Medicare Advantage and Prescription Drug Plans December 28 ...

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Plan Communications User Guide Appendices, Version 6.3 J.10 Payment Records Report Description This report lists the Part B physician and supplier claims that were processed under Medicare fee-for-service for Beneficiaries enrolled in the contract. Example 1 PART B CLAIMS RECORDS POSTED IN OCT 2002 PAGE 1 0 * * * * *HMO H2222 * * * * * 0 CLAIM NAME EXPENSE DATES ALLOWED REIMB COINSURANCE DED PHYS PAY CARRIER CARRIER INFORMATION NUMBER FIRST LAST TOTAL AMT AMT APP SUPP ID IND NUMBER PAID CONTROL NUMBER CHARGES 123456789A JONES 20020917 20020917 9.72 7.78 1.94 .00 L99999 1 11111 20021014 620902283027160 123456789A JONES 20020920 20020920 12.00 9.60 2.40 .00 L88888 1 11111 20021014 620902283027550 123456789A JONES 20020830 20020830 12.65 10.12 2.53 .00 P77777 1 11111 20021017 620902283028810 123456789A JONES 20020831 20020831 12.00 9.60 2.40 .00 P77777 1 11111 20021014 620902283028800 123456789A JONES 20020915 20020915 12.00 9.60 2.40 .00 P77777 1 11111 20021014 620902283028820 123456789A HOWARD 20020708 20020708 5.43 5.43 .00 .00 0000000000 1 22222 20021023 02262828553000 123456789A WILLS 20020908 20020908 87.97 70.38 17.59 .00 666666666 1 22222 20021018 02254815230000 123456789A LEE 20020920 20020920 27.21 21.77 5.44 .00 555555555 1 22222 20021016 02270301676000 123456789A BRILL 20011019 20011119 26.46 21.17 5.29 .00 4444444444 1 33333 20021013 02266171165000 123456789D SOMMER 20020916 20020916 134.47 107.58 26.89 .00 333333333 1 22222 20021023 02262834339000 123456789A JONES 20020917 20020919 115.79 92.63 23.16 .00 222222 1 11111 20021005 620202275864060 123456789A JONES 20020925 20020925 11.16 11.16 .00 .00 111111 1 11111 20021024 620202294476660 123456789A JONES 20021010 20021010 28.97 28.97 .00 .00 111111 1 11111 20021024 620202294476670 123456789A JONES 20021011 20021011 28.97 28.97 .00 .00 111111 1 11111 20021024 620202294476680 December 28, 2012 J-23 Payment Records Report
Plan Communications User Guide Appendices, Version 6.3 J.11 Plan Payment Report (APPS Payment Letter) Description Also known as the APPS Payment Letter, this report itemizes the final monthly payment to the MCO. This report is produced by APPS when final payments are calculated. CMS makes this report available to MCOs as part of monthend processing. Plan Payment Report (PPR) - Final The PPR includes Part D payments and adjustments, the National Medicare Education Campaign (NMEC) and COB User Fees and premium settlement information. There is one version of the PPR applicable to all Plans and it is provided monthly. Following is an updated example of a PPR or APPS Payment Letter: December 28, 2012 24 Plan Payment Report
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Medicare Advantage and Prescription Drug Plans December 28 ...

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