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preferred provider

pref_prvdr_ind
quality·Updated Jun 23, 2026

Definition

ISO-11179 Definition

A boolean indicator identifying a healthcare provider designated as preferred within a tiered network benefit structure, where members receive lower cost sharing for services delivered by preferred providers who have demonstrated superior quality and cost efficiency relative to other in-network providers. Preferred provider designations are determined through data-driven quality and efficiency assessments including HEDIS performance rates, total cost of care relative to risk-adjusted benchmarks, patient experience scores, and board certification status. Health plans use tiered network designs with preferred and standard in-network tiers to financially incentivize members to choose higher-value providers while maintaining broad network access.

Healthcare data teams build preferred provider designation analytics that calculate composite quality and efficiency scores for each provider, apply threshold criteria to determine preferred status eligibility, model the member cost-sharing differential between tiers, and track member utilization patterns across network tiers to evaluate whether preferred designations are successfully steering care toward high-value providers.

Standard Abbreviation

pref_prvdr_ind

Category

quality

Production DDL — FACT_QUALITY_MEASURE

FACT_QUALITY_MEASURE.sql
CREATE OR REPLACE TABLE FACT_QUALITY_MEASURE (
    qlty_key        INTEGER        NOT NULL  -- surrogate key,
    mbr_key         INTEGER        NOT NULL  -- FK to DIM_MEMBER,
    plan_key        INTEGER        NOT NULL  -- FK to DIM_PLAN,
    meas_yr         SMALLINT                 -- measurement year,
    hedis_meas_cd   VARCHAR(20)              -- HEDIS measure code,
    denom_ind       CHAR(1)                  -- denominator eligible,
    numer_ind       CHAR(1)                  -- numerator met,
    excl_ind        CHAR(1)                  -- exclusion indicator,
    gap_open_ind    CHAR(1)                  -- care gap open,
    star_rtg_nbr    DECIMAL(3,1)             -- star rating,
    qlty_scr        DECIMAL(5,2)             -- quality score,
    perf_thrsh_pct  DECIMAL(5,2)             -- performance threshold,
    raf_scr         DECIMAL(10,3)            -- risk adjustment factor,
    outreach_cnt    SMALLINT                 -- outreach attempts,
    load_dt         TIMESTAMP_NTZ  NOT NULL  -- load timestamp
);

Standard Snowflake DDL for the canonical quality table. Convert to BigQuery or Databricks →

Why This Term Matters

Quality measure data determines how payers and providers are rated and reimbursed under CMS Stars, HEDIS, and value-based care contracts. Data engineers who understand quality terminology build measure calculation pipelines that correctly attribute patients, apply denominator exclusions, and flag documentation gaps before submission deadlines. Incorrect quality data directly affects star ratings, pay-for-performance bonuses, and Medicare Advantage plan bids.

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