Medicare Advantage and Prescription Drug Plans December 28 ...

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Plan Communications User Guide Appendices, Version 6.3 J.5 Monthly Membership Detail Report – Non-Drug Report (Part C) Description This report lists every Medicare member of the contract and provides details about the payments and adjustments made for each beneficiary. Example The example below is one page of a Monthly Membership Detail Report containing non-drug information. The full report includes all members in the contract. (above benchmark bid) 1 1 1 1 1 2 3 4 5 6 7 8 9 0 1 2 3 1234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123 RUN DATE:20090124 MONTHLY MEMBERSHIP REPORT - NON DRUG PAGE: 1 PAYMENT MONTH:200902 PLAN(Hzzzz) PBP(nnn) SEGMENT(mmm) PLAN NAME HERE ------------------------------------------------- REBATES -------------------------------------------- BASIC PREMIUM | COST SHR REDUC MAND SUPP BENEFIT PART D SUPP BENEFIT PART B BAS PRM REDUC PART D BAS PRM REDUC PART A $SSS9.99 | N/A N/A N/A N/A N/A PART B $SSS9.99 | N/A N/A N/A N/A N/A S ----------- FLAGS --------------- ------------------ PAYMENTS/ADJUSTMENTS -------------------- CLAIM E AGE STATE P P M F A D S C MTHS PAYMENT DATE LAG FTYPE----FACTORS-------- AMOUNT NUMBER X GRP CNTY A A H E I C R O D E E O M A B START END FRAILTY-SCORE MSP MSP ------------ - ---- ----- O R R O S N N A A R D F G U M C ---- --- ------------------------------------------------------------ SURNAME F DMG BIRTH O T T S R S H I I E O A H R S A PIP ADJ I RA DATE A A B P D T C D L C N U P C P I DCG REA FCTR-A FCTR-B PART A PART B TOTAL PAYMENT ------------ - ---- ----- - - - - - - - - - - - - - - - - --- ----------------------------------------------------------------- 123456789A F 8084 33800 200405 200405 Y C 99.9999 99.9999 $SSSS9.99 FIRST G 8084 19200206 Y Y 1 A Y Z9Z9 ZZ 1.0650 1.0650 $SSSSSS9.99 $SSSSSS9.99 $SSSSSSS9.99 987654321B M 8084 33800 200405 200405 Y C 99.9999 99.9999 $SSSS9.99 SECOND H 8084 19251008 Y Y Y Y 4 T N Z9Z9 ZZ 1.0650 1.0650 $SSSSSS9.99 $SSSSSS9.99 $SSSSSSS9.99 December 28, 2012 J-13 Monthly Membership Detail Report – Non-Drug Report (Part C)
Plan Communications User Guide Appendices, Version 6.3 (below benchmark bid) 1 1 1 1 1 2 3 4 5 6 7 8 9 0 1 2 3 1234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123 RUN DATE: 20090124 MONTHLY MEMBERSHIP REPORT – NON DRUG PAGE: 1 PAYMENT MONTH:200902 PLAN(Hzzzz) PBP(nnn) SEGMENT(mmm) PLAN NAME HERE ------------------------------------------------- REBATES -------------------------------------------- BASIC PREMIUM | COST SHR REDUC MAND SUPP BENEFIT PART D SUPP BENEFIT PART B BAS PRM REDUC PART D BAS PRM REDUC PART A N/A | $SSS9.99 $SSS9.99 $SSS9.99 $SSS9.99 $SSS9.99 PART B N/A | $SSS9.99 $SSS9.99 $SSS9.99 $SSS9.99 $SSS9.99 S ----------- FLAGS --------------- ------------------ PAYMENTS/ADJUSTMENTS --------------------CLAIM E AGE STATE P P M F A D S C MTHS PAYMENT DATE LAG FTYPE----FACTORS-------- AMOUNT NUMBER X GRP CNTY A A H E I C R O D E E O M A B START END FRAILTY-SCORE MSP MSP ------------ - ---- ----- O R R O S N N A A R D F G U M C ---- --- ------------------------------------------------------------ SURNAME F DMG BIRTH O T T S R S H I I E O A H R S A PIP ADJ I RA DATE A A B P D T C D L C N U P C P I DCG REA FCTR-A FCTR-B PART A PART B TOTAL PAYMENT ------------ - ---- ----- - - - - - - - - - - - - - - - - --- ----------------------------------------------------------------- 1234567890AB F 8084 33800 200405 200405 Y C 99.9999 $SSSS9.99 FIRST G 8084 19200206 Y Y N 1 Y Z9Z9 ZZ 1.0650 1.0650 $SSSSSS9.99 $SSSSSS9.99 $SSSSSSS9.99 0987654321AB M 8084 33800 200405 200405 Y C 99.9999 99.9999 $SSSS9.99 SECOND H 8084 19251008 Y Y Y Y 4 P N Z9Z9 ZZ 1.0650 1.0650 $SSSSSS9.99 $SSSSSS9.99 $SSSSSSS9.99 December 28, 2012 J-14 Monthly Membership Detail Report – Non-Drug Report (Part C)
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Medicare Advantage and Prescription Drug Plans December 28 ...

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