Glossary — A
Abuse and Fraud
[Function: Metric]
The amount of submitted charges not covered due to willful and material misrepresentation of a health care claim.
Found in the following report by default:
Option to add to the following report:
Submitted Charges | minus | Ineligible Charges | equals | Eligible Charges |
---|---|---|---|---|
Duplicate Bills | ||||
R&C (Reasonable and Customary) Reductions | ||||
Benefit Limits | ||||
Pre-existing Conditions | ||||
Abuse and Fraud | ||||
Medical Claim Review | ||||
MNRP (Maximum Non-Network Reimbursement Program) | ||||
Other Ineligible Charges | ||||
Eligible Charges | minus | Discounts | equals | Covered Amount |
Contracted Discount | ||||
Special Negotiated Discount | ||||
Shared Savings Discount | ||||
Prompt Payment Discount | ||||
Customer Specific Discount | ||||
Other Discount | ||||
Covered Amount | minus | Employee Cost Sharing | equals | Gross Payable |
Copay | ||||
Deductible | ||||
Coinsurance | ||||
Gross Payable | minus | Other Savings | equals | Net Paid |
Commercial COB Savings | ||||
Commercial COB Reductions | ||||
Medicare COB Savings | ||||
Medicare COB Reductions | ||||
Provider Sanctions | ||||
All Other Savings Amount |
Accident
[Function: Value]
The cause of an injury for which services are provided by a healh care professional/facility.
Parent Attribute:
Active
[Function: Value]
An employed subscriber or the dependent of an employed subscriber.
Parent Attribute:
Actual Restated Billed Members
[Function: Metric]
The count of subscribers and their covered dependents.
Items of Note:
- The count is based upon monthly updates to the data warehouse.
Found in the following report by default:
Acute
[Function: Value]
A category of admissions consisting of conditions that require immediate services within a defined time span.
Parent Attribute:
Acute-Care Outpatient Facility
[Function: Value]
An establishment licensed and equipped to provide medical and surgical care for seriously ill or injured people (e.g., emergency room, ambulatory surgery center, urgent care facility).
Parent Attribute:
AD&D Benefit
[Function: Value]
Coverage for specific disabling conditions or loss of life due to unnatural or unintentional causes.
Parent Attribute:
Administrative Services Only
[Function: Value]
A funding arrangement under which an insurance carrier or independent organization handles, for a fee, the administration of claims, benefits, and other administrative functions for a self-insured group.
Items of Note:
- Also referenced by the acronym "ASO."
Parent Attribute:
Admission Type Category
[Function: Attribute]
Classifies claims into one of the following categories based on the kind of event for which a person was registered as an inpatient (i.e., admitted for at least 24 hours).
- Acute
- Non-Actute
Items of Note:
- Also includes a category for unknown admission types.
- Level 1 (most general) of the Admission Type Hierarchy's 4 levels.
Option to add to the following reports:
Admission Type Detail
[Function: Attribute]
Further differentiates the following admissions from the hierarchy's summary level (the number in parenthesis equals the additonal lines of detail at this level):
- Maternity (3)
- Newborn (2)
Items of Note:
- Also includes a line of detail for unknown admission types.
- Level 4 (most detailed) of the Admission Type Hierarchy's 4 levels.
Found in the following report by default:
Option to add to the following reports:
Admission Type Group
[Function: Attribute]
Further differentiates acute admissions from the hierarchy's category level.
Items of Note:
- Non-acute admission are labeled as "Other" admissions at this level.
- Also includes a group of unknown admission types.
- Level 2 (next-to-most general) of the Admission Type Hierarchy's 4 levels.
Found in the following report by default:
Option to add to the following reports:
Admission Type Hierarchy
[Function: Hierarchy]
Classifies claims based on the kind of event for which a person was registered as an inpatient (i.e., admitted for at least 24 hours).
Items of Note:
- Used to support cost comparison studies or to track similar types of admissions across providers or provider types.
Consists of the following levels of detail:
Admission Type Category | Admission Type Group | Admission Type Summary | Admission Type Detail |
---|---|---|---|
Acute | Medical/Surgical | Medical | Medical |
Surgical | Surgical | ||
Maternity | Maternity | Maternity - Cesarean Section | |
Maternity - Vaginal Delivery | |||
Maternity - Other | |||
Newborn | Newborn | Newborn - Well | |
Newborn - Other | |||
MH/SA | Mental Health | MH/SA - Mental Health | |
Substance Abuse | MH/SA - Substance Abuse | ||
Non-Acute | Other | Hospice | Hospice |
Skilled Nursing | Skilled Nursing | ||
Rehabilitation | Rehabilitation | ||
Unknown | Unknown | Unknown | Unknown |
Admission Type Summary
[Function: Attribute]
Further differentiates the following admissions from the hierarchy's group level (the number in parenthesis equals the additonal lines of detail at this level):
- Medical/Surgical (2)
- MH/SA (2)
- Other (3)
Items of Note:
- Also includes a line of detail for unknown admission types.
- Level 3 (next-to-most detailed) of the Admission Type Hierarchy's 4 levels.
Option to add to the following reports:
Admissions per 1000
[Function: Metric]
The rate of admissions during a given period for every 1000 health plan members.
Items of Note:
- An admission is a health care event in which a person is registered as an inpatient (i.e., admitted for at least 24 hours) into a hospital, skilled nursing facility, or other health facility.
Calculation:
- Number of Admissions ÷ [Number of Members ÷ 1000]
Found in the following reports by default:
Age
[Function: Attribute]
The number of years elapsed since a person's date of birth.
Items of Note:
- Also includes a line for unknown ages.
- Level 2 (most detailed) of the Age Hierarchy, Managed Pharmacy Age Hierarchy, and Medical Age Hierarchy's 2 levels.
Option to add to the following reports:
- All managed pharmacy reports
- Cost and Utilization by Procedure
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Inpatient Event Ad Hoc
- Inpatient Utilization and Costs by Admission Type
- Inpatient Utilization by Diagnosis
- Medical Dollar Ad Hoc
- Medical Utilization Ad Hoc
- Membership Managed Ad Hoc
- Network Utilization
- Outpatient Utilization by Diagnosis
- Top Hospitals Ranked by Total Net Paid
- Top Physicians Ranked by Total Net Paid
- Utilization and Costs by Provider Type
- Utilization by Age Group
- Utilization by Diagnosis
Age/Gender Factor
[Function: Metric]
An artificial measurement used to illustrate the correlation between a population's age and gender make-up and the amount of health care expenses paid by the plan.
Items of Note:
- Severity is based on variance from a norm score of 1.0.
- An age/gender factor above 1.0 indicates a higher than average demographic risk of expected medical claims.
- An age/gender factor below 1.0 indicates a lower than average demographic risk of expected medical claims.
Found in the following report by default:
Age Group Band
[Function: Attribute]
An incremental set of age ranges into which a person is classified based upon the number of years elapsed since his/her date of birth.
Items of Note:
- Also includes a group for unknown ages.
- Level 1 (most general) of the Age Hierarchy's 2 levels.
Found in the following report by default:
Option to add to the following report:
Age Hierarchy
[Function: Hierarchy]
Classifies members based on the number of years elapsed since their date of birth.
Items of Note:
- The age groups within this hierarchy differ from the Managed Pharmacy Age Hierarchy and Medical Age Hierarchy.
Consists of the following levels of detail:
Group Band | Age |
---|---|
<1 | 0 |
1 – 9 | 1 |
2 | |
3 | |
4 | |
5 | |
6 | |
7 | |
8 | |
9 | |
10 – 19 | 10 |
11 | |
12 | |
13 | |
14 | |
15 | |
16 | |
17 | |
18 | |
19 | |
20 – 24 | 20 |
21 | |
22 | |
23 | |
24 | |
25 – 29 | 25 |
26 | |
27 | |
28 | |
29 | |
30 – 34 | 30 |
31 | |
32 | |
33 | |
34 | |
35 – 39 | 35 |
36 | |
37 | |
38 | |
39 | |
40 – 44 | 40 |
41 | |
42 | |
43 | |
44 | |
45 – 49 | 45 |
46 | |
47 | |
48 | |
49 | |
50 – 54 | 50 |
51 | |
52 | |
53 | |
54 | |
55 – 59 | 55 |
56 | |
57 | |
58 | |
59 | |
60 – 64 | 60 |
61 | |
62 | |
63 | |
64 | |
65 + | 65 |
66 | |
67 | |
68 | |
69 | |
70 | |
71 | |
72 | |
73 | |
74 | |
75 | |
76 | |
77 | |
78 | |
79 | |
80 | |
81 | |
82 | |
83 | |
84 | |
85 | |
86 | |
87 | |
88 | |
89 | |
90 | |
91 | |
92 | |
93 | |
94 | |
95 | |
96 | |
97 | |
98 | |
99 | |
100 | |
Unknown | 999 |
AHFS Category
[Function: Attribute]
Classifies drugs into 1 of 29 categories defined by the AHFS (American Hospital Formulary Service) coding schema.
Items of Note:
- AHFS is an industry standard drug classification system.
- Level 1 (most general) of the AHFS Hierarchy's 3 levels.
Option to add to the following reports:
- Key Generic Substitution Indicators by Month
- Managed Pharmacy Ad Hoc
- Managed Pharmacy Cost and Utilization by Month
- Managed Pharmacy Critical Indicators
- Managed Pharmacy Utilization by Age Group
- Top Therapeutic Class Utilization Ranked by Net Paid
- Top Therapeutic Class Utilization Ranked by Volume
AHFS Class
[Function: Attribute]
Classifies drugs into 1 of 369 classes defined by the AHFS (American Hospital Formulary Service) coding schema.
Items of Note:
- AHFS is an industry standard drug classification system.
- Level 3 (most detailed) of the AHFS Hierarchy's 3 levels.
Option to add to the following reports:
- Key Generic Substitution Indicators by Month
- Managed Pharmacy Ad Hoc
- Managed Pharmacy Cost and Utilization by Month
- Managed Pharmacy Critical Indicators
- Managed Pharmacy Utilization by Age Group
- Top Therapeutic Class Utilization Ranked by Net Paid
- Top Therapeutic Class Utilization Ranked by Volume
AHFS Group
[Function: Attribute]
Classifies drugs into 1 of 200 categories defined by the AHFS (American Hospital Formulary Service) coding schema.
Items of Note:
- AHFS is an industry standard drug classification system.
- Level 2 (more detailed) of the AHFS Hierarchy's 3 levels.
Option to add to the following reports:
- Key Generic Substitution Indicators by Month
- Managed Pharmacy Ad Hoc
- Managed Pharmacy Cost and Utilization by Month
- Managed Pharmacy Critical Indicators
- Managed Pharmacy Utilization by Age Group
- Top Therapeutic Class Utilization Ranked by Net Paid
- Top Therapeutic Class Utilization Ranked by Volume
AHFS Hierarchy
[Function: Hierarchy]
Classifies drugs across 3 levels of detail defined by the AHFS (American Hospital Formulary Service) coding schema.
Items of Note:
- AHFS is an industry standard drug classification system.
Consists of the following levels of detail:
Category | Group | Class |
---|---|---|
AHFS Category Unknown | ||
Antihistamines | ||
Anti-Infective Agents | ||
Antineoplastic Agents | ||
Autonomic Drugs | ||
Blood Derivatives | ||
Blood Formation and Coagulation | ||
Cardiovascular Drugs | ||
Central Nervous System Agents | ||
Contraceptives (e.g., foams, devices) | ||
Dental Agents | ||
Diagnostic Agents | ||
Disinfectants (for non-dermatological) | ||
Electrolytic, Caloric and Water Balance | ||
Enzymes | ||
Antitussives, Expectents and Mucyolytic Agents | ||
Eye, Ear, Nose and Throat (EENT) Preps | ||
Gastrointestinal Drugs | ||
Gold Compounds | ||
Heavy Metal Antagonists | ||
Hormones and Synthetic Substitutes | ||
Local Anesthetics | ||
Oxytocics | ||
Radioactive Agents | ||
Serums, Toxoids, and Vaccines | ||
Skin and Mucous Membrane Agents | ||
Smooth Muscle Relaxants | ||
Vitamins | ||
Unclassified Therapeutic Agents |
All Other
[Function: Value]
A category of miscellaneous health care services (e.g., hearing, home health, transportation and vision services).
Parent Attribute:
All Other Diagnosis Chapters
[Function: Value]
A combination of the following diagnosis chapters:
- Blood and Blood From Organs
- Congenital Anomolies
- Endocr Nutri Metabolic Immun
- Infectious and Parasitic Dis
- Perinatal Period
- Skin and Subcutaneous Tissue
- Other Conditions
Parent Attribute:
All Other Dispensed As Written
[Function: Value]
A reduction in the gross payable amount not attributed to commercial COB savings/reductions, Medicare COB savings/reductions, or provider sanctions.
Parent Attribute:
All Other Savings
[Function: Metric]
A category of admissions consisting of conditions that require immediate services within a defined time span.
Found in the following report by default:
Option to add to the following report:
Submitted Charges | minus | Ineligible Charges | equals | Eligible Charges |
---|---|---|---|---|
Duplicate Bills | ||||
R&C (Reasonable and Customary) Reductions | ||||
Benefit Limits | ||||
Pre-existing Conditions | ||||
Abuse and Fraud | ||||
Medical Claim Review | ||||
MNRP (Maximum Non-Network Reimbursement Program) | ||||
Other Ineligible Charges | ||||
Eligible Charges | minus | Discounts | equals | Covered Amount |
Contracted Discount | ||||
Special Negotiated Discount | ||||
Shared Savings Discount | ||||
Prompt Payment Discount | ||||
Customer Specific Discount | ||||
Other Discount | ||||
Covered Amount | minus | Employee Cost Sharing | equals | Gross Payable |
Copay | ||||
Deductible | ||||
Coinsurance | ||||
Gross Payable | minus | Other Savings | equals | Net Paid |
Commercial COB Savings | ||||
Commercial COB Reductions | ||||
Medicare COB Savings | ||||
Medicare COB Reductions | ||||
Provider Sanctions | ||||
All Other Savings Amount |
Allied Health
[Function: Value]
Non-physician health care professionals (e.g., dentists, optometrics, chiropractors, podiatrists, mental health practitioners and nurses).
Parent Attribute:
Ambulance
[Function: Value]
A provider that is licensed and equipped to provide emergency treatment of seriously injured/sick persons while in route, via a specialized vehicle, to a medical facility.
Parent Attribute:
Ancillary Amount
[Function: Metric]
Any additional dollars a person pays for a prescription above his/her copay, coinsurance, and/or deductible (e.g., the cost differential if the person wants the drug in its bran-name versus generic form).
Found in the follwoing report by default:
Anesthesia
[Function: Value]
Servies associated with inpatient and outpatient anesthetic procedures, or a medical benefit covering such services.
Parent Attribute:
- Benefit Type
- Benefit Type Detail
- Procedure Category
- Service Type Category
- Service Type Class
- Service Type Group
- Service Type Summary
Average Contract Size
[Function: Metric]
An estimate of the number of people covered by any one subscriber — including single subscribers.
Calculation:
- [Number of Subscribers + Number of Dependents] ÷ Number of Subscribers
Found in the following report by default:
Average Coinsurance/Copays per Prescription
[Function: Metric]
An estimate of the typical amount of covered health care costs a person pays at the time a prescription is filled (i.e., copays) and/or any percentage of costs the person is required to pay (coinsurance).
Calculation:
- Savings due to Coinsurance/Copays ÷ Number of Prescriptions
Option to add to the following report:
Average Copay per Prescription
[Function: Metric]
An estimate of the typical amount of covered health care costs a person pays at the time a prescription is filled.
Calculation:
- Savings due to Copay ÷ Number of Prescriptions
Found in the following report by default:
Average Days Supply
[Function: Metric]
An estimate of the typical number of days a person can treat his/her condition using the quantity of medication dispensed via a prescription order.
Calculation:
- Days Supply ÷ Number of Prescriptions
Found in the following report by default:
- Managed Pharmacy Critical Indicators
- Top Drug Utilization Ranked by Net Paid
- Top Drug Utilization Ranked by Volume
- Top Therapeutic Class Utilization Ranked by Net Paid
- Top Therapeutic Class Utilization Ranked by Volume
Option to add to the following report:
Average Enrolled Membership
[Function: Metric]
An estimate of the monthly member count.
Calculation:
- Total Number of Members for all months ÷ Number of Months
Found in the following report by default:
Average Enrolled Subscribers
[Function: Metric]
An estimate of the typical monthly subscriber count.
Calculation:
- Total Number of Subscribers for all months ÷ Number of Months
Found in the following report by default:
Average Family Size
[Function: Metric]
An estimate of the typical number of people covered by any one subscriber with dependent coverage.
Calculation:
- [Number of Subscribers with Dependents + Number of Dependents] ÷ Number of Subscribers with Dependents
Found in the following report by default:
Average Ingredient Cost per Day of Therapy
[Function: Metric]
An estimate of the typical daily costs of drug therapy.
Calculation:
- Ingredient Cost Paid Amount ÷ Days Supply
Found in the following report by default:
Average Length of Stay
[Function: Metric]
An estimate of the typical duration of an inpatient event.
Calculation:
- Number of Days ÷ Number of Admissions
Found in the following report by default:
- Cost and Utilization Summary
- Inpatient Utilization and Costs by Admission Type
- Inpatient Utilization by Diagnosis
Option to add to the following report:
Average Number of Members
[Function: Metric]
An estimate of the typical monthly member count.
Calculation:
- Total Number of Members for all months ÷ Number of Months
Found in the following report by default:
Average Number of Subscribers
[Function: Metric]
An estimate of the typical monthly subscriber count.
Calculation:
- Total Number of Subscribers for all months ÷ Number of Months
Found in the following report by default:
Average Paid Per Day
[Function: Metric]
An estimate of the typical dollar amount reimbursed by a plan for one day of inpatient services.
Calculation:
- Net Paid ÷ Number of Days
Found in the following report by default:
Average Paid per Hight Cost Claimant
[Function: Metric]
An estimate of the typical costs for claimants with total costs at or above $50,000.
Calculation:
- Total Net Paid for High Cost Claimants ÷ Total Number of High Cost Claimants
Found in the following report by default:
Average Participating Provider Discount
[Function: Metric]
An estimate of the typical percentage of savings attributed to claims for services rendered by a participating provider.
Calculation:
- For Participating Provider Claims: [Discount Savings ÷ Eligible Charges] × 100
Found in the following report by default: