W030 Audit Status Report v1.pdf

DD FORM 1423-1, FEB 2001

CONTRACT DATA REQUIREMENTS LIST

(1 Data Item)

PREVIOUS EDITION MAY BE USED.

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP ________ TM _______ OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT

REQUIRED

10. FREQUENCY

11. AS OF DATE

12. DATE OF FIRST SUBMISSION

13. DATE OF SUBSEQUENT

SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final

Reg Repro

15. TOTAL

16. REMARKS

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

Page of Pages

Frequency: Weekly (Sun-Sat) Reporting Period Start Date: Start of service delivery commencing with receipt of first Government transmittal letter notifying the contractor of initial compliance Due Date: First business day after end of reporting period following receipt of the first set of compliance review documentation.

SUBSEQUENT SUBMISSION:

Frequency: SAME AS FIRST SUBMISSION Reporting Period Start Date: Start of service delivery Due Date: First business day after end of reporting period

PHI/PII: No FILE FORMAT: Agreed upon by COR

CONTENT DETAILS:

The Workload Status Report shall provide information on the contractors workload production and inventory for each purchased care contract, compliance review cycle (i.e., Jan-Mar, Apr-Jun, etc.). A separate report for each review type (i.e., Initial Review, Rebuttal Review, Second Rebuttal Review) is required. At a minimum, the report shall be organized by column to provide the following information:

* Purchased care contract/Region (i.e., East, West, TOP, etc.).

* Review Cycle (i.e., Apr-Jun xx).

* Total number of claims received from purchased care contractor for review cycle.

* Total number of claims reviewed and completed for the week (for each purchased care contract and review cycle reported).

* Date claims received from purchased care contractor.

* Compliance review suspense date (date should be calculated based on review type (i.e. initial, rebuttal, second rebuttal), performance standard (i.e., 60-calendar days, 30-calendar days, etc., and date claims received).

* Actual compliance review completion date.

For each review type the report should summarize the total number of claims pending review. The sum of each report type should equal to the sum total of in-house claim inventory.

When appropriate, the report should denote (via asterisk *) when and/or why work has not been performed on in house claim inventory (i.e. *ICN/Claim list just received).