Glossary — A

Abuse and Fraud

[Function: Metric]

The amount of submitted charges not covered due to willful and material misrepresentation of a health care claim.

Found in the following report by default:

Distribution of Ineligible Charges

Option to add to the following report:

Medical Dollar Ad Hoc

Submitted Charges	minus	Ineligible Charges	equals	Eligible Charges
		Duplicate Bills
		R&C (Reasonable and Customary) Reductions
		Benefit Limits
		Pre-existing Conditions
		Abuse and Fraud
		Medical Claim Review
		MNRP (Maximum Non-Network Reimbursement Program)
		Other Ineligible Charges
Eligible Charges	minus	Discounts	equals	Covered Amount
		Contracted Discount
		Special Negotiated Discount
		Shared Savings Discount
		Prompt Payment Discount
		Customer Specific Discount
		Other Discount
Covered Amount	minus	Employee Cost Sharing	equals	Gross Payable
		Copay
		Deductible
		Coinsurance
Gross Payable	minus	Other Savings	equals	Net Paid
		Commercial COB Savings
		Commercial COB Reductions
		Medicare COB Savings
		Medicare COB Reductions
		Provider Sanctions
		All Other Savings Amount

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Accident

[Function: Value]

The cause of an injury for which services are provided by a healh care professional/facility.

Parent Attribute:

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Active

[Function: Value]

An employed subscriber or the dependent of an employed subscriber.

Parent Attribute:

Employment Status

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Actual Restated Billed Members

[Function: Metric]

The count of subscribers and their covered dependents.

Items of Note:

The count is based upon monthly updates to the data warehouse.

Found in the following report by default:

Premium Managed Ad Hoc

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Acute

[Function: Value]

A category of admissions consisting of conditions that require immediate services within a defined time span.

Parent Attribute:

Admission Type Category

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Acute-Care Outpatient Facility

[Function: Value]

An establishment licensed and equipped to provide medical and surgical care for seriously ill or injured people (e.g., emergency room, ambulatory surgery center, urgent care facility).

Parent Attribute:

Place of Service Summary

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AD&D Benefit

[Function: Value]

Coverage for specific disabling conditions or loss of life due to unnatural or unintentional causes.

Parent Attribute:

Benefit Type Category

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Administrative Services Only

[Function: Value]

A funding arrangement under which an insurance carrier or independent organization handles, for a fee, the administration of claims, benefits, and other administrative functions for a self-insured group.

Items of Note:

Also referenced by the acronym "ASO."

Parent Attribute:

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Admission Type Category

[Function: Attribute]

Classifies claims into one of the following categories based on the kind of event for which a person was registered as an inpatient (i.e., admitted for at least 24 hours).

Acute
Non-Actute

Items of Note:

Also includes a category for unknown admission types.
Level 1 (most general) of the Admission Type Hierarchy's 4 levels.

Option to add to the following reports:

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Admission Type Detail

[Function: Attribute]

Further differentiates the following admissions from the hierarchy's summary level (the number in parenthesis equals the additonal lines of detail at this level):

Maternity (3)
Newborn (2)

Items of Note:

Also includes a line of detail for unknown admission types.
Level 4 (most detailed) of the Admission Type Hierarchy's 4 levels.

Found in the following report by default:

Inpatient Utilization and Costs by Admission Type

Option to add to the following reports:

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Admission Type Group

[Function: Attribute]

Further differentiates acute admissions from the hierarchy's category level.

Items of Note:

Non-acute admission are labeled as "Other" admissions at this level.
Also includes a group of unknown admission types.
Level 2 (next-to-most general) of the Admission Type Hierarchy's 4 levels.

Found in the following report by default:

Inpatient Utilization and Costs by Admission Type

Option to add to the following reports:

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Admission Type Hierarchy

[Function: Hierarchy]

Classifies claims based on the kind of event for which a person was registered as an inpatient (i.e., admitted for at least 24 hours).

Items of Note:

Used to support cost comparison studies or to track similar types of admissions across providers or provider types.

Consists of the following levels of detail:

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Admission Type Category	Admission Type Group	Admission Type Summary	Admission Type Detail
Acute	Medical/Surgical	Medical	Medical
	Medical/Surgical	Surgical	Surgical
	Maternity	Maternity	Maternity - Cesarean Section
			Maternity - Vaginal Delivery
			Maternity - Other
	Newborn	Newborn	Newborn - Well
	Newborn	Newborn	Newborn - Other
	MH/SA	Mental Health	MH/SA - Mental Health
	MH/SA	Substance Abuse	MH/SA - Substance Abuse
Non-Acute	Other	Hospice	Hospice
		Skilled Nursing	Skilled Nursing
		Rehabilitation	Rehabilitation
Unknown	Unknown	Unknown	Unknown

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Admission Type Summary

[Function: Attribute]

Further differentiates the following admissions from the hierarchy's group level (the number in parenthesis equals the additonal lines of detail at this level):

Medical/Surgical (2)
MH/SA (2)
Other (3)

Items of Note:

Also includes a line of detail for unknown admission types.
Level 3 (next-to-most detailed) of the Admission Type Hierarchy's 4 levels.

Option to add to the following reports:

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Admissions per 1000

[Function: Metric]

The rate of admissions during a given period for every 1000 health plan members.

Items of Note:

An admission is a health care event in which a person is registered as an inpatient (i.e., admitted for at least 24 hours) into a hospital, skilled nursing facility, or other health facility.

Calculation:

Number of Admissions ÷ [Number of Members ÷ 1000]

Found in the following reports by default:

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Age

[Function: Attribute]

The number of years elapsed since a person's date of birth.

Items of Note:

Also includes a line for unknown ages.
Level 2 (most detailed) of the Age Hierarchy, Managed Pharmacy Age Hierarchy, and Medical Age Hierarchy's 2 levels.

Option to add to the following reports:

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Age/Gender Factor

[Function: Metric]

An artificial measurement used to illustrate the correlation between a population's age and gender make-up and the amount of health care expenses paid by the plan.

Items of Note:

Severity is based on variance from a norm score of 1.0.
An age/gender factor above 1.0 indicates a higher than average demographic risk of expected medical claims.
An age/gender factor below 1.0 indicates a lower than average demographic risk of expected medical claims.

Found in the following report by default:

Cost and Utilization Summary

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Age Group Band

[Function: Attribute]

An incremental set of age ranges into which a person is classified based upon the number of years elapsed since his/her date of birth.

Items of Note:

Also includes a group for unknown ages.
Level 1 (most general) of the Age Hierarchy's 2 levels.

Found in the following report by default:

Membership with Demographic and Geographic Factors

Option to add to the following report:

Membership Managed Ad Hoc

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Age Hierarchy

[Function: Hierarchy]

Classifies members based on the number of years elapsed since their date of birth.

Items of Note:

The age groups within this hierarchy differ from the Managed Pharmacy Age Hierarchy and Medical Age Hierarchy.

Consists of the following levels of detail:

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Group Band	Age
<1	0
1 – 9	1
	2
	3
	4
	5
	6
	7
	8
	9
10 – 19	10
	11
	12
	13
	14
	15
	16
	17
	18
	19
20 – 24	20
	21
	22
	23
	24
25 – 29	25
	26
	27
	28
	29
30 – 34	30
	31
	32
	33
	34
35 – 39	35
	36
	37
	38
	39
40 – 44	40
	41
	42
	43
	44
45 – 49	45
	46
	47
	48
	49
50 – 54	50
	51
	52
	53
	54
55 – 59	55
	56
	57
	58
	59
60 – 64	60
	61
	62
	63
	64
65 +	65
	66
	67
	68
	69
	70
	71
	72
	73
	74
	75
	76
	77
	78
	79
	80
	81
	82
	83
	84
	85
	86
	87
	88
	89
	90
	91
	92
	93
	94
	95
	96
	97
	98
	99
	100
Unknown	999

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AHFS Category

[Function: Attribute]

Classifies drugs into 1 of 29 categories defined by the AHFS (American Hospital Formulary Service) coding schema.

Items of Note:

AHFS is an industry standard drug classification system.
Level 1 (most general) of the AHFS Hierarchy's 3 levels.

Option to add to the following reports:

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AHFS Class

[Function: Attribute]

Classifies drugs into 1 of 369 classes defined by the AHFS (American Hospital Formulary Service) coding schema.

Items of Note:

AHFS is an industry standard drug classification system.
Level 3 (most detailed) of the AHFS Hierarchy's 3 levels.

Option to add to the following reports:

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AHFS Group

[Function: Attribute]

Classifies drugs into 1 of 200 categories defined by the AHFS (American Hospital Formulary Service) coding schema.

Items of Note:

AHFS is an industry standard drug classification system.
Level 2 (more detailed) of the AHFS Hierarchy's 3 levels.

Option to add to the following reports:

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AHFS Hierarchy

[Function: Hierarchy]

Classifies drugs across 3 levels of detail defined by the AHFS (American Hospital Formulary Service) coding schema.

Items of Note:

AHFS is an industry standard drug classification system.

Consists of the following levels of detail:

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Category	Group	Class
AHFS Category Unknown
Antihistamines
Anti-Infective Agents
Antineoplastic Agents
Autonomic Drugs
Blood Derivatives
Blood Formation and Coagulation
Cardiovascular Drugs
Central Nervous System Agents
Contraceptives (e.g., foams, devices)
Dental Agents
Diagnostic Agents
Disinfectants (for non-dermatological)
Electrolytic, Caloric and Water Balance
Enzymes
Antitussives, Expectents and Mucyolytic Agents
Eye, Ear, Nose and Throat (EENT) Preps
Gastrointestinal Drugs
Gold Compounds
Heavy Metal Antagonists
Hormones and Synthetic Substitutes
Local Anesthetics
Oxytocics
Radioactive Agents
Serums, Toxoids, and Vaccines
Skin and Mucous Membrane Agents
Smooth Muscle Relaxants
Vitamins
Unclassified Therapeutic Agents

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All Other

[Function: Value]

A category of miscellaneous health care services (e.g., hearing, home health, transportation and vision services).

Parent Attribute:

Service Type Category

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All Other Diagnosis Chapters

[Function: Value]

A combination of the following diagnosis chapters:

Parent Attribute:

Diagnosis Chapter Roll-up

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All Other Dispensed As Written

[Function: Value]

A reduction in the gross payable amount not attributed to commercial COB savings/reductions, Medicare COB savings/reductions, or provider sanctions.

Parent Attribute:

DAW Status Category

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All Other Savings

[Function: Metric]

A category of admissions consisting of conditions that require immediate services within a defined time span.

Found in the following report by default:

Distribution of Other Savings

Option to add to the following report:

Medical Dollar Ad Hoc

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Submitted Charges	minus	Ineligible Charges	equals	Eligible Charges
		Duplicate Bills
		R&C (Reasonable and Customary) Reductions
		Benefit Limits
		Pre-existing Conditions
		Abuse and Fraud
		Medical Claim Review
		MNRP (Maximum Non-Network Reimbursement Program)
		Other Ineligible Charges
Eligible Charges	minus	Discounts	equals	Covered Amount
		Contracted Discount
		Special Negotiated Discount
		Shared Savings Discount
		Prompt Payment Discount
		Customer Specific Discount
		Other Discount
Covered Amount	minus	Employee Cost Sharing	equals	Gross Payable
		Copay
		Deductible
		Coinsurance
Gross Payable	minus	Other Savings	equals	Net Paid
		Commercial COB Savings
		Commercial COB Reductions
		Medicare COB Savings
		Medicare COB Reductions
		Provider Sanctions
		All Other Savings Amount

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Allied Health

[Function: Value]

Non-physician health care professionals (e.g., dentists, optometrics, chiropractors, podiatrists, mental health practitioners and nurses).

Parent Attribute:

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Ambulance

[Function: Value]

A provider that is licensed and equipped to provide emergency treatment of seriously injured/sick persons while in route, via a specialized vehicle, to a medical facility.

Parent Attribute:

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Ancillary Amount

[Function: Metric]

Any additional dollars a person pays for a prescription above his/her copay, coinsurance, and/or deductible (e.g., the cost differential if the person wants the drug in its bran-name versus generic form).

Found in the follwoing report by default:

Managed Pharmacy Plan Performance

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Anesthesia

[Function: Value]

Servies associated with inpatient and outpatient anesthetic procedures, or a medical benefit covering such services.

Parent Attribute:

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Average Contract Size

[Function: Metric]

An estimate of the number of people covered by any one subscriber — including single subscribers.

Calculation:

[Number of Subscribers + Number of Dependents] ÷ Number of Subscribers

Found in the following report by default:

Cost and Utilization Summary

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Average Coinsurance/Copays per Prescription

[Function: Metric]

An estimate of the typical amount of covered health care costs a person pays at the time a prescription is filled (i.e., copays) and/or any percentage of costs the person is required to pay (coinsurance).

Calculation: