Exhibit_A.3_-_Claims_Reporting_Fields_FINAL.pdf
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- Solicitation number
- 25-P-115TF
- Issued by
- Volusia County, Florida
About this file
Exhibit A.3 is a detailed claims reporting fields document for the 25-P-115TF Self-Funded Group Health Plan Administrative Services contract for Volusia County Government in Florida. The document comprehensively outlines three distinct claims reporting categories: Eligibility, Medical, and RX (Prescription), each with extensive data fields for tracking and managing health plan information. The contract is structured for an initial five-year term with a potential subsequent five-year renewal, effective January 1, 2027, and seeks to provide administrative services for the county's self-insured health plans covering employees, retirees, and COBRA participants.
The reporting fields demonstrate a robust, granular approach to claims management, capturing detailed information across member demographics, coverage details, provider information, service specifics, financial components, and clinical data. The document includes fields for tracking member eligibility, medical claim details (including diagnosis codes, provider information, and financial breakdowns), and prescription drug claims (with extensive data on drug characteristics, pharmacy details, and cost components). This comprehensive reporting structure suggests the county is seeking a highly sophisticated administrative services approach that enables precise tracking, analysis, and management of health plan claims and member interactions.
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Text version
25-P-115TF Exhibit A.3 - Claims Reporting Fields
ELIGIBILITY
Member Number (SSN plus extension) Member Last Name Member First Name Member Date of Birth Member Sex Relationship Policy Code, Claim Division, Branch Benefit Option, Plan Effective date Cancellation date of coverage Coverage Tier Member Zip Code Provider ID Eligibility Date Member Street Address Member City Name Member State Alternate Member ID Member Age Age Band Medicare indicator Street Address Street Address - secondary City name State Coverage Indicator Employment Status
MEDICAL
Client ID Plan Code Group or policy number Subgroup for retiree, active, cobra Employee ID Employee Name Employee State Code Employee Zip Full time or retiree Member Number Alternate Member ID Member Name Relationship Member DOB Member Gender Claimant Age Servicing Provider Name Servicing Provider Address Servicing Provider Address Second Line Servicing Provider City Servicing Provider State Servicing Provider Zip Servicing Provider Tax ID or NPI Provider Name Provider Tax ID Provider ZIP National Provider ID Ordering Provider ID Referring provider Provider Specialty Billing Provider Name Billing Provider Address Billing Provider Address Second Line Billing Provider City Billing Provider State Billing Provider Zip Claim # Claim Line # Service Date Claim Service Date
Claim Received Date Claim Paid Date Last Service Date Admit Date Discharge Date Discharge Status Code Hospital Days Service Unit Count Type of Bill Service Type Place of Service Hospital, Ancillary, Professional In/Out Network Indicator Submitted Claim Charge Not Covered Amount Covered/Allowed Amount Discount Amount Deductible Amount Copay Amount Coinsurance Amount Paid Amount HRA Amount State Surcharge Amount Surcharge State Code Procedure Code Procedure Code Type Procedure Code Modifier CPT/HCPCS/Revenue Code ICD Diagnosis Code ICD Procedure Code ICD Version Indicator MS DRG Code Primary Dx Secondary Dx Tertiary Dx POA Indicator Savings Reason Code Remark Code Transaction Code Reason Not Covered Code
RX
Source Data Client Number Customer Number Employee ID Employee Name Member Number Member Name Patient First Name Patient Last Name Member DOB Member Age Member Gender Relationship Member Zip Code Member State Member City Name Street Address Street Address - secondary Coverage Indicator Pharmacy coverage indicator Benefit Plan (If Applicable) Plan Code Group or policy number Subgroup for retiree, active, cobra Branch Code Network Indicator (In or Out) Coverage Tier Pharmacy NABP# Pharmacy Name Pharmacy Address Pharmacy City Pharmacy State Pharmacy ZIP Rx Account Number Script # Claim Number Source of Claim Fill Date Paid Date Refill Number
Days Supply Metric Quantity Dispensed Drug Name Drug Strength Ndc Number Generic Indicator Generic/Brand/OTC Generic Therapeutic Class Code Single or Multi-Source (Must Include SSG) Formulary Indicator Specialty (Y/N) Compounding Code Tier Value Prior Auth (Yes or No) Physician ID Physician NPI Physician DEA Ordering Provider Npi Manufacturer/Distributer Name Average Wholesale Price Cost Basis (AWP, MAC, U&C,etc.)
Ingredient Cost Dispensing Fee Admin Fee Sales Tax U&C Amount Total Paid Amount Total Covered Amount Copay Amount Deductible Coinsurance Paid Amount DAW Indicator Code Retail/Mail
File details come from the government source that posted it. Updated .