Sample_Report_2017.xlsx
XLSX spreadsheet 24 KB Posted
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- Health & Life Insurance Services
- Solicitation number
- SPM070-17-R-0001
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Samples of Reports
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Text version
EmpClaims1
SAMPLE REPORT ONLY
| EMBASSY OF THE UNITED STATES OF AMERICA, PANAMA | |||||||||||||
| GROUP LIFE AND HEALTH | |||||||||||||
| EMPLOYEES DAILY CLAIMS REPORT | |||||||||||||
| Policy No. | XXXXXX | ||||||||||||
| From: | mm/dd/yyyy | To: | mm/dd/yyyy | ||||||||||
| Certificate No. | Beneficiary First Name | Beneficiary Last Name | Claimant First Name | Claimant Last Name | Dependent | Claim No. | Total Expenses | Date of Expenses | Claim Submission Date | Claim Process Date | Amount Paid | Payee | Rejection |
| 001 | John | Doe | Same | Same | Self | 1234 | $ 56.02 | mm/dd/yyyy | mm/dd/yyyy | mm/dd/yyyy | $ 40.00 | Hospital | Explanation |
| 002 | Maria | Smith | Bob | Smith | Spouse | 2345 | $ 600.00 | mm/dd/yyyy | mm/dd/yyyy | mm/dd/yyyy | $ 510.00 | Dr. Yoga |
Total $ 656.02 $ 550.00
| Notes: |
| Beneficiary: Primary Insurance Holder (i.e. Employee) |
| Claimant: Person that submits a claim for medical services received. |
| Date of Expenses: Date medical service received. |
| Claim Submission Date: Date claim picked up by vendor. |
| Claim Process Date: Date claim completed or rejected by vendor. |
| Amount Paid: Amount paid by vendor to employee or medical provider once benefits are confirmed. |
| Payee: Name of medical provider or employee that receives payment. |
| Rejection: Explanation as to why claim was rejected. (i.e. additional forms needed, medical service not covered, etc.) |
&"Times New Roman,Regular"Health and Life Solicitation &"Times New Roman,Regular"Section H.5
EmpMaster2
SAMPLE REPORT ONLY
| EMBASSY OF THE UNITED STATES OF AMERICA, PANAMA | |||||||||||||
| GROUP LIFE AND HEALTH | |||||||||||||
| EMPLOYEE MASTER ENROLLMENT REPORT | |||||||||||||
| Policy No. | XXXXXX | ||||||||||||
| Date | mm/dd/yyyy | ||||||||||||
| Enrollment Date | Certificate No. | Employee First Name | Employee Last Name | Date of Birth | Enrolled Health | Enrolled Life | Annual Salary | Spouse First Name | Spouse Last Name | Date of Birth | Child First Name | Child Last Name | Date of Birth |
| 1/5/06 | 1 | John | Doe | 12/6/54 | N | Y | $ 20,243.00 | n/a | n/a | n/a | na/ | n/a | n/a |
| 6/1/06 | 2 | Maria | Smith | 3/2/66 | Y | Y | $ 8,150.00 | Tranquilino | Smith | 4/1/65 | Bob | Smith | 2/17/96 |
&"Times New Roman,Regular"Health and Life Solicitation &"Times New Roman,Regular"Section H.5
PremColl3
| EMBASSY OF THE UNITED STATES OF AMERICA, PANAMA |
| GROUP LIFE AND HEALTH |
| CLAIMS PAID/PREMIUMS COLLECTED UTILIZATION REPORT |
| Policy Month | Life Premium Received | Health Premium Received | Life Reimbursement | Health Reimbursement | Life Experience | Health Experience |
| Mar-14 | - 0 | 34,644.23 | - 0 | 19,524.45 | 0.0% | 56.4% |
| Apr-14 | 5,814.90 | - 0 | - 0 | 14,161.16 | 0.0% | 0.0% |
| May-14 | 4,369.04 | 56,015.45 | - 0 | 23,364.31 | 0.0% | 41.7% |
| Jun-14 | 1,465.50 | 37,463.85 | - 0 | 28,614.69 | 0.0% | 76.4% |
| Jul-14 | 14,727.41 | 75,697.32 | - 0 | 15,279.34 | 0.0% | 20.2% |
| Aug-14 | - 0 | - 0 | - 0 | 16,605.39 | 0.0% | 0.0% |
| Sep-14 | 4,362.13 | 37,310.14 | - 0 | 16,866.22 | 0.0% | 45.2% |
| Oct-14 | 1,520.64 | 57,216.74 | - 0 | 12,974.32 | 0.0% | 22.7% |
| Nov-14 | 1,534.96 | 38,607.89 | - 0 | 7,040.51 | 0.0% | 18.2% |
| Dec-14 | 4,425.55 | 39,028.53 | - 0 | 17,472.02 | 0.0% | 44.8% |
| Jan-15 | - 0 | 38,946.48 | - 0 | 16,301.15 | 0.0% | 41.9% |
| Feb-15 | 453.31 | 78,610.92 | - 0 | 12,492.74 | 0.0% | 15.9% |
| Mar-15 | 4,548.51 | 41,300.80 | - 0 | 29,740.29 | 0.0% | 72.0% |
| Apr-15 | 8,633.42 | 105.00 | - 0 | 24,823.31 | 0.0% | 23641.2% |
| May-15 | 9,519.70 | 63,676.50 | - 0 | 21,735.13 | 0.0% | 34.1% |
| Jun-15 | 9,078.47 | 42,332.43 | - 0 | 11,983.93 | 0.0% | 28.3% |
| Jul-15 | 1,522.02 | 42,420.63 | - 0 | 22,965.03 | 0.0% | 54.1% |
| Aug-15 | 10,671.60 | 43,307.03 | - 0 | 15,826.46 | 0.0% | 36.5% |
| Sep-15 | 18,687.86 | 65,699.73 | - 0 | 19,001.37 | 0.0% | 28.9% |
| Oct-15 | 5,176.46 | 44,405.91 | - 0 | 26,079.17 | 0.0% | 58.7% |
| Nov-15 | 761.01 | 45,010.91 | - 0 | 9,523.24 | 0.0% | 21.2% |
| Dec-15 | 761.01 | 89,639.28 | - 0 | 12,519.54 | 0.0% | 14.0% |
| Jan-16 | 15,098.87 | - 0 | - 0 | 25,929.60 | 0.0% | 0.0% |
| Feb-16 | 4,733.31 | 44,466.84 | - 0 | 13,320.28 | 0.0% | 30.0% |
| Mar-16 | 6,088.49 | 110,810.26 | - 0 | 18,209.90 | 0.0% | 16.4% |
| Apr-16 | 6,589.26 | - 0 | - 0 | 10,466.02 | 0.0% | 0.0% |
| May-16 | 4,220.10 | 47,223.16 | - 0 | 23,770.53 | 0.0% | 50.3% |
| Jun-16 | 10,835.74 | 95,062.99 | - 0 | 25,197.86 | 0.0% | 26.5% |
| Jul-16 | 1,183.52 | 47,267.32 | - 0 | 18,085.16 | 0.0% | 38.3% |
| Aug-16 | 10,164.91 | 71,065.82 | 1,479.67 | 7,384.76 | 14.6% | 10.4% |
| Sep-16 | 5,493.38 | - 0 | 1,479.67 | 15,923.85 | 26.9% | 0.0% |
| Oct-16 | - 0 | 46,926.68 | 1,479.67 | 16,277.19 | 0.0% | 34.7% |
| Nov-16 | 5,613.51 | 47,412.82 | 1,479.67 | 12,814.69 | 26.4% | 27.0% |
| Dec-16 | - 0 | 95,715.08 | 1,479.67 | 14,296.98 | 0.0% | 14.9% |
| Jan-17 | 11,192.26 | 23,611.58 | 48,446.34 | 12,990.85 | 432.9% | 55.0% |
| Feb-17 | 11,660.55 | 69,791.61 | 20,715.31 | 12,611.79 | 177.7% | 18.1% |
| Mar-17 | - 0 | 65,078.45 | - 0 | 14,252.51 | 0.0% | 21.9% |
| 200,907.40 | 1,735,872.38 | 76,560.00 | 636,425.74 | 38.1% | 36.7% |
| Note: |
| The Embassy has obtained the following historical data from the current contractor but cannot certify as to whether this data will be indicative of future claims. Therefore, it is each offeror’s decision on whether or not to use this information. However, under no circumstances shall the U.S. Government be liable for this information or shall it become the basis for a request to adjust the premium rates once the contract is awarded. Rather, offerors are advised any adjustments to contract premium rates shall be in accordance with the Price Adjustment clauses (B.4 and B.8) of the contract. |
&"Times New Roman,Regular"Health and Life Solicitation &"Times New Roman,Regular"Section H.5
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