CurrentColorado Rocky Mountain Health PlansPolicy N/A

Premium Specialty: Internal Medicine Patient Episode Cost (Condition-Based Episodes list)

List of condition-based episodes included in the UnitedHealth Premium methodology for Internal Medicine patient episode cost reporting; identifies many specific conditions and notes about the Premium program applicability to physicians and members. Applies to the payer's use of UnitedHealth Premium methodology documents.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPremium Specialty: Internal Medicine Patient Episode Cost (Condition-Based Episodes list)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionReview listed condition-based episodes and submit requests for corrections if evaluation data appears inaccurate.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~150+condition-based episode entries listed

1Premium Specialty header present

1Important notes section

Provider Actions and Program Notices

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Denial Risk

Claims Data and Attribution Risk

There is a risk of error in the claims data used and in the way patient care is attributed to physicians. UnitedHealth Premium uses statistical testing to compare a physician's performance to benchmarks. There is a risk of error in statistical tests when applied to the data and a result based on statistical testing is not a guarantee of correct inference or classification.

Errors can occur in claims records, coding, and attribution methods that affect evaluations and designations.
Statistical testing may produce false positives or negatives; results are not definitive proof of quality.
Designations based on sample evaluations may not reflect a physician's overall practice or outcomes.

Documentation Required

Physician Review and Correction Requests

Physicians have the opportunity to review the data and evaluation results and may submit requests for changes or corrections.

Physicians may review the underlying claims and attribution data used in evaluations.
Physicians can submit requests to correct or change data and evaluation results when inaccuracies are identified.
Lack of sufficient measures, patients, or attributed episodes may prevent evaluation; non-designation can result from insufficient data rather than poor quality.

Background and Scope

This document lists the condition-based episodes used by UnitedHealth Premium to evaluate patient episode costs for Internal Medicine. It enumerates numerous specific conditions and subtypes (for example, bilateral vs. single-side designations) that comprise the episode framework and serves as the source list for UnitedHealth Premium methodology applied to Internal Medicine reporting ([[chunk 0]]).

UnitedHealth Premium designations are evaluative and informational: they are not endorsements of clinical quality, do not guarantee outcomes, and physicians remain solely responsible for medical judgments and treatments. The document also notes that designations may not be assigned if a physician is not evaluated or there are insufficient measures, patients, or episodes attributed, and that the information is subject to change ([[chunk 19]]).

Key Definitions

inv-06: UnitedHealth Premium designation

DefinitionAn evaluative designation based on UnitedHealth Premium methodology and claims data; not an endorsement of clinical quality or a guarantee of outcomes.

ScopeUsed as a guide for members when choosing physicians; applies to physicians evaluated by UnitedHealth Premium in specific specialties/markets.

Physician responsibilityPhysicians remain solely responsible for medical judgments and treatments regardless of designation.

Limitations and non-endorsementA Premium designation is not an endorsement of a physician's suitability for a member's health care needs; lack of designation does not imply poor quality.

Data and error riskDesignations are based on claims data and statistical testing; there is a risk of error in data, attribution methods, and statistical inference.

Right to reviewPhysicians may review evaluation data and submit requests for changes or corrections; information is subject to change.