URSA-PHF-903: PMPM Plan Spending (Reduced Fields)

Measure Description

This measure is designed specifically for validation exercises in comparing patient counts to reports provided by the entity generating the source data (e.g., the payor) and has only critical and validation fields published. For analytic use cases, please use measure URSA-PHF-001. Among active plan membership periods, the per-member-per-month payor spending. Note: this measure does not restrict on periods of medical claim data coverage.

Metadata

• Measure Type: Rate Measure
• Temporal Structure: Interval
• Component Class: Long-Form
• Denominator Case Field: Patient ID
• Target Direction: Down

Denominator Description

The elapsed patient-months of active plan membership periods during which the patient is alive and has active plan coverage; includes periods of without medical claim coverage which is change from the standard URSA-PHF-001 PMPM measure.

Numerator Description

Total payor spending for claims with covered start date falling within the observation period start and end dates; includes claim financials with a non-zero plan paid or allowed amount.

Published Fields

• Data Model Keys

  • Patient ID
  • Primary Payor ID
  • Primary Plan ID

• Date Fields

  • Current Continuous Primary Payor Membership Episode Start Date
  • Current Continuous Primary Payor Membership Episode 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)
  • Segmented Period Start Date
  • Segmented Period End Date

• Location Fields

  • Patient State Abbreviation

• Insurance Fields

  • Primary Payor Description
  • Primary Plan Description
  • Primary Plan Financial Class Description

• Metadata Fields

  • Is Any Current Data Coverage
  • Is Medical Claim Data Coverage
  • Is Institutional Claim Paid Amount Data Coverage
  • Is Professional Claim Data Coverage
  • Is Professional Claim Paid Amount Data Coverage
  • Is Pharmacy Claim Data Coverage
  • Is Pharmacy Claim Paid Amount Data Coverage

• Validation Only Fields

  • Is Claim Payor =! Patient Primary Payor
  • Is Claim Plan=! Patient Primary Plan

• Measure Fields

  • Denominator
  • Numerator

• Numerator

  • Document ID
  • Source ID
  • Document Effective Date
  • Document Type Category
  • Claim Class Category
  • Claim Financial Class Description
  • Medicare Benefit Type Category
  • Document Allowed Amount
  • Document Plan Paid Amount
  • Document Patient Responsibility Amount
  • Document Patient Paid Amount
  • Document Effective Date Text YYYYMM

• [No Field Group]