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

  • Published on Apr 23, 2026
  • 4 minute(s) read
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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 Identifier: URSA-PHF-903
  • 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 -- 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 Payor ID -- The internal database identifier (used, e.g., for joins and primary keys) for the Primary Payor. (See also [URSA-CORE] Primary Payor)
    • Primary Plan ID -- The identifier for the health insurance plan product that is the first party responsible for payment.

  • Date Fields

    • Current Continuous Primary Payor Membership Episode Start Date -- The start date of the Continuous Primary Payor Membership Episode in effect as of the (potentially historical) period covered by the record. (See also [URSA-CORE] Continuous Primary Payor Membership Episode)
    • Current Continuous Primary Payor Membership Episode End Date -- The end date of the Continuous Primary Payor Membership Episode in effect as of the (potentially historical) period covered by the record. Values follow the standard exclusive convention for Period End Dates. (See also [URSA-CORE] Continuous Primary Payor Membership Episode, [URSA-CORE] Period 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

  • Numerator Fields

    • Document ID -- The internal database identifier (used, e.g., for joins and primary keys) for the document. (See also [URSA-CORE] Document)
    • Source ID -- The identifier for the original source data system from which the current record originated.
    • 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
    • Document Allowed Amount
    • Document Plan Paid Amount
    • Document Patient Responsibility 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 Setting Tier 1 Description
    • Ursa Service Type Tier 1 Description

  • Metadata Fields

    • Is Any Current Data Coverage
    • Is Medical Claim Data Coverage -- Indicates data coverage for medical claims (i.e., institutional and professional claims) from at least one data source for the patient and time period specified on the record. (See also [URSA-CORE] Data Coverage)
    • Is Institutional Claim Paid Amount Data Coverage -- Indicates data coverage for institutional claims, with plan paid amounts populated at least at the claim header level, from at least one data source for the patient and time period specified on the record. (See also [URSA-CORE] Data Coverage)
    • Is Professional Claim Data Coverage -- Indicates data coverage for professional claims from at least one data source for the patient and time period specified on the record. (See also [URSA-CORE] Data Coverage)
    • Is Professional Claim Paid Amount Data Coverage -- Indicates data coverage for professional claims, with plan paid amounts populated at least at the claim header level, from at least one data source for the patient and time period specified on the record. (See also [URSA-CORE] Data Coverage)
    • Is Pharmacy Claim Data Coverage -- Indicates data coverage for pharmacy claims from at least one data source for the patient and time period specified on the record. (See also [URSA-CORE] Data Coverage)
    • Is Pharmacy Claim Paid Amount Data Coverage -- Indicates data coverage for pharmacy claims, with plan paid amounts populated, from at least one data source for the patient and time period specified on the record. (See also [URSA-CORE] Data Coverage)

  • Validation Only Fields

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

  • Measure Fields

    • Denominator
    • Numerator

  • [No Field Group]