Annual/Periodic Reports Sample Clauses

Annual/Periodic Reports. 16 a. Alphabetic listing of all claims by patient name, including name, case number, Provider 17 name, service dates, xxxx type, total billed, total allowed, denial code, Contract Rate, share of cost, date 18 paid, check number, total paid. (As requested) 19 b. Cumulative, alphabetic listing of physician Providers to include Provider name, tax I.D. 20 number, total billed, total allowed, and total paid. (As Requested) 21 c. Reports of final payout results, settlements, and adjustments including listings of 22 payments for each provider pool and Provider. 23

Annual/Periodic Reports. 37 // 1 a. Alphabetic listing of all claims by patient name, including name, case number, Provider 2 name, service dates, xxxx type, total billed, total allowed, denial code, reimbursement rate, share of cost, 3 date paid, check number, total paid. (As requested) 4 b. Cumulative, alphabetic listing of physician Providers to include Provider name, tax I.D. 5 number, total billed, total allowed, and total paid. (As Requested) 6 7 H. CONTRACTOR and ADMINISTRATOR may mutually agree, in writing, to modify the Claims 8 Additional Reports Paragraph of this Exhibit C to the Agreement. 9 // 10 // 11 // 12 // 13 // 14 // 15 // 16 // 17 // 18 // 19 // 20 // 21 // 22 // 23 // 24 // 25 // 26 // 27 // 28 // 29 // 30 // 31 // 32 // 33 // 34 // 35 // 36 // 37 // 1 EXHIBIT D 2 TO AGREEMENT FOR PROVISION OF 3 FISCAL INTERMEDIARY SERVICES 4 FOR THE 5 MEDICAL SAFETY NET PROGRAM 6 WITH 7 ADVANCED MEDICAL MANAGEMENT, INC. 8 JULY 1, 2019 THROUGH JUNE 30, 2024 9

Annual/Periodic Reports. 9 a. Alphabetic listing of all claims by patient name in both hardcopy and electronically, 10 including name, case number, provider name, service dates, xxxx type, total billed, total allowed, denial 11 code, Contract Rate, share of cost, date paid, check number, total paid. (Annually) 12 b. Cumulative, quarterly, alphabetic listing of physician providers to include provider 13 name, tax I.D. number, total billed, total allowed, and total paid; to be provided in hardcopy and 14 machine readable format by December 30, 2007. (As Requested) 15 c. The following reports shall be submitted to both ADMINSTRATOR’S MSI Program 16 Manager and Strategic Projects Manager as specified on Page 4 of this Agreement. 17 1) Reports of final payout results, settlements, and adjustments including listings of 18 payments for each provider pool and provider. Semi-monthly preliminary final payout reports 19 commencing in November 2006. 20 2) Quarterly and annual estimated/actual data (reflecting final settlements) in report 21 formats as specified by the State in both hardcopy and required electronic medium (e.g., ASCII text file 22 on floppy diskette). 23 3) Quarterly and annual estimated/actual data (reflecting final settlements) of 24 unduplicated users by specified identifiers (SSN, DOB, Name) which merge medical services and other 25 indigent services data for State reporting, in both hardcopy and floppy diskette as required by the 26 Medically Indigent Care Reporting System (MICRS). 27 4) Quarterly and annual estimated/actual uncompensated care listings, including 28 charges by medical providers, and payment by ICD9 codes, as required to meet California Healthcare 29 for Indigents Program and Emergency Medical Services Fund reporting requirements, in both hard copy 30 and magnetic medium. 31

Annual/Periodic Reports. 19 a. Alphabetic listing of all claims by patient name in both hardcopy and electronically, 20 including name, case number, provider name, service dates, xxxx type, total billed, total allowed, denial 21 code, Contract Rate, share of cost, date paid, check number, total paid. (Annually) 22 b. Cumulative, quarterly, alphabetic listing of physician providers to include provider 23 name, tax I.D. number, total billed, total allowed, and total paid; to be provided in hardcopy and 24 machine readable format by February 28, 2010 for Period One, February 28, 2011 for Period Two. And 25 February 29, 2012 for Period Three (As Requested) 26 c. The following reports shall be submitted to both ADMINSTRATOR’S MSI Program 27 Manager and Strategic Projects Manager as specified on Page 4 of this Agreement. 28 1) Reports of final payout results, settlements, and adjustments including listings of 29 payments for each provider pool and provider. Semi-monthly preliminary final payout reports 30 commencing in January 2010 for Period One, January 2011 for Period Two, and January 2012 for 31 Period Three. 32 2) Quarterly and annual estimated/actual data (reflecting final settlements) in report 33 formats as specified by the State in both hardcopy and required electronic medium (e.g., ASCII text file 34 on floppy diskette). 35 3) Quarterly and annual estimated/actual data (reflecting final settlements) of 36 37 5 of 8 EXHIBIT F 1 unduplicated users by specified identifiers (SSN, DOB, Name) which merge medical services and other 2 indigent services data for State reporting, in both hardcopy and floppy diskette as required by the 3 Medically Indigent Care Reporting System (MICRS). 4 4) Quarterly and annual estimated/actual uncompensated care listings, including 5 charges by medical providers, and payment by ICD9 codes, as required to meet California Healthcare 6 Initiative Program and Emergency Medical Services Fund reporting requirements, in both hard copy and 7 magnetic medium.