Schedule K Sample Claims Report and Invoice Format.xlsx

This file contains invoice and claims reporting templates for Behavioral Health and Substance Use Disorder (BH/SUD) Benefits administration under RFP No. 260000002410 for the State of Michigan's State Health Plan PPO. The document provides standardized formats for regular invoicing, quarterly reporting, and year-end financial reporting that vendors must follow when billing for BH/SUD services. Regular invoices must include the invoice date, invoice period (weekly, bi-weekly, or monthly), and itemized breakdowns of total claims, administrative fees, and applicable taxes across five benefit categories: Actives, COBRA (including Active & Retiree COBRA), SERS, SPRS, JRS, and MRS. The templates specify that Applied Behavior Analysis (ABA) cases must be identified separately, and all claims taxes must be reported separately and rolled up to quarterly and year-end reports.

Quarterly and year-end reporting requirements include comprehensive claims reports, administrative fee summaries, claims tax documentation, and an estimated liability report for incurred but unpaid claims segregated by claims less than one year and claims greater than one year. The document also includes a claims lag report template that tracks incurred claims by month and their corresponding paid dates over a twelve-month period, enabling analysis of payment timing patterns. Actives and retiree data must be submitted monthly in separate sections. These reporting and invoicing formats establish the financial accounting framework for the BH/SUD benefits administration contract and ensure consistent, detailed tracking of all claims and administrative costs across all covered populations.