Schedule H - Sample Claims Report and Invoice Format Final.xlsx
XLSX spreadsheet 15 KB Posted
- Attached to
- Vision Insurance Plan Administration for CSC
- Solicitation number
- RFP-171-180000001030-4
- Issued by
- Grand Traverse County, Lansing City, Michigan
About this file
This is a sample claims report and invoice format template for the State of Michigan Civil Service Commission (MCSC) Vision Insurance RFP No. 180000001030 for the 2018 fiscal year. The document provides a standardized format for reporting vision insurance claims, administrative costs, and Health Insurance Claims Assessment (HICA) charges across different employee groups including Actives (including COBRA), State Employees' Retirement System (SERS), State Police Retirement System (SPRS), Judges Retirement System (JRS), and Military Retirement System (MRS).
The template is structured to track financial data across three main categories: claims payments, administrative costs, and HICA charges, with separate sections for claims less than one year old and claims greater than one year old. The document includes spaces to record total invoiced amounts for the period of October 1, 2017, through September 30, 2018, with requirements that the totals should match the invoice totals billed and paid for the year. All monetary fields in the template are currently showing zero values, indicating this is a blank format document for future use.
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Other files
| File | Type | Posted |
|---|---|---|
| Schedule A - Final.docx | DOCX document | |
| Schedule C - Plan Design Final.docx | DOCX document | |
| Schedule E - HIPAA 834 File Layouts Final.pdf | ||
| RFP 180000001030 Questions and Answers Final.docx | DOCX document | |
| Schedule F - Provider Cost Claims Data Final.XLSX | XLSX spreadsheet | |
| Schedule J Safeguard Requirements of Confidential Data Final.docx | DOCX document | |
| Schedule D - GeoAccess Data Final_Rev 2-28-18.xlsx | XLSX spreadsheet | |
| Standard Contract Terms Final.docx | DOCX document | |
| Vision RPF Q&A #28.xlsx | XLSX spreadsheet | |
| Vision RPF Q&A #33.xlsx | XLSX spreadsheet | |
| Proposal Instructions and Vendor Questions Worksheet Final.docx | DOCX document | |
| Schedule B - Pricing Matrix Final.xlsx | XLSX spreadsheet | |
| Schedule G - Provider Location Data for Disruption Analysis Final_Rev 2-28-18.xlsx | XLSX spreadsheet | |
| Schedule I - SLA Reporting Format Final.pdf |
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Text version
Monthly & Year-End
| 2018 MCSC Vision RFP No. 180000001030 |
| Schedule H - Sample SOM Vision Insurance Claims Report |
| Estimated Liability for Incurred |
but Unpaid Vision Claims
| as of September 30, 2018 | Claims less than one year | Claims greater than one year | |
| Actives (including Active COBRA) | $ - 0 | $ - 0 | |
| SERS (including Retiree COBRA) | $ - 0 | $ - 0 | |
| SPRS (including Retiree COBRA) | $ - 0 | $ - 0 | |
| JRS (including Retiree COBRA) | $ - 0 | $ - 0 | |
| MRS (including Retiree COBRA) | $ - 0 | $ - 0 | |
| Total | $ - 0 | $ - 0 |
| Vision Claims | Total Invoiced 10/1/17 - 9/30/18 |
| Actives (including Active COBRA) | $ - 0 |
| SERS (including Retiree COBRA) | $ - 0 |
| SPRS (including Retiree COBRA) | $ - 0 |
| JRS (including Retiree COBRA) | $ - 0 |
| MRS (including Retiree COBRA) | $ - 0 |
| Total | $ - 0 |
| (should match | |
| invoice totals | |
| billed and paid | |
| for the year) |
| Vision Admin | Total Admin 10/1/17 - 9/30/18 |
| Actives (including Active COBRA) | $ - 0 |
| SERS (including Retiree COBRA) | $ - 0 |
| SPRS (including Retiree COBRA) | $ - 0 |
| JRS (including Retiree COBRA) | $ - 0 |
| MRS (including Retiree COBRA) | $ - 0 |
| Total | $ - 0 |
| (should match | |
| admin totals | |
| invoices for the | |
| year) |
| Vision HICA | Total HICA 10/1/17 - 9/30/18 |
| Actives (including Active COBRA) | $ - 0 |
| SERS (including Retiree COBRA) | $ - 0 |
| SPRS (including Retiree COBRA) | $ - 0 |
| JRS (including Retiree COBRA) | $ - 0 |
| MRS (including Retiree COBRA) | $ - 0 |
| Total | $ - 0 |
| (should match | |
| HICA totals | |
| that appeared on | |
| invoices for the | |
| year) |
Invoicing
| 2018 MCSC Vision RFP No. 180000001030 | |||
| Schedule H - Sample SOM Vision Insurance Invoice Format | |||
| Vision Invoicing | Total Claims 10/1/17 - 9/30/18 | Total Admin 10/1/17 - 9/30/18 | Total HICA 10/1/17 - 9/30/18 |
| Actives (including Active COBRA) | $ - 0 | $ - 0 | $ - 0 |
| SERS (including Retiree COBRA) | $ - 0 | $ - 0 | $ - 0 |
| SPRS (including Retiree COBRA) | $ - 0 | $ - 0 | $ - 0 |
| JRS (including Retiree COBRA) | $ - 0 | $ - 0 | $ - 0 |
| MRS (including Retiree COBRA) | $ - 0 | $ - 0 | $ - 0 |
| Total | $ - 0 | $ - 0 | $ - 0 |
File details come from the government source that posted it. Updated .