Description and Important Notes
The provider utilization report shows how much a group is spending with each provider. It aggregates the group's approved medical claims by billing Tax ID Number (TIN), with claim counts, allowed amounts, and plan payments for each. The report is found on the "Reports" tab of the portal under Claims Analytics.
A few important notes:
The report includes approved medical claims only. Pharmacy claims are not included, and pending, denied, and voided claims are excluded. Totals here will match the medical claims report if you filter for approved claims and download at the same time.
The report is a snapshot in time. In order to get up-to-date information, regenerate the report on a regular basis.
The report is generated as a .csv file with one row per billing TIN. Note that sometimes many provider names bill under one TIN, and so the provider name field can be misleading.
A PDF version is also available and shows the top 10 providers by plan spending.
If you are unable to download the report, try normal troubleshooting steps. If you're still unable to access, email partners@yuzu.health.
Interpretation Guide
1. Each row is one billing provider, not one claim. All of a provider's approved medical claims are rolled up into a single row. claimCount shows how many claims are included, and the dollar columns are totals across all of them.
2. Providers are grouped by tax ID first. Claims are matched to a provider by billing TIN; when a TIN isn't available, the NPI is used, and failing that, the provider name. Because of this, the same provider name can appear on more than one row if it bills under different tax IDs. Treat rows with the same name but different TINs as separate billing entities. This also means that multiple provider names billing under one TIN will only appear once in the report. If you cannot find a provider’s name, check for their TIN.
3. Follow the money. totalAllowedAmount is the price the plan recognizes for the provider's services after network discounts. totalPlanPaid is the portion the plan actually paid, and percentagePlanPaid expresses that as a share of the allowed amount. The gap between allowed and plan paid is generally the members' share: deductible, copay, and coinsurance.
4. A 0.00% plan-paid share does not mean claims went unpaid. It usually means the allowed amounts were applied to members' deductibles or other cost sharing, so the plan owed nothing.
5. Rows are sorted by total allowed amount, largest first. The top of the report shows where the most total spend is recognized, which is not always where the plan paid the most. For a plan-paid view, sort by totalPlanPaid or use the PDF version.
6. Mind the timing. Only claims that have finished adjudication and been approved are counted, so recent activity is usually understated.
Data Definitions
This section explains each field, its format, any applicable calculations, and a basic definition.
Provider Information
Column | Format | Calculation (if applicable) | What it means |
|---|---|---|---|
providerName | String | Billing provider name; shows "UNKNOWN" if unavailable | Name of the billing provider. Only one name is shown when multiple provider names bill under the same TIN. |
providerBillingTIN | String | — | The provider's 9-digit tax identification number; blank when not on file. TINs can begin with a zero, so keep this column formatted as text if you open the file in a spreadsheet. |
Utilization and Spending
All amounts below are totals across the provider's approved medical claims.
Column | Format | Calculation (if applicable) | What it means |
|---|---|---|---|
claimCount | Number | Count of the provider's approved, non-voided medical claims | Number of claims included in the provider's row. |
totalAllowedAmount | Dollars | Sum of allowed amounts across all of the provider's claim lines | The total amount the plan recognizes for the provider's services, after network discounts. |
totalPlanPaid | Dollars | Sum of plan-paid amounts across all of the provider's claim lines | The total amount the health plan paid to the provider. |
percentagePlanPaid | Percentage (e.g., 82.34%) or "N/A" | totalPlanPaid ÷ totalAllowedAmount × 100; shows N/A when the allowed amount is $0 | The share of the allowed amount that the plan paid. The remainder is generally member cost sharing. |