RFP Attachment - TPL Comparision Report Sample.xlsx
XLSX spreadsheet 24 KB Posted
- Attached to
- Medicaid Third Party Liability (TPL), Recovery Audit Contracting (RAC), and Medicaid Estate Recovery
- Solicitation number
- 41NHA-S3818
- Issued by
- Nevada
About this file
This is an RFP attachment for the Nevada Health Authority's Medicaid Third Party Liability (TPL), Recovery Audit Contracting (RAC), and Medicaid Estate Recovery (MER) services, specifically containing a sample TPL Comparison Report template in Excel format. The document outlines the standardized reporting requirements that Managed Care Organizations (MCOs) must follow when submitting encounters that failed to report when compared to completed attachment documentation. The report template is segmented into three claim categories: Facility, Professional, and Pharmacy claims, each with defined data fields and submission requirements including claim identifiers, provider information, member details, service dates, procedure/diagnosis codes, and financial data.
The TPL Comparison Report template establishes comprehensive data collection standards requiring MCOs to document specific information fields such as Medicaid Member IDs, Aid Codes (TANF, CHIP, or Medicaid Expansion designation), claim paid dates, provider tax IDs and NPIs, member demographics, and claim amounts. The report mandates tracking of submitted charges, MCO paid amounts, amounts recovered, and denial reasons, with particular emphasis on recovery timelines subject to a 365-day threshold per RFP section 3.12.6.6, after which vendors forfeit recovery rights unless they can demonstrate active or disputed recovery efforts. Vendors are designated as responsible for paying costs associated with TPL payment recovery to the Nevada Department of Health Care Financing and Policy (DHCFP), with all recovery indicators required to be documented as Yes or No responses on submitted reports.
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Other files
| File | Type | Posted |
|---|---|---|
| RFP Attachment - SLA TPL Vendor Checklist.xlsx | XLSX spreadsheet | |
| 41NHA-S3818 SOWs Final 06.08.26.docx | DOCX document | |
| RFP Attachment - 213 MCO Subrogation Sample.xlsx | XLSX spreadsheet | |
| Standard-form-contract~3.docx | DOCX document | |
| RFP Attachment - Vendor Recovery Recoup Checklist.xlsx | XLSX spreadsheet | |
| 41NHA-S3818-Request-for-Proposals.docx | DOCX document | |
| 41NHA-S3818-Reference-Questionnaire.docx | DOCX document | |
| 41NHA-S3818 - Insurance Schedule - RFP.docx | DOCX document | |
| Terms-and-conditions-for-services~5.pdf | ||
| 41NHA-S3818 - Cost Schedule Final 06.09.26.xlsx | XLSX spreadsheet | |
| 41NHA-S3818 - Business Associate Addendum.docx | DOCX document | |
| Certification-regarding-lobbying~5.pdf | ||
| RFP Attachment - 210 MCO TPL Report Sample.xlsx | XLSX spreadsheet |
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Text version
Facility
| Attachment N - MCQA 210 TPL Comparison Report |
| This report should contain only encounters the MCOs failed to report when comparing a completed Attachment M to the reports submitted by the MCOs. |
| Submitted by: | |||||||||||||||||||||||||||
| Date: | |||||||||||||||||||||||||||
| Reporting period: | |||||||||||||||||||||||||||
| MCO Name: | |||||||||||||||||||||||||||
| Facility Claims | |||||||||||||||||||||||||||
| Medicaid | Aid Code | Claim Paid Date | Claim # | Pay to Provider | Pay to Provider | Pay to Provider | Pay to Provider | Attending Provider | Attending Provider | Member | Member | Beg DOS | End DOS | Place of | DRG Code | Bill Type | Principle | Carrier Code | Carrier Name | Policy | Policy # | Submitted Charge | MCO Paid Amount | Amount Recovered | Denial Reason or | Provider/Carrier | 365 days from |
| Member ID | Tax Id | NPI | Name | Address | NPI | Name | DOB | Name | Service | Diag code | Holder | No response | Last date Billed | Claim paid Ind | |||||||||||||
| Y/N |
Professional
| MCQA 210 TPL Comparison Report | ||||||||||||||||||||||||||||
| Submitted by: | ||||||||||||||||||||||||||||
| Date: | ||||||||||||||||||||||||||||
| Reporting period: | ||||||||||||||||||||||||||||
| MCO Name: | ||||||||||||||||||||||||||||
| Medicaid | Aid Code | Claim Paid Date | Claim # | Pay to Provider | Pay to Provider | Pay to Provider | Pay to Provider | Attending Provider | Attending Provider | Member | Member | Beginning DOS | End DOS | Place of | Procedure Code/Modifier | Procedure Code Description | Units | Diagnosis Code(s) | Carrier Code | Carrier Name | Policy | Policy # | Submitted Charge | Paid Amount | Amount Recovered | Denial Reason or | Provider/Carrier | 365 days from |
| Member ID | Tax Id | NPI | Name | Address | NPI | Name | DOB | Name | Service | Holder | No response | Last date Billed | Claim paid Ind | |||||||||||||||
| Y/N |
Pharmacy
| MCQA 210 TPL Comparison Report | ||||||||||||||||||||||||||||
| Submitted by: | ||||||||||||||||||||||||||||
| Date: | ||||||||||||||||||||||||||||
| Reporting period: | ||||||||||||||||||||||||||||
| MCO Name: | ||||||||||||||||||||||||||||
| Medicaid | Aid Code | Claim Paid Date | Claim # | Pay to Provider | Pay to Provider | Pay to Provider | Pay to Provider | Prescribing | Prescribing | Member | Member | Dispense Date | NDC# | RX# | Drug Name/Description | Quantity | Days supply | Refill# | Carrier Code | Carrier Name | Policy | Policy # | Submitted Charge | Paid Amount | Amount Recovered | Denial Reason or | Provider/Carrier | 365 days from |
| Member ID | Tax Id | NPI | Name | Address | Physician | Phsyician | DOB | Name | Holder | No response | Last date Billed | Claim paid Ind | ||||||||||||||||
| NPI | Name | Y/N |
Definition
| Facility and Professional Claims | Pharmacy Claims | ||
| Medicaid Member ID | NV DHHS issued 10 digit Medicaid Identification Number for each beneficiary | Medicaid Member ID | NV DHHS issued 10 digit Medicaid Identification Number for each beneficiary |
| Aid Code | Indicate if the member is TANF, CHIP or Medicaid Expansion | Aid Code | Indicate if the member is TANF, CHIP or Medicaid Expansion |
| Claim Paid/Processed Date | The date the MCO processed/paid the claim in question. | Claim Paid/Processed Date | The date the MCO processed/paid the claim in question. |
| Claim Number | 10 digit ICN number | Claim Number | 10 digit ICN number |
| Pay to Provider Tax ID | Federal Tax Identification number of the Paid to Provider | Pay to Provider Tax ID | Federal Tax Identification number of the Paid to Provider |
| Pay to Provider NPI | The National Provider Identifier of the individual or group that was reimbursed for the claim in question. | Pay to Provider NPI | The National Provider Identifier of the individual or group that was reimbursed for the claim in question. |
| Rendering Provider | The National Provider Identifier of the provider rendering care. | Prescribing | The NPI of the prescribing provider. |
| NPI | Physician | ||
| NPI | |||
| Rendering Provider | The name of the provider rendering care. | Prescribing Physician Name | The name of provider prescribing medication |
| Name | |||
| Attending Provider NPI | The National Provider Identifier of the attending provider. | ||
| Attending Provider Name | The name of the attending provider. | ||
| Member | Medicad Member Date of Birth | Member | Medicad Member Date of Birth |
| DOB | DOB | ||
| Member | Medicaid Member Name (First, Last Middle initial) | Member | Medicaid Member Name (First, Last Middle initial) |
| Name | Name | ||
| End DOS | Ending Date of service | NDC# (Drug Code) | Universal product identifier for human drugs. The NDC number must be utilized for reporting purposes. |
| Place of | Place of service where delivered | RX# | The number assigned to the prescription by the pharmacy. |
| Service | |||
| Procedure Code/Modifier | Procedure code to include any modifier | Drug Name Description | The Drug Name that corresponds to the drug code. |
| Procedure Code Description | Description of Procedure documented | ||
| DRG Code | Diagnosis Related Group Code | ||
| Bill Type | Institutional Bill Type Inpatient/Outpatient | Quantity | Amount of drug dispensed |
| Units | # of units billed | Days Supply | For example, 30 day supply |
| Diagnosis Code(s) | ICD 9 or 10 codes billed on the claim | Refill # | The number assigned to the refill by the pharmacy. |
| Carrier Code | Carrier Code of Carrier billed | Carrier Code | Carrier Code of Carrier billed |
| Carrier Name | Name of Primary Carrier | Carrier Name | Name of Primary Carrier |
| Policy Holder | The name of the insurance policy holder | Policy Holder | The name of the insurance policy holder |
| Policy Number | Identification of the Policy -could be numbers and letters | Policy Number | Identification of the Policy -could be numbers and letters |
| Submitted Charge | Submitted charge for each code (if more than one line -total) | Submitted Charge | Submitted charge for drug |
| Paid Amount | The amount paid by the MCO. | Paid Amount | The amount paid by the MCO. |
| Amount Recovered | The amount recovered on the claim. | Amount Recovered | The amount recovered on the claim. |
| Denial Reason or | When there is no recovery amount, list the denial reason or no response. | Denial Reason or | When there is no recovery amount, list the denial reason or no response. |
| No response | No response | ||
| Provider/Carrier | Date last billed to carrier or provider | Provider/Carrier | Date last billed to carrier or provider |
| Last date Billed | Last date Billed | ||
| 365 days from | (RFP 3.12.6.6) after 365 days, vendor forfeits the right to recovery to the State unless vendor can provide evidence that the recovery effort is active and/or in dispute. The vendor will be responsible to pay for the cost incurred to complete the recovery of the TPL payment to the DHCFP. Please indicate Yes or No. | 365 days from | (RFP 3.12.6.6) after 365 days, vendor forfeits the right to recovery to the State unless vendor can provide evidence that the recovery effort is active and/or in dispute. The vendor will be responsible to pay for the cost incurred to complete the recovery of the TPL payment to the DHCFP. Please indicate Yes or No. |
| Claim paid Ind | Claim paid Ind | ||
| Y/N | Y/N |
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