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tiered network

tierd_ntwk_ind
quality·Updated Jun 23, 2026

Definition

ISO-11179 Definition

A health plan network design that organizes contracted providers into multiple performance tiers with different member cost-sharing levels, financially incentivizing members to choose higher-quality and more cost-efficient providers by offering lower deductibles, copays, and coinsurance for preferred tier providers. Tiered networks create quality and efficiency competition among contracted providers because providers who demonstrate superior performance earn preferred tier designation that generates more patient referrals through lower member cost sharing. Tiers are typically based on composite quality and cost efficiency scores derived from claims analytics and quality measure performance.

CMS allows Medicare Advantage plans to implement tiered network designs that vary cost sharing by provider tier. Healthcare data teams build tiered network analytics that calculate provider-level quality and efficiency scores, assign tier designations based on performance thresholds, model member utilization shifts between tiers in response to cost-sharing differentials, and evaluate whether tiered network designs are achieving their intended objective of steering volume toward high-value providers.

Standard Abbreviation

tierd_ntwk_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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