Medicare Advantage and Prescription Drug Plans December 28 ...

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Plan Communications User Guide Appendices, Version 6.3 J.3 HMO Bill Itemization Report Description This report lists the Part A bills processed under Medicare fee-for-service for beneficiaries enrolled in the contract. Example 1 PART A BILLS POSTED IN OCT 2002 PAGE 1 BILL TYPE: INPATIENT * * * * * HMO H4444 * * * * * HMO ADM TOTAL NON-COV INP NC BLD COINSURANCE TOTAL FROM THRU COV REIM NP CLAIM NUM NAME PROV INTER PD DATE CHARGES CHARGES DED DEDUCT DAYS CHGS AMOUNT DEDUCT DATE DATE DAYS AMT CD CR 123456789A BAKER 010084 00010 20020630 7821 0 812 0 0 0 0 812 20020630 20020703 0 0 123456789C2 MILLER 014007 00010 20020819 8320 8320 0 0 0 0 0 0 20020819 20020920 0 0 N 1 PART A BILLS POSTED IN OCT 2002 PAGE 2 * * * * * HMO H4444 * * * * * BILL TYPE: HOSPICE HMO ADM TOTAL NON-COV INP NC BLD COINSURANCE TOTAL FROM THRU COV REIM NP CLAIM NUM NAME PROV INTER PD DATE CHARGES CHARGES DED DEDUCT DAYS CHGS AMOUNT DEDUCT DATE DATE DAYS AMT CD CR 1234567891 CANDLE 011570 00380 20020826 3084 0 0 0 0 0 0 0 20020901 20020930 0 3084 12345678946 FLICKE 011570 00380 20020912 1953 0 0 0 0 0 0 0 20020912 20020930 0 1953 December 28, 2012 J-11 HMO Bill Itemization Report
Plan Communications User Guide Appendices, Version 6.3 J.4 Monthly Membership Detail Report – Drug Report (Part D) Description This report lists every Medicare member of the contract and provides details about the payments and adjustments made for each Beneficiary. The two Monthly Membership Detail Reports are for drugs and for non-drugs. Example The example below is part of a Monthly Membership Detail Report containing drug information. The full report includes all members in the contract. 1 2 3 4 5 6 7 8 9 0 1 2 3 1234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123 RUN DATE:20050115 MONTHLY MEMBERSHIP REPORT-DRUG PAGE: 1 PAYMENT MONTH:200502 PLAN(Hzzzz) PBP(nnn) SEGMENT(mmm) PLAN NAME HERE BASIC PREMIUM | ESTIMATED REINSURANCE PART D $SS9.99 | $SS9.99 S --- FLAGS ----- ------------------ PAYMENTS/ADJUSTMENTS --------------------------- CLAIM E AGE STATE P P S L L D C ADJ RA FCTR DATES LOW-INCOME COST LOW-INCOME COST NUMBER X GRP CNTY A A E 0 O I E M RES START END SHARING PERCENTAGE SHARING SUBSIDY ------------ - ---- ----- O R R G U I N M C ---- ------------------------------------------------------------------- SURNAME F DMG BIRTH O T T H R N S I A MTHS DIRECT SUBSIDY COVERAGE GAP I RA DATE A A B P C C T N I D PAYMENT AMT DISCOUNT TOTAL PAYMENT ------------ - ---- ----- - - - - - - - - - ---- ------------------------------------------------------------------- 1234567890AB F 33800 XXXXXXXXXXXX 99 20.0405 200504 200505 ZZ $SSSSSS9.99 FIRST G 8084 19200206 Y Y N N Y Z9 $SSSSSS9.99 $SSSSSS9.99 $SSSSSSS9.99 0987654321AB M 8084 33800 Z9 20.0405 200504 200505 ZZ $SSSSSS9.99 SECOND H 8084 19251008 Y Y Y Y N Z9 $SSSSSS9.99 $SSSSSS9.99 $SSSSSSS9.99 December 28, 2012 J-12 Monthly Membership Detail Report – Drug Report (Part D)
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Medicare Advantage and Prescription Drug Plans December 28 ...

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