Reports Glossary. Enhanced Personal Health Care

Transcription

1 Enhanced Personal Health Care Reports Glossary This glossary is a reference for providers participating in Enhanced Personal Health Care. It is organized to allow the user to quickly find the definition for a term by the report in which it appears. Attribution Active Report... 2 Attribution Inactive Report... 3 Hot Spotter Report... 4 Inpatient Authorization Report... 5 Emergency Room Report... 6 Care Opportunity Report... 6 Other... 7

2 Attribution Active Report New to report Prospective Risk Score Product: LOB Product: Product Provider Organization PCP NPI Method Effective Date Mts Attribute Visits: Primary PCP Visits: Other PCP Visits: Specialist A patient who is on the report for the first time will have an X in this field. Patient s first and last name Identification number assigned to the patient Displayed as M (male) or F (female) Line of business (e.g., commercial) Product that the patient is participating in at the time of service (e.g., HMO, PPO) The name of the organization to which the patient s Primary Care Provider belongs. A provider group (higher level) is made up of provider organizations (lower level). Name of the primary care provider to whom the patient is attributed National Provider Identifier, a 10-digit identifier issued by the Centers for Medicare and Medicaid Services The attribution methodology used to determine the patient s primary care provider: either visit-based (e.g., Dartmouth, Episode-based) or patient selection (e.g., assignment) The date the patient met the attribution criteria for the current provider Number of months the patient has been attributed to the Primary Care Provider (displayed in whole numbers) Number of visits to the primary care provider to whom the patient is attributed over the Number of visits to primary care providers to whom the patient is not attributed over the Number of visits to a specialist over the 2

3 Attribution Inactive Report New to report Prospective Risk Score Product: LOB Product: Product Provider Organization PCP NPI Method Effective Date Mts Attribute End Date Provider Visits: Attr PCP Provider Visits: Other PCP Provider Visits: Specialist A patient who is on the report for the first time will have an X in this field Patient s first and last name Identification number assigned to the patient Displayed as M (male) or F (female) Line of business (e.g., commercial) Product that the patient is participating in at the time of service (e.g., HMO, PPO) The name of the organization to which the patient s Primary Care Provider belongs. A provider group (higher level) is made up of provider organizations (lower level). Name of the primary care provider to whom the patient is attributed. National Provider Identifier, a 10-digit identifier issued by the Centers for Medicare and Medicaid Services The attribution methodology used to determine the patient s primary care provider: either visit-based (e.g., Dartmouth, Episode-based) or patient selection (e.g., assignment) The date the patient met the attribution criteria for the current provider Number of months the patient has been attributed to the Primary Care Provider (displayed in whole numbers) Date that the patient is no longer attributed to the provider Number of visits to the primary care provider to whom the patient is attributed over the Number of visits to primary care providers to whom the patient is not attributed over the Number of visits to a specialist over the 3

4 Hot Spotter Report New to report Months on Report Prospective Risk: Score Prospective Risk: Change Readmission Risk Primary Care Provider: Name Primary Care Provider: NPI Risk Model Risk Driver 1 Risk Driver 2 Risk Driver 3 Risk Driver 4 Emergency Room Utilization: Visits Emergency Room Utilization: Last Visit Dt Emergency Room Utilization: Last Visit Diagnosis Chronic Conditions Program Disease Management History: Program Disease Management History: A patient who is on the report for the first time will have an X in this field Patient s first and last name Identification number assigned to the patient Displayed as M (male) or F (female) Number of months the patient has been on the report, including the first date that the patient appeared on the report Percent of change in the patient s risk score, the readmission score is refreshed daily and the chronic risk is refreshed month on the Hot Spotter report. Risk Change and Color Code: Less than 10%, no color From 10% to 20%, yellow cell More than 20%, red cell A patient s risk for an inpatient readmission within 90-days of a primary inpatient event based on a predefined algorithm. Provider s first and last name National Provider Identifier, a 10-digit identifier issued by the Centers for Medicare and Medicaid Services Chronic, Readmission, or Chronic & Readmission. Risk model is used to identify patients who could benefit from a care plan. The top four risk categories for the patient. Risk categories are associated with chronic disease, readmission or both. Based on a risk model provided by WellPoint s Comprehensive Health Solutions analytics. Number of Emergency Room visits the patient had over the. Date of last Emergency Room visit over the Diagnosis code used for the patient s last Emergency Room visit Primary (1), secondary (2) and tertiary (3) chronic condition for this patient based on a risk model from Comprehensive Health Solutions The most recent care management program associated with the patient over the The status of patient s participation in our Case Management program The most recent Disease Management program associated with the patient over the. of patient s participation in our Disease Management program. indicators are: Participating; Declined with reason; Complete. 4

5 Inpatient Authorization Report New to Report Readmission Risk Facility Name Admit Date Admitting Diagnosis Primary Care Provider: Name Primary Care Provider: NPI Prospective Risk Score ER Visits (12M) Program Disease Management History: Program Disease Management History: Whether patient is new to report over past seven days Yes/No The name of the patient The member identification number Male or Female A patient s risk for an inpatient readmission within 90-days of a primary inpatient event based on a predefined algorithm Name of facility where procedure/treatment took place Date of procedure/service Diagnosis for procedure/service. Sensitive codes are masked. The name of the patient s Primary Care Provider The Primary Care Provider s identification number Number of emergency room visits in the last 12 months for the patient The most recent care management program associated with the patient over the The status of patient s participation in our Case Management program The most recent Disease Management program associated with the patient over the of patient s participation in our Disease Management program. indicators are: Participating; Declined with reason; Complete. 5

6 Emergency Room Report Primary Provider: Name Primary Provider: NPI ER Visits: Date ER Visits: Day ER Visits: Facility Diagnosis: Primary Diagnosis: Secondary Visits per year The name of the patient on record for using the Emergency Room The member identification number Male or Female The name of the patient s Primary Care Provider The Primary Care Provider s identification number The date the patient visited the Emergency Room The day of the week the patient visited the Emergency Room The facility Emergency Room that saw the patient Primary diagnosis coded for the ER visit by the facility Secondary diagnosis coded for the ER visit by the facility Number of visits recorded for the patient for the preceding 12-month period. Care Opportunity Report Measure number Patient: LOB Primary Provider: Name Primary Provider: NPI Last Date of Service Clinical Due Date Mths this status The measure that the patient requires care for, which comes from a fixed list of 12 identified measures The name of the patient with the care opportunity The health plan identification number Line of business (e.g., Commercial, Medicare, Medicaid, etc.) The name of the patient s Primary Care Provider The Primary Care Provider s identification number The date the patient was last treated for the given measure. Examples of why this field could be blank no paid claim for the service, new to the practice/ insurance plan. If more than one service required for the measure, the date of the first paid claim displayed and the clinical due date factors in all services. The date the patient is required to receive treatment/service for the given measure, as determined by their primary provider. If no last day of service available: the last day of the month the patient appears on the report displays. The status of the treatment and/or service for the given measure based on the clinical due date (e.g., past due, due in 60 days, due in 30 days, complete). Specific colors are associated with each status. The number of consecutive months for the given status 6

7 Other Attribution Prospective Risk Score detail Patients assigned to a provider, or providers through analysis of the patient s claims data. A score of 1 represents an average patient. If someone has a score of 2 they are predicted to use twice the amount of medical services as the average patient, and cost twice as much as the average patient. A score of 10 means the patient is predicted to use 10 times the amount of services and cost as an average patient. The risk scores are based on demographic factors age and gender and diagnosis codes from administrative health care claims data There is no data available for this field at this time. ****** There is a sensitive code identified for this field. Contact your Clinical Liaison or Care Consultant for further information or use Member Medical History Plus (MMH+). Revised 12/11/2013 7