Common use of Claims Inventory Summary Report Clause in Contracts

Claims Inventory Summary Report. 1. The Health Plan shall file an Aging Claims Summary Report quarterly, noting paid, denied and unpaid claims by provider type. The Health Plan will submit this report using the template supplied by the Agency and presented in Tables 7, 7-A, 7-B, 7-C and 7-D. This file is an Excel spreadsheet and must be submitted to the following email address: xxxxxxx@xxxx.xxxxxxxxx.xxx. Table 7 Total Claims Aging By Provider Type 00/00/00 NOTE: List ALL claims including those contained in the beginning inventory on this page. days days days days days TOTAL PROVIDER 1-30 % 31-60 % 61-90 % 91-120 % 120+ % CLAIMS PRIMARY CARE 0% 0% 0% 0% 0% 0 SPECIALTY 0% 0% 0% 0% 0% 0 OTHER 0% 0% 0% 0% 0% 0 HOSPITALS: 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 REMAINDER OF PAGE LEFT INTENTIONALLY BLANK Table 7-A Paid Claims Aging by Provider Type Report 00/00/00 days days days days days TOTAL PROVIDER 1-30 % 31-60 % 61-90 % 91-120 % 120+ % CLAIMS PRIMARY CARE 0% 0% 0% 0% 0% 0 SPECIALTY 0% 0% 0% 0% 0% 0 OTHER 0% 0% 0% 0% 0% 0 HOSPITALS: 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 Table 7-B Denied Claims Aging By Provider Type 00/00/00 days days days days days TOTAL PROVIDER 1-30 % 31-60 % 61-90 % 91-120 % 120+ % CLAIMS PRIMARY CARE 0% 0% 0% 0% 0% 0 SPECIALTY 0% 0% 0% 0% 0% 0 OTHER 0% 0% 0% 0% 0% 0 HOSPITALS: 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 REMAINDER OF PAGE LEFT INTENTIONALLY BLANK Table 7-C Unpaid Claims Aging by Provider Type Report 00/00/00 days days days days days TOTAL PROVIDER 1-30 % 31-60 % 61-90 % 91-120 % 120+ % CLAIMS PRIMARY CARE 0 0% 0 0% 0 0% 0 0% 0 0% 0 SPECIALTY 0 0% 0 0% 0 0% 0 0% 0 0% 0 OTHER 0 0% 0 0% 0 0% 0 0% 0 0% 0 HOSPITALS: 0 0% 0 0% 0 0% 0 0% 0 0% 0 0 0% 0 0% 0 0% 0 0% 0 0% 0 0 0% 0 0% 0 0% 0 0% 0 0% 0 Table 7-D Claims Inventory by Provider Type 00/00/00 Inventory (Ending Inventory from Previous quarter) Beginning Claims Ending PROVIDER Inventory Received Claims Paid Claims Denied Inventory PRIMARY CARE 0 0 0 0 OTHER 0 0 0 0 HOSPITALS: REMAINDER OF PAGE LEFT INTENTIONALLY BLANK

Claims Inventory Summary Report. 1. The Health Plan shall file an Aging Claims Summary Report quarterly, noting paid, denied and unpaid claims by provider type. The Health Plan will submit this report using the template supplied by the Agency and presented in Tables 7, 7-A, 7-B, 7-C and 7-D. This file is an Excel spreadsheet and must be submitted to the following email address: xxxxxxx@xxxx.xxxxxxxxx.xxx. Table 7 Total Claims Aging By Provider Type 00/00/00 NOTE: List ALL claims including those contained in the beginning inventory on this page. days days days days days TOTAL PROVIDER 1-30 % 31-60 % 61-90 % 91-91- 120 % 120+ % CLAIMS PRIMARY CARE 0% 0% 0% 0% 0% 0 SPECIALTY 0% 0% 0% 0% 0% 0 OTHER 0% 0% 0% 0% 0% 0 HOSPITALS: 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 REMAINDER OF PAGE LEFT INTENTIONALLY BLANK Table 7-A Paid Claims Aging by Provider Type Report 00/00/00 days days days days days TOTAL PROVIDER 1-30 % 31-60 % 61-90 % 91-120 % 120+ % CLAIMS PRIMARY CARE 0% 0% 0% 0% 0% 0 SPECIALTY 0% 0% 0% 0% 0% 0 OTHER 0% 0% 0% 0% 0% 0 HOSPITALS: 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 Table 7-B Denied Claims Aging By Provider Type 00/00/00 days days days days days TOTAL PROVIDER 1-30 % 31-31- 60 % 61-61- 90 % 91-91- 120 % 120120 + % CLAIMS PRIMARY CARE 0% 00 % 00 % 00 % 00 % 0 SPECIALTY 0% 00 % 00 % 00 % 00 % 0 OTHER 0% 00 % 00 % 00 % 00 % 0 HOSPITALS: 0% 00 % 00 % 00 % 00 % 0 0% 00 % 00 % 00 % 00 % 0 0% 00 % 00 % 00 % 00 % 0 REMAINDER OF PAGE LEFT INTENTIONALLY BLANK Table 7-C Unpaid Claims Aging by Provider Type Report 00/00/00 00/00/0 0 days days days days days TOTAL PROVIDER 1-30 % 31-31- 60 % 61-61- 90 % 91-91- 120 % 120120 + % CLAIMS PRIMARY CARE 0 00 % 0 00 % 0 00 % 0 00 % 0 00 % 0 SPECIALTY 0 00 % 0 00 % 0 00 % 0 00 % 0 00 % 0 OTHER 0 00 % 0 00 % 0 00 % 0 00 % 0 00 % 0 HOSPITALS: 0 0% 0 0% 0 0% 0 0% 0 0% 0 0 0% 0 0% 0 0% 0 0% 0 0% 0 0 0% 0 00 % 0 00 % 0 00 0 % 0 00 % 0 0 % 0 0 % 0 0 % 0 0 0 % 0 0 % 0 0 % 0 0 % 0 0 % 0 Table 7-D Claims Inventory by Provider Type 00/00/00 Inventory (Ending Inventory from Previous quarter) Beginning Claims Ending PROVIDER Inventory Received Claims Paid Claims Denied Inventory PRIMARY CARE 0 0 0 0 OTHER 0 0 0 0 HOSPITALS: REMAINDER OF PAGE LEFT INTENTIONALLY BLANK

Claims Inventory Summary Report. 1. The Health Plan shall file an Aging Claims Summary Report quarterly, noting paid, denied and unpaid claims by provider type. The Health Plan will submit this report using the template CLAIMS AGING TEMPLATE.xls file supplied by the Agency and presented in Tables 76, 76-A, 76-B, 76-C and 76-D. This file is an Excel spreadsheet and must may be submitted to the following email address: xxxxxxx@xxxx.xxxxxxxxx.xxx. Table 7 6 Total Claims Aging By Provider Type 00/00/00 NOTE: List ALL claims including those contained in the beginning inventory on this page. days days days days days TOTAL PROVIDER 1-30 % 31-60 % 61-90 % 91-120 % 120+ % CLAIMS PRIMARY CARE 0% 0% 0% 0% 0% 0 SPECIALTY 0% 0% 0% 0% 0% 0 OTHER 0% 0% 0% 0% 0% 0 HOSPITALS: 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 REMAINDER OF PAGE LEFT INTENTIONALLY BLANK Table 76-A Paid Claims Aging by Provider Type Report 00/00/00 days days days days days TOTAL PROVIDER 1-30 % 31-60 % 61-90 % 91-120 % 120+ % CLAIMS PRIMARY CARE 0% 0% 0% 0% 0% 0 SPECIALTY 0% 0% 0% 0% 0% 0 OTHER 0% 0% 0% 0% 0% 0 HOSPITALS: 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 Table 76-B Denied Claims Aging By Provider Type 00/00/00 days days days days days TOTAL PROVIDER 1-30 % 31-60 % 61-90 % 91-120 % 120+ % CLAIMS PRIMARY CARE 0% 0% 0% 0% 0% 0 SPECIALTY 0% 0% 0% 0% 0% 0 OTHER 0% 0% 0% 0% 0% 0 HOSPITALS: 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 REMAINDER OF PAGE LEFT INTENTIONALLY BLANK Table 76-C Unpaid Claims Aging by Provider Type Report 00/00/00 days days days days days TOTAL PROVIDER 1-30 % 31-60 % 61-90 % 91-120 % 120+ % CLAIMS PRIMARY CARE 0 0% 0 0% 0 0% 0 0% 0 0% 0 SPECIALTY 0 0% 0 0% 0 0% 0 0% 0 0% 0 OTHER 0 0% 0 0% 0 0% 0 0% 0 0% 0 HOSPITALS: 0 0% 0 0% 0 0% 0 0% 0 0% 0 0 0% 0 0% 0 0% 0 0% 0 0% 0 0 0% 0 0% 0 0% 0 0% 0 0% 0 Table 76-D Claims Inventory by Provider Type 00/00/00 Inventory (Ending Inventory from Previous quarter) Beginning Claims Ending PROVIDER Inventory Received Claims Paid Claims Denied Inventory PRIMARY CARE 0 0 0 0 OTHER 0 0 0 0 HOSPITALS: REMAINDER OF PAGE LEFT INTENTIONALLY BLANK

Claims Inventory Summary Report. 1. The Health Plan shall file an Aging Claims Summary Report quarterly, noting paid, denied and unpaid claims by provider type. The Health Plan will submit this report using the template supplied by the Agency and presented in Tables 7, 7-A, 7-B, 7-C and 7-D. This file is an Excel spreadsheet and must be submitted to the following email address: xxxxxxx@xxxx.xxxxxxxxx.xxx. Table 7 Total Claims Aging By Provider Type 00/00/00 NOTE: List ALL claims including those contained in the beginning inventory on this page. days days days days days TOTAL PROVIDER 1-30 % 31-60 % 61-90 % 91-91- 120 % 120+ % CLAIMS PRIMARY CARE 0% 0% 0% 0% 0% 0 SPECIALTY 0% 0% 0% 0% 0% 0 OTHER 0% 0% 0% 0% 0% 0 HOSPITALS: 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 REMAINDER OF PAGE XXXX LEFT INTENTIONALLY BLANK Table 7-A Paid Claims Aging by Provider Type Report 00/00/00 days days days days days TOTAL PROVIDER 1-30 % 31-60 % 61-90 % 91-120 % 120+ % CLAIMS PRIMARY CARE 0% 0% 0% 0% 0% 0 SPECIALTY 0% 0% 0% 0% 0% 0 OTHER 0% 0% 0% 0% 0% 0 HOSPITALS: 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 Table 7-B Denied Claims Aging By Provider Type 00/00/00 days days days days days TOTAL PROVIDER 1-30 % 31-31- 60 % 61-61- 90 % 91-91- 120 % 120120 + % CLAIMS PRIMARY CARE 0% 00 % 00 % 00 % 00 % 0 SPECIALTY 0% 00 % 00 % 00 % 00 % 0 OTHER 0% 00 % 00 % 00 % 00 % 0 HOSPITALS: 0% 00 % 00 % 00 % 00 % 0 0% 00 % 00 % 00 % 00 % 0 0% 00 % 00 % 00 % 00 % 0 REMAINDER OF PAGE XXXX LEFT INTENTIONALLY BLANK Table 7-C Unpaid Claims Aging by Provider Type Report 00/00/00 00/00/0 0 days days days days days TOTAL PROVIDER 1-30 % 31-31- 60 % 61-61- 90 % 91-91- 120 % 120120 + % CLAIMS PRIMARY CARE 0 00 % 0 00 % 0 00 % 0 00 % 0 00 % 0 SPECIALTY 0 00 % 0 00 % 0 00 % 0 00 % 0 00 % 0 OTHER 0 00 % 0 00 % 0 00 % 0 00 % 0 00 % 0 HOSPITALS: 0 0% 0 0% 0 0% 0 0% 0 0% 0 0 0% 0 0% 0 0% 0 0% 0 0% 0 0 0% 0 00 % 0 00 % 0 00 0 % 0 00 % 0 0 % 0 0 % 0 0 % 0 0 0 % 0 0 % 0 0 % 0 0 % 0 0 % 0 Table 7-D Claims Inventory by Provider Type 00/00/00 Inventory (Ending Inventory from Previous quarter) Beginning Claims Ending PROVIDER Inventory Received Claims Paid Claims Denied Inventory PRIMARY CARE 0 0 0 0 OTHER 0 0 0 0 HOSPITALS: REMAINDER OF PAGE XXXX LEFT INTENTIONALLY BLANK

Claims Inventory Summary Report. 1. The Health Plan shall file an Aging Claims Summary Report quarterly, noting paid, denied and unpaid claims by provider type. The Health Plan will submit this report using the template CLAIMS AGING TEMPLATE.xls file supplied by the Agency and presented in Tables 76, 76-A, 76-B, 76-C and 76-D. This file is an Excel spreadsheet and must may be submitted to the following email address: xxxxxxx@xxxx.xxxxxxxxx.xxx. Table 7 6 Total Claims Aging By Provider Type 00/00/00 NOTE: List ALL claims including those contained in the beginning inventory on this page. days days days days days TOTAL PROVIDER 1-30 % 31-60 % 61-90 % 91-120 % 120+ % CLAIMS PRIMARY CARE 0% 0% 0% 0% 0% 0 SPECIALTY 0% 0% 0% 0% 0% 0 OTHER 0% 0% 0% 0% 0% 0 HOSPITALS: 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 REMAINDER OF PAGE LEFT INTENTIONALLY BLANK Table 76-A Paid Claims Aging by Provider Type Report 00/00/00 days days days days days TOTAL PROVIDER 1-30 % 31-60 % 61-90 % 91-120 % 120+ % CLAIMS PRIMARY CARE 0% 0% 0% 0% 0% 0 SPECIALTY 0% 0% 0% 0% 0% 0 OTHER 0% 0% 0% 0% 0% 0 HOSPITALS: 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 Table 76-B Denied Claims Aging By Provider Type 00/00/00 days days days days days TOTAL PROVIDER 1-30 % 31-60 % 61-90 % 91-120 % 120+ % CLAIMS PRIMARY CARE 0% 0% 0% 0% 0% 0 SPECIALTY 0% 0% 0% 0% 0% 0 OTHER 0% 0% 0% 0% 0% 0 HOSPITALS: 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0 REMAINDER OF PAGE LEFT INTENTIONALLY BLANK Table 76-C Unpaid Claims Aging by Provider Type Report 00/00/00 days days days days days TOTAL PROVIDER 1-30 % 31-60 % 61-90 % 91-120 % 120+ % CLAIMS PRIMARY CARE 0 0% 0 0% 0 0% 0 0% 0 0% 0 SPECIALTY 0 0% 0 0% 0 0% 0 0% 0 0% 0 OTHER 0 0% 0 0% 0 0% 0 0% 0 0% 0 HOSPITALS: 0 0% 0 0% 0 0% 0 0% 0 0% 0 0 0% 0 0% 0 0% 0 0% 0 0% 0 0 0% 0 0% 0 0% 0 0% 0 0% 0 Table 76-D Claims Inventory by Provider Type 00/00/00 Inventory (Ending Inventory from Previous quarter) Beginning Claims Ending PROVIDER Inventory Received Claims Paid Claims Denied Inventory PRIMARY CARE 0 0 0 0 OTHER 0 0 0 0 HOSPITALS: REMAINDER OF PAGE LEFT INTENTIONALLY BLANK