Glossary P
Partial Fill
[Function: Value]
Indicates that the initial amount of the prescription dispensed was less than the full portion.
Parent Attribute:
Partial/Complete Fill Status
[Function: Attribute]
Classifies prescriptions via the portions in which the drugs are dispensed.
Consists of the following values:
Option to add to the following reports:
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:
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:
Payee
[Function: Attribute]
The recipient of a check for reimbursement of a claim.
Consists of the following values:
Option to add to the following reports:
- All financial reports except Premium Managed Ad Hoc and Premium vs Claims Paid.
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):
- Fee for Service (4)
- Capitated Arrangement (17)
Items of Note:
- Includes a line for unknown payment arrangements.
- Level 2 (most detailed) of the Payment Arrangement Hierarchy's 2 levels.
Option to add to the following reports:
Payment Arrangement Category
[Function: Attribute]
Classifies the general methods adopted for reimbursing providers into one of the following categories:
Items of Note:
- Also includes a category of unknown payment arrangements.
- Level 1 (most general) of the Payment Arrangement Hierarchy's 2 levels.
Option to add to the following reports:
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Network Utilization
Payment Arrangement Hierarchy
[Function: Hierarchy]
Classifies claims based on the methods of provider reimbursement.
Includes the following levels of detail:
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 |
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:
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):
- Capitation (5)
- NYHCRA (3)
Items of Note:
- Level 2 (most detailed) of the Payment Type Hierarchy's 2 levels.
Found in the following reports by default:
Option to add to the following reports:
- Claim Expenses by Size of Payment
- Claim Lag Study
- Financial Managed Ad Hoc
- Large Loss Claim Payments
- Payments by Benefit Type
- Payments by Month
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:
- Level 2 (most detailed) of the Payment Type Hierarchy's 2 levels.
Option to add to the following reports:
- All financial reports except Premium Managed Ad Hoc and Premium vs Claims Paid.
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:
- Financial Managed Ad Hoc
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Healthcare Cost Management Summary
- Inpatient Event Ad Hoc
- Inpatient Utilization and Costs by Admission Type
- Medical Dollar Ad Hoc
- Medical Utilization Ad Hoc
- Member Cost Sharing Detail ASO Confidential
- Member Cost Sharing Detail Non Confidential
- Utilization and Costs by Provider Type
Payment Type Hierarchy
[Function: Attribute]
Classifies claims based on the methods by which the provider is reimbursed.
Includes the following levels of detail:
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 |
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:
- Only found in financial reports.
Found in the following reports by default:
- Claim Expenses by Size of Payment
- Claim Lag Study
- Detail Payment
- Detail Payment Non Confidential
- Large Loss Claim Payments
- Payments by Benefit Type
- Payment by Month
Option to add to the following reports:
PDL Status Unknown
[Function: Value]
A prescription thats position on the carrier/group's list of cost-effective drugs is unclear or undetermined.
Parent Attribute:
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:
- A ratio of 1.0 indicates a neutral effect.
Found in the following report by default:
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:
- A ratio of 1.0 indicates a neutral effect.
Found in the following report by default:
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:
- A ratio of 1.0 indicates a neutral effect.
Found in the following report by default:
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:
- A ratio of 1.0 indicates a neutral effect.
Found in the following report by default:
% [Percent] Claimants
[Function: Metric]
The portion of people with a claim within a specified subset of all people with a claim.
Calculation:
- [Some Number of Claimants χ Total Number of Claimants] Χ 100
Found in the following report by default:
% [Percent] Eligible Expenses
[Function: Metric]
The portion of eligible expenses within a specified subset of all eligible expenses.
Items of Note:
- An eligible expense is amount of submitted charges remaining after all ineligible charges are deducted.
Calculation:
- [Some Eligible Charges χ Total Eligible Charges] Χ 100
Found in the following report by default:
Percent Generic Scripts
[Function: Metric]
The rate at which a chemically equivalent form of a brand-name drug is dispensed.
Calculation:
- Number of Generic Subscriptions χ [Number of Generic Prescriptions + Number of Multisource Brand Prescriptions] Χ 100
Found in the following report by default:
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:
- [Number of Home Delivery Subscriptions χ Total Number of Prescriptions] Χ 100
Found in the following report by default:
% [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:
- DAW stands for Dispensed as Written
Calculation:
- [Number of All Other DAW χ Multisource Brand Number of Prescriptions] Χ 100
Found in the following reports by default:
% [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:
- DAW stands for Dispensed as Written
Calculation:
- [Number of Patient DAW χ Multisource Brand Number of Prescriptions] Χ 100
Found in the following reports by default:
% [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:
- DAW stands for Dispensed as Written
Calculation:
- [Number of Physician DAW χ Multisource Brand Number of Prescriptions] Χ 100
Found in the following reports by default:
% [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:
- DAW stands for Dispensed as Written
Calculation:
- [Number of Legal DAW χ Multisource Brand Number of Prescriptions] Χ 100
Found in the following reports by default:
% [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:
- [HRA Net Paid χ Total Net Paid] Χ 100
Found in the following reports by default:
- Cost and Utilization Summary
- Top Drug Utilization Ranked by Net Paid
- Top Drug Utilization Ranked by Volume
% [Percent] of Plan Net Paid
[Function: Metric]
The portion of the net paid amount within a specified subset of all net paid amounts.
Calculation:
- [Net Paid χ Total Net Paid] Χ 100
Found in the following reports by default:
- Cost and Utilization Summary
- Top Drug Utilization Ranked by Net Paid
- Top Drug Utilization Ranked by Volume
% [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:
- [Total Net Paid] Χ 100
Found in the following reports by default:
- Cost and Utilization Summary
- Top Drug Utilization Ranked by Net Paid
- Top Drug Utilization Ranked by Volume
% [Percent] Payments
[Function: Metric]
The portion of all payments attributed to a defined subset of payments.
Calculation:
- [Some Payment Amount χ Total Payment Amount] Χ 100
Found in the following reports by default:
% [Percent] of Total Prescriptions
[Function: Metric]
The portion of drug orders within a specified subset of all drug orders.
Calculation:
- [Some Prescriptions χ Total Number of Prescriptions] Χ 100
Found in the following reports by default:
% [Percent] Total Prescriptions Generic
[Function: Metric]
The portion of all drug orders filled with the chemically equivalent form of a brand-name drug.
Calculation:
- [Number of Generic Prescriptions χ Total Number of Prescriptions] Χ 100
Found in the following reports by default:
- Key Generic Substitution Indicators by Month
- Managed Pharmacy Critical Indicators
- Top Therapeutic Class Utilization Ranked by Net Paid
- Top Therapeutic Class Utilization Ranked by Volume
% [Percent] Total Prescriptions Multisource
[Function: Metric]
The portion of all drug orders filled with brand name drug for which a generic equivalent exists.
Calculation:
- [Number of Multisource Prescriptions χ Total Number of Prescriptions] Χ 100
Found in the following reports by default:
- Key Generic Substitution Indicators by Month
- Managed Pharmacy Critical Indicators
- Top Therapeutic Class Utilization Ranked by Net Paid
- Top Therapeutic Class Utilization Ranked by Volume
% [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:
- [Number of Single Source Prescriptions χ Total Number of Prescriptions] Χ 100
Found in the following reports by default:
- Key Generic Substitution Indicators by Month
- Managed Pharmacy Critical Indicators
- Top Therapeutic Class Utilization Ranked by Net Paid
- Top Therapeutic Class Utilization Ranked by Volume
Percentage of Member Distribution
[Function: Metric]
The portion of all members attributed to a defined subset of members.
Calculation:
- [Some Number of Members χ Total Number of Members] Χ 100
Found in the following reports by default:
Perinatal Period
[Function: Value]
Diagnoses attributed to conditions of pregnancy arising immediately before and after birth.
Parent Attribute:
Pharmacy
[Function: Value]
A retail establishment licensed to provide/dispense prescription drugs.
Parent attributes:
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:
- Level 2 (more detailed) of the Pharmacy Location Hierarchy's 4 levels.
Option to add to the following report:
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:
- Level 4 (most detailed) of the Pharmacy Location Hierarchy's 4 levels.
Option to add to the following report:
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:
- Level 1 (most general) of the Pharmacy Age Hierarchy's 2 levels.
Found in the following report by default:
Option to add to the following reports:
- All managed pharmacy reports except those it is found in by default.
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:
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 |
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:
- Medco
- DPS
- MedImpact
- Unknown
Option to add to the following reports:
- All managed pharmacy reports.
Pharmacy City
[Function: Attribute]
Classifies pharmacies based on the incorporated municipality in which the establishment is located.
Items of Note:
- Level 3 (next-to-most detailed) of the Pharmacy Location Hierarchy's 4 levels.
Option to add to the following report:
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:
Pharmacy Name
[Function: Attribute]
The name of the retail establishment licensed to dispense prescription drugs.
Option to add to the following report:
Pharmacy State
[Function: Attribute]
Classifies pharmacies based on the US state/territory in which the establishment is located.
Items of Note:
- Level 1 (most general) of the Pharmacy Location Hierarchy's 4 levels.
Option to add to the following report:
Pharmacy Provider
[Function: Value]
A retail establishment licensed to provide/dispense prescription drugs.
Parent Attribute:
Physician
[Function: Value]
A doctor of medicine.
Parent Attribute:
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:
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:
- OB/GYN stands for Obstetrics and Gynecology.
Parent attributes:
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:
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:
Physician Visits/Professional
[Function: Value]
A category of services attributed to meetings with medical doctors and other credentialed health care workers.
Parent Attribute:
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):
- Acute-Care Outpatient Facility (9)
- Inpatient Mental Health/Chem. Dep. Facility (3)
- Long-Term Care Facility (3)
- Non Acute-Care Outpatient Facility (2)
- Office/Clinic (8)
- Other (14)
Items of Note:
- Includes a line for claims with an unknown places of service.
- Level 3 (most detailed) of the Place of Service Hierarchy's 3 levels.
Option to add to the following reports:
- Managed Pharmacy Ad Hoc
- Cost and Utilization by Procedure
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Healthcare Cost Management Summary
- Inpatient Event Ad Hoc
- Medical Dollar Ad Hoc
- Medical Utilization Ad Hoc
- Member Cost Sharing Detail ASO Confidential
- Member Cost Sharing Detail Non Confidential
- Network Utilization
- Top Physicians Ranked by Total Net Paid
- Utilization and Costs by Provider Type
- Utilization by Age Group
- Utilization by Diagnosis
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:
- Level 1 (most general) of the Place of Service Hierarchy's 3 levels.
Found in the following report by default:
Option to add to the following reports:
- Managed Pharmacy Ad Hoc
- Cost and Utilization by Procedure
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Healthcare Cost Management Summary
- Inpatient Event Ad Hoc
- Medical Dollar Ad Hoc
- Medical Utilization Ad Hoc
- Member Cost Sharing Detail ASO Confidential
- Member Cost Sharing Detail Non Confidential
- Network Utilization
- Top Physicians Ranked by Total Net Paid
- Utilization by Age Group
- Utilization by Diagnosis
Place of Service Hierarchy
[Function: Hierarchy]
Classifies claims based on the location in which services were provided.
Includes the following levels of detail:
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 |
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):
- Inpatient (5)
- Outpatient (5)
Items of Note:
- Outpatient also includes a line for claims with an unknown places of service.
- Level 2 (more detailed) of the Place of Service Hierarchy's 3 levels.
Option to add to the following reports:
- Managed Pharmacy Ad Hoc
- Cost and Utilization by Procedure
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Healthcare Cost Management Summary
- Inpatient Event Ad Hoc
- Medical Dollar Ad Hoc
- Medical Utilization Ad Hoc
- Member Cost Sharing Detail ASO Confidential
- Member Cost Sharing Detail Non Confidential
- Network Utilization
- Top Physicians Ranked by Total Net Paid
- Utilization and Costs by Provider Type
- Utilization by Age Group
- Utilization by Diagnosis
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:
- Gross Payable Amount - Other Savings
Found in the following reports by default:
- Healthcare Cost Management Summary
- Managed Pharmacy Cost and Utilization by Month
- Managed Pharmacy Plan Performance
- 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
- Utilization by Age Group
Option to add to the following reports:
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 |
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:
- Net Paid χ Number of Admissions
Found in the following reports by default: None
Option to add to the following reports:
Plan Net Paid per Claimant
[Function: Metric]
The average dollar amount reimbursed by a plan for costs incurred for any one claimant.
Calculation:
- Net Paid χ Number of Claimants
Found in the following reports by default:
Found in the following reports by default:
Plan Net Paid per Day
[Function: Metric]
The average dollar amount reimbursed by a plan for one day of inpatient services.
Calculation:
- Net Paid χ Number of Days
Found in the following reports by default: None
Plan Net Paid per Member
[Function: Metric]
The average dollar amount reimbursed by the plan for a set of outpatient services.
Calculation:
- Net Paid χ [Number of Subscribers + Number of Dependents]
Found in the following reports by default:
Plan Net Paid per Prescription
[Function: Metric]
The average dollar amount reimbursed by a managed pharmacy plan for filling a drug
Calculation:
- Net Paid χ Number of Prescriptions
Found in the following reports by default:
- Managed Pharmacy Cost and Utilization by Month
- Managed Pharmacy Plan Performance
- Managed Pharmacy Utilization by Age Group
- Top Therapeutic Class Utilization Ranked by Net Paid
- Top Therapeutic Class Utilization Ranked by Volume
Option to add to the following reports:
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:
- PMPM stands for Per Member Per Month
Calculation:
- Net Paid χ [Number of Subscribers + Number of Dependents]
Found in the following reports by default:
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:
- All financial reports except Premium Managed Ad Hoc and Premium vs Claims Paid.
- All managed pharmacy reports.
- All medical reports except Cost and Utilization Summary.
- All membership reports.
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:
- All financial reports except Premium Managed Ad Hoc and Premium vs Claims Paid.
- All managed pharmacy reports.
- All medical reports except Cost and Utilization Summary.
- All membership reports.
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:
- The net result of the pooling amount and pooling adjustments is $0 (zero).
Parent Attribute:
Pooling Adjustment (45)
[Function: Value]
The negating transaction of the pooling amount.
Items of Note:
- A negative amount reported against ASO funding (e.g., a claimant with a stop-loss of $100K who incurs $120K in claims would report a pooling adjustment of −$20K).
Parent Attribute:
Pooling Amount (36)
[Function: Value]
Any portion of a claim above the individual stop-loss threshold.
Items of Note:
- A positive amount reported as fully-insured for customers with ASO funding (e.g., a claimant with a stop-loss of $100K who incurs $120K in claims would report a pooling amount of $20K).
Parent Attribute:
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:
- POS stands for Point of Service.
Parent Attribute:
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:
- A level of the Service Area Hierarchy
Consists of the following values:
Option to add to the following reports:
- Managed Pharmacy Ad Hoc
- All medical reports except Bill Count by Month, Claim Experience, and Cost and Utilization Summary.
- All membership reports.
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:
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:
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:
- [∑ Ages of All Positively Enrolled Dependents] χ Number of Positively Enrolled Dependents
Found in the following reports by default:
PPO
[Function: Value]
An industry product that establishes contracts with providers of medical care.
Items of Note:
- PPO stands for Preferred Provider Organization.
- Usually provides significantly better benefits and lower member cost for services received from preferred providers, thus encouraging covered persons to use these providers.
- Covered persons generally are allowed benefits for non-participating providers' services, usually on an indemnity basis.
- A PPO arrangement can be insured or self-funded. Providers may be, but are not necessarily, paid on a discounted fee-for-service basis.
Parent Attribute:
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:
- A level of the Service Area Hierarchy.
Consists of the following values:
Option to add to the following reports:
- Managed Pharmacy Ad Hoc
- All medical reports except Bill Count by Month, Claim Experience, and Cost and Utilization Summary.
- All membership reports.
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:
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 |
Pregnancy Childbirth Puerp
[Function: Value]
Diagnoses pertaining to the delivery of a newborn or conditions arising from the delivery.
Parent Attribute:
Premium Product
[Function: Attribute]
Differentiates UnitedHealthcare products available to groups with a fully-insured funding arrangement.
Option to add to the following reports:
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:
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:
- All managed pharmacy reports except Managed Pharmacy Plan Performance.
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:
- All managed pharmacy reports except those it is found in by default.
Prescriptions per Claimant
[Function: Metric]
The average number of drug orders filled by any one claimant.
Calculation:
- Number of Prescriptions χ Number of Claimants
Found in the following reports by default:
- 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
Option to add to the following report:
Prescriptions PMPY
[Function: Metric]
An estimate of the number of drug orders filled by any one member within a 12 month period.
Calculation:
- [Number of Prescriptions χ Number of Members] Χ 12
Found in the following reports by default:
Primary Coverage
[Function: Value]
The principal part of a single claim for which a secondary part is being processed separately.
Items of Note:
- Used as a mechanism of the database to avoid double-counting of subscribers and dependents.
Parent Attribute:
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:
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:
- Level 2 (more detailed) of the Diagnosis Hierarchy's 3 levels.
Option to add to the following reports:
- Cost and Utilization by Procedure
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Inpatient Event Ad Hoc
- Medical Dollar Ad Hoc
- Medical Utilization 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
Procedure Category
[Function: Attribute]
Further differentiates the following procedure chapters (the number in parentheses equals the additional lines of detail at this level):
- Misc Diag Therapeutic (61)
- Obstetrical Procedures (13)
- Oper Cardiovascular Sys (20)
- Oper Digestive Sys (32)
- Oper Female Genital Organs (12)
- Oper Hemic Lymphatic Sys (4)
- Oper Inetergumentary Sys (11)
- Oper Male Genital Organs (6)
- Oper Musculoskeletal Sys (23)
- Oper Nose, Mouth, Pharynx (7)
- Oper Respiratory Sys (9)
- Oper Urinary Sys (13)
- Operations Ear (5)
- Operations Endocrine Sys (3)
- Operations Eye (9)
- Operations Nervous Sys (9)
Items of Note:
- "Misc Diag Therapeutic" also includes a line for unknown procedures.
- Level 2 (more detailed) of the Procedure Hierarchy's 3 levels.
Option to add to the following reports:
- Cost and Utilization by Procedure
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Inpatient Event Ad Hoc
- Medical Dollar Ad Hoc
- Medical Utilization 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
Procedure Chapter
[Function: Attribute]
Classifies claims into one of the following chapters based on the surgical/diagnostic services rendered by a health care provider:
- Misc Diag Therapeutic
- Obstetrical Procedures
- Oper Cardiovascular Sys
- Oper Digestive Sys
- Oper Female Genital Organs
- Oper Hemic Lymphatic Sys
- Oper Inetergumentary Sys
- Oper Male Genital Organs
- Oper Musculoskeletal Sys
- Oper Nose, Mouth, Pharynx
- Oper Respiratory Sys
- Oper Urinary Sys
- Operations Ear
- Operations Endocrine Sys
- Operations Eye
- Operations Digestive Sys
- Operations Nervous Sys
- No Procedure
Items of Note:
- Level 1 (most general) of the Procedure Hierarchy's 3 levels.
Found in the following report by default:
Option to add to the following reports:
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Inpatient Event Ad Hoc
- Medical Dollar Ad Hoc
- Medical Utilization 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
Procedure Code Description
[Function: Attribute]
Classifies claims based on the specific surgical/diagnostic service rendered by a health care provider.
Items of Note:
- Level 3 (most detailed) of the Procedure Hierarchy's 3 levels.
Option to add to the following reports:
- Cost and Utilization by Procedure
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Inpatient Event Ad Hoc
- Medical Dollar Ad Hoc
- Medical Utilization 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
Procedure Hierarchy
[Function: Attribute]
Classifies claims based on the surgical/diagnostic services rendered by a health care provider.
Includes the following levels of detail:
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 |
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:
- Process Year
- Process Quarter
- Process Year/Month
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 |
Process Quarter
[Function: Attribute]
The quarterly period in which information derived from the claim was entered into the accounting system.
Items of Note:
- Level 2 (more detailed) of the Process Period Hierarchy's 3 levels.
Option to add to the following reports:
- All managed pharmacy reports.
- All medical reports except Claim Experience, Cost and Utilization Summary, and Utilization by Age Group.
Process Year
[Function: Attribute]
The calendar year in which information derived from the claim was entered into the accounting system.
Items of Note:
- Level 1 (most general) of the Process Period Hierarchy's 3 levels.
Option to add to the following reports:
- All managed pharmacy reports.
- All medical reports except Claim Experience, Cost and Utilization Summary, and Utilization by Age Group.
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:
- Level 3 (most detailed) of the Process Period Hierarchy's 3 levels.
Option to add to the following reports:
- All managed pharmacy reports.
- All medical reports except Claim Experience, Cost and Utilization Summary, and Utilization by Age Group.
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):
- United Healthcare Choice HMO (2)
- United Healthcare Choice Plus HMO (3)
- United HealthCare Managed Indemnity (2)
- United HealthCare Options w/ Ben Diff (2)
- United HealthCare Options w/o Ben Diff (2)
- United Healthcare Select EPO (3)
- United Healthcare Select HMO (2)
- United Healthcare Select Plus HMO (3)
Items of Note:
- Includes a line for unknown products.
- Level 4 (most detailed) of the Product Hierarchy's 4 levels.
Found in the following report by default:
Option to add to the following reports:
- All financial reports except those it is found in by default.
- All managed pharmacy reports.
- All medical reports except Cost and Utilization Summary.
- All membership reports.
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:
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 |
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:
- Includes a line for claims with an unknown product type.
- Level 1 (most general) of the Product Hierarchy's 4 levels.
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:
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 |
Professional
[Function: Value]
A physician or allied health care practitioner , or a health care costs attributed to services provided such a person.
Parent Attribute:
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:
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:
- Level 2 (most general) of the Provider Location Hierarchy's 3 levels.
Option to add to the following reports:
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Inpatient Event Ad Hoc
- Medical Dollar Ad Hoc
- Medical Utilization Ad Hoc
- Utilization and Costs by Provider Type
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:
- Level 3 (most general) of the Provider Location Hierarchy's 3 levels.
Option to add to the following reports:
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Inpatient Event Ad Hoc
- Medical Dollar Ad Hoc
- Medical Utilization Ad Hoc
- Utilization and Costs by Provider Type
Provider Location Hierarchy
[Function: Hierarchy]
Classifies health care professionals/facilities based on the professional/facility's locale.
Includes the following levels of detail:
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:
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Medical Dollar Ad Hoc
- Medical Utilization Ad Hoc
- Utilization and Costs by Provider Type
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:
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Medical Dollar Ad Hoc
- Medical Utilization Ad Hoc
- Utilization and Costs by Provider Type
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:
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Medical Dollar Ad Hoc
- Medical Utilization Ad Hoc
- Utilization and Costs by Provider Type
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:
- Cost and Utilization by Procedure
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Inpatient Event Ad Hoc
- Medical Dollar Ad Hoc
- Medical Utilization 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
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:
- Cost and Utilization by Procedure
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Inpatient Event Ad Hoc
- Medical Dollar Ad Hoc
- Medical Utilization Ad Hoc
- Network Utilization
- Outpatient Utilization by Diagnosis
- Utilization and Costs by Provider Type
- Utilization by Age Group
- Utilization by Diagnosis
Provider Participation Status
[Function: Attribute]
Further differentiates participating provider claims identified at the hierarchy's category level.
Items of Note:
- Level 2 (most detailed) of the Provider Participation Status Hierarchy's 2 levels.
Option to add to the following reports:
- All managed pharmacy reports except Managed Pharmacy Plan Performance and Managed Pharmacy Utilization by Age Group.
- Cost and Utilization by Procedure
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Healthcare Cost Management Summary
- Inpatient Event Ad Hoc
- Inpatient Utilization and Costs by Admission Type
- Inpatient Utilization by Diagnosis
- Medical Dollar Ad Hoc
- Medical Utilization Ad Hoc
- Member Cost Sharing Detail ASO Confidential
- Member Cost Sharing Detail Non Confidential
- Outpatient Utilization by Diagnosis
- Utilization and Costs by Provider Type
- Utilization by Age Group
- Utilization by Diagnosis
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:
- Level 2 (most detailed) of the Provider Participation Status Hierarchy's 2 levels.
Found in the following reports by default:
Option to add to the following reports:
- All managed pharmacy reports except Managed Pharmacy Plan Performance and Managed Pharmacy Utilization by Age Group.
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Healthcare Cost Management Summary
- Inpatient Event Ad Hoc
- Inpatient Utilization and Costs by Admission Type
- Inpatient Utilization by Diagnosis
- Medical Dollar Ad Hoc
- Medical Utilization Ad Hoc
- Member Cost Sharing Detail ASO Confidential
- Member Cost Sharing Detail Non Confidential
- Utilization and Costs by Provider Type
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:
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 |
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:
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 |
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:
- Level 1 (most general) of the Provider Location Hierarchy's 3 levels.
Found in the following reports by default:
Option to add to the following reports:
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Inpatient Event Ad Hoc
- Medical Dollar Ad Hoc
- Medical Utilization Ad Hoc
- Utilization and Costs by Provider Type
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:
- Cost and Utilization by Procedure
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Inpatient Event Ad Hoc
- Medical Dollar Ad Hoc
- Medical Utilization 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
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):
- Allied Health (12)
- Primary Care (3)
- Specialist (13)
Items of Note:
- Level 4 (most detailed) of the Provider Type Hierarchy's 4 levels.
Option to add to the following reports:
- Managed Pharmacy Ad Hoc
- Cost and Utilization by Procedure
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Healthcare Cost Management Summary
- Inpatient Event Ad Hoc
- Medical Dollar Ad Hoc
- Medical Utilization Ad Hoc
- Member Cost Sharing Detail ASO Confidential
- Member Cost Sharing Detail Non Confidential
- Network Utilization
- Outpatient Utilization by Diagnosis
- Top Physicians Ranked by Total Net Paid
- Utilization by Age Group
- Utilization by Diagnosis
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:
- Level 2 (more detailed) of the Provider Type Hierarchy's 4 levels.
Option to add to the following reports:
- Managed Pharmacy Ad Hoc
- Cost and Utilization by Procedure
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Healthcare Cost Management Summary
- Inpatient Event Ad Hoc
- Medical Dollar Ad Hoc
- Medical Utilization Ad Hoc
- Member Cost Sharing Detail ASO Confidential
- Member Cost Sharing Detail Non Confidential
- Network Utilization
- Outpatient Utilization by Diagnosis
- Utilization by Age Group
- Utilization by Diagnosis
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):
- Facility (3)
- Professional (2)
- Miscellaneous (4)
Items of Note:
- Level 2 (more detailed) of the Provider Type Hierarchy's 4 levels.
Option to add to the following reports:
- Managed Pharmacy Ad Hoc
- Cost and Utilization by Procedure
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Healthcare Cost Management Summary
- Inpatient Event Ad Hoc
- Medical Dollar Ad Hoc
- Medical Utilization Ad Hoc
- Member Cost Sharing Detail ASO Confidential
- Member Cost Sharing Detail Non Confidential
- Network Utilization
- Outpatient Utilization by Diagnosis
- Utilization by Age Group
- Utilization by Diagnosis
Provider Type Hierarchy
[Function: Hierarchy]
Classifies claims based on the health care entity that rendered the service.
Includes the following levels of detail:
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 |
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):
- Hospital (3)
- Non-Hospital Facilities (13)
- Physician (3)
Items of Note:
- Level 3 (next-to-most detailed) of the Provider Type Hierarchy's 4 levels.
Option to add to the following reports:
- Managed Pharmacy Ad Hoc
- Cost and Utilization by Procedure
- Distribution of Discounts
- Distribution of Ineligible Charges
- Distribution of Other Savings
- Healthcare Cost Management Summary
- Inpatient Event Ad Hoc
- Medical Dollar Ad Hoc
- Medical Utilization Ad Hoc
- Member Cost Sharing Detail ASO Confidential
- Member Cost Sharing Detail Non Confidential
- Network Utilization
- Outpatient Utilization by Diagnosis
- Top Physicians Ranked by Total Net Paid
- Utilization by Age Group
- Utilization by Diagnosis
Provider Type Utilization
[Function: Attribute]
Classifies claims based on the health care entity that rendered the service.
Items of Note:
- A mix of the category and summary levels of the Provider Type Hierarchy.
Consists of the following values:
- Facility
- Physician Primary Care
- Physician OB/GYN
- Physician Specialist
- Allied Health
- Miscellaneous
- Pharmacy
Found in the following report by default: