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Report Templates

Contract Section       Report 

3.6Manual Maternity Kicker 
3.17Call Center Performance 
4.2High Cost No Experience Drugupdated
4.3Additional Services Form 
4.3Additional Services Evaluation Report 
4.3Additional Service Template Report 
4.8Member Incentive Form 
5.4Care Management 
6.3Provider Network 
7.4FQHC/RHC Wrap Detail Data 
7.4FQHC/RHC Wrap Summary Data 
8.3Service Authorization 
9.1Member Grievance and Appeal Report Quarterly 
9.1Member Grievance and Appeal Report Annual 
9.2Provider Dispute Log 
10.9TPL Cost Avoidance 
10.9TPL COB Savings 
10.9TPL Recoveries 
10.9TPL Casualty Cases 
11.1PI Fraud and Abuse Definitions 
11.1PI Rules for Share Point Suspension Termination Exclusion 
11.1PI Instructions-Use of SharePoint Suspension Termination Exclusion 
11.10Pharmacy Lock In Member Letter 
11.10Pharmacy Lock In Member Instructions 
11.10Pharmacy Lock In Member Removal Letter 
11.10Pharmacy Lock In Pharmacy Letter 
12.4MCO Material Minimal Change Attestation 
13.1Claims Payment Accuracy 
13.1GME Report 
14.6Encounter Submission Summary 
15.5Alternative Payment Models 
16.3Managed Care Question and Answer Grid 

 Additional Resources

HIPAA 5010 834 Transaction Layout

Enrollment Broker 5010 834 Transaction Guide

Encounter Errors Mapping to 277CA

Enrollment Broker Provider File Format


Reference Tools

Managed Care Organization Notification forms


MCO Comprehensive Drug Lists

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