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Deliverable Number
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Commodity/Service Type
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Major Deliverable
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Method of Payment
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Economic or financial evaluation of projects
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Final Claims Activity Report to include at a minimum:
"• # of claims received
• # of claims adjudi...
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Fixed Price - Lump Sum
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| Major Deliverable: Final Claims Activity Report to include at a minimum:
"• # of claims received
• # of claims adjudicated
• # of claims pending
• # of phone calls
• Total Amount Billed
• Total Adjustments Applied
• Total Amount Allowed
"
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| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: At the conclusion of the adjudication process
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| Financial Consequences: Cancellation
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| Source Documentation Page Reference: Page 5-Contract |
| Deliverable Number: |
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Economic or financial evaluation of projects
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EOB for each member claim evaluated in image or pdf format with an associated index file.
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Fixed Price - Lump Sum
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| Major Deliverable: EOB for each member claim evaluated in image or pdf format with an associated index file.
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| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: At the conclusion of the adjudication process
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| Financial Consequences: Cancellation
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| Source Documentation Page Reference: Page 5-Contract |
| Deliverable Number: |
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Economic or financial evaluation of projects
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RA for each medical provider claim evaluated (summary of all claims submitted by the medical provide...
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Fixed Price - Lump Sum
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| Major Deliverable: RA for each medical provider claim evaluated (summary of all claims submitted by the medical provider) in image or pdf format with an associated index file.
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| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: At the conclusion of the adjudication process
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| Financial Consequences: Cancellation
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| Source Documentation Page Reference: Page 5-Contract |
| Deliverable Number: |
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Economic or financial evaluation of projects
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"Claim Detail Report
• PayerFusion Claim ID
• Member RCN
• Member Name
• Insured ID#
• Renderin...
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Fixed Price - Lump Sum
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| Major Deliverable: "Claim Detail Report
• PayerFusion Claim ID
• Member RCN
• Member Name
• Insured ID#
• Rendering NPI (Medical Provider)
• Rendering Provider (Name)
• Billing RCN
• Receiver Billing Provider
• Billing NPI (Provider)
• Billing Tax ID (Provider NPI)
• From Date of Service
• To Date of Service
• Payee Tax ID
• Payee (Name)
• Billed Charges
• Allowed Amount
Adjustments Applied (co-pays, deductions, etc.)
"
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| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: Monthly
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| Financial Consequences: Cancellation
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| Source Documentation Page Reference: Page 2-Amendment 1 |
| Deliverable Number: |
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Economic or financial evaluation of projects
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Part B- Claims Activity report to include at a minimum: # of claims received, # of claims adjudicate...
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Fixed Price - Lump Sum
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| Major Deliverable: Part B- Claims Activity report to include at a minimum: # of claims received, # of claims adjudicated, # of claims pending, # phone calls, Total Amount Billed, Total Adjustments Applied, Total Amount Allowed, Total Amount to be funded/paid by the GA. Report should contain both MTD as well as YTD summary totals. Provider Detail data submission to include adjudication activity per medical provider RCN/NPI. Data should include at a minimum: RCN, NPI, Provider Name, Tax ID/FEIN, Total Amount Billed (Total of all bills submitted), Total Adjustments Applied (co-pays, deductions etc.), Total Amount Allowed, Amount to be funded/paid by GA. Member Detail data submission to include adjudication activity per member RCN. Data should include at a minimum: RCN, Member Enrollee #, Member Name, Medical Provider NPI, Medical Provider Name, Date of Service, Total Amount Billed (total provider bill), Total Adjustments Applied (co-pays, deductions etc.), Total Amount Allowed, GA State, Amount to be funded/paid by GA. RA for each medical provider claim evaluated (summary of all claims submitted by the medical provider) in image or pdf format with an associated index file. EOB for each member claim evaluated in image or pdf format with an associated index file. Final Claims Activity Report to include at a minimum: # of claims received, # of claims adjudicated, # of claims pending, # of phone calls, Total Amount Billed, Total Adjustments Applied, Total Amount Allowed, Total Amount Paid by the GA. Major Deliverable Price: $9.06 per claim |
| Deliverable Price: $9.06 |
| Non Price Justification: |
| Performance Metrics: Bi-weekly (every two weeks) |
| Financial Consequences: Cancellation |
| Source Documentation Page Reference: pages 4-5 |
| Deliverable Number: |
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Economic or financial evaluation of projects
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Part A:Company data and administrative set-up in order to perform under Part B
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Fixed Price - Lump Sum
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| Major Deliverable: Part A:Company data and administrative set-up in order to perform under Part B |
| Deliverable Price: $31,000.00 |
| Non Price Justification: |
| Performance Metrics: Within 45 days of the effective date of the contract |
| Financial Consequences: Cancellation |
| Source Documentation Page Reference: Page 6 |
| Deliverable Number: |
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Information technology consultation services
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Weekly Call Log that reflects inception to date phone calls received from providers related to an NO...
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Fixed Price - Lump Sum
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| Major Deliverable: Weekly Call Log that reflects inception to date phone calls received from providers related to an NOD mailing in Microsoft Excel or other format agreed upon by the RECEIVER to include at a minimum:
Date Call Received
Name of Provider/Payee/Group Name
Payee NPI number
RCN
Calling Party
Title/Position
Email Address
Mailing Address
Phone Number
Nature of Inquiry
Resolution of Inquiry
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| Deliverable Price: $5.50 |
| Non Price Justification: |
| Performance Metrics: weekly call log
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| Financial Consequences: cancellation
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| Source Documentation Page Reference: Contract page 4 |
| Deliverable Number: |
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