PROVIDER MANUAL CAPITATION REPORT TRAINING

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PROVIDER MANUAL CAPITATION REPORT TRAINING Updated June 2017 Page 1

PROVIDER CAPITATION REPORT Report # MEDICARE & RETIREMENT GROUP REPORTS Report Name EC-7030-A01 EC-7010-A01/A02 EC-7020-A01/A02 EC-7090-A01/A02 EC-7250-A01 EC-7280-A01 EC-7290-A01 EC-7810 Capitation Analysis Summary Capitation Paid Recap Summary - PMG/PCP Capitation Adjustment Summary - PMG/PCP Member Changes Capitation Summary - PMG/PCP Capitation Details Member Changes Capitation Details Capitation Adjustment Detail Capitation Detail File PCP Reconciliation of the EC7810 Third Party Ancillary Vendor Reports EC-7010-D08 EC-7020- D08 EC-7030-D04 EC-7090- D08 EC-7250-D05 EC-7280-D05 EC-7290-D05 Capitation Paid Recap - Third Party Report - Summary Capitation Adjustment Summary - Third Party Report - Summary Capitation Analysis Summary - Third Party Report Member Changes Capitation Summary - Third Party Report Capitation Details - Third Party Report For Standard Services Member Changes Capitation Details - Third Party Report For Standard Services-(PMG) Capitation Adjustment Details - Third Party Report-(PMG) Updated June 2017 Page 2

CAPITATION ANALYSIS SUMMARY (EC7030) A report summarizing current and retro member counts and capitation amounts in columnar format. Report is produced at medical group level. Medicare & Retirement Provider Medical Group EC7030-A01 Capitation Analysis Summary The report shows the following information: Capitated Member Month Standard Service Capitation Benefits and Capitated Adjustments Noncapitated adjustments & Withholds The Following Fields in EC7030 Grand Total Tie Back to the EC7010-A01 Report Field Field Name Ties To Field in EC7010 Report A Current Capped Member Month A1 B Retro Capped Member Month A2 C Total Member Month A3 D Current Standard Service Cap C1 E Retro Standard Service Cap C2 F Sub-Total Standard Service Cap C3 G Current Benefits and Cap Adjustment C7 H Retro Benefits and Cap Adjustment C11 I Sub-Total Benefits & Cap Adjustment C12 J Non Capitated Adjustment and Withhold C19 K Total Capitation Paid C20 Updated June 2017 Page 3

CAPITATION PAID RECAP (EC7010) A report summarizing current and retro member counts and capitation amounts by capitated categories. Report is produced at medical group and PCP level. Medicare & Retirement Provider Medical Group EC7010-A01 Capitation Paid Recap Summary Updated June 2017 Page 4

EC7010-A01 (Continued) The report shows the following information: Standard Service Capitation Benefits and Capitated Adjustments Noncapitated adjustments and Withholds The Following Fields for Benefits and Capitated Adjustments in EC7010 Tie Back to the EC7020 Report Field Field Name Ties To Fields in EC7020 Report C4 Current Supplemental Benefit A1 C5 Current System Adjustments A2 C6 Current Manual Cap Adjustments A3 C7 Total Current Benefits and Capitated Adjustments A4 C8 Retro Supplemental Benefits A5 C9 Retro System Adjustments A6 C10 Retro Manual Cap Adjustments A7 C11 Total Retro Benefits and Capitated Adjustments A8 C12 Total Current and Retro Adjustments A4+A8 C13 Current System Adjustments Non Capitated A9 C14 Current Manual Adjustments Non Capitated A10 C15 Sub-Total Current Non Capitated Adjustments and Withholds A11 C16 Retro System Adjustments Non Capitated A12 C17 Retro Manual Adjustments Non Capitated A13 C18 Sub-Total Retro Non Capitated Adjustments and Withholds A15 Updated June 2017 Page 5

CAPITATION ADJUSTMENT SUMMARY (EC7020) A report summarizing current and retro system and manual capitation adjustments. Report is produced at medical group and PCP level. Medicare & Retirement Provider Medical Group EC7020-A01 Capitation Adjustment Summary Updated June 2017 Page 6

The report shows the following information: Supplemental Benefits Capitated adjustment (system and manual) Noncapitated adjustments & Withholds (system and manual) Updated June 2017 Page 7

PRIMARY MEMBER CHANGES CAPITATION SUMMARY (EC7090) A report summarizing retroactive member changes by member change type. Report is produced at medical group and PCP level. Medicare & Retirement Provider Medical Group EC7090-A01 Member Changes Capitation Summary EC7010-A01 Member Changes Member Change Type (EC7090- Capitation Amount (EC7090-A01) A01) (C2a) Additions $31,402.97 (C2b) Deductions ($1,954.90 (C2c) Demographic changes Demographic change 0.00 Force Cap 0.00 Reprocess changes ($490,835.84) The report shows the following information: Member Change Type - Adds - Terminations - Demographic Changes - Force Cap - Reprocess Changes Capitation Amount Updated June 2017 Page 8

CAPITATION DETAILS (EC7250) Member capitation detail report by PCP for all assigned eligible members in the current capitation period. Medicare & Retirement Provider Medical Group EC7250-A01 Capitation Details The report shows the following information for each member: State, County Code and Zip Code Contract-PBP-Div/Group X1234 - HMO Contract (CMS) 000 - Plan Benefit Package ABC - Div 00000 - Employer/Member Group Demographic Data Elements: - Sex - Date of Birth - Age - PCP Start Date RAF - Risk Adjusted Factor Score HEAIW status indicator - (H) Hospice Status Indicator - (E) End Stage Renal Diseases (ESRD) Status Indicator - (A) Working Aged Status Indicator - (I) Institutionalized Status Indicator - (W) Medicaid (Welfare) Indicator Base Amount Gross Capitation (CMS MMR premium amount less Plan Adjustments) Base Rate Contracted Percent of Premium Cap Amount Member s Capitation for the month (Base Amount multiplied by Base Rate) Updated June 2017 Page 9

MEMBER CHANGES CAPITATION DETAILS (EC7280) Member retroactive capitation changes detail report by PCP and incurred period for all assigned eligible members within system retro window. Medicare & Retirement Provider Medical Group EC7280-A01 Member Changes Capitation Details by PCP In addition to the attributes on the EC7250 above, this report has the following additional fields and categories: Ch Trm (Change Termination)/Ch Add (Change Addition) Effect Date: effective date of the member change transaction Cap Per (Cap Period): incurred month of the member change Trans Date (Transaction Date): system date of the member change Member Change Type - Adds - Terminations - Demographic Changes - Force Cap - Reprocess Changes Updated June 2017 Page 10

CAPITATION ADJUSTMENT DETAIL (EC7290) A report detailing current and retro member or provider manual capitation adjustments Medicare & Retirement Provider Medical Group EC7290-A01 Capitation Adjustment Detail Adjustment Amount in EC7290-A01 ties to EC7020-A01 column references A3+A7+A10+A13 MBR (Member level adjustment)/prv (Provider level adjustment) Updated June 2017 Page 11

EC7810 Detail Member and Provider information Capitation Flat File Capitation_Amount in the EC7810 Record Type ZZ (column BI) ties with the Grand Total on reports EC7010-A01 (column reference C20) and EC7030- A01 (column reference K) Updated June 2017 Page 12

Sample of Report Reconciliation for a PCP Primary Care Provider: xxxxxxxxxxx 123 Siwy, Jeffrey EC7030-A01 Updated June 2017 Page 13

EC7010-A02 B4 ties to column reference F on EC7030-A01 for the PCP B13 ties to column reference I on EC7030-A01 for the PCP B20 ties to column reference J on EC7030-A01 for the PCP Field Name Field in EC7010-A02 Field in EC7020-A02 B5 Current Supplemental Benefit B1 B6 Current System Adjustments B2 B7 Current Manual Cap Adjustments B3 B8 Total Current Benefits and Capitated Adjustments B4 B9 Retro Supplemental Benefits B5 B10 Retro System Adjustments B6 B11 Retro Manual Cap Adjustments B7 B12 Total Retro Benefits and Capitated Adjustments B8 B13 Total Current and Retro Adjustments B4+B6 B14 Current System Adjustments Non Capitated B9 B15 Current Manual Adjustments Non Capitated B10 B16 Sub-Total Current Non Capitated Adjustments and Withholds B11 B17 Retro System Adjustments Non Capitated B12 B18 Retro Manual Adjustments Non Capitated B13 B19 Sub-Total Retro Non Capitated Adjustments and Withholds B14 Updated June 2017 Page 14

EC7020-A02 Updated June 2017 Page 15

Column reference B15 ties to column reference I + J on EC7030 A01 for the PCP Updated June 2017 Page 16

EC7090-A02 Capitation Amount in EC7090-A02 column reference A1 ties to EC7030-A01 column reference E for the PCP Updated June 2017 Page 17

EC7250-A01 Cap Amount in EC7250-A01 column reference C1 ties to EC7030-A01 column reference D for the PCP Updated June 2017 Page 18

EC7280-A01 Cap Adjustment in EC7280-A01 column reference B1 ties to EC7030-A01 column reference E for the PCP Updated June 2017 Page 19

Reconciliation of the Primary Care Provider Report in the EC7030 A01 to the EC7810 (Cap Detail File) Capitation Amount for current period in EC7810 (record type 1R) ties to EC7030-A01 reference column D for a PCP Capitation Amount for retro periods in EC7810 (record type 1R) ties to EC7030-A01 column reference E for a PCP Updated June 2017 Page 20

Capitation Amount in EC7810 (record type 4S) for current period ties to EC7030-A01 column reference G for a PCP Capitation Amount in EC7810 (record type 4S) for retro periods ties to EC7030-A01 column reference H for a PCP Updated June 2017 Page 21

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