Shared funding: Network/Benefit Summary guide

Use this monthly report to gauge operational and provider network performance as well as utilization patterns. All claim and utilization trend information is year-to-date. We'll help you use this tool to design future benefit plans that meet your needs.

Network Performance & Benefit Design Summary at-a-glance

This report shows you:

• Where every claim dollar has been spent, with a summary and description of all claims submitted and paid
• How you're saving money with our network discounts
• In-network utilization vs. out-of-network utilization
• The types of services your employees are receiving and which providers they’re seeing
• Your employees' out-of-pocket costs
• How we're saving you money through cost containment initiatives, including:
  
  • Coordination of Benefits
  • Clinical code edits such as subset of a claim already paid or duplicate service coded incorrectly
  • Benefit limits and exclusions
  • Health management authorizations

Walk through the Network Performance & Benefit Design Summary

Terms

• Submitted charges - Amount charged by provider of health care services
• Cost containment - Programs administered by Priority Health to reduce your costs
• Approved charges - Amounts Priority Health will pay based on contract agreements
• Network discount - The discount we’ve negotiated with a provider and passed on to you and our members
• Net approved amount - Submitted charges less cost containment discount and employee liability/cost sharing
• COB - Coordination of benefits with other payers
• PEPM - Per employee per month
• Member liability/member cost share - Amount member is responsible for paying on this claim
• Facility claims - All claims billed on a facility claims form (UB-92). These claims are submitted by a skilled nursing, mental health, rehab or acute care facility (i.e. hospital).
• Professional claims - All claims billed on a professional claims form (HCFA 1500). These claims are from a physician or ancillary provider such as laboratory, anesthesiology or x-ray.
• Pharmacy claims - All claims billed by a retail pharmacy

Points to consider

Network discount (page 2)

An overview of how we calculate and report network discounts:

1. Savings percentage is based on the difference between allowable and paid claims
2. Discounts totals are reported by network and as a combined total

Network usage (page 3)

An overview of how we calculate and report network usage:

1. Includes data for paid medical claims only
2. All contracted networks are represented on this report

Member cost sharing

Understanding utilization levels for employees, spouses and dependent children can help you formulate eligibility, contribution guidelines and cost sharing design. Here's how we calculate cost sharing:

1. Data is based on paid claims
2. Data represents member out-of-pocket claims vs. those paid by Priority Health

Cost containment

This report does not include adjusted claim amounts. (For example, if a claim is closed because an employee didn't respond to a request for accident information but the claim was subsequently paid, we did not include the original amount that was not covered in this report.)

Benefit utilization

Seeing the breakdown of which types of benefits your employees are using can help you decide about plan benefits in coming years and identify potential overuse of certain services, like emergency room visits.


Call your account manager with questions about terms and calculations.