Population

The observed total paid amount for all medical, pharmacy, and ancillary services delivered to a member during a defined measurement period, used as the primary outcome metric in value-based care contracts and total cost of care benchmarking analyses against predicted or benchmark expenditures.

A flag indicating that a member has completed an advance care planning discussion or has a documented advance directive on file, including living will or healthcare power of attorney. Advance care planning completion is a quality metric in elderly and seriously ill populations associated with care aligned with patient preferences and reduced end-of-life hospitalizations.

A flag indicating that a member was screened for unhealthy alcohol use using a validated instrument such as the AUDIT-C or single-question screening tool during a qualifying encounter, corresponding to HEDIS unhealthy alcohol use screening and follow-up measures increasingly required in commercial and Medicaid populations.

A flag indicating that a member completed an annual wellness visit, a Medicare-covered preventive service including a health risk assessment and personalized prevention plan, during the measurement year. Annual wellness visit completion is a key quality metric and an opportunity to close multiple care gaps in a single encounter.

The NPI or internal identifier of the primary care provider to whom a member is attributed for value-based contract performance measurement. This field is used to aggregate quality, utilization, and cost metrics at the provider level for performance reporting and incentive payment calculation.

An indicator identifying an emergency department visit that was potentially avoidable based on the primary diagnosis treated, such as conditions typically manageable in a primary care or urgent care setting. Avoidable ED visits are a key utilization efficiency metric in value-based contracts and population health programs targeting primary care access improvement.

The expected or target total cost of care for an attributed population under a value-based contract, derived from historical trend analysis, regional cost benchmarks, and risk adjustment factors. Actual total cost of care performance relative to this benchmark determines shared savings or shared risk payments under the contract.

A flag indicating that a member with hypertension has achieved blood pressure control as defined by HEDIS Controlling High Blood Pressure measure criteria, typically a most recent blood pressure reading below 140 over 90 millimeters of mercury. This is one of the highest-weighted quality measures in Medicare Advantage star ratings.

The numeric body mass index value calculated from a member's height and weight measurements, expressed in kilograms per square meter. BMI is used in obesity population identification, bariatric program eligibility determination, and as a risk factor input in cardiovascular and diabetes population health models.

A flag corresponding to the HEDIS Breast Cancer Screening measure, indicating whether a female member aged 50 through 74 received a mammogram during the required measurement period. Breast cancer screening is one of the most widely reported HEDIS measures and a significant driver of Medicare Advantage star ratings.

A flag identifying a member with an active or historical cancer diagnosis based on ICD-10-CM codes in the C00 through C97 range, used to segment the oncology population for specialty care coordination, high-cost drug management, and risk adjustment purposes where cancer diagnoses carry significant HCC weights.

A flag indicating that a specific quality care gap for a member has been closed through completion of the recommended service, submission of supplemental data, or medical record documentation, used to track quality measure compliance rates and calculate star ratings performance at the plan level.

The total number of open quality care gaps identified for a member based on HEDIS or proprietary quality measure algorithms, representing recommended preventive services, chronic disease monitoring tests, or follow-up visits that have not yet been completed within the required timeframe. Care gap counts drive outreach prioritization in quality improvement programs.

A composite score reflecting the clinical complexity and care coordination intensity required for a member currently enrolled in care management, used to drive caseload stratification ensuring the most complex members receive proportionally more intensive case manager engagement and intervention frequency.

The date on which a member was discharged or disenrolled from a care management program, used in conjunction with enrollment date to calculate length of engagement, and to identify members who may need re-enrollment based on subsequent utilization or risk score changes.

A code identifying the reason a member was discharged from a care management program, such as goal achievement, member request, loss of eligibility, inability to contact, or transfer to a higher level of care, used in program effectiveness analysis and re-enrollment targeting.

The date on which a member was formally enrolled in a care management or disease management program, used to calculate time-in-program metrics, establish pre-post enrollment comparison periods for outcomes measurement, and track program census trends over time.

An indicator showing that a member is actively enrolled in a care management or disease management program, used to track program reach, measure intervention effectiveness by comparing outcomes between enrolled and non-enrolled high-risk members, and calculate care management program return on investment.

A unique identifier for the care manager or case manager assigned to coordinate a member's care management plan, used to link member outreach activities, care plans, and outcomes to the responsible clinician for productivity reporting, caseload management, and performance evaluation.

A flag corresponding to the HEDIS Cervical Cancer Screening measure, indicating whether a female member aged 21 through 64 received the required cervical cancer screening, either a Pap smear or human papillomavirus co-testing, within the required timeframe.