Medicare Advantage and Prescription Drug Plans December 28 ...

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Plan Communications User Guide Appendices, Version 6.3 J.7 Monthly Summary of Bills Report Description This report summarizes all Medicare fee-for-service activity, both Part A and Part B, for Beneficiaries enrolled in the contract. Example 1 MONTHLY SUMMARY OF CLAIMS PAID BY CARRIERS FOR HMO ENROLLEES 0 HMO NO H123A HMO NAME ABC FOUNDATION, INC. HMO FY ENDING 12/2004 CURRENT MONTH 01/2009 0 TOTALS FOR THIS MONTH 0 CARRIER MEDICAL REIMB TOTAL NUMBER CHARGES AMOUNT BILLS NO ACTIVITY FOR THIS HMO FOR THIS PERIOD FY TOTAL $198,903- $151,602- 4,266 1 MONTHLY SUMMARY OF BILLS PAID BY INTERMEDIARIES FOR HMO ENROLLEES 0 HMO NO H123B HMO NAME ABC FOUNDATION, INC. HMO FY ENDING 12/2005 CURRENT MONTH 01/2009 BILLS THROUGH 01/30/2009 0 ------------------ INPATIENT BILLS -------------- ------ OUTPATIENT BILLS -------- -------------- HHA BILLS ------------ NON TOTAL COVERED REIMB COVERED TOTAL COVERED REIMB TOTAL TOTAL REIMB TOTAL TOTAL CHARGES CHARGES AMOUNT DAYS BILLS CHARGES AMOUNT BILLS CHARGES AMOUNT VISITS BILLS NO ACTIVITY FOR THIS HMO FOR THIS PERIOD FY TOTAL $123,526,251 $113,627,247 42,572 $570,708- $245,326 9 $1,315,398 16,614 $3,309,867- 1,606 $229,640 617 1 MONTHLY SUMMARY OF CLAIMS PAID BY CARRIERS FOR HMO ENROLLEES 0 HMO NO H123C HMO NAME ABC FOUNDATION, INC. HMO FY ENDING 12/2005 CURRENT MONTH 01/2009 0 TOTALS FOR THIS MONTH 0 CARRIER MEDICAL REIMB TOTAL NUMBER CHARGES AMOUNT BILLS NO ACTIVITY FOR THIS HMO FOR THIS PERIOD FY TOTAL $548,050- $428,202- 8,315 1 MONTHLY SUMMARY OF BILLS PAID BY INTERMEDIARIES FOR HMO ENROLLEES 0 HMO NO H123D HMO NAME ABC FOUNDATION, INC. HMO FY ENDING 12/2006 CURRENT MONTH 01/2009 BILLS THROUGH 01/30/2009 0 ------------------ INPATIENT BILLS -------------- ------ OUTPATIENT BILLS -------- -------------- HHA BILLS ------------ NON TOTAL COVERED REIMB COVERED TOTAL COVERED REIMB TOTAL TOTAL REIMB TOTAL TOTAL December 28, 2012 J-19 Monthly Summary of Bills Report
Plan Communications User Guide Appendices, Version 6.3 CHARGES CHARGES AMOUNT DAYS BILLS CHARGES AMOUNT BILLS CHARGES AMOUNT VISITS BILLS 0INTER NO 0000A PROV NO 00000A 1,147 0 1,147 0 1 0 0 0 0 0 0 0 ------------------------------------------------------------------------------------------------------------------------------------ INT TOTAL 1,147 0 1,147 0 1 0 0 0 0 0 0 0 0INTER NO 0000B PROV NO 00000B 4,488 0 0 0 2 0 0 0 0 0 0 0 00000C 0 0 0 0 0 78- 90- 1 0 0 0 0 00000D 0 0 0 0 0 102- 90- 1 0 0 0 0 ------------------------------------------------------------------------------------------------------------------------------------ INT TOTAL 4,488 0 0 0 2 180- 180- 2 0 0 0 0 0INTER NO 0000C PROV NO 00000E 182,012 0 0 23 2 0 0 0 0 0 0 0 ------------------------------------------------------------------------------------------------------------------------------------ INT TOTAL 182,012 0 0 23 2 0 0 0 0 0 0 0 -HMO TOTAL 187,647 0 1,147 23 5 180- 180- 2 0 0 0 0 FY TOTAL $116,001,944 $85,570,972 34,354 $937,010- $159,078 102 $2,835,588 14,675 $6,493,082- 2,876 $162,661 485 1 MONTHLY SUMMARY OF CLAIMS PAID BY CARRIERS FOR HMO ENROLLEES 0 HMO NO H123E HMO NAME ABC FOUNDATION, INC. HMO FY ENDING 12/2006 CURRENT MONTH 01/2009 0 TOTALS FOR THIS MONTH 0 CARRIER MEDICAL REIMB TOTAL NUMBER CHARGES AMOUNT BILLS 0 01192 224 161 1 0 HMO TOTAL 224 161 1 FY TOTAL $750,298- $574,946- 8,412 December 28, 2012 J-20 Monthly Summary of Bills Report
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Medicare Advantage and Prescription Drug Plans December 28 ...

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