Exhibit_37B_Individual_Employer_Experience_Reports.xlsx

XLSX spreadsheet 42 KB Posted

Attached to
OEIBA Program Commercial HMO, MSP, and MAPD Plans State and local contract opportunity
Solicitation number
EV00000681
Issued by
Oklahoma County, Hobart City, Oklahoma

About this file

The document is an Excel template for Individual Employer Experience Reports for the Oklahoma Employee and Innovative Benefits Association (OEIBA) Program, specifically Exhibit 37B. The template is designed for comprehensive healthcare claims and enrollment reporting, requiring vendors to submit detailed electronic reports to EGIDVendorReporting@omes.ok.gov within ten business days of request. The reporting covers three consecutive years (2014-2016) and includes multiple reporting categories such as medical and pharmacy claims, enrollment data, high-cost claims, and top medical and pharmaceutical providers.

The reports are structured to capture granular data across different coverage categories including employee/self, spouse/partner, and child/dependent segments, with separate tracking for current employees, pre-Medicare, and Medicare populations. Each report section (37a through 37f) tracks different aspects of healthcare utilization, including claims paid, premiums, net payments, enrollment census, and provider/drug rankings. The template requires detailed documentation including provider tax IDs, geographic information, net payment amounts, and specific medical and pharmaceutical product insights, enabling comprehensive analysis of healthcare spending and utilization patterns for the State of Oklahoma's benefits program.

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Text version

Report Cover

Exhibit 37B: Individual Employer Experience Reports
[Supplier Name]
OEIBA Program
[Date]
ReportReport TitleTab Name
37aExperienceExperience
37bClaims and EnrollmentRequest #1a
37cNet Pay over $25kRequest #2
37dTop 15 Medical ProvidersRequest #3
37eTop 15 DrugsRequest #4a
37fTop 15 Drug ProvidersRequest #4b
Notes:
1) Reports are required upon request for all of the above using the same template.
2) Completed template must be submitted electronically as an Excel file via secure email to: EGIDVendorReporting@omes.ok.gov
3) Dates should be updated to reflect current reporting periods. Example: In Report 37a Experience, years reflect 2014-2016 but should be updated accordingly to reflect current information.
4) Reports should be completed and returned within ten (10) business days from request.

37a Experience

Experience
2016 Medical and Pharmacy
Current employee and Pre-MedicareClaims paid
PremiumMedicalPharmacyExperience
Employee/Self$ - 0$ - 0$ - 0
Spouse/Partner$ - 0$ - 0$ - 0
Child/Other Dependent$ - 0$ - 0$ - 0
Total$ - 0$ - 0$ - 0$ - 0
MedicareClaims paid
PremiumMedicalPharmacyExperience
Employee/Self$ - 0$ - 0$ - 0
Spouse/Partner$ - 0$ - 0$ - 0
Child/Other Dependent$ - 0$ - 0$ - 0
Total$ - 0$ - 0$ - 0$ - 0
Total Experience$ - 0$ - 0$ - 0$ - 0
2015 Medical and Pharmacy
Current employee and Pre-MedicareClaims paid
PremiumMedicalPharmacyExperience
Employee/Self$ - 0$ - 0$ - 0
Spouse/Partner$ - 0$ - 0$ - 0
Child/Other Dependent$ - 0$ - 0$ - 0
Total$ - 0$ - 0$ - 0$ - 0
MedicareClaims paid
PremiumMedicalPharmacyExperience
Employee/Self$ - 0$ - 0$ - 0
Spouse/Partner$ - 0$ - 0$ - 0
Child/Other Dependent$ - 0$ - 0$ - 0
Total$ - 0$ - 0$ - 0$ - 0
Total Experience$ - 0$ - 0$ - 0$ - 0
2014 Medical and Pharmacy
Current employee and Pre-MedicareClaims paid
PremiumMedicalPharmacyExperience
Employee/Self$ - 0$ - 0$ - 0
Spouse/Partner$ - 0$ - 0$ - 0
Child/Other Dependent$ - 0$ - 0$ - 0
Total$ - 0$ - 0$ - 0$ - 0
MedicareClaims paid
PremiumMedicalPharmacyExperience
Employee/Self$ - 0$ - 0$ - 0
Spouse/Partner$ - 0$ - 0$ - 0
Child/Other Dependent$ - 0$ - 0$ - 0
Total$ - 0$ - 0$ - 0$ - 0
Total Experience$ - 0$ - 0$ - 0$ - 0

37b Request #1a Claims and Enrollment

Active / Pre-MedicareMedicare
Employee/SelfSpouse/PartnerChild/Other DependentEmployee/SelfSpouse/PartnerChild/Other Dependent
Net Pay MedNet Pay RxCensusNet Pay MedNet Pay RxCensusNet Pay MedNet Pay RxCensusNet Pay MedNet Pay RxCensusNet Pay MedNet Pay RxCensusNet Pay MedNet Pay RxCensus
Incurred
Dec 2016
Nov 2016
Oct 2016
Sep 2016
Aug 2016
Jul 2016
Jun 2016
May 2016
Apr 2016
Mar 2016
Feb 2016
Jan 2016
Dec 2015
Nov 2015
Oct 2015
Sep 2015
Aug 2015
Jul 2015
Jun 2015
May 2015
Apr 2015
Mar 2015
Feb 2015
Jan 2015
Dec 2014
Nov 2014
Oct 2014
Sep 2014
Aug 2014
Jul 2014
Jun 2014
May 2014
Apr 2014
Mar 2014
Feb 2014
Jan 2014

37c Request #2 State of Oklahoma High Cost Claims Net Pay Over $25K

2016
Provider NameCharge SubmittedAllowed AmountNet Payment
Person ID UnencryptedGenderEmployee StatusRelationshipProvider NameHealthChoice Network
2015
Provider NameCharge SubmittedAllowed AmountNet Payment
2014
Provider NameCharge SubmittedAllowed AmountNet Payment

37d Request #3 Top 15 Medical Providers

2016
RankProvider NameProvider Tax IDCityStateNet Pay
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
2015
RankProvider NameProvider Tax IDCityStateNet Pay
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
2014
RankProvider NameProvider Tax IDCityStateNet Pay
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

37e Request #4a Top 15 Drugs

2016
RankProduct NameNet Pay
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
2015
RankProduct NameNet Pay
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
2014
RankProduct NameNet Pay
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

37f Request #4b Top 15 Drug Providers

2016
RankProvider NameNet Pay
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
2015
RankProvider NameNet Pay
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
2014
RankProvider NameNet Pay
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

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