| 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: Page 4 - 5 |
| Deliverable Number: 2 |
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