Dental Benefit Plan Reporting Deliverables
| Weekly Reports | Revision Date | Due Date | |
| 150 | Encounter Data Certification Form - W | 1/4/23 | Every Wednesday by 5pm |
| Monthly Reports | |||
| 022 | Third Party Liability (TPL) Report- M | 1/10/23 | Due 15 calendar days of the end of each month except where indicated |
| 107 | Member Service Call Center - M | 9/26/23 | Due 5 calendar days of the end of each month except where indicated |
| 113 | Grievance, Appeal and Fair Hearing Log - M | 9/14/23 | Due 15 calendar days of the end of each month except where indicated |
| 148 | Monthly Debarment/Exclusion Verification Attestation | Due 15 calendar days of the end of each month except where indicated | |
| 167 | Claims Payment Accuracy Report - M | Due 15 calendar days of the end of each month except where indicated | |
| 173 | Denied Claims Report - M | 1/9/23 | Due 15 calendar days of the end of each month except where indicated |
| 181 | Provider Call Center - M | 10/29/21 | Due 15 calendar days of the end of each month except where indicated |
| 182 | Provider Complaint & Appeal Summary Report - M | 9/13/23 | Due 15 calendar days of the end of each month except where indicated |
| 221 | Claims Payment Summary - M | 1/9/23 | Due 15 calendar days of the end of each month except where indicated |
| Quarterly Reports | |||
| 018 | Medical Loss Ratio - Q | 9/21/23 | Due May 31, August 31, November 30, and February 28, except where indicated |
| 069 | Utilization Management Dental Record Review Report - Q | 5/26/21 | Due April 30, July 30, October 30, and January 30, except where indicated |
| 072 | QAPI PCD Profile Reports - Q | 5/26/21 | Due April 30, July 30, October 30, and January 30, except where indicated |
| 082 | PCD Linkages - Q | 5/26/21 | Due April 30, July 30, October 30, and January 30, except where indicated |
| 109 | Marketing and Member Education Activities Report - Q | 6/24/22 | Due April 30, July 30, October 30, and January 30, except where indicated |
| 119 | QAPI Committee (minutes) - Q | 08/15/17 | Due April 30, July 30, October 30, and January 30, except where indicated |
| 145 | Fraud and Abuse Activity Report - Q | 8/9/23 | Due April 30, July 30, October 30, and January 30, except where indicated |
| 147 | Sampling of Paid Claims Report | 5/2/23 | Due April 30, July 30, October 30, and January 30, except where indicated |
| 152 | Act 710 Report | 4/29/21 | Due April 30, July 30, October 30, and January 30, except where indicated |
| 183 | Claims Processing Interest Payments - Q | 5/26/21 | Due April 30, July 30, October 30, and January 30, except where indicated |
| 185 | Quarterly Unaudited Financial Statement - Q (60 days after QTR)* | 2/10/23 | Due May 31, August 31, November 30, and February 28 |
| 188 | PA Summary - Q | 10/29/21 | Due April 30, July 30, October 30, and January 30, except where indicated |
| 220 | Network Adequacy Review - Q | 5/26/21 | Due April 30, July 30, October 30, and January 30, except where indicated |
| 225 | Network Summary Dental Report - Q | 5/26/21 | Due April 30, July 30, October 30, and January 30, except where indicated |
| Due April 30, July 30, October 30, and January 30, except where indicated | |||
| Annual Reports | |||
| 017 | Key Staff Organizational Chart Listing | 8/29/17 | January 30th |
| 019 | Medical Loss Ratio - A | 8/1/23 | January 15th |
| 053 | NW Provider Development Management Plan - A | January 30th | |
| 068 | Utilization Management Dental Record Review Stategy - A | January 30th | |
| 110 | Marketing Activities Annual Review - A | January 30th | |
| 132 | Member Satisfaction Survey Report (CAHPS) - A | 9/8/23 | April 30th |
| 133 | Provider Satisfaction Survey Report - A | 9/8/23 | April 30th |
| 134 | Appointment Availability Survey Report | 8/17/23 | April 30th |
| 138 | QAPI Performance Improvement Projects (outcomes) | 3/14/17 | June 30th |
| 151 | Systems Refresh Plan - A | January 30th | |
| 157 | Emergency Management Plan - A | January 30th | |
| 159 | Back-up File List - A | 5/26/21 | January 30th |
| 170 | Form CMS 1513 Ownership and Control Interest Statement - A | March 30th | |
| 177 | Total and OON Claims | 1/9/23 | July 30th (30 days after the prior SFY) |
| 184 | Annual Audited Financial Statement - A | 2/10/23 | June 30th |
| 189 | Independent-Subcontractor EDP Audit (SSAE16) - A *** | Based on Audit Period (45 days after corporate audit complete) | |
| 216 | QAPI Impact and Effectiveness of QAPI Program Evaluation - A | March 30th | |
| 221 | Claims Payment Summary | 5/10/19 |
July 30th |
Q/A means Quarterly and Annually
* Template not provided. Will accept Health Plans' corporate standard.
**Draft versions are due 90 days after year end.
***- 45 days after the corporate audit Period is comlete.