URSA-CORE-901: Claims Without Contemporaneous Membership

Measure Description

Among non-denied institutional, professional, or pharmacy claims, the percentage for patients without any contemporaneous plan membership as of the claim covered start date. Claims whose denial status is not known are considered denied for the purpose of this measure if the allowed and plan paid amounts are both zero.

Metadata

• Measure Type: Rate Measure
• Temporal Structure: Event
• Component Class: Normal-Form
• Denominator Case Field: Claim ID
• Target Direction: Down

Denominator Description

One per non-denied institutional, professional, or pharmacy claims. Claims whose denial status is not known are considered denied for the purpose of this measure if the allowed and plan paid amounts are both zero.

Numerator Description

One per qualifying denominator observation without any contemporaneous plan membership, for any plan, as of the claim covered start date.

Published Fields

• Data Model Keys

  • Claim ID
  • Patient ID
  • Payor ID
  • Plan ID
  • Document ID
  • Source ID

• Date Fields

  • Claim Covered Start Date
  • Claim Covered End Date
  • Segment Start Date -- The start date of the reporting segment. (See also [URSA-CORE] Reporting Segment)
  • Segment End Date -- The end date of the reporting segment. (See also [URSA-CORE] Reporting Segment)

• Insurance Fields

  • Claim Payor Description
  • Claim Plan Description
  • Claim Plan Financial Class Description

• Billing and Claims Fields

  • Claim Class Category

• Denominator Fields

  • Is Zero Plan Paid Amount Claim

• Numerator Fields

  • Patient Contemporaneous Primary Plan ID

• Measure Fields

  • Denominator
  • Numerator