Schedule H - Sample Claims Report and Invoice Format Final.xlsx

This is a Sample Claims Report and Invoice Format document for the 2018 MCSC (presumably a state or local consortium) Vision Insurance Request for Proposal No. 180000001030. The document provides templates for reporting estimated liability for incurred but unpaid vision claims as of September 30, 2018, segmented by membership categories including Actives with Active COBRA, SERS with Retiree COBRA, SPRS with Retiree COBRA, JRS with Retiree COBRA, and MRS with Retiree COBRA. The reporting structure distinguishes between claims less than one year old and claims greater than one year old, establishing a framework for tracking outstanding claim liabilities across the plan year from October 1, 2017, through September 30, 2018.

The document includes standardized invoice formatting templates for vision claims, administrative costs, and HICA (Health Insurance Clearing Account) charges to be submitted by the contractor. All sample figures presented in the document are shown as zero dollars, indicating this is a blank template for contractor use rather than actual billing data. The invoice format requires breakdown by the same five membership categories and must reconcile with actual invoiced amounts, administrative totals, and HICA charges billed and paid during the 2018 plan year. This template establishes the required reporting and invoicing standards that the selected vision insurance contractor must follow throughout the contract period.