Request Health Coverage Proposal

Accessibility Report

Data must be in MS Excel format

• Zip codes of employees (from census)
• Access standards from the client

Sample format

Disruption Analysis

Data must be in MS Excel format

• TIN#'s
• Providers' names (please separate the first and last names)
• Providers' addresses (street, city, state and zip)

Sample format

Claims Repricing

• Claim Type (HCFA/UB) * (Required)
• Bill Type (for institutional claims)
• Provider TIN
• Provider Organization Name
• Rendering Provider Last Name (for Professional claims)
• Rendering Provider First Name (for Professional Claims and must be in separate column from Last Name)
• Provider Address
• Provider City
• Provider State
• Provider Zip
• Number of Days for Service (required for inpatient institutional claims)
• Place of service (required for Professional Claims)
• Revenue Code (for institutional claims)
• HCPCS Code (required for professional claims and if present on institutional claims)
• DRG Number
• Units of Service
• Charges
• Allowed Amount (required for WC)
• Modifier (if present on the claim)
• No punctuation in headers
• Excel Format (dates should be expressed as MM/DD/YYYY)
• Although it is not required, it would be helpful to have both service and billing addresses for providers so we can determine the best and most accurate provider match