Glossary — P

Partial Fill

[Function: Value]

Indicates that the initial amount of the prescription dispensed was less than the full portion.

Parent Attribute:

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Partial/Complete Fill Status

[Function: Attribute]

Classifies prescriptions via the portions in which the drugs are dispensed.

Consists of the following values:

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Partial Hospitalization Facility

[Function: Value]

A mental health or substance abuse program operated by a hospital and providing clinical services as an alternative or follow-up to inpatient hospital care.

Parent Attribute:

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Participating Provider

[Function: Value]

A professional/facility that is contracted to provide services within the UnitedHealth Group network (i.e., not a contracted provider); or, more generally, any professional/facility that has a contract or association with the carrier/group to deliver services to covered persons.

Parent Attribute:

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Payee

[Function: Attribute]

The recipient of a check for reimbursement of a claim.

Consists of the following values:

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Payment Arrangement

[Function: Attribute]

Further differentiates the following payment arrangements from the hierarchy's category level (the number in parentheses equals the additional lines of detail at this level):

Items of Note:

Option to add to the following reports:

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Payment Arrangement Category

[Function: Attribute]

Classifies the general methods adopted for reimbursing providers into one of the following categories:

Items of Note:

Option to add to the following reports:

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Payment Arrangement Hierarchy

[Function: Hierarchy]

Classifies claims based on the methods of provider reimbursement.

Includes the following levels of detail:

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Payment Arrangement Category Payment Arrangement
Fee for Service Fee for Service
Fee for Service – UBH
Fee for Service – Unknown Type
Multiple Payment Arrangements
Capitated Arrangement Capitated
Capitated – Declined
Capitated – No EOB or Check
Capitated – Provider EOB, No Check
Capitated – Risk Pool Carve Out
Capitated – TAP Risk Pool
Capitated – TPA
Capitated – Primary Care Encounter
Capitated – Specialist Encounter
Capitated – Professional Encounter
Capitated – Unknown Type
Hospital Encounter
Priced Encounter – EOB, No Check
Auto Cap Deduction
Risk Pool
UBH Liability – In-Network not TN or TX markets
UBH Liability – Out-of-Network or In-Net TN or TX
Unknown Unknown

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Payment Category

[Function: Attribute]

Classifies claims into incremental dollar ranges (e.g., $50-$99, $100-$249, etc.) based on the amount reimbursed by the plan for the claim.

Found in the following report by default:

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Payment Type

[Function: Attribute]

Further differentiates the following payment types from the hierarchy's category level (the number in parentheses equals the additional lines of detail at this level):

Items of Note:

Found in the following reports by default:

Option to add to the following reports:

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Payment Type Category

[Function: Attribute]

Classifies claims into 1 of 4 categories based on the methods by which the provider is reimbursed.

Items of Note:

Option to add to the following reports:

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Payment Type Group

[Function: Attribute]

Classifies claims within an incremental set of dollar ranges (e.g., $50–$99, $100–$249, etc.) based on the total amount reimbursed by the plan for the claim.

Items of Note:

Option to add to the following reports:

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Payment Type Hierarchy

[Function: Attribute]

Classifies claims based on the methods by which the provider is reimbursed.

Includes the following levels of detail:

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Payment Type Category Payment Type Detail
Capitation IPA regular; Caps for POS/NPP
IPA regular; Caps for HMO
Cap, Long Beach Northern CA
Cap, Long Beach Southern CA
Capitation, Uncategorized
MA Surcharge Massachusetts – Surcharge
NYHCRA NYHCRA – Individual Assessment
NYHCRA – Family Assessment
NYHCRA – Surcharge
Other Payments Other Payments

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Payments

[Function: Metric]

The dollar amount paid by the plan after all plan provisions (i.e., discounts, employee cost sharing, and other savings) are deducted.

Items of Note:

Found in the following reports by default:

Option to add to the following reports:

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PDL Status Unknown

[Function: Value]

A prescription that’s position on the carrier/group's list of cost-effective drugs is unclear or undetermined.

Parent Attribute:

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Per Member Demographic Factor

[Function: Metric]

An artificial measure of the effect that the target population's age/gender distribution is likely to have on overall health care expenses paid by the plan for any one member.

Items of Note:

Found in the following report by default:

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Per Member Geographic Factor

[Function: Metric]

An artificial measure of the effect that the area in which the target population predominantly resides is likely to have on overall health care expenses paid by the plan for any one member.

Items of Note:

Found in the following report by default:

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Per Subscriber Demographic Factor

[Function: Metric]

An artificial measure of the effect that the target population's age/gender distribution is likely to have on overall health care expenses paid by the plan for any one subscriber.

Items of Note:

Found in the following report by default:

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Per Subscriber Geographic Factor

[Function: Metric]

An artificial measure of the effect that the area in which the target population predominantly resides is likely to have on overall health care expenses paid by the plan for any one subscriber.

Items of Note:

Found in the following report by default:

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% [Percent] Claimants

[Function: Metric]

The portion of people with a claim within a specified subset of all people with a claim.

Calculation:

Found in the following report by default:

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% [Percent] Eligible Expenses

[Function: Metric]

The portion of eligible expenses within a specified subset of all eligible expenses.

Items of Note:

Calculation:

Found in the following report by default:

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Percent Generic Scripts

[Function: Metric]

The rate at which a chemically equivalent form of a brand-name drug is dispensed.

Calculation:

Found in the following report by default:

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Percent Home Delivery Scripts

[Function: Metric]

The rate at which prescriptions are filled via fax, mail, or Internet and received via a postal carrier.

Calculation:

Found in the following report by default:

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% [Percent] Multisource – Other DAW

[Function: Metric]

The rate at which prescriptions are filled with a brand drug (in lieu of a generic equivalent) due to non-traditional entities/reasons.

Items of Note:

Calculation:

Found in the following reports by default:

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% [Percent] Multisource – Patient DAW

[Function: Metric]

The rate at which prescriptions are filled using the brand drug (in lieu of a generic equivalent) per the request of the person for whom the order is written.

Items of Note:

Calculation:

Found in the following reports by default:

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% [Percent] of Multisource Physician DAW

[Function: Metric]

The rate at which prescriptions are filled using the brand drug (in lieu of a generic equivalent) per the request of the person for whom the order is written.

Items of Note:

Calculation:

Found in the following reports by default:

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% [Percent] Multisource – State Law DAW

[Function: Metric]

The rate at which prescriptions are filled using the brand drug (in lieu of a generic equivalent) per a legal mandate.

Items of Note:

Calculation:

Found in the following reports by default:

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% [Percent] of HRA Net Paid

[Function: Metric]

The portion of the HRA net paid amount within a specified subset of all net paid amounts.

Calculation:

Found in the following reports by default:

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% [Percent] of Plan Net Paid

[Function: Metric]

The portion of the net paid amount within a specified subset of all net paid amounts.

Calculation:

Found in the following reports by default:

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% [Percent] of Total Net Paid

[Function: Metric]

The portion of the total net paid amount within a specified subset of all net paid amounts.

Calculation:

Found in the following reports by default:

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% [Percent] Payments

[Function: Metric]

The portion of all payments attributed to a defined subset of payments.

Calculation:

Found in the following reports by default:

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% [Percent] of Total Prescriptions

[Function: Metric]

The portion of drug orders within a specified subset of all drug orders.

Calculation:

Found in the following reports by default:

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% [Percent] Total Prescriptions – Generic

[Function: Metric]

The portion of all drug orders filled with the chemically equivalent form of a brand-name drug.

Calculation:

Found in the following reports by default:

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% [Percent] Total Prescriptions – Multisource

[Function: Metric]

The portion of all drug orders filled with brand name drug for which a generic equivalent exists.

Calculation:

Found in the following reports by default:

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% [Percent] Total Prescriptions – Single Source

[Function: Metric]

The portion of all drug orders filled with a brand name drug for which there is no generic equivalent.

Calculation:

Found in the following reports by default:

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Percentage of Member Distribution

[Function: Metric]

The portion of all members attributed to a defined subset of members.

Calculation:

Found in the following reports by default:

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Perinatal Period

[Function: Value]

Diagnoses attributed to conditions of pregnancy arising immediately before and after birth.

Parent Attribute:

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Pharmacy

[Function: Value]

A retail establishment licensed to provide/dispense prescription drugs.

Parent attributes:

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Pharmacy 3 Digit Zip Code

[Function: Attribute]

Classifies pharmacies based upon the 3-digit zip code (i.e., region of the country) in which the establishment is located.

Items of Note:

Option to add to the following report:

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Pharmacy 5 Digit Zip Code

[Function: Attribute]

Classifies pharmacies based on the 5-digit zip code (i.e., the region of the country and postal zone within a city) in which the establishment is located.

Items of Note:

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Pharmacy Age Group

[Function: Attribute]

An incremental set of age ranges into which people with pharmacy claims are classified based on the number of years elapsed since their date of birth.

Items of Note:

Found in the following report by default:

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Pharmacy Age Hierarchy

[Function: Attribute]

Classifies people with pharmacy claims based on the number of years elapsed since their date of birth.

Includes the following levels of detail:

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Age Group 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
65-69 65
66
67
68
69
70-74 70
71
72
73
74
75 + 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

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Pharmacy Benefits Management

[Function: Attribute]

Indicates the name of the outside commercial entity that adjudicated managed pharmacy claims on behalf of UnitedHealth Group.

Consists of the following values:

Option to add to the following reports:

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Pharmacy City

[Function: Attribute]

Classifies pharmacies based on the incorporated municipality in which the establishment is located.

Items of Note:

Option to add to the following report:

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Pharmacy Location Hierarchy

[Function: Hierarchy]

Classifies retail establishments licensed to dispense prescription drugs based on the establishment's locale.

Includes the following levels of detail:

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Pharmacy Name

[Function: Attribute]

The name of the retail establishment licensed to dispense prescription drugs.

Option to add to the following report:

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Pharmacy State

[Function: Attribute]

Classifies pharmacies based on the US state/territory in which the establishment is located.

Items of Note:

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Pharmacy Provider

[Function: Value]

A retail establishment licensed to provide/dispense prescription drugs.

Parent Attribute:

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Physician

[Function: Value]

A doctor of medicine.

Parent Attribute:

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Physician Capitation

[Function: Value]

Coverage via monthly per-member payments made up-front to an insurance carrier for contracted services provided by medical doctors.

Parent Attribute:

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Physician – OB/GYN

[Function: Value]

Health care costs attributed to services provided by a medical doctor who delivers babies and treats diseases of the female reproductive organs.

Items of Note:

Parent attributes:

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Physician – Primary Care

[Function: Value]

Health care costs attributed to a medical doctor (e.g., most family physicians, pediatricians and internists) whose job it is to provide a broad spectrum of care over a period of time and to coordinate all of the care the patient receives.

Parent attributes:

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Physician – Specialty

[Function: Value]

Health care costs attributed to a medical doctor with a formally recognized knowledge and practical application of a specific branch of medicine (e.g., a neurologist, an oncologist).

Parent attributes:

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Physician Visits/Professional

[Function: Value]

A category of services attributed to meetings with medical doctors and other credentialed health care workers.

Parent Attribute:

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Place of Service

[Function: Attribute]

Further differentiates the following places of service from the hierarchy's summary level (the number in parentheses equals the additional lines of detail at this level):

Items of Note:

Option to add to the following reports:

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Place of Service Category

[Function: Attribute]

Classifies claims, into one of the following categories, based on the location in which services were provided:

Items of Note:

Found in the following report by default:

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Place of Service Hierarchy

[Function: Hierarchy]

Classifies claims based on the location in which services were provided.

Includes the following levels of detail:

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Category Summary Place of Service
Inpatient Inpatient Acute Care Facility Inpatient Hospital
Inpatient Rehabilitation Facility Comprehensive IP Rehab Facility
Long-Term Care Facility Skilled Nursing Facility
Intermediate Care Facility
Custodial Care Facility
Inpatient Hospice Hospice
Inpatient Mental Health/Chem. Dep. Facility Inpatient Psychiatric Facility
Residential Substance Abuse Facility
Psychiatric Residential Treatment Facility
Outpatient Partial Hospitalization Facility Psychiatric Facility Partial Hospitalization
Acute-Care Outpatient Facility Outpatient Hospital
Emergency Room
Ambulatory Surgery Center
Birthing Center
Indian Health Service Free-Standing Facility
Indian Health Service Provider-Based Facility
Tribal 638 Free-Standing Facility
Tribal 638 Provider-Based Facility
Urgent Care Facility
Non Acute-Care Outpatient Facility Comprehensive OP Rehab Facility
ESRD Treatment Facility
Office/Clinic Office
Free Standing Emergency Center
Military Treatment Center
Federally Qualified Health Center
State or Local Public Health Clinic
Rural Health Clinic
Community Mental Health Center
Mass Immunization Center
Other Ambulance, Land
Ambulance, Air/Water
Home
Independent Laboratory
Pharmacy/Medical Supplier
Client-Specific Location/Clinic
School
Homeless Shelter
Assisted Living Facility
Group Home
Mobile Unit
Independent Care Clinic
Non-Residential Substance Abuse Treatment Facility
Other Location
Unknown Unknown

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Place of Service Summary

[Function: Attribute]

Further differentiates the following places of service from the hierarchy's category level (the number in parentheses equals the additional lines of detail at this level):

Items of Note:

Option to add to the following reports:

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Plan Net Paid

[Function: Metric]

The dollar amount reimbursed by a plan after all ineligible charges and plan provisions (i.e., discounts, employee cost sharing, and other savings) are accounted for by the carrier.

Calculation:

Found in the following reports by default:

Option to add to the following reports:

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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

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Plan Net Paid per Admission

[Function: Metric]

The average dollar amount reimbursed by a medical plan for being checked into a bed at a hospital or other health care facility.

Calculation:

Found in the following reports by default: None

Option to add to the following reports:

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Plan Net Paid per Claimant

[Function: Metric]

The average dollar amount reimbursed by a plan for costs incurred for any one claimant.

Calculation:

Found in the following reports by default:

Found in the following reports by default:

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Plan Net Paid per Day

[Function: Metric]

The average dollar amount reimbursed by a plan for one day of inpatient services.

Calculation:

Found in the following reports by default: None

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Plan Net Paid per Member

[Function: Metric]

The average dollar amount reimbursed by the plan for a set of outpatient services.

Calculation:

Found in the following reports by default:

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Plan Net Paid per Prescription

[Function: Metric]

The average dollar amount reimbursed by a managed pharmacy plan for filling a drug

Calculation:

Found in the following reports by default:

Option to add to the following reports:

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Plan Net Paid per PMPM

[Function: Metric]

An estimate of the typical monthly dollar amount reimbursed by a medical plan for any one member.

Items of Note:

Calculation:

Found in the following reports by default:

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Plan Variation

[Function: Attribute]

Codes assigned by an employer that are used to identify specific business units or populations within the company at-large.

Option to add to the following reports:

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Plan Variation&Report Code

[Function: Attribute]

Combines, into a single field, the following 2 attributes used to identify varying segments of the claimant population:

Option to add to the following reports:

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Pooled Transactions

[Function: Value]

Classifies payments based on the positive (i.e., pooling amount) and negative (i.e., pooling adjustment) details of individual stop-loss activity.

Items of Note:

Parent Attribute:

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Pooling Adjustment (45)

[Function: Value]

The negating transaction of the pooling amount.

Items of Note:

Parent Attribute:

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Pooling Amount (36)

[Function: Value]

Any portion of a claim above the individual stop-loss threshold.

Items of Note:

Parent Attribute:

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POS

[Function: Value]

An industry product allowing the covered person to receive services from participating or non-participating providers, with different benefit levels associated with the use of participating providers.

Items of Note:

Parent Attribute:

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POS Service Area Indicator

[Function: Attribute]

For managed pharmacy and medical reports, it classifies claims based on whether or not services are provided within the POS (Point of Service) network.

For membership reports, it classifies members based on whether or not they reside within the product's service area.

Items of Note:

Consists of the following values:

Option to add to the following reports:

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Positively Enrolled Dependent Months

[Function: Metric]

The number of months for each dependent who is registered for coverage (e.g., if there are 10 such people in 1 month, the result is 10 months).

Option to add to the following report:

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Positively Enrolled Dependents

[Function: Metric]

The number of spouses, children, and other individuals related to the subscriber who are registered for coverage.

Found in the following reports by default:

Option to add to the following report:

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Positively Enrolled Dependents Average Age

[Function: Metric]

An estimate of the typical age of spouses, children, and other individuals related to the subscriber who are registered for coverage.

Calculation:

Found in the following reports by default:

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PPO

[Function: Value]

An industry product that establishes contracts with providers of medical care.

Items of Note:

Parent Attribute:

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PPO Service Area Indicator

[Function: Attribute]

For managed pharmacy and medical reports, it classifies claims based on whether or not services are provided within the PPO (Preferred Provider Organization) network.

For membership reports, it classifies members based on whether or not they reside within the product's service area.

Items of Note:

Consists of the following values:

Option to add to the following reports:

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Pre-existing Conditions

[Function: Metric]

The amount of submitted charges not covered because the disease/illness/injury was present before the claimant was covered under the benefit.

Found in the following reports by default:

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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

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Pregnancy Childbirth Puerp

[Function: Value]

Diagnoses pertaining to the delivery of a newborn or conditions arising from the delivery.

Parent Attribute:

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Premium Product

[Function: Attribute]

Differentiates UnitedHealthcare products available to groups with a fully-insured funding arrangement.

Option to add to the following reports:

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Premium Product Hierarchy

[Function: Hierarchy]

Classifies claims based on the benefit plan under which coverage for the claim is provided.

Includes the following levels of detail:

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Prescription Drug List Status

[Function: Attribute]

Classifies drug orders based on whether or not the drug is included on the carrier/group's inventory of cost-effective drugs.

Consists of the following values:

Option to add to the following reports:

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Prescription Tier

[Function: Attribute]

Classifies drug orders based on the level of a drug's co-payment option under the Flexible Prescription Drug List (FPDL) system.

Consists of the following values:

Found in the following report by default:

Option to add to the following reports:

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Prescriptions per Claimant

[Function: Metric]

The average number of drug orders filled by any one claimant.

Calculation:

Found in the following reports by default:

Option to add to the following report:

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Prescriptions PMPY

[Function: Metric]

An estimate of the number of drug orders filled by any one member within a 12 month period.

Calculation:

Found in the following reports by default:

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Primary Coverage

[Function: Value]

The principal part of a single claim for which a secondary part is being processed separately.

Items of Note:

Parent Attribute:

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Primary Coverage Indicator

[Function: Attribute]

A mechanism of the database used to avoid double-counting of subscribers and dependents by assigning an artificial code to track the parts of a single claim that are processed separately.

Consists of the following values:

Option to add to the following report:

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Primary Diagnosis Code

[Function: Attribute]

Classifies health care services using the numerical ICD-9 value of the disease/condition for which services were provided.

Items of Note:

Option to add to the following reports:

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Procedure Category

[Function: Attribute]

Further differentiates the following procedure chapters (the number in parentheses equals the additional lines of detail at this level):

Items of Note:

Option to add to the following reports:

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Procedure Chapter

[Function: Attribute]

Classifies claims into one of the following chapters based on the surgical/diagnostic services rendered by a health care provider:

Items of Note:

Found in the following report by default:

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Procedure Code Description

[Function: Attribute]

Classifies claims based on the specific surgical/diagnostic service rendered by a health care provider.

Items of Note:

Option to add to the following reports:

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Procedure Hierarchy

[Function: Attribute]

Classifies claims based on the surgical/diagnostic services rendered by a health care provider.

Includes the following levels of detail:

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Chapter Category Code
Obstetrical Procedures Abortion  
Artificial ROM to Asst Del  
Cesarean Section  
Diagnostic Amniocentesis  
Episiotomy  
Fetal Monitoring  
Forceps/Vac/Breech Delivery  
Removal Ectopic Pregnancy  
Repair Obstetric Laceration  
VBAC  
Vaginal Delivery  
Other Proc to Asst Del  
Other Ther Obstetrical Proc  
Operations Ear Diagnostic Proc On Ear  
Mastioidectomy  
Myringotomy  
Tympanoplasty  
Other Ther Ear Proc  
Operations Endocrine Sys Diagnostic Endocrine Proc  
Thyroidectomy  
Other Ther Endocrine Proc  
Operations Eye Corneal Transplant  
Diagnostic Proc On Eye  
Extraocular Therapeutic Proc  
Glaucoma Procedures  
Intraocular Therapeutic Proc  
Lens And Cataract Procedures  
Lesion Destr Retina/Choroid  
Repair Retinal Tear Detach  
Ther Proc Eyelid/Conj/Cornea  
Oper Cardiovascular Sys Aortic Resection/Replacement  
CABG  
Coronary Thrombolysis  
Diag Cardiac Hath/Arterio  
Endarterectomy Head/Neck  
Endarterectomy Lower Limbs  
Extracorp Circ To Open Heart  
Heart Valve Procedures  
Hemodialysis  
Inst/REM Cariac Pacemaker  
Non-OR Ther Cardiovas Proc  
OR Proc Vessels Not Head  
Peripheral Vascular Bypass  
PTCA  
Revision AV Fistula/Cannula  
Varicose Stripping/Lower Limb  
Other OR Heart Proc  
Other OR Proc Head/Neck  
Other Vasc Bypass Not Heart  
Other Vasc Cath Not Heart  
Oper Digestive Sys Abdominal Paracentesis  
Appendectomy  
Biopsy of Liver  
Cholecystectomy/CDE  
Colorectal Resection  
Colonoscopy and Biopsy  
Colostomy  
ERCP  
Esophageal Dilation  
Exc Large Intestine Lesion  
Excl/Lys Peritoneal Adhesions  
Exploratory Laparotomy  
Gastrectomy  
Gastrostomy  
Hemorrhoid Procedures  
Inguinal/Femoral Hernia Repair  
Inject/Ligat Esoph Varices  
Ilegostromy/Other Enterostomy  
Laparoscopy  
Small Bowel Resection  
Upper GI Endoscopy Biopsy  
Peritoneal Dialysis  
Non-OR GI Ther Proc  
Non-OR Lower GI Ther Proc  
Non-OR Upper GI Ther Proc  
OR GI Ther Proc  
OR Lower GI Ther Proc  
OR Upper GI Ther Proc  
Procto/Anorectal Biopsy  
Other GI Diagnostic Proc  
Other GI Diagnostic Procs  
Other Hernia Repair  
Oper Female Genital Organs D & C  
Diagnostic D & C  
Diag Proc Female Organs  
Exc of Cervix and Uterus  
Hysterectomy  
Ligation of Fallopian Tubes  
Non-OR Ther Female Organs  
Oophorectomy Uni/Bilateral  
Operation on Fallopian Tubes  
OR Ther Female Organs  
Repair Cystocele/Rectocele  
Other Operations on Ovary  
Oper Hemic Lympahtic Sys Bone Marrow Biopsy  
Bone Marrow Transplant  
Procedures on Spleen  
Other Ther Proc Hemic/Lymph  
Oper Integumentary Sys Breast Biopsy/Breast Diag  
Debride Wound/Infection Burn  
Diag Proc Skin/Subcutaneous  
Excision of Skin Lesion  
I/D Skin Subcutaneous  
Lumpectomy Breast  
Mastectomy  
Non-OR Ther Skin/Breast  
OR Ther Skin/Breast  
Skin Graft  
Suture skin/Subcutaneous  
Oper Male Genital Organs Circumcision  
Diag Proc Male Genital  
Non-OR Ther Male Genital Proc  
Open Prostatectomy  
OR Ther Male Genital Proc  
TURP  
Oper Musculoskeletal Sys Amputation of Low Extremity  
Arthrocentesis  
Arthroplasty Knee  
Arthroplasty Not Hip or Knee  
Arthroscopy  
Aspiration Joints/Soft Tissue  
Bunionectomy/Repair toe Def  
Diag Proc Musculoskeletal  
Div Joint/Ligament/Cartilage  
Exc Semilunar Cart Knee  
Hip Replacement  
Non-OR Ther Proc Musculo  
OR Ther Proc on Bone  
OR Ther Proc on Joints  
OR Ther Proc Musculo  
Partial Excision Bone  
Spinal Fusion  
Ther Proc Musc and Tendon  
TX Facial FX or Dislocation  
TX FX/Dislocation Hip/Femur  
TX FX/Dislocation Low Extrem  
TX FX/Dislocation Radius/Ulna  
Other FX/Dislocation Proc  
Operations Nervous Sys Decompr Peripheral Nerve  
Diagnostic Spinal Tap  
Extracranial Ventricular Shunt  
Incision/Excision of CNS  
Injection Into Spinal Canal  
Laminectomy  
Other Diagnostic NS Proc  
Other Non-OR Ther NS Proc  
Other OR Ther NS Proc  
Oper Nose Mouth Pharynx Control of Epistaxis  
Dental Procedures  
Diag Proc Nose/Mouth/Phar  
Non-OR Ther Proc Nose/Phar  
OR Ther Proc Nose/Pharynx  
Plastic Procedures On Nose  
Tonsillectomy/Adenoidect  
Oper Respiratory Sys Bronchoscopy/Biopsy Bronchus  
Diag Proc On Lung/Bronchus  
Diag Proc Respiratory Tract  
Incision Pleura/Thoracentesis  
Lobectomy/Pneumonectomy  
Non-OR Ther Proc Resp Sys  
OR Ther Proc Respiratory Sys  
Tracheoscopy/Laryngoscopy  
Tracheostomy  
Oper Urinary Sys Endoscopy/Biopsy Urinary  
Extracorp Lithotripsy Urinary  
GU Incontinence Proc  
Indwelling Catheter  
Kidney Transplant  
Nephrectomy  
Nephrotomy/Nephrostomy  
Non-OR Ther Proc Urinary  
OR Ther Proc of Urinary Tract  
Procedures on the Urethra  
Tur Excision Urinary Obstr  
Ureteral Catheterization  
Other Diag Proc Urinary Tract  
Misc Diag Therapeutic Alcohol and Drug Rehab/Detox  
Anesthesia  
Arterial Blood Gases  
Arteriogram Femoral/Low Ext  
Arteriogram Not Heart/Head  
Blood Transfusion  
Cancer Chemotherapy  
Cardiac Stress Tests  
Cerebral Arteriogram  
Contrast Aortogram  
Conv of Cardiac Rhythm  
CT Scan Abdomen  
CT Scan Chest  
CT Scan Head  
Diagnostic Physical Therapy  
Diag Ultrasound Abdomen  
Diag Ultrasound GI Tract  
Diag Ultrasound Head/Neck  
Diag Ultrasound Urinary Tract  
Echocardiogram  
Electrocardiogram  
Electroencephalogram (EEG)  
Electrographic Cardiac Monit  
Entral/Parenteral Nutrition  
ESWL Other than Urinary  
HCPCS  
Intraoperative Cholangiogram  
Intravenous Pyelogram  
Lower Gastrointestinal X-Ray  
Magnetic Resonance Imaging  
Mammography  
Micro Exam (Smear Culture)  
Myelogram  
Naso-Gastric Tube  
Non-Op Remove Foreign Body  
Non-Op Urinary Measurements  
Not Assigned  
Ophth/Otologic Diagnosis/Tx  
Prophylactic Vaccinations  
Psych Eval/Therapy  
PT Exercises/Manipulaiton  
Radioisotope Bone Scan  
Radioisotope Pulmon Scan  
Radioisotope Scan/Function  
Resp Intubation/Mech Vent  
Routine Chest X-ray  
State Assigned  
Swan-Ganz Cath for Monit  
Therapeutic Radiology  
Traction/Splints/Wound Care  
Upper Gastrointestinal X-ray  
Other CT Scan  
Other Diagnostic Ultrasound  
Other Diag Proc Eval/Consult  
Other Diag Radiology  
Other Lab  
Other Organ Transplantation  
Other PT/Rehab  
Other Radioisotope Scan  
Other Respiration Therapy  
Other Therapeutic Proc  
Unknown  
No Procedure No Procedure  

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Process Period Hierarchy

[Function: Hierarchy]

Classifies claims based on the point in time during which information derived from the claim was entered into the accounting system.

Includes the following levels of detail:

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Year Quarter Year/Months
YYYY Q1YYYY YYYY-01
YYYY-02
YYYY-03
Q2YYYY YYYY-04
YYYY-05
YYYY-06
Q3YYYY YYYY-07
YYYY-08
YYYY-09
Q4YYYY YYYY-10
YYYY-11
YYYY-12

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Process Quarter

[Function: Attribute]

The quarterly period in which information derived from the claim was entered into the accounting system.

Items of Note:

Option to add to the following reports:

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Process Year

[Function: Attribute]

The calendar year in which information derived from the claim was entered into the accounting system.

Items of Note:

Option to add to the following reports:

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Process Year/Month

[Function: Attribute]

The year and month in which information derived from the claim was entered into the accounting system.

Items of Note:

Option to add to the following reports:

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Product

[Function: Attribute]

Differentiates the following traditional products based on the product's generic name (the number in parentheses equals the additional lines of detail at this level):

Items of Note:

Found in the following report by default:

Option to add to the following reports:

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Product Hierarchy

[Function: Hierarchy]

Classifies claims based on the benefit plan under which coverage for the claim is provided.

Includes the following levels of detail:

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Product Type UHC Product Name Traditional Product Name Product Industry Product
Primary Medical United HealthCare Select United HealthCare Select HMO HMO Select (HM1) HMO
HMO Select, Small Group (HM2)
United HealthCare Select EPO EPO Select (EPO) EPO
EPO Select (NNP)
EPO Select (TSP)
United HealthCare Choice United HealthCare Choice HMO HMO Choice (HM6) HMO
HMO Choice, Small Group (HM8)
United HealthCare Choice EPO EPO Choice (EP1) EPO
United HealthCare Select Plus United HealthCare Select Plus HMO HMO Select Plus (HM3) HMO
HMO Select Plus, Single Contract (HM5)
HMO Select Plus, Small Group (HM4)
United HealthCare Select Plus POS POS Select Plus (POS) POS
United HealthCare Choice Plus United HealthCare Choice Plus HMO HMO Choice Plus (HM7) HMO
HMO Choice Plus, Single Contract (HMA)
HMO Chioce Plus, Small Group (HM9)
United HealthCare Choice Plus POS POS Choice Plus (PS1) POS
United HealthCare Choice Plus Rhaspsody Rhapsody (RHA)
United HealthCare Options w/ Ben Diff United HealthCare Options w/ Ben Diff PPO PPO
TCM with National PPO (TCP)
United HealthCare Options w/o Ben Diff United HealthCare Options w/o Ben Diff National PPO (PP1)
TCM with National PPO as SSP (TC1)
United HealthCare Managed Indemnity United HealthCare Managed Indemnity Managed Indemnity (MIN) IND
Total Care Management (TCM)
United HealthCare Indemnity United HealthCare Indemnity Indemnity (IND)
United HealthCare Stop Loss United HealthCare Stop Loss n/a n/a
United HealthCare Medicare Complement United HealthCare Medicare Complement Medicare Complement OTH
Managed Pharmacy United HealthCare Managed Pharmacy United HealthCare Managed Pharmcy Managed Pharmacy
Non-Medical United HealthCare Dental Options PPO United HealthCare Dental Options PPO Dental Options PPO (DNP)
United HealthCare Dental Managed Indemnity United HealthCare Dental Managed Indemnity Dental Managed Indemnity (DNI)
Non-Medical Non-Medical Non-Medical
No Coverage No Coverage No Coverage No Coverage
Unknown Unknown Unknown Unknown

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Product Type

[Function: Attribute]

Classifies claims into one of the following values based on the benefit plan under which coverage for the claim is provided:

Items of Note:

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Prompt Payment Discount

[Function: Metric]

The amount of eligible charges saved due to an arrangement by which the carrier/group reimburses the provider at a lower rate because the reimbursement was made expeditiously.

Found in the following report by default:

Option to add to the following report:

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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

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Professional

[Function: Value]

A physician or allied health care practitioner , or a health care costs attributed to services provided such a person.

Parent Attribute:

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Provider

[Function: Value]

A health care professional or facility to which a check is issued by the carrier as reimbursement of a claim.

Parent Attribute:

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Provider 3 Digit Zip Code

[Function: Attribute]

Classifies health care professionals/facilities based upon the 3-digit zip code (i.e., region of the country) in which the professional/facility is located.

Items of Note:

Option to add to the following reports:

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Provider 5 Digit Zip Code

[Function: Attribute]

Classifies health care professionals/facilities based on the 5-digit zip code (i.e., the region of the country and postal zone within a city) in which the professional/facility is located.

Items of Note:

Option to add to the following reports:

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Provider Location Hierarchy

[Function: Hierarchy]

Classifies health care professionals/facilities based on the professional/facility's locale.

Includes the following levels of detail:

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Provider Market Name

[Function: Attribute]

A label, assigned by UnitedHealthcare, that defines the location of a health care professional/facility within a geographical area:

Option to add to the following reports:

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Provider Market Number

[Function: Attribute]

A 7-digit code, assigned by UnitedHealthcare, that defines the location of a health care professional/facility within a geographical area:

Option to add to the following reports:

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Provider Market Number&Name

[Function: Attribute]

Combines, into a single field, the following 2 attributes used to define the location of a health care professional/facility within a geographical area:

Option to add to the following reports:

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Provider MPIN

[Function: Attribute]

Identifies health care professionals/facilities based on the medical provider's identification number (MPIN).

Option to add to the following reports:

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Provider Name

[Function: Attribute]

Identifies the name of the health care professional/facility.

Found in the following reports by default:

Option to add to the following reports:

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Provider Participation Status

[Function: Attribute]

Further differentiates participating provider claims identified at the hierarchy's category level.

Items of Note:

Option to add to the following reports:

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Provider Participation Status Category

[Function: Attribute]

Classifies claims into 1 of 2 categories based on whether or not the professional/facility is contracted with the health plan to deliver services to covered persons.

Items of Note:

Found in the following reports by default:

Option to add to the following reports:

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Provider Participation Status Hierarchy

[Function: Hierarchy]

Classifies claims based on whether or not the professional/facility is contracted with the health plan to deliver services to covered persons.

Includes the following levels of detail:

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Category Provider Participation Status
Participating Provider Participating Provider
Contracted Provider
Contracted Provider/Pay As Par
Contracted Provider/Pay As Non-Par
Non-Participating Provider Non-Participating Provider

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Provider Sanction

[Function: Metric]

Reductions in the gross payable amount attributed to a contracted professional/facility's lack of notification regarding specific treatment actions, or due to investigations requiring more detailed medical information.

Found in the following reports by default:

Option to add to the following report:

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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

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Provider State

[Function: Attribute]

Classifies health care professionals/facilities based on the US state/territory in which the professional/facility is located.

Items of Note:

Found in the following reports by default:

Option to add to the following reports:

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Provider TIN

[Function: Attribute]

Identifies professionals/facilities using the professional/facility's 10-digit tax identification number (TIN).

Option to add to the following reports:

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Provider Type

[Function: Attribute]

Further differentiates the following provider types from the hierarchy's summary level (the number in parentheses equals the additional lines of detail at this level):

Items of Note:

Option to add to the following reports:

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Provider Type Category

[Function: Attribute]

Classifies claims into one of the following categories based on the health care entity that rendered the service:

Items of Note:

Option to add to the following reports:

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Provider Type Group

[Function: Attribute]

Further differentiates the following provider types from the hierarchy's category level (the number in parentheses equals the additional lines of detail at this level):

Items of Note:

Option to add to the following reports:

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Provider Type Hierarchy

[Function: Hierarchy]

Classifies claims based on the health care entity that rendered the service.

Includes the following levels of detail:

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Category Group Summary Provider Type
Professional Physician Primary Care Family Practice/General Practice
Internal Medicine
Pediatrics
OB/GYN Obstetrics & Gynecology
Specialist Allergy & Immunology
Anesthesiology
Cardiology
Colon & Rectal Surgery
Critical Care Medicine
Dermatology
Emergency Medicine
Endocrinology
Gastroenterology
General Surgery
Genetics
Geriatric Medicine
Hematology & Oncology
Infectious Diseases
Neonatology
Nephrology
Neurological Surgery
Neurology
Ophthalmology
Orthopedics
Osteopathy
Otolaryngology
Physical Medicine & Rehabilitation
Plastic & Reconstructive Surgery
Podiatry MD
Preventive Medicine
Psychiatry
Pulmonary Medicine
Rheumatology
Sports Medicine
Therapeutic Radiology
Thoracic Surgery
Urology
Vascular Surgery
Other Physician Specialties
Unknown Physician Specialties
Allied Health Allied Health Provider Audiologist
Chiropractor
Dentist
Holistic Health Provider
MH/SA Professional
Nurse
Nutritionist
Optician/Optometrist
Podiatrist - Non-MD
Psychologist
Therapy Provider
Other Allied Health Provider
Facility Hospital General Acute-Care Hospital Acute-Care Hospitals
Psychiatric Hospital Psychiatric Hospitals
Specialty Hospital Specialty Hospitals
Non-Hospital Facilities Ambulatory Surgery Center Ambulatory Surgery Centers
Birthing Center Birthing Centers
Cardiac & Medical Rehab Facility Cardiac & Medical Rehab Facilities
Clinic Clinics
Dialysis Facility Dialysis Facilities
Emergency Room Center Emergency Room Centers
Laboratory Laboratories
Mental Health/Substance Abuse Facility MH/SA Facilities
Hospice Hospices
Pathology Provider Pathology Providers
Radiology Provider Radiology Providers
Skilled Nursing Facility Skilled Nursing Facility
Urgent Care Center Urgent Care Centers
Other Facilities Other Facility Other Facility
Miscellaneous Ambulance Ambulance Provider Ambulance
Home Health Specialty Home Health Specialty Provider Home Health Specialty Provider
Medical Supplier Medical Supply Provider Medical Supply Provider
Unknown Provider Type Unknown Unknown
Pharmacy Pharmacy Provider Pharmacy Provider Pharmacy Provider

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Provider Type Summary

[Function: Attribute]

Further differentiates the following provider types from the hierarchy's group level (the number in parentheses equals the additional lines of detail at this level):

Items of Note:

Option to add to the following reports:

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Provider Type Utilization

[Function: Attribute]

Classifies claims based on the health care entity that rendered the service.

Items of Note:

Consists of the following values:

Found in the following report by default: