentage change in Vision Cost per member per month in the current rolling 12 month period vs. previous rolling 12 month period for the Normative Population. Completion Factors are applied.

Norm Comparison - Dashlet

Variance Vision PMPM

Percentage change in Vision Cost per member per month in the current rolling 12 month period vs. previous rolling 12 month period for the plan.

Payment Overview - Dashlet

Vision Actual PMPM

Vision cost per member per month for the actual population for the current rolling 12 month period. Completion factors are applied and capitation payments are included.

Cost Overview -Dashlet

Vision Current

The total adjusted paid amount for Vision services in the current rolling 12 month period. Completion factors are applied then capitation payments are included.

Payment Summary -Dashlet

Vision Norm PMPM

Vision cost per member per month for the normative population for the current rolling 12 month period. Completion factors are applied and capitation payments are included.

Cost Overview -Dashlet

Vision Previous

The total adjusted paid amount for Vision services in the previous rolling 12 month period. Completion factors are applied then capitation payments are included.

Payment Summary -Dashlet

Vision Variance

The variance in the total adjusted paid amount for Vision services from the current period versus the previous one. Completion factors are applied then capitation payments are included.

Payment Summary -Dashlet

Weighted Risk Score

A calculation for the defined population of each individual members retrospective risk multiplied by the individual members medical member months for the current time period, divided by the total member months for the population measured.

Weighted Risk Score - Population Measures (Puntaje de riesgo ponderado - Medidas de la población)

Year Over Year Trend

Evaluating two or more measured events to compare the results at one time period with those of a comparable time period on an annualized basis.

Executive Report- Action Report