Population

A flag indicating that a member completed at least one qualifying preventive care encounter during a defined measurement period, used in population health analytics to measure preventive care access rates across attributed populations and to identify members who have not engaged with preventive services.

An indicator showing that a member has been attributed to a specific primary care provider for value-based contract performance measurement purposes, typically based on plurality of primary care visits or explicit member selection. Attribution is the foundational step in accountable care organization and primary care capitation models.

The total number of primary care physician or provider encounters for a member during a defined measurement period, used as an access-to-care indicator and inverse predictor of avoidable ED and inpatient utilization. Members with high primary care engagement typically have better chronic disease control and lower total cost of care.

A flag identifying that a member meets the eligibility criteria to be included in the denominator of a specific quality measure calculation, meaning the member is in the target population for whom the recommended service or outcome is expected based on age, diagnosis, enrollment, and other criteria.

A flag identifying that a member who would otherwise be included in a quality measure denominator qualifies for a valid exclusion, such as a hospice enrollment exclusion, medical contraindication, or patient refusal documentation, removing them from both the denominator and numerator without negatively impacting the performance rate.

A flag identifying that a member included in a quality measure denominator also met the numerator criteria, meaning the recommended service was received, the desired outcome was achieved, or the required documentation was submitted, contributing positively to the plan's or provider's quality measure performance rate.

A flag indicating that a member is enrolled in a remote patient monitoring program, receiving connected devices such as blood pressure cuffs, glucometers, or pulse oximeters that transmit readings to a care team for between-visit monitoring of chronic conditions, used in digital health program tracking and outcomes measurement.

A flag identifying a member currently in a lower risk tier who is predicted to transition to a higher risk tier within a defined future period based on predictive model outputs. Rising-risk identification enables proactive intervention before members become high-cost claimants, representing the highest return on investment segment for population health programs.

A code classifying a member into a defined risk tier based on a combination of clinical diagnoses, utilization history, pharmacy data, and predictive model scores, typically ranging from low to rising to high to very high risk. Risk stratification drives case management resource allocation, ensuring the most intensive interventions are directed at members with the greatest clinical need and highest projected cost.

A flag identifying a member as part of the attributed population eligible for shared savings calculation under an accountable care organization or value-based care contract, used to define the denominator population for total cost of care and quality performance calculations that determine shared savings distributions.

A binary indicator showing that a member has been identified as having one or more social determinants of health risk factors, such as housing instability, food insecurity, transportation barriers, social isolation, or financial hardship, that may negatively impact health outcomes and healthcare utilization patterns.

A flag identifying a member assessed as socially isolated or lacking adequate social support, a risk factor associated with depression, cognitive decline, medication non-adherence, and delayed care-seeking that is increasingly screened for in population health programs serving elderly and chronically ill populations.

The total number of specialist physician encounters for a member during a defined measurement period, used in care coordination analytics to identify members with high specialist utilization that may benefit from care navigation, and in total cost of care modeling where specialist visit intensity is a key cost driver.

A flag identifying a member who has an active statin therapy prescription, used in population health analytics to measure preventive cardiovascular medication use rates across attributed populations and to identify members with cardiovascular disease or diabetes who are not receiving guideline-recommended statin therapy.

A flag indicating that evidence of a member meeting a quality measure numerator was submitted through supplemental data, such as medical record review or electronic clinical data submission, rather than being captured through administrative claims data alone. Supplemental data submission is critical for closing care gaps that are documented in clinical records but not reflected in claims.

The numeric systolic blood pressure reading in millimeters of mercury from the most recent blood pressure measurement on record for a member, used in hypertension population management, cardiovascular risk stratification, and HEDIS Controlling High Blood Pressure measure calculation.

A flag indicating that a tobacco-using member received tobacco cessation counseling or a prescription for cessation pharmacotherapy during the measurement period, corresponding to HEDIS medical assistance with smoking and tobacco use cessation measures required across multiple lines of business.

A flag identifying a member who is a current tobacco user, based on ICD-10-CM diagnosis codes for tobacco dependence, health risk assessment responses, or pharmacy claims for tobacco cessation medications. Tobacco use is a primary modifiable risk factor for multiple chronic conditions and is screened for in several HEDIS and Medicare quality measures.

A flag indicating that a member transitioning between care settings, such as from inpatient to outpatient, received a documented transition of care plan including medication reconciliation, follow-up appointment scheduling, and patient education, used in care transition quality measurement and readmission prevention program tracking.

A flag identifying a member who has reported or been assessed as having inadequate transportation access that creates barriers to attending medical appointments, picking up prescriptions, or accessing other healthcare services. Transportation barriers are a significant driver of missed appointments and care gap non-closure in rural and low-income populations.