Attachment_J.1.3_-_Appendix_C_WCRC_Weekly_Status_Report_Template.pdf

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Workers Compensation Review Contractor
Solicitation number
RFP-CMS-2016-8A-0008
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Attachment J.1.3 WCRC SOW Appendix C

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Boston Philadelphia Chicago Dallas San Francisco Seattle Total Avg per case Ending Not screened in 7 days =

*For cases received or reopened prior to June 1, 2009, Rx proposed is Rx recommended unless denied liability is alleged and proven.

Appendix C

Submitter Medical

Proposed Beginning (includes adjustments) Plus receipts from COBC/ROs

Inventory Data for Last Week

Results of Submitted Cases for the Week of Month/Day/Year - Month/day/Year

Region

Total Cases

Submitted to Regions

Ineligible Cases

Submitted to Regions

Eligible Cases

Submitted to Regions

Monetary Data Only for Eligible Cases Submitted to Regions

Minus transfers out by ViPS of unworked cases Minus submitted to Regions

Total Settlement Amount

Total Proposed

WCMSA

Total WCRC Recommended

WCMSA

WCRC Medical Recommended

Submitter Rx Proposed*

WCRC Rx Recommended*

Weekly Status Report Example

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