external extract for gloucester co.xlsx

XLSX spreadsheet 688 KB Posted

Attached to
RFP 26-025-CJ GCPS- Employee Medical, Stop Loss, Dental, Vision, Disability & Voluntary Benefits Coverage
Solicitation number
RFP-115259
Issued by
Frederick County, Virginia

View the file

Other files

File Type Posted
Addendum 1.pdf PDF
Attachment T – Vision Top Providers for Disruption Analysis.xlsx XLSX spreadsheet
Attachment M – Long Term Disability Claims History.xlsx XLSX spreadsheet
Attachment 2A. HCCs Sept 2023 - Oct 2024-GLOUCESTER COUNTY SCHOOL BOARD(Total Account)_HCC-01_20260318 03_32 PM.xlsx XLSX spreadsheet
Attachment 3 Retiree Dental GCPS Addendum Question.xlsx XLSX spreadsheet
Addendum 3 FINAL.pdf PDF
Attachment O – Medical Claim Repricing File for Discount and Disruption Analysis.xlsx XLSX spreadsheet
Attachment 2B. HCCs Oct 2024 - Sept 2025-GLOUCESTER COUNTY SCHOOL BOARD(Total Account)_HCC-01_20260318 03_31 PM.xlsx XLSX spreadsheet
Addendum 1.pdf PDF
Attachment V - Hybrid STD Benefit Summary.pdf PDF
external extract for gloucester co.xlsx XLSX spreadsheet
Attachment L – Disability Benefits.pdf PDF
Attachment S – Dental Network Utilization for Disruption Analysis .xlsx XLSX spreadsheet
Gloucester County Repricing Summary 02032026 file.xlsx XLSX spreadsheet
Addendum 2.pdf PDF
Attachment 2C. HCCs Oct 2025 - Feb 2026-GLOUCESTER COUNTY SCHOOL BOARD(Total Account)_HCC-01_20260318 03_29 PM.xlsx XLSX spreadsheet
Attachment D – Current census and enrollment for all lines of coverage (including COBRA and Retirees).xlsx XLSX spreadsheet
Attachment J – Dental Claims and enrollment history.xlsx XLSX spreadsheet
Attachment 2. HCCS over 50k Feb 2024 - Jan 2025-GLOUCESTER COUNTY SCHOOL BOARD(Total Account)_HCC-01_20260317 03_43 PM.pdf PDF
Attachment H – Vision Benefits.pdf PDF
Attachment B - Price Proposal.xlsx XLSX spreadsheet
Attachment R – Current and Historical Rates - All Lines.pdf PDF
Attachment W - Hybrid LTD Benefit Summary.pdf PDF
Attachment Q – Pharmacy Questionnaire.docx DOCX document
1B Member and claims oct 2025- Feb 2026.xlsx XLSX spreadsheet
Attachment 1. Mem and Claims Oct 2023 - Sept 2024-GLOUCESTER COUNTY SCHOOL BOARD(Total Account)_FIN-01_20260317 03_29 PM (2).xlsx XLSX spreadsheet
Attachment K – Vision Claims and enrollment history.pdf PDF
Attachment U - Supplemental Plan Claims Utilization.pdf PDF
Attachment 1A. Mem and Claims Oct 2024 - Sept 2025-GLOUCESTER COUNTY SCHOOL BOARD(Total Account)_FIN-01_20260317 03_28 PM.xlsx XLSX spreadsheet
Attachment P – Pharmacy Claim Repricing & Disruption Analysis - DELETE YELLOW ONCE APPROVED.xlsx XLSX spreadsheet
Gloucester County Repricing Cover Letter 02032026.docx DOCX document
Attachment N – Accident, Critical Illness, Hospital Benefits.pdf PDF
Attachment I – Medical Claims, Enrollment, HCCs.xlsx XLSX spreadsheet
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Claim_Extract_External

Line_NoCLAIM_TYPEPROV_NPIPROV_TINPROV_NAMEPROV_ADDR1PROV_ADDR2PROV_CITYPROV_STPROV_ZIPMEMBER_ZIPPROV_SPECIALTYPLACE_OF_SERVICEMSCPROC_CDMODIFIERREVENUE_CDCONSIDERED_CHARGE
1IN541547408SENTARA WILLIAMSBURG REGIONAL MEDICAL CENTER100 SENTARA CIRWILLIAMSBURGVA2318823062Hospital21FACILITY INPATIENT0171$3,722.00
2IN541547408SENTARA WILLIAMSBURG REGIONAL MEDICAL CENTER100 SENTARA CIRWILLIAMSBURGVA2318823062Hospital21FACILITY INPATIENT0270$311.00
3IN541547408SENTARA WILLIAMSBURG REGIONAL MEDICAL CENTER100 SENTARA CIRWILLIAMSBURGVA2318823062Hospital21FACILITY INPATIENT0300$2,299.00
4IN541547408SENTARA WILLIAMSBURG REGIONAL MEDICAL CENTER100 SENTARA CIRWILLIAMSBURGVA2318823062Hospital21FACILITY INPATIENT0410$1,063.00
5IN541547408SENTARA WILLIAMSBURG REGIONAL MEDICAL CENTER100 SENTARA CIRWILLIAMSBURGVA2318823062Hospital21FACILITY INPATIENT0430$820.00
6IN541547408SENTARA WILLIAMSBURG REGIONAL MEDICAL CENTER100 SENTARA CIRWILLIAMSBURGVA2318823062Hospital21FACILITY INPATIENT0434$432.00
7IN541547408SENTARA WILLIAMSBURG REGIONAL MEDICAL CENTER100 SENTARA CIRWILLIAMSBURGVA2318823062Hospital21FACILITY INPATIENT0471$589.00
8IN541547408SENTARA WILLIAMSBURG REGIONAL MEDICAL CENTER100 SENTARA CIRWILLIAMSBURGVA2318823062Hospital21FACILITY INPATIENT0636$233.75
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57IN1164456034203276076MEDICAL DRIVE GLOUCESTER6740 MAIN STGLOUCESTERVA2306123128Dialysis Services65FACILITY OUTPATIENTA49130270$447.30
58IN1164456034203276076MEDICAL DRIVE GLOUCESTER6740 MAIN STGLOUCESTERVA2306123128Dialysis Services65FACILITY OUTPATIENTG00080771$243.05
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63IN1164456034203276076MEDICAL DRIVE GLOUCESTER6740 MAIN STGLOUCESTERVA2306123128Dialysis Services65FACILITY OUTPATIENTJ0887EC0636$5,885.10
64IN1164456034203276076MEDICAL DRIVE GLOUCESTER6740 MAIN STGLOUCESTERVA2306123128Dialysis Services65FACILITY OUTPATIENTJ16440636$4,641.00
65IN1164456034203276076MEDICAL DRIVE GLOUCESTER6740 MAIN STGLOUCESTERVA2306123128Dialysis Services65FACILITY OUTPATIENTJ17560636$63,252.00
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146IN1275893307271540267RIVERSIDE DOCTORS HOSPITAL WILLIAMSBURG219 BULIFANTS BLVD # CWILLIAMSBURGVA2318823072Hospital22FACILITY OUTPATIENT875290300$220.22
147IN1275893307271540267RIVERSIDE DOCTORS HOSPITAL WILLIAMSBURG219 BULIFANTS BLVD # CWILLIAMSBURGVA2318823072Hospital22FACILITY OUTPATIENT87529910300$220.22
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153IN1275893307271540267RIVERSIDE DOCTORS HOSPITAL WILLIAMSBURG219 BULIFANTS BLVD # CWILLIAMSBURGVA2318823149Hospital22FACILITY OUTPATIENT932250731$483.50
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211IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0112$14,145.00
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213IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0173$16,695.00
214IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0210$1,713.00
215IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0250$8,552.91
216IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0258$37.48
217IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0270$280.34
218IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0271$35.89
219IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0272$3,052.31
220IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0278$356.89
221IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0300$3,600.52
222IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0301$4,315.33
223IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0302$404.51
224IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0305$841.00
225IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0306$911.97
226IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0310$107.00
227IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0324$191.50
228IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0370$4,539.48
229IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0402$1,329.00
230IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0410$5,213.72
231IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0480$479.16
232IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0481$13,139.75
233IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0483$1,365.75
234IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0720$17,768.00
235IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0730$303.45
236IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0761$2,334.80
237IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0771$75.75
238IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital21FACILITY INPATIENT0920$220.00
239IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital22FACILITY OUTPATIENT0250$977.77
240IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital22FACILITY OUTPATIENT0258$4.16
241IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital22FACILITY OUTPATIENT0370$3,859.61
242IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital22FACILITY OUTPATIENT0682$6,270.00
243IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital22FACILITY OUTPATIENT0710$10,056.75
244IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital22FACILITY OUTPATIENT006700370$2,450.82
245IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital22FACILITY OUTPATIENT007310370$2,933.72
246IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital22FACILITY OUTPATIENT016300370$2,789.90
247IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital22FACILITY OUTPATIENT24516RT0360$15,732.50
248IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital22FACILITY OUTPATIENT364150300$821.28
249IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital22FACILITY OUTPATIENT43239XS0750$1,959.00
250IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital22FACILITY OUTPATIENT432480750$3,945.00
251IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital22FACILITY OUTPATIENT432590750$3,316.00
252IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital22FACILITY OUTPATIENT590250720$1,217.25
253IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital22FACILITY OUTPATIENT630470360$6,790.00
254IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital22FACILITY OUTPATIENT630480360$6,790.00
255IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital22FACILITY OUTPATIENT64415590761$918.07
256IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital22FACILITY OUTPATIENT64493500761$3,688.46
257IN1366547747521245746RIVERSIDE REGIONAL MEDICAL CENTER500 J CLYDE MORRIS BLVDNEWPORT NEWSVA2360123061Hospital22FACILITY OUTPATIENT64494LT0761$963.88
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