Medicare Advantage and Prescription Drug Plans December 28 ...

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Plan Communications User Guide Appendices, Version 6.3 123456789A MARTIN L F 19150709 200401-200401 73.38 653.71 -73.38 389.01 191.32 580.33 123456789A COHEN R M 19171019 200401-200401 73.38 811.54 -73.38 479.27 258.89 738.16 123456789D RUBIN J F 19121124 200401-200401 73.38 857.74 -73.38 509.52 274.84 784.36 123456789A TROUTMA J M 19110502 200401-200401 73.38 980.15 -73.38 577.46 329.31 906.77 123456789A ROUND P F 19170127 200401-200401 73.38 569.89 -73.38 339.14 157.37 496.51 123456789A AZMAN F F 19180203 200401-200401 73.38 734.82 -73.38 436.59 224.85 661.44 123456789D PRATT F F 19080919 200401-200401 73.38 746.11 -73.38 443.95 228.78 672.73 123456789A LOMBARD F F 19160926 200401-200401 73.38 834.62 -73.38 496.76 264.48 761.24 123456789D BALTIMO M F 19080301 200401-200401 73.38 837.34 -73.38 498.26 265.70 763.96 123456789D HOWARD J F 19070402 200401-200401 73.38 580.51 -73.38 345.61 161.52 507.13 123456789A COLUMBU F M 19180904 200401-200401 73.38 1,004.55 -73.38 593.51 337.66 931.17 123456789C2 CARROLL K M 19580202 200401-200401 73.38 333.27 -73.38 182.23 77.66 259.89 PBP ID: 027 TOTALS: 39 $ 26,783.70 $ -2,861.82 $ 23,921.88 AGED REDUCTION: $ -2,568.30 DIB REDUCTION: $ -293.52 0 CONTRACT: H3333 TOTALS: 77 $ 54,385.95 $ -4,049.32 $ 50,336.63 AGED REDUCTION: $ -3,755.80 DIB REDUCTION: $ -293.52 December 28, 2012 J-5 BIPA 606 Payment Reduction Report
Plan Communications User Guide Appendices, Version 6.3 J.2 Bonus Payment Report Description This report lists members for whom the MCO receives a bonus. (MCOs are paid a bonus for extending services to beneficiaries in some underserved areas.) This report only reflects data for periods prior to 2004. Example 1 RUN DATE: 2003/10/03 PAY MONTH: 2003/03 BONUS PAYMENT REPORT PAGE: 2 CONTRACT#: H5555 REPORT DATE: 2003/10/03 0 STATE/COUNTY CODE: 27030 0 CLAIM SURNAME F S BIRTH ADJ PAY/ADJ BONUS BLENDED BONUS BONUS BONUS ----- BLENDED PLUS BONUS ---- NUMBER I E DATE RC DATES PCT W/O BONUS PART A PART B TOTAL PART A PART B TOTAL X 123456789A JONES J M 19280611 200303-200303 3.00 480.44 7.66 6.75 14.41 263.03 231.82 $ 494.85 123456789A CHANG A M 19140222 200303-200303 3.00 647.58 11.47 7.96 19.43 393.75 273.26 $ 667.01 123456789B CHANG F F 19151105 200303-200303 3.00 569.89 10.17 6.92 17.09 349.31 237.67 $ 586.98 123456789A COHEN A M 19250714 200303-200303 3.00 650.30 10.65 8.86 19.51 365.74 304.07 $ 669.81 123456789A PULASKI W M 19290909 200303-200303 3.00 449.12 7.14 6.33 13.47 245.23 217.36 $ 462.59 * STATE/COUNTY 27030 TOTALS: 5 $ 2,797.33 $ 83.91 $ 2,881.24 0 STATE/COUNTY CODE: 27040 0 CLAIM SURNAME F S BIRTH ADJ PAY/ADJ BONUS BLENDED BONUS BONUS BONUS ----- BLENDED PLUS BONUS ---- NUMBER I E DATE RC DATES PCT W/O BONUS PART A PART B TOTAL PART A PART B TOTAL X 123456789A KIRBY C M 19220222 200303-200303 3.00 599.47 10.16 7.83 17.99 348.73 268.73 $ 617.46 December 28, 2012 J-6 Bonus Payment Report
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Medicare Advantage and Prescription Drug Plans December 28 ...

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