Appendix%207.12%20Bank%20Draft%20Report%20Template.xlsx
XLSX spreadsheet 11 KB Posted
- Solicitation number
- RFP 31786-00190
- Issued by
- Davidson County, Tennessee
About this file
This file is a Bank Draft Report Template for the Third Party Administrator (TPA) Services contract with the State of Tennessee for its public sector health plans. The template establishes the standardized format that the TPA must use to submit detailed claims payment reports on a regular basis, including ACH (Automated Clearing House) transaction details, the specific plan names and descriptions associated with each payment, and comprehensive accounting of all financial transactions processed during each reporting period.
The report format requires the TPA to document each bank draft amount, its date, the number, date range, and total amount of associated claims adjudicated per draft, along with corresponding account numbers and fund codes. All non-claim-based payments, including credits, subrogation amounts, fees, and specialty pharmacy charges, must be separately identified and itemized by plan type and division. The template mandates that reports must be submitted directly by the TPA rather than by the financial institution, and all plans must be listed in the report regardless of whether weekly or daily debits are zero for any given period. The report must include total columns for all categories to provide a comprehensive accounting of all payments and adjustments processed during each reporting cycle.
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Text version
ACH detail
| TPA Name |
| TPA Date of ACH Report |
| Date range of claims |
| Date of ACH Debit |
Plan Plan Description Claims Credits (previous) Other (Subrogation) Other (Fees) Other (Speciality Pharmacy) TOTAL each plan listed seperately specific to division, plan type, etc. $ amount $ amount $ amount $ amount $ amount $ amount The format of the claims reports shall include at a minimum: each bank draft amount; date of bank draft; number, date range, and amount of associated claims adjudicated per draft; account number; fund code; any non-claim based payments which shall be separate and identified; etc. The report format shall
| TOTAL | $ amount | $ amount | $ amount | $ amount | $ amount | $ amount |
| Additional Notes: | ||||||
| Must be submitted by TPA, cannot be from financial institution | ||||||
| Do not exclude plan from listing if weekly/daily debit is zero |
Appendix 7.12
File details come from the government source that posted it. Updated .