The Medical Claims Detail by PCP report is designed to show medical claims detail based on the combination selected PCP Group in the PCP Groups panel and the member’s PCP selected in the PCP panel.  

 

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All medical claims by PCP Group, PCP, and member are loaded by default.  Page filters are available on every screen and may then be used to filter to the desired subset of data.  The filters can be used to build a subset based on any field including:  organizational entities, member/patient, provider/group, diagnoses, procedures, disease, time range, claim type, etc.  Once a PCP Group is selected in the PCP Groups panel, the respective PCPs are listed in the PCP panel.  “Member PCP Name” field is a hyperlink that takes you to its profile.   Next when a PCP is selected in the PCP panel, the respective members are listed in the Members panel.  “Member Name” field is a hyperlink that takes you to the member’s profile.  And then when a member is selected in the Members panel, the respective claim detail is shown in the Claim Detail panel.  

 

Detail and Definitions

The header data is based on detailed reporting period, as are each panel (PCP Groups, PCP, Members, and Claim Detail).   

 

PCP Groups

  • PCP Group
  • PCP Group Name
  • Claims
  • Panel
  • Paid
  • Avg Risk
  • ER/1000
  • Admit/1000
  • Readmit/1000
  • ALOS
  • Direct Costs
  • Indirect Costs

 

PCPs

  • PCP NPI
  • PCP Name
  • Claims
  • Panel
  • Paid
  • Avg Risk
  • ER/1000
  • Admit/1000
  • Readmit/1000
  • ALOS
  • Direct Costs
  • Indirect Costs

 

Members

  • Member Number
  • Member Name
  • Claims
  • Paid
  • Risk

 

Claim Details

  • Member Number
  • Claim #
  • Service Date
  • POS
  • Dx Code
  • Dx Description
  • Provider Billing Group
  • Paid