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UnitedHealthcare-Capitation Operations Department- Enterprise Capitation Training

Updated June 2017

PROVIDER MANUAL

CAPITATION REPORT TRAINING


Updated June 2017

PROVIDER CAPITATION REPORT

MEDICARE & RETIREMENT GROUP REPORTS

Report # Report Name

EC-7030-A01 Capitation Analysis Summary

EC-7010-A01/A02 Capitation Paid Recap Summary - PMG/PCP

EC-7020-A01/A02 Capitation Adjustment Summary - PMG/PCP

EC-7090-A01/A02 Member Changes Capitation Summary - PMG/PCP

EC-7250-A01 Capitation Details

EC-7280-A01 Member Changes Capitation Details

EC-7290-A01 Capitation Adjustment Detail

EC-7810 Capitation Detail File

PCP Reconciliation of the EC7810

Third Party Ancillary Vendor Reports

EC-7010-D08 Capitation Paid Recap - Third Party Report - Summary

EC-7020- D08 Capitation Adjustment Summary - Third Party Report - Summary

EC-7030-D04 Capitation Analysis Summary - Third Party Report

EC-7090- D08 Member Changes Capitation Summary - Third Party Report

EC-7250-D05 Capitation Details - Third Party Report For Standard Services

EC-7280-D05 Member Changes Capitation Details - Third Party Report For Standard Services-(PMG)

EC-7290-D05 Capitation Adjustment Details - Third Party Report-(PMG)


Updated June 2017

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

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.


EC7010-A01 – Capitation Paid Recap – Summary


Updated June 2017

EC7010-A01 (Continued)


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

CAPITATION ADJUSTMENT SUMMARY (EC7020)

A report summarizing current and retro system and manual capitation adjustments. Report is produced at

medical group and PCP level.


EC7020-A01 – Capitation Adjustment Summary


Updated June 2017


Supplemental Benefits

Capitated adjustment (system and manual)

Noncapitated adjustments & Withholds (system and manual)


Updated June 2017

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.


EC7090-A01 – Member Changes Capitation Summary

EC7010-A01 Member Changes Member Change Type (EC7090-

A01)

Capitation Amount (EC7090-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)


Member Change Type

- Adds

- Terminations

- Demographic Changes

- Force Cap

- Reprocess Changes

Capitation Amount


Updated June 2017

CAPITATION DETAILS (EC7250)

Member capitation detail report by PCP for all assigned eligible members in the current capitation period.


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

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.


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

CAPITATION ADJUSTMENT DETAIL (EC7290)

A report detailing current and retro member or provider manual capitation adjustments


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

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

Sample of Report Reconciliation for a PCP

Primary Care Provider:

xxxxxxxxxxx 123

Siwy, Jeffrey

EC7030-A01


Updated June 2017

EC7010-A02

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

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


Updated June 2017

EC7020-A02


Updated June 2017

Column reference B15 ties to column reference I + J on EC7030 – A01 for the PCP


Updated June 2017

EC7090-A02

Capitation Amount in EC7090-A02 column reference A1 ties to EC7030-A01 column reference E for the PCP


Updated June 2017

EC7250-A01

Cap Amount in EC7250-A01 column reference C1 ties to EC7030-A01 column reference D for the PCP


Updated June 2017

EC7280-A01

Cap Adjustment in EC7280-A01 column reference B1 ties to EC7030-A01 column reference E for the PCP


Updated June 2017

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

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

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