The ER report provides both a snapshot and opportunity to gain in-depth information of cost and utilization by disease, diagnoses, PCPs, and members.  ER costs and utilization are significant cost drivers for health plans and many value based strategies identify ER utilization as a key metric to monitor.



Target Audience for this Report

Chief Medical Officer, Finance Department and CFO, Leadership Team, Medical management/Care Management Department, Physician Relations, Quality Management, and Utilization Management.


Business Processes Impacted by this Report

Supports the reports required for Medicaid compliance.


Allows the leadership team to assess current provider networks to effectively meet the needs of members who require visits for sick and urgent visits to avoid cost ER services.


Leadership team will use these metrics for benchmarking, determine network structure, and creating focused strategies to reduce ER visits where appropriate.  Emergency Room data supports quality report cards.  The health plan and employer collaborate for outreach to members and families to increase awareness of alternatives to emergency room use - urgent care, PCPs.


Quality Management and Medical Management will evaluate emergency room visits to determine member specific utilization and care management needs.  In addition, evaluation of PCP trends identifies possible need to educate providers regarding access to care when members are ill.


UM staff with CMO evaluate medical necessity and determine needs for authorizations/denials for ER visits.


Finance may evaluate ER visits to determine co-pays and methods to help members make good choices for urgent care.



Detail and Definitions

The header information and the table data (below the trend charts) are based on the reporting data date range.  Note that the header information is active, and will change when selections are made/filters are applied.  The trend charts are based off the entire period for which QualMetrix received data from the client, and may also reflect a calendar year.  An ER visit consists of the following criteria:  1) Place of service code = 23; 2) Revenue codes between 450 and 459, and 981; and 3) Paid Amount > $0.  Also, an ER visit will be counted with this logic:  a) if institutional claims only then use claim types IP and OP; and b) if both institutional and professional claims then use all claim types.



  • ER Visits
  • ER Costs
  • ER Rate/1000


By Diagnosis Group – table is populated from the Clinical Classification System (CCS) to diagnoses table.  That table is available for review in Appendix A.

  • Disease Group
  • ER Visits
  • ER Costs


Primary Care Physicians

  • PCP
  • ER Visits
  • ER Costs


By Diagnosis

  • Diagnosis
  • Avoidable
  • ER Visits
  • ER Costs
  • Avoidable Costs


Members with ER Visits

  • Member (Number)
  • Member Name
  • ER Visits
  • ER Costs
  • Avoidable ER Costs


Trending Graphs

Accessed by clicking on the graph icon in the upper right of the report.

Period by Period Trends (Graph)

Displays the trends of ER Visits and ER Costs trends by the selected period; year, quarter, or month.  The graph changes with applied filters found in the header.  This snapshot of these indicators provides significant information regarding Emergency Room Visits and the graphical display provides quick reference points to guide a deeper analysis.


Period Over Period Trends (Graph)

Displays the selected time period trends of Admits/1000, ALOS, and Paid/Admit in percentages over the previous period.  The graph changes with the applied filters found in the header.  By describing period over period in this manner the user can easily determine progress or decline in the indicators.