Da Vinci Value-Based Performance Reporting Implementation Guide
1.0.0 - STU1
Da Vinci Value-Based Performance Reporting Implementation Guide
1.0.0 - STU1
Da Vinci Value-Based Performance Reporting Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-vbpr/ and changes regularly. See the Directory of published versions
| Active as of 2024-06-12 |
<CodeSystem xmlns="http://hl7.org/fhir">
<id value="vbp-performance-metric"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p>This case-sensitive code system <code>http://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metric</code> defines the following codes:</p><table class="codes"><tr><td style="white-space:nowrap"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td style="white-space:nowrap">avg-risk-score<a name="vbp-performance-metric-avg-risk-score"> </a></td><td>Average risk score</td><td>Average risk score is a numeric score where a higher score indicates a riskier population on average. Example scores: 0.70, 1.00, 1.30.</td></tr><tr><td style="white-space:nowrap">avg-risk-score-market<a name="vbp-performance-metric-avg-risk-score-market"> </a></td><td>Market average risk score</td><td>The market average risk score.</td></tr><tr><td style="white-space:nowrap">capitation<a name="vbp-performance-metric-capitation"> </a></td><td>Capitation</td><td>Total capitation amount.</td></tr><tr><td style="white-space:nowrap">capitation-pmpm<a name="vbp-performance-metric-capitation-pmpm"> </a></td><td>Capitation per member per month</td><td>Capitation per member per month (PMPM). Capitation is a fixed amount of money per patient per month paid in advance to the physician [or health care provider] for the delivery of health care services.</td></tr><tr><td style="white-space:nowrap">dental-capitation<a name="vbp-performance-metric-dental-capitation"> </a></td><td>Dental capitation</td><td>Total dental capitation.</td></tr><tr><td style="white-space:nowrap">dental-capitation-pmpm<a name="vbp-performance-metric-dental-capitation-pmpm"> </a></td><td>Dental capitation PMPM</td><td>Total dental capitation per member per month (PMPM).</td></tr><tr><td style="white-space:nowrap">reinsurance-capitation<a name="vbp-performance-metric-reinsurance-capitation"> </a></td><td>Reinsurance capitation</td><td>Total reinsurance capitation.</td></tr><tr><td style="white-space:nowrap">reinsurance-capitation-pmpm<a name="vbp-performance-metric-reinsurance-capitation-pmpm"> </a></td><td>Reinsurance capitation PMPM</td><td>Reinsurance captitation per member per month (PMPM).</td></tr><tr><td style="white-space:nowrap">ccf<a name="vbp-performance-metric-ccf"> </a></td><td>Care coordination fee</td><td>Care coordination fee (CCF) is per member per payments based on the number of patients that are assigned to primary care physicians.</td></tr><tr><td style="white-space:nowrap">goal-hcc-raf<a name="vbp-performance-metric-goal-hcc-raf"> </a></td><td>Goal HCC RAF</td><td>Goal or target hierarchical condition category (HCC) Risk Adjustment Factor (RAF).</td></tr><tr><td style="white-space:nowrap">actual-hcc-raf<a name="vbp-performance-metric-actual-hcc-raf"> </a></td><td>Actual HCC RAF</td><td>Acutal hierarchical condition category (HCC) Risk Adjustment Factor (RAF).</td></tr><tr><td style="white-space:nowrap">earnings-ccf<a name="vbp-performance-metric-earnings-ccf"> </a></td><td>Earnings CCF</td><td>Earnings from care coordination fees.</td></tr><tr><td style="white-space:nowrap">performance-ccf<a name="vbp-performance-metric-performance-ccf"> </a></td><td>Performance CCF</td><td>Performance for care coordination fees.</td></tr><tr><td style="white-space:nowrap">potential-upside-ccf<a name="vbp-performance-metric-potential-upside-ccf"> </a></td><td>Potential upside CCF</td><td>Potential upside earnings for care coordination fees.</td></tr><tr><td style="white-space:nowrap">potential-downside-ccf<a name="vbp-performance-metric-potential-downside-ccf"> </a></td><td>Potential downside CCF</td><td>Potential downside earnings for care coordination fees.</td></tr><tr><td style="white-space:nowrap">earned-incentive<a name="vbp-performance-metric-earned-incentive"> </a></td><td>Earned incentive</td><td>Earned incentive payment.</td></tr><tr><td style="white-space:nowrap">earnings-qip<a name="vbp-performance-metric-earnings-qip"> </a></td><td>Earnings QIP</td><td>Earnings from quality incentive payments.</td></tr><tr><td style="white-space:nowrap">performance-qip<a name="vbp-performance-metric-performance-qip"> </a></td><td>Performance QIP</td><td>Performance for quality incentive payments.</td></tr><tr><td style="white-space:nowrap">potential-upside-qip<a name="vbp-performance-metric-potential-upside-qip"> </a></td><td>Potential upside QIP</td><td>Potential upside earnings for quality incentive payments.</td></tr><tr><td style="white-space:nowrap">potential-downside-qip<a name="vbp-performance-metric-potential-downside-qip"> </a></td><td>Potential downside QIP</td><td>Potential downside earnings for quality incentive payments.</td></tr><tr><td style="white-space:nowrap">earnings-ssl<a name="vbp-performance-metric-earnings-ssl"> </a></td><td>Earnings SSL</td><td>Earnings from shared savings surplus/loss.</td></tr><tr><td style="white-space:nowrap">performance-ssl<a name="vbp-performance-metric-performance-ssl"> </a></td><td>performance SSL</td><td>Performance for shared savings surplus/loss.</td></tr><tr><td style="white-space:nowrap">potential-upside-ssl<a name="vbp-performance-metric-potential-upside-ssl"> </a></td><td>Potential upside SSL</td><td>Potential upside earnings for shared savings surplus/loss.</td></tr><tr><td style="white-space:nowrap">potential-downside-ssl<a name="vbp-performance-metric-potential-downside-ssl"> </a></td><td>potential downside SSL</td><td>Potential downside earnings for shared savings surplus/loss.</td></tr><tr><td style="white-space:nowrap">earnings-cap<a name="vbp-performance-metric-earnings-cap"> </a></td><td>Earnings capitated</td><td>Earnings from capitated payments.</td></tr><tr><td style="white-space:nowrap">performance-cap<a name="vbp-performance-metric-performance-cap"> </a></td><td>Performance capitated</td><td>Performance for capitated payments.</td></tr><tr><td style="white-space:nowrap">potential-upside-cap<a name="vbp-performance-metric-potential-upside-cap"> </a></td><td>Potential upside capitated</td><td>Potential upside earnings from capitated payments.</td></tr><tr><td style="white-space:nowrap">potential-downside-cap<a name="vbp-performance-metric-potential-downside-cap"> </a></td><td>Potential downside capitated</td><td>Potential downside earnings for capitated payments.</td></tr><tr><td style="white-space:nowrap">quality-gate-percentage<a name="vbp-performance-metric-quality-gate-percentage"> </a></td><td>Quality gate percentage</td><td>% of payment tied to quality.</td></tr><tr><td style="white-space:nowrap">quality-gate-performance-percentage<a name="vbp-performance-metric-quality-gate-performance-percentage"> </a></td><td>Quality gate performance percentage</td><td>% of shared savings can earn based on quality metric performance.</td></tr><tr><td style="white-space:nowrap">interim-pmt-rate<a name="vbp-performance-metric-interim-pmt-rate"> </a></td><td>Interim payment rate</td><td>Interim payment rate.</td></tr><tr><td style="white-space:nowrap">ibnr-pmpm<a name="vbp-performance-metric-ibnr-pmpm"> </a></td><td>IBNR PMPM</td><td>Incurred but not yet reported (IBNR) per member per month (PMPM).</td></tr><tr><td style="white-space:nowrap">med-ibnr<a name="vbp-performance-metric-med-ibnr"> </a></td><td>Medical IBNR</td><td>Estimated medical expenses incurred but not yet reported (IBNR).</td></tr><tr><td style="white-space:nowrap">rx-ibnr<a name="vbp-performance-metric-rx-ibnr"> </a></td><td>Pharmacy IBNR</td><td>Estimated pharmacy expenses incurred but not yet reported (IBNR).</td></tr><tr><td style="white-space:nowrap">med-rx-ibnr<a name="vbp-performance-metric-med-rx-ibnr"> </a></td><td>Medical pharmacy IBNR</td><td>Estimated medical and pharmacy expenses incurred but not yet reported (IBNR).</td></tr><tr><td style="white-space:nowrap">revenue<a name="vbp-performance-metric-revenue"> </a></td><td>Revenue</td><td>Total revenues earned, which includes premiums and other resources that a payer receives.</td></tr><tr><td style="white-space:nowrap">revenue-pmpm<a name="vbp-performance-metric-revenue-pmpm"> </a></td><td>Revenue PMPM</td><td>Revenue earned per member per month (PMPM).</td></tr><tr><td style="white-space:nowrap">avg-revenue-pmpm-market<a name="vbp-performance-metric-avg-revenue-pmpm-market"> </a></td><td>Market average revenue PMPM</td><td>Average revenue per member per month (PMPM) for a market.</td></tr><tr><td style="white-space:nowrap">cost-target<a name="vbp-performance-metric-cost-target"> </a></td><td>Cost target</td><td>Cost target.</td></tr><tr><td style="white-space:nowrap">admin-cost<a name="vbp-performance-metric-admin-cost"> </a></td><td>Administrative cost</td><td>A general term that refers to Medicare and Medicaid administrative costs, as well as CMS administrative costs. Medicare administrative costs are comprised of the Medicare related outlays and non-CMS administrative outlays. Medicaid administrative costs refer to the Federal share of the States' expenditures for administration of the Medicaid program. CMS administrative costs are the costs of operating CMS (e.g., salaries and expenses, facilities, equipment, rent and utilities, etc.). These costs are reflected in the Program Management account.</td></tr><tr><td style="white-space:nowrap">rx-cost<a name="vbp-performance-metric-rx-cost"> </a></td><td>Pharmacy cost</td><td>Total amount of the pharmacy cost.</td></tr><tr><td style="white-space:nowrap">rx-cost-target<a name="vbp-performance-metric-rx-cost-target"> </a></td><td>Pharmacy cost target</td><td>The goal or target pharmacy spend level as specified by a value-based contract below which savings are generated, often represented as a percent of total revenue.</td></tr><tr><td style="white-space:nowrap">rx-cost-pmpm<a name="vbp-performance-metric-rx-cost-pmpm"> </a></td><td>Pharmacy cost PMPM</td><td>Pharmacy cost per member per month (PMPM).</td></tr><tr><td style="white-space:nowrap">rx-cost-pmpm-target<a name="vbp-performance-metric-rx-cost-pmpm-target"> </a></td><td>Pharmacy cost PMPM target</td><td>The goal or target pharmacy spend level per member per month (PMPM) as specified by a value-based contract below which savings are generated, often represented as a percent of total revenue.</td></tr><tr><td style="white-space:nowrap">med-cost<a name="vbp-performance-metric-med-cost"> </a></td><td>Medical cost</td><td>Total amount of the medical cost.</td></tr><tr><td style="white-space:nowrap">med-cost-target<a name="vbp-performance-metric-med-cost-target"> </a></td><td>Medical cost target</td><td>The goal or target medical spend level as specified by a value-based contract below which savings are generated, often represented as a percent of total revenue.</td></tr><tr><td style="white-space:nowrap">med-cost-pmpm<a name="vbp-performance-metric-med-cost-pmpm"> </a></td><td>Medical cost PMPM</td><td>Medical cost per member per month (PMPM).</td></tr><tr><td style="white-space:nowrap">med-cost-pmpm-target<a name="vbp-performance-metric-med-cost-pmpm-target"> </a></td><td>Medical cost PMPM target</td><td>The goal or target medical cost per member per month (PMPM).</td></tr><tr><td style="white-space:nowrap">med-cost-fund<a name="vbp-performance-metric-med-cost-fund"> </a></td><td>Medical cost fund</td><td>Total dollars available for medical spend calculated using the medical cost target relative to estimated revenue.</td></tr><tr><td style="white-space:nowrap">avg-med-cost-fund-market<a name="vbp-performance-metric-avg-med-cost-fund-market"> </a></td><td>Market average medical cost fund</td><td>The market average medical cost per member per month (PMPM) over revenue PMPM.</td></tr><tr><td style="white-space:nowrap">med-rx-cost<a name="vbp-performance-metric-med-rx-cost"> </a></td><td>Medical pharmacy cost</td><td>Total spend on medical and pharmacy cost for a specified population.</td></tr><tr><td style="white-space:nowrap">med-rx-cost-target<a name="vbp-performance-metric-med-rx-cost-target"> </a></td><td>Medical pharmacy cost target</td><td>Target spend on medical and pharmacy cost for a specified population.</td></tr><tr><td style="white-space:nowrap">med-rx-cost-pmpm<a name="vbp-performance-metric-med-rx-cost-pmpm"> </a></td><td>Medical pharmacy cost PMPM</td><td>Total spend on pharmacy cost for a specified population represented on a per member per month (PMPM) basis.</td></tr><tr><td style="white-space:nowrap">avg-med-rx-cost-pmpm-market<a name="vbp-performance-metric-avg-med-rx-cost-pmpm-market"> </a></td><td>Market average medical pharmacy cost PMPM</td><td>The market average medical pharmacy cost per member per month (PMPM).</td></tr><tr><td style="white-space:nowrap">variance-cost<a name="vbp-performance-metric-variance-cost"> </a></td><td>Variance cost</td><td>How much actual costs vary from projected (target) costs.</td></tr><tr><td style="white-space:nowrap">med-loss-ratio<a name="vbp-performance-metric-med-loss-ratio"> </a></td><td>Medical loss ratio</td><td>The Medical Loss Ratio (MLR) is the proportion of premium revenues spent on clinical services and quality improvement.</td></tr><tr><td style="white-space:nowrap">med-loss-ratio-target<a name="vbp-performance-metric-med-loss-ratio-target"> </a></td><td>Medical loss ratio target</td><td>The goal or target medical spend level relative to revenue as specified in a value-based care contract, often represented as a percent of revenue.</td></tr><tr><td style="white-space:nowrap">med-expense-ratio<a name="vbp-performance-metric-med-expense-ratio"> </a></td><td>Medical expense ratio</td><td>Medical expense ratio.</td></tr><tr><td style="white-space:nowrap">med-expense-ratio-pmpm<a name="vbp-performance-metric-med-expense-ratio-pmpm"> </a></td><td>Medical expense ratio PMPM</td><td>Medical expense ratio per member per month (PMPM).</td></tr><tr><td style="white-space:nowrap">member-months<a name="vbp-performance-metric-member-months"> </a></td><td>Member months</td><td>Total member months in a given period.</td></tr><tr><td style="white-space:nowrap">med-member-months<a name="vbp-performance-metric-med-member-months"> </a></td><td>Medical member months</td><td>Total medical member months in a given period.</td></tr><tr><td style="white-space:nowrap">rx-member-months<a name="vbp-performance-metric-rx-member-months"> </a></td><td>Pharmacy member months</td><td>Total pharmacy member months in a given period.</td></tr><tr><td style="white-space:nowrap">adjusted-paid-claim<a name="vbp-performance-metric-adjusted-paid-claim"> </a></td><td>Adjusted paid claim</td><td>Adjusted paid claim, excludes catastrophic claims.</td></tr><tr><td style="white-space:nowrap">annual-care-visit-bonus<a name="vbp-performance-metric-annual-care-visit-bonus"> </a></td><td>Annual care visit bonus</td><td>Bonus to qualified annual care visit (ACV). A type of quality incentive payment.</td></tr><tr><td style="white-space:nowrap">avg-star-rating-bonus<a name="vbp-performance-metric-avg-star-rating-bonus"> </a></td><td>Average star rating bonus</td><td>Bonus earned when achieve a certain Average Star Rating. A type of quality incentive payment.</td></tr><tr><td style="white-space:nowrap">avg-star-rating-improvement-bonus<a name="vbp-performance-metric-avg-star-rating-improvement-bonus"> </a></td><td>Average star rating improvement bonus</td><td>Bonus earned when achieve improvement performance year over year based on average star rating. A type of quality incentive payment</td></tr><tr><td style="white-space:nowrap">quality-metric-performance-incentive<a name="vbp-performance-metric-quality-metric-performance-incentive"> </a></td><td>Quality metric performance incentive</td><td>Quality metric performance incentive payment is a type of quality incentive payment.</td></tr><tr><td style="white-space:nowrap">quality-pmt-chronic<a name="vbp-performance-metric-quality-pmt-chronic"> </a></td><td>Quality payment chronic disease management</td><td>Quality payment chronic disease management.</td></tr><tr><td style="white-space:nowrap">quality-pmt-office-visit<a name="vbp-performance-metric-quality-pmt-office-visit"> </a></td><td>Quality payment annual office visit</td><td>Quality payment annual office visit.</td></tr><tr><td style="white-space:nowrap">shared-saving-deficit<a name="vbp-performance-metric-shared-saving-deficit"> </a></td><td>Shared saving deficit</td><td>The amount of shared saving deficit.</td></tr><tr><td style="white-space:nowrap">weighted-avg-star<a name="vbp-performance-metric-weighted-avg-star"> </a></td><td>Weighted average star</td><td>The average quality score across a specified set of measures, weighted by importance of the individual measures for a specific population. Often used in relation to CMS Medicare Star rating reports, e.g., where medication adherence measures are 3x weighted relative to other quality measures in the set.</td></tr><tr><td style="white-space:nowrap">condition-count<a name="vbp-performance-metric-condition-count"> </a></td><td>Condition count</td><td>The number of conditions.</td></tr><tr><td style="white-space:nowrap">1-gap-closed<a name="vbp-performance-metric-1-gap-closed"> </a></td><td>1 gap closed</td><td>Number of members with 1 closed gap.</td></tr><tr><td style="white-space:nowrap">2-gap-closed<a name="vbp-performance-metric-2-gap-closed"> </a></td><td>2 gaps closed</td><td>Number of members with 2 closed gaps.</td></tr><tr><td style="white-space:nowrap">paid-claim<a name="vbp-performance-metric-paid-claim"> </a></td><td>Paid claim</td><td>Total paid claim amount.</td></tr><tr><td style="white-space:nowrap">paid-claim-pmpm<a name="vbp-performance-metric-paid-claim-pmpm"> </a></td><td>Paid claim PMPM</td><td>Paid claim per member per month (PMPM).</td></tr><tr><td style="white-space:nowrap">drg-expense<a name="vbp-performance-metric-drg-expense"> </a></td><td>DRG expense</td><td>Total diagnosis related group (DRG) expense.</td></tr><tr><td style="white-space:nowrap">drg-expense-pmpm<a name="vbp-performance-metric-drg-expense-pmpm"> </a></td><td>DRG expense PMPM</td><td>Diagnosis related group (DRG) expense per member per month (PMPM).</td></tr><tr><td style="white-space:nowrap">provider-quality-expense-pmpm<a name="vbp-performance-metric-provider-quality-expense-pmpm"> </a></td><td>Provider quality expense PMPM</td><td>Provider quality expense per member per month (PMPM).</td></tr><tr><td style="white-space:nowrap">subrogation-pmpm<a name="vbp-performance-metric-subrogation-pmpm"> </a></td><td>Subrogation PMPM</td><td>Subrogation per member per month (PMPM).</td></tr><tr><td style="white-space:nowrap">avg-member-office-visit<a name="vbp-performance-metric-avg-member-office-visit"> </a></td><td>Average members with office visit</td><td>Average number of members with office visit.</td></tr><tr><td style="white-space:nowrap">ed-visit<a name="vbp-performance-metric-ed-visit"> </a></td><td>ED visit</td><td>Total number of Emergency Department (ED) visits.</td></tr><tr><td style="white-space:nowrap">eligible-member<a name="vbp-performance-metric-eligible-member"> </a></td><td>Eligible members</td><td>Total number of eligible members.</td></tr><tr><td style="white-space:nowrap">inpatient-acute<a name="vbp-performance-metric-inpatient-acute"> </a></td><td>Inpatient acute</td><td>Total number of inpatient acute stays.</td></tr><tr><td style="white-space:nowrap">inpatient-admission<a name="vbp-performance-metric-inpatient-admission"> </a></td><td>Inpatient admission</td><td>Total number of inpatient admissions.</td></tr><tr><td style="white-space:nowrap">nurse-hotline<a name="vbp-performance-metric-nurse-hotline"> </a></td><td>Nurse hotline</td><td>Total number calls of the nurse hotline.</td></tr><tr><td style="white-space:nowrap">nurse-hotline-pmpm<a name="vbp-performance-metric-nurse-hotline-pmpm"> </a></td><td>Nurse hotline PMPM</td><td>Total nurse hotline per member per month (PMPM).</td></tr><tr><td style="white-space:nowrap">snf-avg-los<a name="vbp-performance-metric-snf-avg-los"> </a></td><td>Skilled Nursing Facility average length of stay</td><td>The number of skilled nursing facility average length of stay.</td></tr><tr><td style="white-space:nowrap">readmission<a name="vbp-performance-metric-readmission"> </a></td><td>Readmission</td><td>Total number of readmissions</td></tr><tr><td style="white-space:nowrap">snf-admission<a name="vbp-performance-metric-snf-admission"> </a></td><td>Skilled Nursing Facility admission</td><td>Total number of skilled nursing facility admissions.</td></tr><tr><td style="white-space:nowrap">provider-quality-expense<a name="vbp-performance-metric-provider-quality-expense"> </a></td><td>Provider quality expense</td><td>Total provider quality expense.</td></tr><tr><td style="white-space:nowrap">subrogation<a name="vbp-performance-metric-subrogation"> </a></td><td>Subrogation</td><td>Total subrogation amount.</td></tr><tr><td style="white-space:nowrap">avg-membership<a name="vbp-performance-metric-avg-membership"> </a></td><td>Average membership</td><td>Average membership.</td></tr></table></div>
</text>
<extension
url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
<valueCode value="cqi"/>
</extension>
<url
value="http://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metric"/>
<identifier>
<system value="urn:ietf:rfc:3986"/>
<value value="urn:oid:2.16.840.1.113883.4.642.40.30.16.9"/>
</identifier>
<version value="1.0.0"/>
<name value="VbpPerformanceMetricsCS"/>
<title value="Performance Metric Codes"/>
<status value="active"/>
<experimental value="false"/>
<date value="2024-06-12T03:00:05+00:00"/>
<publisher value="HL7 International / Clinical Quality Information"/>
<contact>
<name value="HL7 International / Clinical Quality Information"/>
<telecom>
<system value="url"/>
<value value="http://www.hl7.org/Special/committees/cqi"/>
</telecom>
</contact>
<description value="Type of value-based performance metrics."/>
<jurisdiction>
<coding>
<system value="urn:iso:std:iso:3166"/>
<code value="US"/>
<display value="United States of America"/>
</coding>
</jurisdiction>
<caseSensitive value="true"/>
<content value="complete"/>
<count value="93"/>
<concept>
<code value="avg-risk-score"/>
<display value="Average risk score"/>
<definition
value="Average risk score is a numeric score where a higher score indicates a riskier population on average. Example scores: 0.70, 1.00, 1.30."/>
</concept>
<concept>
<code value="avg-risk-score-market"/>
<display value="Market average risk score"/>
<definition value="The market average risk score."/>
</concept>
<concept>
<code value="capitation"/>
<display value="Capitation"/>
<definition value="Total capitation amount."/>
</concept>
<concept>
<code value="capitation-pmpm"/>
<display value="Capitation per member per month"/>
<definition
value="Capitation per member per month (PMPM). Capitation is a fixed amount of money per patient per month paid in advance to the physician [or health care provider] for the delivery of health care services."/>
</concept>
<concept>
<code value="dental-capitation"/>
<display value="Dental capitation"/>
<definition value="Total dental capitation."/>
</concept>
<concept>
<code value="dental-capitation-pmpm"/>
<display value="Dental capitation PMPM"/>
<definition value="Total dental capitation per member per month (PMPM)."/>
</concept>
<concept>
<code value="reinsurance-capitation"/>
<display value="Reinsurance capitation"/>
<definition value="Total reinsurance capitation."/>
</concept>
<concept>
<code value="reinsurance-capitation-pmpm"/>
<display value="Reinsurance capitation PMPM"/>
<definition value="Reinsurance captitation per member per month (PMPM)."/>
</concept>
<concept>
<code value="ccf"/>
<display value="Care coordination fee"/>
<definition
value="Care coordination fee (CCF) is per member per payments based on the number of patients that are assigned to primary care physicians."/>
</concept>
<concept>
<code value="goal-hcc-raf"/>
<display value="Goal HCC RAF"/>
<definition
value="Goal or target hierarchical condition category (HCC) Risk Adjustment Factor (RAF)."/>
</concept>
<concept>
<code value="actual-hcc-raf"/>
<display value="Actual HCC RAF"/>
<definition
value="Acutal hierarchical condition category (HCC) Risk Adjustment Factor (RAF)."/>
</concept>
<concept>
<code value="earnings-ccf"/>
<display value="Earnings CCF"/>
<definition value="Earnings from care coordination fees."/>
</concept>
<concept>
<code value="performance-ccf"/>
<display value="Performance CCF"/>
<definition value="Performance for care coordination fees."/>
</concept>
<concept>
<code value="potential-upside-ccf"/>
<display value="Potential upside CCF"/>
<definition
value="Potential upside earnings for care coordination fees."/>
</concept>
<concept>
<code value="potential-downside-ccf"/>
<display value="Potential downside CCF"/>
<definition
value="Potential downside earnings for care coordination fees."/>
</concept>
<concept>
<code value="earned-incentive"/>
<display value="Earned incentive"/>
<definition value="Earned incentive payment."/>
</concept>
<concept>
<code value="earnings-qip"/>
<display value="Earnings QIP"/>
<definition value="Earnings from quality incentive payments."/>
</concept>
<concept>
<code value="performance-qip"/>
<display value="Performance QIP"/>
<definition value="Performance for quality incentive payments."/>
</concept>
<concept>
<code value="potential-upside-qip"/>
<display value="Potential upside QIP"/>
<definition
value="Potential upside earnings for quality incentive payments."/>
</concept>
<concept>
<code value="potential-downside-qip"/>
<display value="Potential downside QIP"/>
<definition
value="Potential downside earnings for quality incentive payments."/>
</concept>
<concept>
<code value="earnings-ssl"/>
<display value="Earnings SSL"/>
<definition value="Earnings from shared savings surplus/loss."/>
</concept>
<concept>
<code value="performance-ssl"/>
<display value="performance SSL"/>
<definition value="Performance for shared savings surplus/loss."/>
</concept>
<concept>
<code value="potential-upside-ssl"/>
<display value="Potential upside SSL"/>
<definition
value="Potential upside earnings for shared savings surplus/loss."/>
</concept>
<concept>
<code value="potential-downside-ssl"/>
<display value="potential downside SSL"/>
<definition
value="Potential downside earnings for shared savings surplus/loss."/>
</concept>
<concept>
<code value="earnings-cap"/>
<display value="Earnings capitated"/>
<definition value="Earnings from capitated payments."/>
</concept>
<concept>
<code value="performance-cap"/>
<display value="Performance capitated"/>
<definition value="Performance for capitated payments."/>
</concept>
<concept>
<code value="potential-upside-cap"/>
<display value="Potential upside capitated"/>
<definition value="Potential upside earnings from capitated payments."/>
</concept>
<concept>
<code value="potential-downside-cap"/>
<display value="Potential downside capitated"/>
<definition value="Potential downside earnings for capitated payments."/>
</concept>
<concept>
<code value="quality-gate-percentage"/>
<display value="Quality gate percentage"/>
<definition value="% of payment tied to quality."/>
</concept>
<concept>
<code value="quality-gate-performance-percentage"/>
<display value="Quality gate performance percentage"/>
<definition
value="% of shared savings can earn based on quality metric performance."/>
</concept>
<concept>
<code value="interim-pmt-rate"/>
<display value="Interim payment rate"/>
<definition value="Interim payment rate."/>
</concept>
<concept>
<code value="ibnr-pmpm"/>
<display value="IBNR PMPM"/>
<definition
value="Incurred but not yet reported (IBNR) per member per month (PMPM)."/>
</concept>
<concept>
<code value="med-ibnr"/>
<display value="Medical IBNR"/>
<definition
value="Estimated medical expenses incurred but not yet reported (IBNR)."/>
</concept>
<concept>
<code value="rx-ibnr"/>
<display value="Pharmacy IBNR"/>
<definition
value="Estimated pharmacy expenses incurred but not yet reported (IBNR)."/>
</concept>
<concept>
<code value="med-rx-ibnr"/>
<display value="Medical pharmacy IBNR"/>
<definition
value="Estimated medical and pharmacy expenses incurred but not yet reported (IBNR)."/>
</concept>
<concept>
<code value="revenue"/>
<display value="Revenue"/>
<definition
value="Total revenues earned, which includes premiums and other resources that a payer receives."/>
</concept>
<concept>
<code value="revenue-pmpm"/>
<display value="Revenue PMPM"/>
<definition value="Revenue earned per member per month (PMPM)."/>
</concept>
<concept>
<code value="avg-revenue-pmpm-market"/>
<display value="Market average revenue PMPM"/>
<definition
value="Average revenue per member per month (PMPM) for a market."/>
</concept>
<concept>
<code value="cost-target"/>
<display value="Cost target"/>
<definition value="Cost target."/>
</concept>
<concept>
<code value="admin-cost"/>
<display value="Administrative cost"/>
<definition
value="A general term that refers to Medicare and Medicaid administrative costs, as well as CMS administrative costs. Medicare administrative costs are comprised of the Medicare related outlays and non-CMS administrative outlays. Medicaid administrative costs refer to the Federal share of the States' expenditures for administration of the Medicaid program. CMS administrative costs are the costs of operating CMS (e.g., salaries and expenses, facilities, equipment, rent and utilities, etc.). These costs are reflected in the Program Management account."/>
</concept>
<concept>
<code value="rx-cost"/>
<display value="Pharmacy cost"/>
<definition value="Total amount of the pharmacy cost."/>
</concept>
<concept>
<code value="rx-cost-target"/>
<display value="Pharmacy cost target"/>
<definition
value="The goal or target pharmacy spend level as specified by a value-based contract below which savings are generated, often represented as a percent of total revenue."/>
</concept>
<concept>
<code value="rx-cost-pmpm"/>
<display value="Pharmacy cost PMPM"/>
<definition value="Pharmacy cost per member per month (PMPM)."/>
</concept>
<concept>
<code value="rx-cost-pmpm-target"/>
<display value="Pharmacy cost PMPM target"/>
<definition
value="The goal or target pharmacy spend level per member per month (PMPM) as specified by a value-based contract below which savings are generated, often represented as a percent of total revenue."/>
</concept>
<concept>
<code value="med-cost"/>
<display value="Medical cost"/>
<definition value="Total amount of the medical cost."/>
</concept>
<concept>
<code value="med-cost-target"/>
<display value="Medical cost target"/>
<definition
value="The goal or target medical spend level as specified by a value-based contract below which savings are generated, often represented as a percent of total revenue."/>
</concept>
<concept>
<code value="med-cost-pmpm"/>
<display value="Medical cost PMPM"/>
<definition value="Medical cost per member per month (PMPM)."/>
</concept>
<concept>
<code value="med-cost-pmpm-target"/>
<display value="Medical cost PMPM target"/>
<definition
value="The goal or target medical cost per member per month (PMPM)."/>
</concept>
<concept>
<code value="med-cost-fund"/>
<display value="Medical cost fund"/>
<definition
value="Total dollars available for medical spend calculated using the medical cost target relative to estimated revenue."/>
</concept>
<concept>
<code value="avg-med-cost-fund-market"/>
<display value="Market average medical cost fund"/>
<definition
value="The market average medical cost per member per month (PMPM) over revenue PMPM."/>
</concept>
<concept>
<code value="med-rx-cost"/>
<display value="Medical pharmacy cost"/>
<definition
value="Total spend on medical and pharmacy cost for a specified population."/>
</concept>
<concept>
<code value="med-rx-cost-target"/>
<display value="Medical pharmacy cost target"/>
<definition
value="Target spend on medical and pharmacy cost for a specified population."/>
</concept>
<concept>
<code value="med-rx-cost-pmpm"/>
<display value="Medical pharmacy cost PMPM"/>
<definition
value="Total spend on pharmacy cost for a specified population represented on a per member per month (PMPM) basis."/>
</concept>
<concept>
<code value="avg-med-rx-cost-pmpm-market"/>
<display value="Market average medical pharmacy cost PMPM"/>
<definition
value="The market average medical pharmacy cost per member per month (PMPM)."/>
</concept>
<concept>
<code value="variance-cost"/>
<display value="Variance cost"/>
<definition
value="How much actual costs vary from projected (target) costs."/>
</concept>
<concept>
<code value="med-loss-ratio"/>
<display value="Medical loss ratio"/>
<definition
value="The Medical Loss Ratio (MLR) is the proportion of premium revenues spent on clinical services and quality improvement."/>
</concept>
<concept>
<code value="med-loss-ratio-target"/>
<display value="Medical loss ratio target"/>
<definition
value="The goal or target medical spend level relative to revenue as specified in a value-based care contract, often represented as a percent of revenue."/>
</concept>
<concept>
<code value="med-expense-ratio"/>
<display value="Medical expense ratio"/>
<definition value="Medical expense ratio."/>
</concept>
<concept>
<code value="med-expense-ratio-pmpm"/>
<display value="Medical expense ratio PMPM"/>
<definition value="Medical expense ratio per member per month (PMPM)."/>
</concept>
<concept>
<code value="member-months"/>
<display value="Member months"/>
<definition value="Total member months in a given period."/>
</concept>
<concept>
<code value="med-member-months"/>
<display value="Medical member months"/>
<definition value="Total medical member months in a given period."/>
</concept>
<concept>
<code value="rx-member-months"/>
<display value="Pharmacy member months"/>
<definition value="Total pharmacy member months in a given period."/>
</concept>
<concept>
<code value="adjusted-paid-claim"/>
<display value="Adjusted paid claim"/>
<definition value="Adjusted paid claim, excludes catastrophic claims."/>
</concept>
<concept>
<code value="annual-care-visit-bonus"/>
<display value="Annual care visit bonus"/>
<definition
value="Bonus to qualified annual care visit (ACV). A type of quality incentive payment."/>
</concept>
<concept>
<code value="avg-star-rating-bonus"/>
<display value="Average star rating bonus"/>
<definition
value="Bonus earned when achieve a certain Average Star Rating. A type of quality incentive payment."/>
</concept>
<concept>
<code value="avg-star-rating-improvement-bonus"/>
<display value="Average star rating improvement bonus"/>
<definition
value="Bonus earned when achieve improvement performance year over year based on average star rating. A type of quality incentive payment"/>
</concept>
<concept>
<code value="quality-metric-performance-incentive"/>
<display value="Quality metric performance incentive"/>
<definition
value="Quality metric performance incentive payment is a type of quality incentive payment."/>
</concept>
<concept>
<code value="quality-pmt-chronic"/>
<display value="Quality payment chronic disease management"/>
<definition value="Quality payment chronic disease management."/>
</concept>
<concept>
<code value="quality-pmt-office-visit"/>
<display value="Quality payment annual office visit"/>
<definition value="Quality payment annual office visit."/>
</concept>
<concept>
<code value="shared-saving-deficit"/>
<display value="Shared saving deficit"/>
<definition value="The amount of shared saving deficit."/>
</concept>
<concept>
<code value="weighted-avg-star"/>
<display value="Weighted average star"/>
<definition
value="The average quality score across a specified set of measures, weighted by importance of the individual measures for a specific population. Often used in relation to CMS Medicare Star rating reports, e.g., where medication adherence measures are 3x weighted relative to other quality measures in the set."/>
</concept>
<concept>
<code value="condition-count"/>
<display value="Condition count"/>
<definition value="The number of conditions."/>
</concept>
<concept>
<code value="1-gap-closed"/>
<display value="1 gap closed"/>
<definition value="Number of members with 1 closed gap."/>
</concept>
<concept>
<code value="2-gap-closed"/>
<display value="2 gaps closed"/>
<definition value="Number of members with 2 closed gaps."/>
</concept>
<concept>
<code value="paid-claim"/>
<display value="Paid claim"/>
<definition value="Total paid claim amount."/>
</concept>
<concept>
<code value="paid-claim-pmpm"/>
<display value="Paid claim PMPM"/>
<definition value="Paid claim per member per month (PMPM)."/>
</concept>
<concept>
<code value="drg-expense"/>
<display value="DRG expense"/>
<definition value="Total diagnosis related group (DRG) expense."/>
</concept>
<concept>
<code value="drg-expense-pmpm"/>
<display value="DRG expense PMPM"/>
<definition
value="Diagnosis related group (DRG) expense per member per month (PMPM)."/>
</concept>
<concept>
<code value="provider-quality-expense-pmpm"/>
<display value="Provider quality expense PMPM"/>
<definition
value="Provider quality expense per member per month (PMPM)."/>
</concept>
<concept>
<code value="subrogation-pmpm"/>
<display value="Subrogation PMPM"/>
<definition value="Subrogation per member per month (PMPM)."/>
</concept>
<concept>
<code value="avg-member-office-visit"/>
<display value="Average members with office visit"/>
<definition value="Average number of members with office visit."/>
</concept>
<concept>
<code value="ed-visit"/>
<display value="ED visit"/>
<definition value="Total number of Emergency Department (ED) visits."/>
</concept>
<concept>
<code value="eligible-member"/>
<display value="Eligible members"/>
<definition value="Total number of eligible members."/>
</concept>
<concept>
<code value="inpatient-acute"/>
<display value="Inpatient acute"/>
<definition value="Total number of inpatient acute stays."/>
</concept>
<concept>
<code value="inpatient-admission"/>
<display value="Inpatient admission"/>
<definition value="Total number of inpatient admissions."/>
</concept>
<concept>
<code value="nurse-hotline"/>
<display value="Nurse hotline"/>
<definition value="Total number calls of the nurse hotline."/>
</concept>
<concept>
<code value="nurse-hotline-pmpm"/>
<display value="Nurse hotline PMPM"/>
<definition value="Total nurse hotline per member per month (PMPM)."/>
</concept>
<concept>
<code value="snf-avg-los"/>
<display value="Skilled Nursing Facility average length of stay"/>
<definition
value="The number of skilled nursing facility average length of stay."/>
</concept>
<concept>
<code value="readmission"/>
<display value="Readmission"/>
<definition value="Total number of readmissions"/>
</concept>
<concept>
<code value="snf-admission"/>
<display value="Skilled Nursing Facility admission"/>
<definition value="Total number of skilled nursing facility admissions."/>
</concept>
<concept>
<code value="provider-quality-expense"/>
<display value="Provider quality expense"/>
<definition value="Total provider quality expense."/>
</concept>
<concept>
<code value="subrogation"/>
<display value="Subrogation"/>
<definition value="Total subrogation amount."/>
</concept>
<concept>
<code value="avg-membership"/>
<display value="Average membership"/>
<definition value="Average membership."/>
</concept>
</CodeSystem>
IG © 2023+ HL7 International / Clinical Quality Information. Package hl7.fhir.us.davinci-vbpr#1.0.0 based on FHIR 4.0.1. Generated 2024-06-12
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