Provider Utilization Help Document
*Please note that all screenshots in this document are mock-ups used for training purposes and do not display any real member information.
These screenshots are subject to change.
The Provider Utilization allows PCMH providers and groups to:
 View their Medical and Pharmacy Utilization Metrics
 Review/print list of members who need intervention based on the Utilization reports
 Initiate Print or Export report functions
Logging into the Provider Utilization
 To access, please log in to your provider portal account, and click on “Provider Utilization” at the
top menu bar. The Provider Utilization is accessible to the “Admin”, “All Access” (which includes
clinical and non-clinical), and “Clinical” web portal user roles. Billers and non-clinical portal user
roles will not be able to access the Provider Utilization from their web portal account.
 Individual providers and medical groups/clinics can view and use the tool.
 If you are signed in under a non-clinical role or non-admin role, then the Provider Utilization will
not be accessible to you. If you are part of group and need to request clinical or admin access,
please notify the Admin in your group. Your Admin can grant you that access.
Currently, the Provider Utilization displays data for Medicaid only. Providers who registered multiple
lines of business under one username can view information specific to that account. The drop-down list
currently shows the Facility/Medical Group associated with the Medicaid accounts.
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“My Utilization” Tab
Once you land on the Provider Utilization tool, the “My Utilization” tab will display.
Facility/Medical Groups
 Users who are registered as a Facility/Group type will be able to view the Provider Utilization
data for that group or IPA.
 You can select a provider that belong to the group/IPA by using the “Select a Provider” dropdown. Click on the name of the provider and results for the selected provider will display.
o
Please note that for the selected provider you will only see members assigned within
the group/IPA account. If the provider has members assigned from other groups/IPA’s,
those members or group information will not be available to the logged in group/IPA
account.
 Individual Physician providers must log in as an individual to view all their
membership. Individual Physicians who log in their business account where membership is not
assigned will not have visibility to the information.
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o
Note: Functional changes are under way to allow Individual Provider businesses to add
their individual provider ID and view this information. No date is available for when this
will be completed, however it will be placed within the Manage Provider function of
Account Tools.
 Providers whose names are grayed out do not have members assigned to them to display.
“Report Type” Dropbox
 The “Report Type” dropbox allows you to select an option for the following report types:
o Provider Utilization Report
o Top 25 Drugs by Volume rolling past year
o Top 25 Drugs by Average Cost rolling past year
o Top 25 Diagnosis for rolling past year
Individual Providers
 Users who are registered as an Individual Provider are also able to view their Provider Utilization
Data for all members assigned to them.
 If the Provider belongs to a medical group or IPA, they will see the Group Name on their
Provider Utilization.
 Individual Providers belonging to multiple groups or IPA’s will see their name and a drop down
with all the groups they are affiliated. Providers can select to display their Provider Utilization
information for a particular group by using the “Select a Group” drop-down. Click on the name
of the group and results for the selected group will display.
o Please note that the selected group will only display the individual provider’s
information within the group and not the group as a whole.
o Please be sure that you have registered on the portal as an individual provider. If you
already have a group/IPA account, this will require registering again with a separate email address.
 Groups whose names are grayed out do not have members assigned to them to display.
Select a Service Location
 Groups and individual providers can filter the data by Service Location. Click on the “Select a
Service Location” drop-down and the Provider Utilization will display data for that Service
Location.
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“Show Data For” Dropbox
 The “Show Data For” dropbox allows you to select an option to display data for All Members,
Inactive Only, or Active Only. The dropbox is defaulted to show data for All Members.
PCMH Type
 The ‘PCMH Type’ dropdox allow syou to select an option to display data for All, Yes, No. The
dropbox is defaulted to show data for All PCMH Types.
Provider Utilization Report
Here are definitions for each row shown for the last 5 quarters of data with a claim lag of 2 months:
 Member Counts - Total number of members that are being reported for each Utilization metric
type.
 ER Visits per 1000 members – Number of admissions shown for 1000 members for the period.
 30 Day all cause Readmission rate – Number of admissions shown for 1000 members within 30
days ond all-cause
 CT/MRI/PET Utilization per 1000 members – Number of incidence shown for 1000 members for
the period shown.
 Total Rx Volume - Rx counts applies to selection group of providers.
 Rx Per 100 Patients – Rx count per 100 members to selection group of providers.
 Generic Dispensing % - The Percentage of generic fills in the total number of prescriptions
filled.
 Controlled Substance % - Percentage of controlled substance Rxs filled.
 Amount Paid Total Rx – Average cost from total amount paid by each member.
Additional Reporting
The following reports display Last Rolling Year data:
 Top 25 Drugs by Volume rolling past
 Top 25 Drugs by Average Cost rolling past year
 Top 25 Diagnostic for Last Year
Print and Export Provider Utilization tab
 To print a report, click on “Print” and a print-ready version of the report will display in a new
window.
 To export a report, click on “Export” and a pop-up will display to choose between two formats PDF or Excel. Click on the radio button, to select the report type. By clicking ok, the PDF or Excel
file will be generated that you can either “Open” or “Save” reports. Exporting by PDF does not
support sorting results. Sorted printouts can be retrieved through exporting the data into Excel.
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“Member” Tab
The “Member” tab displays a detailed list of members for each of the Utilization Measure that was
selected.
Facility/Medical Groups
 Users who are registered as a Facility/Group type will be able to view the Provider Utilization
data for that group or IPA.
 You can select a provider that belongs to the group/IPA by using the “Select a Provider” dropdown. Click on the name of the provider and results for the selected provider will display.
o Please note that for the selected provider you will only see members assigned within
the group/IPA account. If the provider has members assigned from other groups/IPA’s,
those members or group information will not be available to the logged in group/IPA
account.
o Individual Physician providers must log in as an individual to view all their
membership. Individual Physicians who log in their business account where
membership is not assigned will not have visibility to the information.
 Note: Functional changes are under way to allow Individual Provider businesses to add their
individual provider ID and view this information. No date is available for when this will be
completed, however it will be placed within the Manage Provider function of Account Tools.
 Providers whose names are grayed out do not have members assigned to them to display.
Individual Providers
 Users who are registered as an Individual Provider are also able to view their Provider Utilization
Data for all members assigned to them.
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 If the Provider belongs to a medical group or IPA, they will see the Group Name on their
Provider Utilization.
 Individual Providers belonging to multiple groups or IPA’s will see their name and a drop down
with all the groups they are affiliated. Providers can select to display their Provider Utilization
information for a particular group by using the “Select a Group” drop-down. Click on the name
of the group and results for the selected group will display.
o Please note that the selected group will only display the individual provider’s
information within the group and not the group as a whole.
o Please be sure that you have registered on the portal as an individual provider. If you
already have a group/IPA account, this will require a registering again with a separate
e-mail address.
 Groups whose names are grayed out do not have members assigned to them to display.
Select a Service Location
 Groups and individual providers can filter the data by Service Location. Click on the “Select a
Service Location” drop-down and the Provider Utilization will display data for that Service
Location.
“Show Data For” Dropbox
 The “Show Data For” dropbox allows you to select an option to display data for All Members,
Inactive Only, or Active Only. The dropbox is defaulted to show data for All Members.
PCMH Type
 The ‘PCMH Type’ dropdox allow syou to select an option to display data for All, Yes, No. The
dropbox is defaulted to show data for All PCMH Types.
Utilization Measure
Each report is based on member-PCP relationship tied to the end of each quarter for the last 5 quarters,
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ER Visits
CT/MRI/PET Uses
30 Day all cause Readmissions
Total Rx Volume
Generic Dispensing %
Controlled Substance %
Amount Paid Total Rx
List of Members
 The Member ID and member Name fields are searchable by entering your search term in the
blank text boxes below the respective column headers.
 Click on the titles of each column to sort by ascending/descending order.
 You can also click on the member’s last name to take you to that member’s
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Eligibility Details page.
 For providers that have registered multiple lines of business under one account:
o If you are viewing your Medicaid account, you will only see Medicaid members in the
Provider Utilization tool associated with that Medicaid login ID.
Print and Export for Member tab
 To print the member list, click on “Print” and a print-ready
version of the report will display in a new window. Please
note that sorting is not supported in the PDF report.
 To export the member list, click on “Export” and a pop-up will
display for you to select between two report types: PDF or
Excel. Click on the radio button to select the report type. By
clicking ok, the PDF or Excel file will be generated that you
can either “Open” or “Save.”
Who can I contact?
If you have any other questions regarding Provider Utilization or the information on the reports, please
contact your Provider Services representative.
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