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] | ||
| Report | Report Title | Tab Name |
| 37a | Experience | Experience |
| 37b | Claims and Enrollment | Request #1a |
| 37c | Net Pay over $25k | Request #2 |
| 37d | Top 15 Medical Providers | Request #3 |
| 37e | Top 15 Drugs | Request #4a |
| 37f | Top 15 Drug Providers | Request #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-Medicare | Claims paid | |||
| Premium | Medical | Pharmacy | Experience | |
| Employee/Self | $ - 0 | $ - 0 | $ - 0 | |
| Spouse/Partner | $ - 0 | $ - 0 | $ - 0 | |
| Child/Other Dependent | $ - 0 | $ - 0 | $ - 0 | |
| Total | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| Medicare | Claims paid | |||
| Premium | Medical | Pharmacy | Experience | |
| 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-Medicare | Claims paid | |||
| Premium | Medical | Pharmacy | Experience | |
| Employee/Self | $ - 0 | $ - 0 | $ - 0 | |
| Spouse/Partner | $ - 0 | $ - 0 | $ - 0 | |
| Child/Other Dependent | $ - 0 | $ - 0 | $ - 0 | |
| Total | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| Medicare | Claims paid | |||
| Premium | Medical | Pharmacy | Experience | |
| 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-Medicare | Claims paid | |||
| Premium | Medical | Pharmacy | Experience | |
| Employee/Self | $ - 0 | $ - 0 | $ - 0 | |
| Spouse/Partner | $ - 0 | $ - 0 | $ - 0 | |
| Child/Other Dependent | $ - 0 | $ - 0 | $ - 0 | |
| Total | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| Medicare | Claims paid | |||
| Premium | Medical | Pharmacy | Experience | |
| 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-Medicare | Medicare | |||||||||||||||||
| Employee/Self | Spouse/Partner | Child/Other Dependent | Employee/Self | Spouse/Partner | Child/Other Dependent | |||||||||||||
| Net Pay Med | Net Pay Rx | Census | Net Pay Med | Net Pay Rx | Census | Net Pay Med | Net Pay Rx | Census | Net Pay Med | Net Pay Rx | Census | Net Pay Med | Net Pay Rx | Census | Net Pay Med | Net Pay Rx | Census | |
| Incurred | ||||||||||||||||||
| Dec 2016 | ||||||||||||||||||
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| Jan 2014 |
37c Request #2 State of Oklahoma High Cost Claims Net Pay Over $25K
| 2016 | |||||||||
| Provider Name | Charge Submitted | Allowed Amount | Net Payment | ||||||
| Person ID Unencrypted | Gender | Employee Status | Relationship | Provider Name | HealthChoice Network |
| 2015 | |||
| Provider Name | Charge Submitted | Allowed Amount | Net Payment |
| 2014 | |||
| Provider Name | Charge Submitted | Allowed Amount | Net Payment |
37d Request #3 Top 15 Medical Providers
| 2016 | |||||
| Rank | Provider Name | Provider Tax ID | City | State | Net Pay |
| 1 | |||||
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| 2015 | |||||
| Rank | Provider Name | Provider Tax ID | City | State | Net Pay |
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| 2014 | |||||
| Rank | Provider Name | Provider Tax ID | City | State | Net Pay |
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37e Request #4a Top 15 Drugs
| 2016 | ||
| Rank | Product Name | Net Pay |
| 1 | ||
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| 2015 | ||
| Rank | Product Name | Net Pay |
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| 2014 | ||
| Rank | Product Name | Net Pay |
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37f Request #4b Top 15 Drug Providers
| 2016 | ||
| Rank | Provider Name | Net Pay |
| 1 | ||
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| 2015 | ||
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| 2014 | ||
| Rank | Provider Name | Net Pay |
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