Schedule I Sample 5 year Claims Report.xlsx

20 KB Posted

Attached to
Long Terms Disability Insurance Administration Service
Solicitation number
RFP - 171 - 240000001383
Issued by
Ingham County, Lansing City, Michigan

About this file

Written by GovTribe AI ·

The provided document is a Sample 5-year Claims Report for a Long-Term Disability (LTD) Insurance Administration Service contract opportunity for the State of Michigan involving Ingham County and the City of Lansing. The contract requires the provision of LTD insurance administration services, and the claims report provides detailed information on past claims, including claim numbers, claimant names, employment details, diagnoses, benefit amounts, and other relevant data. The contract opportunity has a proposed scope of work, enrollment census, and other supporting documents that bidders should review. The contract term is not specified, but typical LTD insurance contracts include renewal options.

The pricing terms, set-asides, incumbent provider, and funding details are not provided in the given materials. Bidders should review the full solicitation package, including the revised Statement of Work and Proposal Instructions, to ensure they have a comprehensive understanding of the contract requirements and submit a responsive proposal.

View the file

Other files

File Type Posted
Hybrid Contract Terms.docx DOCX document
IRS Publication 1075.pdf PDF
Non-disclosure-agreement.docx DOCX document
Schedule E Data Security Requirements for Hybrid Purchases.docx DOCX document
Schedule G Section 2 Software Table.xlsx XLSX spreadsheet
Schedule J LTD Enrollment Census.xlsx XLSX spreadsheet
Department of Treasury Safeguard Requirements of Confidential Tax Data 7.doc DOC document
Schedule C Insurance Requirements.docx DOCX document
Schedule H Service Availability Report.xlsx XLSX spreadsheet
Exhibit 7 Safeguarding Contract Language.pdf PDF
Proposal Instructions Vendor Questions WorksheetREVISED.docx DOCX document
Schedule A Statement of WorkREVISED.docx DOCX document
Schedule B Pricing.xlsx XLSX spreadsheet
Schedule D Service Level Agreements for Hybrid Purchases.docx DOCX document
240000001383 LTD Questions Answers.pdf PDF
Schedule F File Layout.doc DOC document
Show all 16

On GovTribe

Work with this file

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file
Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

tblMonthlyData4yr

ClaimNoClaimantNameEmpIDSSNDOBGenderOccupationHireDateLTD_Plan_CdDept_DescDept_CdProcessLvl_DescProcessLvl_CdUnionCodeReceivedDateStatusClosedDateFiscalYearDODFirst_Absnc_DtDeniedDeniedDateDeniedReasonAppealedAppealRecDateAppealDecisionDtAppealResultDt_ApprvdDt_Bene_BeganApprvd_Thru_DtClosure_ReasonLengthOfDisBene_AmtIME_ExpLegalTotal_IncurredFY_Paid_To_DateTotal_Paid_LifeICD_VersionP1ICD_CodeP1ICD_DesP1ICD_VersionP2ICD_CodeP2ICD_DescP2MonthlyBenefit
3000-DI19-00519John Jonesxxxxxxxxxxxxxxxx12/22/1971FASSISTANCE PAYM02/06/20112VOS CONVERSION70970099VOS CONVERSION LOCATIONNULLW2212/02/2019Closed02/11/2020202001/01/202001/02/2020Limitation or exclusionN01/02/202001/16/202001/24/20208793.18793.18793.18M75.51Bursitis of right shoulder3062.55
3000-DI19-0064304/16/1971FASSISTANCE PAYM07/07/20022VOS CONVERSION70970099VOS CONVERSION LOCATIONNULLW2212/13/2019Closed03/25/2020202001/01/202001/02/2020Limitation or exclusionN01/02/202001/16/202003/16/2020403293.33293.33293.3C50.919Malignant neoplasm of unspecified site of unspecified female breast2820.1
3000-DI19-0069307/14/1969MREGISTERED NURS09/17/20122CORRECTIONS70970047G ROBERT COTTON CORR FACILITY4279Y5112/20/2019Closed03/02/2020202001/01/202001/02/2020YES6/29/20Eligibility Not MetN01/02/202001/16/202006/29/2020162069.972069.972069.97E27.8Other specified disorders of adrenal gland4183.17
3000-DI19-0078508/30/1987FCIVIL RIGHTS RE09/19/20102CIVIL RIGHTS70970015DETROIT CADILLAC PLACE BLDG1208W2201/03/2020Closed02/21/2020202001/02/202001/03/2020Limitation or exclusionN01/03/202001/17/202002/14/2020283186.853186.853186.85O80Encounter for full-term uncomplicated delivery3675.06
3000-DI19-0074910/07/1971MCORRECTIONS OFF07/08/20012709700473631C1212/30/2019Closed03/03/2020202001/02/202001/03/2020Limitation or exclusionN01/03/202001/17/202002/15/2020292857.532857.532857.53M72.2Plantar fascial fibromatosis3139.12
3000-DI19-0067310/05/1987FDEPARTMENT OF S08/04/20132STATE70970023GRAND RAPIDS RIC CENTER10334W4112/18/2019Closed05/18/2020202001/03/202001/04/2020Limitation or exclusionN01/04/202001/18/202005/01/20201048941.078987.388987.38Z34.83Encounter for supervision of other normal pregnancy, third trimesterO24.410Gestational diabetes mellitus in pregnancy, diet controlled2642.61
3000-DI19-0073507/31/1963FGENERAL OFFICE08/09/19982MDHHS - HUMAN SERVICES70970043GRANDMONT SERVICE CENTER8445W4112/26/2019Closed04/14/2020202001/05/202001/06/2020YES5/29/20Medical did not supportN01/06/202001/20/202005/29/2020706081.746081.746081.74M16.12Unilateral primary osteoarthritis, left hip2665.81
3000-DI19-0074302/04/1986FASSISTANCE PAYM02/22/20112MDHHS - HUMAN SERVICES70970043TAYLOR SERVICE CENTER8825W2212/27/2019Closed09/25/2020202001/05/202001/06/2020Limitation or exclusionN01/06/202001/20/202005/01/202010210235.9910235.9910235.99F33.1Major depressive disorder, recurrent, moderateO24.919Unspecified diabetes mellitus in pregnancy, unspecified trimester3062.56
3000-DI19-0078312/27/1974FHUMAN RESOURCES04/18/19992CIVIL SERVICE COMMISSION70970019CONSTITUTION HALL10349Y9901/03/2020Closed02/21/2020202001/05/202001/06/2020Limitation or exclusionN01/06/202001/20/202001/27/202071004.031004.031004.03L30.4Erythema intertrigoE66.01Morbid (severe) obesity due to excess calories4416.34
3000-DI19-0079508/24/1981FSUPREME COURT E07/23/20122VOS CONVERSION70970099VOS CONVERSION LOCATIONNULLZ7601/06/2020Closed04/02/2020202001/02/202001/03/2020Limitation or exclusionN01/06/202001/17/202003/16/2020599340.949340.949340.94S82.851ADisplaced trimalleolar fracture of right lower leg, initial encounter for5000
3000-DI19-0067201/27/1980FCORRECTIONS OFF02/20/20002CORRECTIONS70970047RICHARD HANDLON CORR FACILITY3619C1212/18/2019Closed03/20/2020202001/05/202001/06/2020Limitation or exclusionN01/06/202001/20/202003/06/2020464563.834563.834563.83D21.9Benign neoplasm of connective and other soft tissue, unspecified3139.12
3000-DI19-0076707/14/1974FACCOUNTING TECH07/24/20112VOS CONVERSION70970099VOS CONVERSION LOCATIONNULLW4101/02/2020Closed01/31/2020202001/06/202001/07/2020Limitation or exclusionN01/07/202001/21/202001/27/20206580.09580.09580.09N80.3Endometriosis of pelvic peritoneum3011.51
3000-DI19-0080702/20/1965FREGISTERED NURS02/11/19962CORRECTIONS70970047LAKELAND CORR FACILITY4255W2201/07/2020Closed07/08/2022202001/04/202001/05/2020Expiration of BenefitsN01/07/202001/19/202001/18/202273064991.0667191.0667191.06S92.411DDisplaced fracture of proximal phalanx of right great toe, subsequentM21.6113980.16
3000-DI19-0080603/09/1966MFOOD SERVICES S01/15/19952CORRECTIONS70970047G ROBERT COTTON CORR FACILITY3240Y5101/07/2020Closed02/20/2020202001/06/202001/07/2020Limitation or exclusionN01/07/202001/07/202001/07/2020100M20.11Hallux valgus (acquired), right footQ74.2Other congenital malformations of lower limb(s), including pelvic girdle2959.31
3000-DI19-0080409/07/1990FSOCIAL SERVICES10/21/20182MDHHS - HUMAN SERVICES70970043SOUTH CENTRAL CFS10365W2201/07/2020Closed06/08/2020202001/05/202001/06/2020Limitation or exclusionN01/07/202001/20/202005/25/202012610730.9210730.9210730.92F43.23Adjustment disorder with mixed anxiety and depressed moodZ33.1Pregnant state, incidental2505.72
3000-DI19-0071609/29/1984FSOCIAL SERVICES02/11/20132MDHHS - HUMAN SERVICES70970043MUSKEGON CO OFFICE10808W2212/23/2019Closed05/13/2020202001/06/202001/07/2020Limitation or exclusionN01/07/202001/22/202005/01/202010010680.3610680.3610680.36Z3A.3737 weeks gestation of pregnancyF53Puerperal psychosis3303.85
3000-DI19-0080302/11/1961MPHYSICAL PLANT12/10/20002MDHHS - COMMUNITY HEALTH70970039WALTER P REUTHER COMNTY HLTH2450Y5101/07/2020Closed03/09/2020202001/01/202001/02/2020Limitation or exclusionN01/07/202001/16/202002/17/2020324531.744531.744531.74G56.22Lesion of ulnar nerve, left upper limb4648.35
3000-DI19-0078708/13/1960FPRACTICAL NURSE12/13/20102MILITARY & VETERAN AFFAIRS70970051GRAND RAPIDS HOME FOR VETERANS4659U1101/06/2020Closed03/16/2020202001/06/202001/07/2020Limitation or exclusionN01/07/202001/21/202003/02/2020414029.114029.114029.11G57.52Tarsal tunnel syndrome, left lower limb3018.47
3000-DI19-0078607/16/1992FCORRECTIONS OFF03/29/20152CORRECTIONS70970047HURON VALLEY CORR FACILITY3650C1201/06/2020Closed02/03/2021202001/06/202001/07/2020Yes2/3/2021Did not satisfy waiting periodN01/07/202001/21/202034631864.2133289.2133289.21F53Puerperal psychosisZ34.80Encounter for supervision of other normal pregnancy, unspecified trimester2860.71

File details come from the government source that posted it. Updated .