URSA-PHF-001b: Simplified PMPM Plan Spending (Patient-Month)

  • Published on Apr 23, 2026
  • 6 minute(s) read
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Measure Description

Among distinct patient-months with any active plan membership, the per-member-per-month plan spending. This measure simplifies the PMPM calculation by always assigning observations an integer-valued denominator contribution (either 1 or 0, depending on whether their membership was active at any time during the month) even if member are not enrolled for the full month; this simplification follows many organization's existing conventions, and so is meant to provide backward compatibility with existing analytics.

Metadata

  • Measure Identifier: URSA-PHF-001b
  • Measure Type: Rate Measure
  • Temporal Structure: Event
  • Component Class: Long-Form
  • Denominator Case Field: Patient ID, Month Start Date Text YYYYMM
  • Target Direction: Down

Denominator Description

One per distinct patient-month in which the patient had an active plan membership, was alive, and has medical claims data coverage.

Numerator Description

Total payor spending from claims with covered start date falling within the observation patient-month; includes claim financials with a non-zero plan paid our allowed amount.

Published Fields

  • Data Model Keys

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    • Patient ID -- The internal database identifier (used, e.g., for joins and primary keys) for the patient. This value is typically mastered, i.e., all records for the same patient, regardless of the source data system from which that record originated, should have the same Patient ID value. (Note that while the mastered Patient ID value might resemble a local identifier used in one of the upstream data sources, this does not indicate any special priority of that source system in determining the characteristics of the patient.) (See also [URSA-CORE] Patient)
    • Primary Plan ID -- The identifier for the health insurance plan product that is the first party responsible for payment.
    • Month Start Date Text YYYYMM

  • Patient Fields

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    • Patient Last Name
    • Patient Date of Birth -- The patient's date of birth. On the Patients Natural Object, this field reflects the "best" known value for the patient available from all data sources; on other Natural Objects, e.g., MMR Member-Months, the value faithfully reflects the date of birth found on that particular type of record in the source data.

  • Date Fields

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    • Month Start Date -- The start date (e.g., January 1, February 1, etc.) of the month in the patient's life described by the current record.
    • 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)

  • Provider Fields

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  • Location Fields

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    • Patient State Abbreviation

  • Insurance Fields

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  • Diagnosis Fields

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  • Numerator Fields

    • Document ID -- The internal database identifier (used, e.g., for joins and primary keys) for the document. (See also [URSA-CORE] Document)
    • Claim ID -- The internal database identifier (used, e.g., for joins and primary keys) for the claim. (See also [URSA-CORE] Claim)
    • Claim Service Line Item ID -- The identifier for a service line item on an institutional or professional claim.
    • Primary Encounter ID
    • Document Effective Date -- The most appropriate single date that events associated with the document occurred. For documents spanning multiple calendar days, the earliest date is typically used; Document Effective Start Date and Document Effective End Date can be used for a more precise range of dates, if necessary.
    • Document Effective Date Text YYYYMM
    • Billing Provider Description -- The natural language description of the billing provider. (See also [URSA-CORE] Billing Provider)
    • CMS Type of Bill Code -- The standard CMS 3-digit Type of Bill (TOB) Code; 111 = Hospital Inpatient Admit Through Discharge, etc.
    • CMS Place of Service Code -- The standard CMS 2-digit Place of Service code; e.g., 01 = Pharmacy, 02 = Telehealth, etc.
    • CMS Place of Service Description -- The natural language description of a standard CMS Place of Service code (See also [URSA-CORE] CMS Place of Service Code)
    • HCPCS Code -- The Healthcare Common Procedure Coding System (HCPCS) code associated with a service. Includes both HCPCS Level I codes (commonly called CPT codes) and Level II codes (which includes products, supplies, and services not included in CPT). Level II codes consist of a letter followed by four numeric digits. Current Dental Terminology codes are included in the Level II codes as HCDT. (See also [URSA-CORE] HCPCS Description)
    • HCPCS Description -- The natural language description of a HCPCS code. (See also [URSA-CORE] HCPCS Code)
    • CMS Revenue Center Code -- The standard CMS 4-digit Revenue Center code; e.g., 0001 = Total charge, etc. CMS Revenue Center codes should include leading zeros.
    • CMS Revenue Center Description -- The natural language description of a CMS Revenue Center code (See also [URSA-CORE] CMS Revenue Center Code)
    • NDC Code -- The standard 11-digit National Drug Code; e.g., 00045012400 = Tylenol 500 mg.
    • Label Description -- Supplies the name given to the product by the manufacturer.
    • Principal Diagnosis ICD-10-CM Code -- The ICD-10-CM diagnosis code documented as the principal diagnosis for a claim, bill, encounter, etc.
    • Principal Diagnosis ICD-10-CM Description -- The natural language description of the Principal Diagnosis ICD-10-CM Code. (See also [URSA-CORE] Principal Diagnosis ICD-10-CM Code)
    • Principal Diagnosis AHRQ CCS Diagnosis Category Tier 1 Description
    • Principal Diagnosis AHRQ CCS Diagnosis Category Tier 2 Description
    • Document Allowed Amount
    • Document Plan Paid Amount
    • Document Patient Paid Amount
    • Document Type Category
    • Claim Financial Class Description -- The natural language description of the financial class of a claim or plan. (A claim's financial class is inherited from its associated plan.) (See also [URSA-CORE] Financial Class)
    • Medicare Benefit Type Category -- A categorical value identifying whether the claim is a Medicare FFS or Medicare Advantage claim and, if known, what Medicare program component -- i.e., Part A, Part B, or Part D -- it is associated with. (See also [URSA-CORE] Is Medicare Part A, [URSA-CORE] Is Medicare Part B, [URSA-CORE] Is Medicare Part D)
    • Claim Class Category -- Identifies a record as associated with a professional, institutional, or pharmacy claim.
    • Ursa Claim Type Code
    • Ursa Claim Type Category
    • Ursa Claim Type Description
    • Ursa Consolidated Utilization Type Code
    • Ursa Encounter Type Tier 1 Category
    • Ursa Encounter Type Tier 1 Description
    • Ursa Encounter Type Tier 2 Code
    • Ursa Encounter Type Tier 2 Category
    • Ursa Encounter Type Tier 2 Description
    • Ursa Surgery Encounter Type Category
    • Ursa Setting Tier 1 Code
    • Ursa Setting Tier 1 Category
    • Ursa Setting Tier 1 Description
    • Ursa Service Type Tier 1 Description
    • AHFS Therapeutic Class Tier 1 Description -- The natural language description of the first-tier category within the AHFS Therapeutic Classification System that the medication is assigned to. (See also [URSA-CORE] AHFS Pharmacologic-Therapeutic Classification System)
    • AHFS Therapeutic Class Tier 2 Description -- The natural language description of the second-tier category within the AHFS Therapeutic Classification System that the medication is assigned to. (See also [URSA-CORE] AHFS Pharmacologic-Therapeutic Classification System)

  • Metadata Fields

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    • Random Integer 1 to 1000
    • Is Member on Month Start Date

  • Measure Fields

    • Denominator
    • Numerator

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