Provider Central

This monthly report can help groups identify individual patients who, according to claims data, have not had a certain test or exam. It contains member-specific information for all ambulatory quality measures. Many groups use this data to populate registries.

This report includes blinded data that enables groups to compare their performance to similar groups and to the group's own prior year performance.

This report can help groups identify the status of their patients who have been contacted by Blue Cross to enroll in our care management programs. This report may help groups to identify their high-risk patients and patients who have declined to participate in our programs.

These reports provide a census of the group’s patients in any hospital, approved authorizations for services, and referrals to specialists. They can also help your group identify leakage, detect inappropriate referral patterns, and engage your patients in discharge planning.

How to Use this Report (Online Training, 8 mins)

This report lists members with one or more of the following five conditions: asthma, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), coronary artery disease (CAD), and diabetes. When a member is identified with one or more of these conditions, the information will be shared with the group so the group can then determine if the member needs to be followed more closely by the group’s health care team. Members identified in these reports will not be followed by our chronic condition management programs.

How to Use this Report (Online Training, 5 mins)

This report compares captured Hierarchical Condition Categories within your organization to the Blue Cross network across two CMS-HCC models (ESRD V24 and Community, NonDual, Aged V28). Additional data elements like HCC weights and chronic vs. non-chronic HCC flags are included to help discern recapture or risk score trends and provide high level information about the disease prevalence of your patients.

These reports can help groups understand the following: utilization variances from network averages; year-over-year utilization and medical expense trends; and potential pharmacy, site-of-service, imaging, and care management opportunities.

It may include the following tabs or components:

• Medical Expense and Trend Report
• Inpatient Retention – All Admissions
• Inpatient Retention – Behavioral Health
• Inpatient Retention – Med/Surgical
• Inpatient Retention – Maternity
• Inpatient Retention – Pediatric
• Inpatient Retention – SNF/Rehab
• Outpatient Retention – All services
• Outpatient Retention – Surgical
• Outpatient Retention – Radiology
• Outpatient Retention – Lab
• High-Cost Member Report
• Stop-Loss Report (if applicable)
• High-Tech Radiology Report

How to Use this Report (online training, 8 mins)

Emergency Department (ED) Utilization

This weekly report shows members who were in the emergency department (ED) in the previous weeks, what hospital the member visited, what their diagnoses were, if they were admitted or not, and if the member had previous ED visits within the last six months.

How to Use this Report (online training, 4 mins)

This report provides a snapshot of a group's overall expenses compared to budget, according to the group's contractual terms.

This report displays HCCs recaptured in the current year compared to prior year, at the PCP and patient level. Recaptured HCCs are further broken down by those recaptured by the provider organization or any provider (also called all claims).

The MAO-004 is a monthly file that informs Medicare Advantage Organizations (MAOs) about the risk adjustment eligibility of diagnosis data they have submitted on Encounter Data Records (EDRs) and Chart Review Records (CRRs). It serves as a receipt, informing the health plan which diagnoses were accepted by the CMS Encounter Data System (EDS) in the previous month.

This quarterly report helps provider groups look at medication possession ratios (MPRs) across several chronic conditions. MPR is the percent of the time a patient has access to medication. The report includes summary information, information identifying members in multiple therapeutic groups, and member detail MPR information for oral antidiabetics, antihyperlipidemics, antihypertensives, and antidepressants.

This report shows which members which members are included in the denominator of each quality measure, and which have not received the measured service or test. We recommend that you review the Member Management report before reaching out to patients to be sure that all additional tests a patient may need are addressed at one time. Please note that Well Child Visits are not included in the Member Management report due to high volume.

The MOR shows the final result of the risk adjustment process, detailing exactly which HCCs were used to calculate a beneficiary’s risk score for a specific period. Risk score data is updated three times per measurement year in accordance with CMS’ initial, mid-year, and final sweeps. The MOR reflects the application of HCC hierarchies, where only the most severe diagnosis in a related disease family is used for the risk score. For this reason, a diagnosis that was accepted in the MAO-004 file may not appear in the MOR if a more severe, related diagnoses was also present.

This report provides comprehensive patient level detail, breaking down HCCs into specific ICD-10-CM diagnoses that have been reported on claims and clarifying whether they have been accepted by CMS for risk adjustment calculations in the current measurement year. Columns displaying most recent Annual Well Visit, Physical Exam, and Office Visit dates are included to assist in scheduling and informing which diagnoses should be considered for assessment at the patient’s next visit. This report will be distributed in excel and text flat file formats.

This report displays provider organization, member and PCP-level risk score, and member’s premium information based on current hospice or end-stage renal disease (ESRD) status, and Risk Adjustment Factor Type.

The exhibit compares your organization’s HCC recapture rates, well visit rates, and risk score data across three time periods: calendar year to date, performance year to date, and performance year final. Additional data elements like percent of New-to-Medicare enrollees and Risk Score breakdowns are included to help discern recapture or risk score trends and provide high level information about risk adjustment key performance indicators for your patients.

This report includes information about specialty and non-specialty pharmacy costs, utilization, and trends. It includes network benchmarks.