Pla - Pro

Place of Service

Place where the billed service(s) took place.

Claim Detail, Inpatient Admission -Action Report

Place of Service Code

Place where the billed service(s) took place.

Claim Summary -Action Report

Plan Cost Share % Dental

% of Total Dental Costs paid by the Plan in the current year.

Member Cost Share Summary -Dashlet

Plan Cost Share % Medical

% of Total Medical Costs paid by the Plan in the current year.

Member Cost Share Summary -Dashlet

Plan Cost Share % Pharmacy

% of Total Pharmacy Costs paid by the Plan in the current year.

Member Cost Share Summary -Dashlet

Plan Cost Share % Vision

% of Total Vision Costs paid by the Plan in the current year.

Member Cost Share Summary -Dashlet

Plan Description

Client developed definition of Plan ID, describing the health plan.

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

Plan Description

Description of the plan's pharmacy product.

Pharmacy Detail -Action Report

Plan Formulary Code

Code identifying the plan's formulary.

Pharmacy Detail -Action Report

Plan Formulary Description

Description of the

Pharmacy Detail -Action Report

Plan ID

Client assigned id which is used to identify a specific health plan.

Capitation Summary -Action Report

Plan ID

Client assigned id which is used to identify a specific health care plan.

Claim Detail, Claim Summary, Enrollment Detail, Enrollment Summary, Expense and Cost Summary by Paid Date, Expense and Cost Summary by Incurred Date, Inpatient Admission, Member Summary -Action Report

Plan ID

Client assigned id which is used to identify a specific dental plan.

Dental Payment Summary -Action Report

Plan ID

Identification number assigned to the Plan Description.

Pharmacy Detail -Action Report

Plan ID

Client assigned id which is used to identify a specific Vision plan.

Vision Payment Summary -Action Report

Plan Paid

Graphical representation of the total dollars paid by the plan for the each of the top 10 condition hierarchies (as determined by paid dollars).

Condition Hierarchy Summary - Action Report

Plan Paid - Non-Outliers

Count of the plan's members, who are not cost outliers, with the condition

Condition Hierarchy Summary - Action Report

Plan Paid - Outliers

Count of the plan's members, who are cost outliers, with the condition

Condition Hierarchy Summary - Action Report

Plan Paid - Total for Plan

Total plan plaid dollars for the condition

Condition Hierarchy Summary - Action Report

Plan Paid Amount

Amount paid by the plan for the service(s) performed.

Claim Detail, Claim Summary, Inpatient Admission -Action Report

Plan Paid Amount

Dollars paid by the plan for the prescription.

Pharmacy Detail -Action Report

Plan Paid Amount Dental

Total Dental Costs paid by the Plan in the current year.

Member Cost Share Summary -Dashlet

Plan Paid Amount Medical

Total Medical Costs paid by the Plan in the current year.

Member Cost Share Summary -Dashlet

Plan Paid Amount Pharmacy

Total Pharmacy Costs paid by the Plan in the current year.

Member Cost Share Summary -Dashlet

Plan Paid Amount Vision

Total Vision Costs paid by the Plan in the current year.

Member Cost Share Summary -Dashlet

Practice / Provider Group ID

The unique identifier for the practice of the provider who was selected by the member or appears to be managing the member's care, based on claims.

Member Summary -Action Report

Practice / Provider Group Name

The name of the practice of the provider who was selected by the member or appears to be managing the member's care, based on claims.

Member Summary -Action Report

Prescribed NDC Description

The National Drug Code associated with the prescribed drug.

Prescribing Pattern -Action Report

Prescribing Provider ID

Unique identifier of the health care provider writing the prescription.

Pharmacy Detail -Action Report

Prescribing Provider Name

The name of the health care provider writing the prescription.

Pharmacy Detail -Action Report

Present on Admission

Flag indicating if the primary diagnosis was present on admission to the hospital.

Inpatient Admission -Action Report

Previous % of Plan Population - Non-Outliers

Percentage of the plan's members, who are not cost outliers, with the condition in the previous reporting period.

Condition Hierarchy Summary - Action Report

Previous % of Plan Population - Outliers

Percentage of the plan's members, who are cost outliers, with the condition in the previous reporting period.

Condition Hierarchy Summary - Action Report

Previous % of Plan Population - Total for Plan

Percentage of the plan's members with the condition in the previous reporting period.

Condition Hierarchy Summary - Action Report

Previous Avg Dental Member Months

Average number of member months for the previous rolling 12 month period for the Dental plan.

Enrollment Overview -Dashlet

Previous Avg Dental Member Months - Norm

Average number of member months for the previous rolling 12 month period for the Dental plan normative population.

Norm Enrollment Overview -Dashlet

Previous Avg Medical Member Months

Average number of member months for the previous rolling 12 month period for the medical plan.

Enrollment Overview -Dashlet

Previous Avg Medical Member Months - Norm

Average number of member months for the previous rolling 12 month period for the medical plan normative population.

Norm Enrollment Overview -Dashlet

Previous Avg Pharmacy Member Months

Average number of member months for the previous rolling 12 month period for the Pharmacy plan.

Enrollment Overview -Dashlet

Previous Avg Pharmacy Member Months - Norm

Average number of member months for the previous rolling 12 month period for the Pharmacy plan normative population.

Norm Enrollment Overview -Dashlet

Previous Avg Vision Member Months

Average number of member months for the previous rolling 12 month period for the Vision plan.

Enrollment Overview -Dashlet

Previous Avg Vision Member Months - Norm

Average number of member months for the previous rolling 12 month period for the Vision plan normative population.

Norm Enrollment Overview -Dashlet

Previous PMPM

PMPM in the previous reporting period.

Financial Summary -Action Report

Previous PMPM Adjusted for Change in Risk

Risk adjusted previous period PMPM. This allows for a comparison between current and previous reporting periods on a constant risk basis.

Financial Summary -Action Report

Previous Risk

Previous risk score for the employer.

Financial Summary -Action Report

Previous Yr Dental PMPM

Dental Cost per member per month for the previous rolling 12 month period for the normative Population. Completion Factors are applied.

Norm Comparison - Dashlet

Previous Yr Dental PMPM

Dental Cost per member per month for the previous rolling 12 month period for the plan. Capitation Payments are included and Completion Factors are applied.

Payment Overview - Dashlet

Previous Yr Medical PMPM

Medical cost per member per month for the previous rolling 12 month period for the normative population. Completion factors are applied then capitation payments are included.

Norm Comparison - Dashlet

Previous Yr Medical PMPM

Medical cost per member per month for the previous rolling 12 month period for the plan. Completion factors are applied then capitation payments are included.

Payment Overview - Dashlet

Previous Yr Pharmacy PMPM

Pharmacy cost per member per month for the previous rolling 12 month period for the normative population. Completion factors are applied then capitation payments are included.

Norm Comparison - Dashlet

Previous Yr Pharmacy PMPM

Pharmacy cost per member per month for the previous rolling 12 month period for the plan. Completion factors are applied.

Payment Overview - Dashlet

Previous Yr Vision PMPM

Vision Cost per member per month for the previous rolling 12 month period for the normative Population. Completion Factors are applied.

Norm Comparison - Dashlet

Previous Yr Vision PMPM

Vision Cost per member per month for the previous rolling 12 month period for the plan. Capitation Payments are included and Completion Factors are applied.

Payment Overview - Dashlet

Primary Care Actual PMPM

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

Cost Overview -Dashlet

Primary Care Actual PMPM

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

Cost Overview w/o Outliers -Dashlet

Primary Care Actual PMPM

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

Cost Overview w/o Outliers -Dashlet

Primary Care Norm PMPM

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

Cost Overview -Dashlet

Primary Care Norm PMPM

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

Cost Overview w/o Outliers -Dashlet

Primary Care Norm PMPM

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

Cost Overview w/o Outliers -Dashlet

Primary Care Visits/1000 Count

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

Cost and Utilization Summary by Cost Bucket - Action Report

Primary Care-All PMPM

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

Cost and Utilization Summary by Cost Bucket - Action Report

Primary Care-Outliers Only PMPM

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

Cost and Utilization Summary by Cost Bucket - Action Report

Primary Care-w/o Outliers PMPM

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

Cost and Utilization Summary by Cost Bucket - Action Report

Primary Diagnosis Code

The diagnosis code for which the service(s) were provided.

Claim Detail, Claim Summary, Inpatient Admission -Action Report

Primary Diagnosis Description

The description of the diagnosis code for which the service(s) were provided.

Claim Detail, Claim Summary, Inpatient Admission -Action Report

Prior Year Grand Total Plan Paid

Total costs (Inpatient/Outpatient Facility, Professional, & Pharmacy) paid by the Plan in the previous year.

CE Executive Report – Total Medical & Pharmacy Cost Page -Action Report

Prior Year Grand Total Plan Paid

Total costs (Inpatient/Outpatient Facility and Professional) paid by the Plan in the previous year.

CE Executive Report – Total Medical Cost Page - Action Report

Prior Year Inpatient Facility - Admissions

Number of Admissions to Inpatient Facility for previous year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Prior Year Inpatient Facility – Admissions/1000 Members

Admissions per 1000 members to Inpatient Facility for previous year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Prior Year Inpatient Facility – Average Length of Stay

Average Length in days of a patient Inpatient Facility stay for previous year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Prior Year Inpatient Facility – Average Paid Per Admission

Average paid per Inpatient Facility admission for previous year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Prior Year Inpatient Facility – Paid PMPM

Plan Paid Per Member Per Month for Inpatient Facility services for previous year. Value includes Capitation and Completion factors.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Prior Year Inpatient Facility – Readmission Percentage

% of patients that were re-admitted to Inpatient Facility less than 30 days between initial discharge and re-admission for previous year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Prior Year Inpatient Facility % of Total Plan Paid

% of Total Inpatient Facility costs paid by the Plan in the previous year.

CE Executive Report – Total Medical Cost Page, Total Medical & Pharmacy Cost Page - Action Report

Prior Year Inpatient Facility Total Plan Paid

Total Inpatient Facility costs paid by the Plan in the previous year.

CE Executive Report – Total Medical & Pharmacy Cost Page, CE Executive Report – Total Medical Cost Page -Action Report

Prior Year Inpatient Professional – Average Paid Per Service

Average Paid per service for Inpatient Professional Services for previous year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Prior Year Inpatient Professional – Paid PMPM

Plan Paid Per Member Per Month for Inpatient Professional services for previous year. Value includes Capitation and Completion factors.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Prior Year Inpatient Professional - Services

Number of Services that are for Inpatient Professional Services for previous year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Prior Year Inpatient Professional – Services/1000 Members

Number of Inpatient Professional Services per 1000 members for previous year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Prior Year Medical & Pharmacy Member Cost Share – Grand Total Member Cost Share

Total Medical & Pharmacy costs (Copy, Coinsurance, Deductible) that Members are responsible for in the previous year.

CE Executive Report – Total Medical & Pharmacy Cost Page -Action Report

Prior Year Medical Member Cost Share - Coinsurance

Total Medical Coinsurance costs that Members are responsible for in the previous year.

CE Executive Report – Total Medical & Pharmacy Cost Page, CE Executive Report – Total Medical Cost Page -Action Report

Prior Year Medical Member Cost Share - Copay

Total Medical Copay costs that Members are responsible for in the previous year.

CE Executive Report – Total Medical & Pharmacy Cost Page, CE Executive Report – Total Medical Cost Page -Action Report

Prior Year Medical Member Cost Share –Deductible

Total Medical Deductible costs that Members are responsible for in the previous year.

CE Executive Report – Total Medical & Pharmacy Cost Page, CE Executive Report – Total Medical Cost Page -Action Report

Prior Year Member Cost Share – Grand Total Member Cost Share

Total Medical & Pharmacy costs (Copay, Coinsurance, Deductible) that Members are responsible for in the previous year.

CE Executive Report – Total Medical & Pharmacy Cost Page -Action Report

Prior Year Member Cost Share – Grand Total Member Cost Share

Total Medical costs (Copay, Coinsurance, Deductible) that Members are responsible for in the previous year.

CE Executive Report – Total Medical Cost Page - Action Report

Prior Year Outpatient Facility – Average Paid Per Service

Average Paid per service for Outpatient Facility services for previous year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Prior Year Outpatient Facility – ED Cost/Visit

Outpatient Facility Emergency Department Costs per visit for previous year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Prior Year Outpatient Facility – ED Visits

Number of visits for Outpatient Facility Emergency Department services for previous year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Prior Year Outpatient Facility – ED Visits/1000 Members

Visits per 1,000 members for Outpatient Emergency Department services for previous year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Prior Year Outpatient Facility – Paid PMPM

Plan Paid Per Member Per Month for Outpatient Facility Services for previous year. Value includes Capitation and Completion factors.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Prior Year Outpatient Facility – Services/1000 Members

Outpatient Facility Services per 1000 members for previous year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Prior Year Outpatient Facility % of Total Plan Paid

% of Total Outpatient Facility costs paid by the Plan in the previous year.

CE Executive Report – Total Medical Cost Page, Total Medical & Pharmacy Cost Page - Action Report

Prior Year Outpatient Facility Total Plan Paid

Total Outpatient Facility costs paid by the Plan in the previous year.

CE Executive Report – Total Medical & Pharmacy Cost Page, CE Executive Report – Total Medical Cost Page -Action Report

Prior Year Outpatient Professional – Average Paid Per Service

Average Paid per service for Outpatient Professional Services for previous year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Prior Year Outpatient Professional – Paid PMPM

Plan Paid Per Member Per Month for Outpatient Professional services for previous year. Value includes Capitation and Completion factors.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Prior Year Outpatient Professional - Services

Number of Services that are for Outpatient Professional Services for previous year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Prior Year Outpatient Professional – Services/1000 Members

Number of Outpatient Professional Services per 1000 members for previous year.

CE Executive Report – Total Medical Cost Key Metrics Page - Action Report

Prior Year Pharmacy % of Total Plan Paid

% of Total Pharmacy costs paid by the Plan in the previous year.

CE Executive Report – Total Medical & Pharmacy Cost Page -Action Report

Prior Year Pharmacy Member Cost Share - Coinsurance

Total Pharmacy Coinsurance costs that Members are responsible for in the previous year.

CE Executive Report – Total Medical & Pharmacy Cost Page -Action Report

Prior Year Pharmacy Member Cost Share - Copay

Total Pharmacy Copay costs that Members are responsible for in the previous year.

CE Executive Report – Total Medical & Pharmacy Cost Page -Action Report

Prior Year Pharmacy Member Cost Share –Deductible

Total Pharmacy Deductible costs that Members are responsible for in the previous year.

CE Executive Report – Total Medical & Pharmacy Cost Page -Action Report

Prior Year Pharmacy Total Plan Paid

Total Pharmacy costs paid by the Plan in the previous year.

CE Executive Report – Total Medical & Pharmacy Cost Page -Action Report

Prior Year Professional Total Plan Paid

Total Professional costs paid by the Plan in the previous year.

CE Executive Report – Total Medical & Pharmacy Cost Page, CE Executive Report – Total Medical Cost Page -Action Report

Prior Year Professional % of Total Plan Paid

% of Total Professional costs paid by the Plan in the previous year.

CE Executive Report – Total Medical Cost Page, Total Medical & Pharmacy Cost Page - Action Report

Procedure Code

Code indicating the service performed on the line.

Claim Detail -Action Report

Procedure Code Modifier

A code that adds additional information about the service performed on the line.

Claim Detail -Action Report

Procedure Description

Description of the procedure performed on the line.

Claim Detail -Action Report

Product Description

Carrier provided description of the insurance product associated with the claim.

Claim Detail, Claim Summary -Action Report

Product Description

Carrier provided description of the insurance product with the enrollment.

Enrollment Detail -Action Report

Product Description

Carrier provided description of the insurance product associated with the enrollment.

Enrollment Summary -Action Report

Product Description

Carrier provided code associated to the insurance product associated with the claim

Inpatient Admission, Pharmacy Detail -Action Report

Product ID

Carrier provided code associated to the insurance product associated with the claim

Claim Detail, Claim Summary -Action Report

Product ID

Carrier provided code associated to the insurance product and the enrollment.

Enrollment Detail -Action Report

Product ID

Carrier provided code associated to the insurance product associated with the enrollment.

Enrollment Summary -Action Report

Product ID

Carrier provided description of the insurance product associated with the claim.

Inpatient Admission -Action Report

Product ID

Carrier provided code associated to the insurance product associated with the claim

Pharmacy Detail -Action Report

Product Line Code

A code describing the Product Line.

Capitation Summary -Action Report

Product Type

Carrier provided code associated to the insurance product.

Enrollment Summary -Action Report

Professional Current

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

Payment Summary -Dashlet

Professional Previous

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

Payment Summary -Dashlet

Professional Variance

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

Payment Summary -Dashlet

Program Code

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

Program Summary -Action Report

Program Description

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

Program Summary -Action Report

Program End Date

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

Program Detail -Action Report

Program Level

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

Program Summary -Action Report

Program Start Date

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

Program Detail -Action Report

Program Summary - Program Code

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

Program Detail -Action Report

Program Summary - Program Description

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

Program Detail -Action Report

Program Summary - Program Level

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

Program Detail -Action Report

Program Summary % Engaged in CM Long Term

Percentage of members who were identified for and actively participated in a longer term case management program, working directly with a Case Management nurse on interventions normally lasting between 3 and 6 months.

Program Management -Dashlet

Program Summary % Engaged in CM Short Term

Percentage of members who were identified for and actively participated in a short term case management program. Interventions are normally completed within a day or two.

Program Management -Dashlet

Program Summary % Engaged in DM High/Moderate Risk

Percentage of high and moderate risk members who were identified for and actively participated in a disease management program.

Program Management -Dashlet

Program Summary Case Mgt Commercial Enrollment

Number of unique members 18 years of age and older in a commercial plan who were identified for a case management program.

Program Management -Dashlet

Program Summary Case Mgt Medicare Adv Enrollment

Number of unique members in a Medicare Advantage plan who were identified for a case management program.

Program Management -Dashlet

Program Summary Case Mgt Peds Enrollment

Number of unique members with age less than 18 years in a commercial plan who were identified for a case management program.

Program Management -Dashlet

Program Summary Disease Mgt Commercial Enrollment

Number of unique members 18 years of age and older in a commercial plan who were identified for a disease management program.

Program Management -Dashlet

Program Summary Disease Mgt Medicare Adv Enrollment

Number of unique members in a Medicare Advantage plan who were identified for a disease management program.

Program Management -Dashlet

Program Summary Disease Mgt Peds Enrollment

Number of unique members with age less than 18 years in a commercial plan who were identified for a disease management program.

Program Management -Dashlet

Program Summary Medicare Adv Enrollment

Carrier provided description of the insurance product associated with the claim.

Program Management -Dashlet

Program Type

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

Program Detail -Action Report

Program Type Description

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

Program Detail -Action Report