SRC0000038100 Exhibit 11.docxSRC0000038100 Exhibit 11.docx

EXHIBIT 11

METHODOLOGY AND ATTESTATION FOR REPORTING PROVIDER DISCOUNTS

Methodology for Reporting Provider Discounts

*The Offeror must provide historical provider discounts for each three digit ZIP code in the Offeror’s service area using the methodology described below. Discounts are to be reported in the tables provided ( Exhibit 12). These discounts are to be attested by the Offeror’s chief actuary.

Data Specifications

Time Period

Include all medical claims incurred January 1, 2025 to December, 31, 2025 and paid through February 28, 2026 for the Historical Discounts.

Please note that for inpatient claims, admission date should be considered the incurred date.

Groupings

Data should be separated into one of the following five groups based on type of service:

A. Inpatient facility (in-network contracted facility charges only; does not include associated professional charges);

B. Outpatient facility (in-network contracted facility charges only; does not include associated professional charges); one exception is all lab/radiology/pathology claims should be grouped here;

C. Professional and other services (in-network contracted only, including professional charges associated with facility claims);

D. Out-of-network contracted services (This includes services where the provider is contracted with the health plan and benefits are paid at an out-of-network benefit level. An example of this is when a plan has a "wrap" network for out-of-network claims). or when a one-time negotiation is completed; and E. All non-contracted services (in-network and out-of-network), which would include claims paid as a percentage of Medicare or other specified levels such as Reasonable &Customary.

Data Content

Please include the following in your analysis:

A. Commercial Group claims only;

B. All claims from all providers except as noted in exclusions below;

1. Include claims for both contracted and non-contracted providers;

2. Include high-cost claims - do not exclude any claim because of high dollar amounts;

3. Include all claims for services covered under medical benefits, regardless of the discount percentage amount;

4. Include claims that are paid through networks that your organization rents if these rental networks are normally part of the product you offer to your customers;

5. Include any additional claim expenses and/or credits passed back to employer groups as a result of provider reimbursement agreements such as withholds, bonuses, and pay for performance arrangements.

*Denotes an update to the requirements relating to Exhibit 12, per amendment 2.

The Contractor must apply all claim adjudication adjustments that each claim before is summarizes the claim.

Please exclude the following in your analysis:

A. Claims for members age 65 or older where age is measured as the difference between the date of service and member’s birth date rounded down to the integer;

B. All Medicare Supplement, Medicare Advantage and Individual claims;

C. All Medicare and Medicaid claims;

D. All claims with Coordination of Benefits where your organization is the secondary payer;

E. All mail order prescription drug, retail prescription drug, dental and vision hardware claims not covered under medical benefits;

F. Payments for interest expense, regulatory fees and prompt payment of penalties;

G. Claims paid through custom network arrangements established for specific customers that are not generally available to other groups;

H. Claim lines that include ineligible services and related charges;

I. All capitations paid as well as any claim lines and/or encounter data associated with or paid through capitated arrangements;

J. All surcharges and covered life assessments such as the New York Health Care Reform Act;

K. All network access fees including access fees for rental networks;

L. R&C savings where balance billing occurs as discount savings;

Attestation by Chief Actuary

By signing below, I certify that I have reviewed the data submitted. Based on my thorough review, I believe it presents a fair and accurate representation of the provider’s reimbursement arrangements of this organization, as reflected in book-of-business claims data.

Except as disclosed below, we have followed the procedures outlined by this document to fulfill the data request.

Carrier Name: ___________________________________________

Signature: ___________________________________________

Printed Name: ___________________________________________

Please disclose and explain any other deviations from this data specification that have not been addressed above:

Please disclose any reliance you have made on other parties in completing this data submission as well as any other areas of concern you may have as they relate to guidance offered under Actuarial Standard of Practice #23, Data Quality.

State of Ohio, Department of Administrative Services Medical Plan Third-Party Administrator – RFP #SRC0000038100 On behalf of the Department of Administrative Services