Document:

exv10w1

 

EXHIBIT 10.1

TREEHOUSE FOODS, INC.

EXECUTIVE DEFERRED COMPENSATION PLAN

 

 

TREEHOUSE FOODS, INC.

EXECUTIVE DEFERRED COMPENSATION PLAN

Table of Contents

	 	 	 	 	 	 	 
	 	 	 	 	Page	 
	ARTICLE I	 	DEFINITIONS
	 	 	1	 
	ARTICLE II	 	ELIGIBILITY
	 	 	3	 
	ARTICLE III	 	CREDITS TO ACCOUNT
	 	 	3	 
	ARTICLE IV	 	BENEFITS
	 	 	5	 
	ARTICLE V	 	PAYMENT OF BENEFITS AT TERMINATION
	 	 	6	 
	ARTICLE VI	 	IN-SERVICE WITHDRAWALS
	 	 	7	 
	ARTICLE VII	 	ADMINISTRATION OF THE PLAN
	 	 	8	 
	ARTICLE VIII	 	CLAIMS REVIEW PROCEDURE
	 	 	9	 
	ARTICLE IX	 	LIMITATION OF RIGHTS
	 	 	10	 
	ARTICLE X	 	LIMITATION OF ASSIGNMENT AND PAYMENTS TO
LEGALLY INCOMPETENT DISTRIBUTEE.
	 	 	11	 
	ARTICLE XI	 	AMENDMENT TO OR TERMINATION OF THE PLAN
	 	 	11	 
	ARTICLE XII	 	GENERAL AND MISCELLANEOUS
	 	 	11	 

 

 

TREEHOUSE FOODS, INC.

EXECUTIVE DEFERRED COMPENSATION PLAN

PREAMBLE

     WHEREAS, the TreeHouse Foods, Inc. (the “Company”), a Delaware corporation, desires to
establish a plan to be known as the TreeHouse Foods, Inc. Executive Deferred Compensation Plan (the
“Plan”) for the exclusive benefit of a select group of management and highly compensated employees
of the Company and its affiliates to provide an additional means by which such employees may defer
funds for their retirement;

     WHEREAS, the American Jobs Creation Act of 2004 imposes new restrictions on deferred
compensation arrangements for compensation earned after 2004;

     NOW, THEREFORE, the Company hereby adopts the Plan to read as follows:

ARTICLE I

DEFINITIONS

     1.1 “Account” shall mean the individual bookkeeping record established by the Committee
showing the monetary value of the interest in the Plan of each Participant or Beneficiary.

     1.2 “Affiliate” shall mean a member of a controlled group of corporations (as defined in
Section 414(b) of the Code), a group of trades or businesses (whether or not incorporated) which
are under common control (as defined in Section 414(c) of the Code), or an affiliated service group
(as defined in Section 414(m) of the Code) of which the Company is a member; and any entity
otherwise required to be aggregated with the Company pursuant to Section 414(o) of the Code or the
regulations issued thereunder; and any other entity in which the Company has an ownership interest
and to which the Company elects to make participation in the Plan available.

     1.3 “Annual Compensation” shall mean the salary, bonuses and commissions paid or accrued by
the Company or an Affiliate to an employee as remuneration for personal services rendered during
each Plan Year, as reported on the employee’s federal income tax withholding statement or
statements (IRS Form W-2 or its subsequent equivalent), together with any amounts not includable in
such employee’s gross income pursuant to Sections 125 or 402(g) of the Code, and any amounts
deferred by such employee pursuant to Section 3.1 hereof. The term “Annual Compensation” shall also
include any amounts paid as director’s fees to members of the Board or members of the board of
directors of an Affiliate.

     1.4 “Beneficiary” shall mean the Beneficiary designated by each Participant under the 401(k)
Plan; provided, however, that a Participant may designate a different Beneficiary

 

 

hereunder by delivering to the Committee a written beneficiary designation, in the form
provided by the Committee, and executed specifically with respect to this Plan.

     1.5 “Board” shall mean the Board of Directors of the Company.

     1.6 “Code” shall mean the Internal Revenue Code of 1986, as it may be amended from time to
time, and the rules and regulations promulgated thereunder.

     1.7 “Committee” shall mean the Compensation Committee of the Board.

     1.8 “Company” shall mean TreeHouse Foods, Inc. or its successor or successors.

     1.9 “Disability” shall mean the Participant either (a) is unable to engage in any substantial
gainful activity by reason of any medically determinable physical or mental impairment which can be
expected to result in death or can be expected to last for a continuous period of not less than 12
months, or (b) is, by reason of any medically determinable physical or mental impairment which can
be expected to result in death or can be expected to last for a continuous period of not less than
12 months, receiving income replacement benefits for a period of not less than 3 months under an
accident and health plan covering employees of the Company.

     1.10 “Effective Date” shall mean August 1, 2005.

     1.11 “401(k) Plan” shall mean the TreeHouse Foods, Inc. 401(k) Plan.

     1.12 “Participant” shall mean an individual who has been designated by the Committee as being
eligible to participate in the Plan.

     1.13 “Performance-Based Compensation” shall mean compensation earned by a Participant based on
satisfaction of variable and contingent individual or organizational performance criteria not
readily ascertainable at the time the election is made and is based on services to be performed
over a period of at least 12 months.

     1.14 “Performance Period” shall mean the period over which Performance-Based Compensation is
earned.

     1.15 “Plan” shall mean the TreeHouse Foods, Inc. Executive Deferred Compensation Plan set
forth in this document, as it may be amended from time to time.

     1.17 “Plan Year” shall mean the twelve-month period beginning each January 1 and ending each
December 31, provided that the initial Plan Year shall mean the period beginning on the Effective
Date and ending on December 31, 2005.

     1.18 “Valuation Date” shall mean each business day on which the financial markets are open for
trading activity or such other dates as may be established by the Committee.

 

 

ARTICLE II

ELIGIBILITY

     Participation in the Plan shall be made available to a select group of individuals, as
determined by the Board or the Committee, who are providing services to the Company or an Affiliate
in key positions of management and responsibility. Participation in the Plan shall also be made
available to members of the Board and any outside directors of subsidiaries of the Company. Such
individuals may elect to participate hereunder by executing a participation agreement in such form
and at such time as the Committee shall require, provided that each participation agreement shall
be executed no later than the day immediately preceding the Plan Year for which an individual
elects to make contributions to the Plan in accordance with the provisions of Section 3.1 hereof
for compensation other than Performance-Based Compensation, and not later than six months before
the end of the Performance Period, for Performance-Based Compensation. Notwithstanding the
foregoing, in the first year in which an individual becomes eligible to participate in the Plan, he
may elect to participate in the Plan by executing a participation agreement, in such form as the
Committee shall require, within thirty (30) days after the date on which he is notified by the
Committee of his eligibility to participate in the Plan or, with respect to Performance-Based
Compensation, such later date as is specified in the preceding sentence. The election to
participate in the Plan for a Participant first enrolled during a Plan Year shall become effective
as of the first full payroll period beginning on or after the Committee’s receipt of his
participation agreement. The determination as to the eligibility of any individual to participate
in the Plan shall be in the sole and absolute discretion of the Committee, whose decision in that
regard shall be conclusive and binding for all purposes hereunder.

ARTICLE III

CREDITS TO ACCOUNT

     3.1 For any Plan Year, a Participant may, in the manner and at the time prescribed by the
Committee, irrevocably elect to defer a portion of the Annual Compensation otherwise payable to
such Participant with respect to such Plan Year, not to exceed the maximum amount established by
the Committee. Any amount deferred, pursuant to this Article III, from the Annual Compensation
otherwise payable to a Participant shall be credited to the Account of such Participant as soon as
practicable after the date on which such amounts would otherwise have been paid to the Participant.

     3.2 At the time of making the deferrals elections described in Section 3.1 and at such other
times as is allowed by the Committee, the Participant shall designate, on a form provided by the
Committee, the types of investments in which the Participant’s Account will be deemed to be
invested for purposes of determining the amount of earnings to be credited to that Account. On a
quarterly or other basis selected by the Committee, the Committee shall credit to each
Participant’s Account an amount equal to the interest, earnings or losses that would have resulted
to the Account if the amounts credited to the Account were invested as elected by the Participant.

 

 

ARTICLE IV

BENEFITS

     4.1 After the death of a Participant, the Beneficiary of such Participant shall be entitled to
the entire value of all amounts credited to such Participant’s Account, determined as of the
Valuation Date coincident with or preceding the date of distribution.

     4.2 After the Disability of a Participant, such Participant shall be entitled to the entire
value of all amounts credited to such Participant’s Account, determined as of the Valuation Date
coincident with or preceding the date of Disability. Such amount shall be payable to the
Participant at the time and in the manner determined by the Committee.

     4.3 After a Participant’s employment terminates or such Participant ceases to be a member of
the Board or a board of directors of a subsidiary for any reason other than death or Disability,
such Participant shall be entitled to the entire value of all amounts credited to the Account of
such Participant, determined as of the Valuation Date coincident with or preceding the date of
distribution.

     4.4 To the extent allowed by regulations issued by the U.S. Department of the Treasury, if
there is a change in the ownership or effective control of the employer of the Participant (or the
employer’s parent) or in the ownership of a substantial portion of the assets of the employer of
the Participant (hereinafter collectively called a “Change in Control”), the Plan shall distribute
the Accounts of all Participants employed by such employer or its subsidiaries impacted by such
Change in Control, in a single lump sum within 30 days after such Change in Control or at such
later date as is required by such regulations. The determination of whether a Change in Control has
occurred and whether a distribution may be made to the Participants shall be made based on the
definition of a Change in Control that is found in the regulations issued by the U.S. Department of
the Treasury under Section 409A of the Code, which regulations are incorporated herein by
reference.

ARTICLE V

PAYMENT OF BENEFITS AT TERMINATION

     5.1 In the case of a Participant who terminates employment with the Company or ceases to be a
member of the Board or an outside director of a subsidiary of the Company, the amount credited to
the Participant’s Account (provided it is more than $25,000 or such smaller amount allowed by
regulations issued by the U.S. Department of the Treasury) shall be paid in cash, to the
Participant, at the time the distribution of the Account is to commence, from among the following
optional forms of benefit as elected by the Participant on the form provided by the Company upon
his or her initial participation in the Plan:

     (1) a lump sum distribution;

     (2) substantially equal annual installments over five (5) years; or

 

 

     (3) substantially equal annual installments over ten (10) years.

     Notwithstanding the Participant’s distribution election, if the amount credited to a
Participant’s Account is equal to or less than $25,000 (or such smaller amount allowed by
regulations issued by the U.S. Department of the Treasury), at the time distribution of the Account
is to commence, payment will be made in a lump sum, and even if installment payments have commenced
under this Section 5.1, at such time as the value of such remaining amounts is $25,000 (or such
smaller amount allowed by regulations issued by the U.S. Department of the Treasury), all remaining
amounts credited to a Participant’s Account shall be distributed in a lump sum.

     Payment shall commence as soon as practicable following the Participant’s termination of
employment with the Company or termination as a member of the Board or a director of a subsidiary
of the Company, or, if so elected by the Participant in the Participant’s deferral election form
provided by the Committee, as soon as practicable during the calendar year following the year in
which such event occurs. Notwithstanding the foregoing, if the Participant is a “specified
employee”, as that term is used in Section 409A of the Code, then no distribution shall be made to
him or her until the date that is six months after the Participant’s termination of employment with
the Company, unless otherwise permitted by Code Section 409A or by regulations issued by the U.S.
Department of the Treasury thereunder. If installment payments are made, the unpaid balance of the
Participant’s Account shall continue to share in the income and losses attributable thereto during
the period for which installment payments are made. To the extent allowed by regulations issued by
the U.S. Department of the Treasury, a Participant may modify the time or form of benefit that he
or she has previously elected, as long as he or she provides the Committee with written notice at
least one (1) year in advance of the effective date of the change and as long as the change
postpones the payment(s) at least five years after their scheduled payment date(s).

     5.2 Payment of a Participant’s benefit on account of death shall be made to the Beneficiary of
such Participant in a lump sum in cash as soon as practicable following the Committee’s receipt of
proper notice of such Participant’s death.

     5.3 Notwithstanding the provisions of Sections 5.1 or 5.2, and to the extent allowed by
regulations issued by the U.S. Department of the Treasury, the benefits payable hereunder may be
paid before they would otherwise be payable if, based on a change in the federal or applicable
state tax or revenue laws, a published ruling or similar announcement issued by the Internal
Revenue Service, a regulation issued by the U.S. Department of the Treasury, a decision by a court
of competent jurisdiction involving a Participant or a Beneficiary, or a closing agreement made
under Section 7121 of the Code that is approved by the Internal Revenue Service and involves a
Participant, the Committee determines that a Participant has or will recognize income for federal
or state income tax purposes with respect to amounts that are or will be payable under the Plan
before they otherwise would be paid. The amount of any payments pursuant to this Section 5.3 shall
not exceed the lesser of: (a) the amount in the Participant’s Account or (b) the amount of taxable
income with respect to which the tax liability is assessed or determined.

 

 

     5.4 The payment of benefits under the Plan shall begin at the date specified in accordance
with the provisions of Sections 5.1 and 5.2 hereof; provided that, in case of administrative
necessity, the starting date of payment of benefits may be delayed up to thirty (30) days as long
as such delay does not result in the Participant’s or Beneficiary’s receiving the distribution in a
different taxable year than if no such delay had occurred.

ARTICLE VI

IN-SERVICE WITHDRAWALS

     6.1 In the event of an unforeseeable emergency, a Participant may make a request to the
Committee for a withdrawal from the Account of such Participant. For purposes of this Section, the
term “unforeseeable emergency” shall mean a severe financial hardship to the Participant resulting
from an illness or accident of the Participant, the Participant’s spouse, or a dependent (as
defined in Section 152(a) of the Code) of the Participant, loss of the Participant’s property due
to casualty, or other similar extraordinary and unforeseeable circumstances arising as a result of
events beyond the control of the Participant. Any determination of the existence of an
unforeseeable emergency and the amount to be withdrawn on account thereof shall be made by the
Committee, in its sole and absolute discretion. However, notwithstanding the foregoing, a
withdrawal will not be permitted to the extent that the financial hardship is or may be relieved:
(i) through reimbursement or compensation by insurance or otherwise; (ii) by liquidation of the
Participant’s assets, to the extent that liquidation of such assets would not itself cause severe
financial hardship; or (iii) by cessation of deferrals under this Plan. In no event shall the need
to send a Participant’s child to college or the desire to purchase a home be deemed to constitute
an unforeseeable emergency. No member of the Committee shall vote or decide upon any matter
relating to the determination of the existence of such member’s own financial hardship or the
amount to be withdrawn on account thereof. A request for a hardship withdrawal must be made in the
manner prescribed by the Committee, and must be expressed as a specific dollar amount. The amount
of a hardship withdrawal may not exceed the amount required to meet the severe financial hardship
plus the amount needed to pay taxes reasonably anticipated as a result of the distribution. All
hardship withdrawals shall be paid in a lump sum in cash.

     6.2 On a form prescribed by the Committee, a Participant, prior to the beginning of any Plan
Year, can elect to receive that Plan Year’s deferrals made pursuant to Section 3.1, and earnings
thereon, at a date specified by the Participant. Such date shall be no earlier than two (2) years
from the last day of the Plan Year for which the deferrals are made. A Participant may extend the
scheduled in-service withdrawal date for any Plan Year, as long as the Participant provides advance
written notice to the Committee at least one year before the scheduled payment date, and such
extension is for a period of not less than five years from the previous, scheduled in-service
withdrawal date. Any withdrawal under this Section 6.2 shall be made in a single lump sum, in
cash.

     6.3 Withdrawals shall be charged pro rata to the investment options in which amounts credited
to a Participant’s Account are deemed to be invested pursuant to Section 3.2 hereof.

 

 

ARTICLE VII

ADMINISTRATION OF THE PLAN

     7.1 The Plan shall be administered by the Committee. The members of the Committee shall not
receive compensation with respect to their services for the Committee. The members of the
Committee shall serve without bond or security for the performance of their duties hereunder unless
applicable law makes the furnishing of such bond or security mandatory or unless required by the
Company.

     7.2 The Committee shall perform any act which the Plan authorizes expressed by a vote at a
meeting or in a writing signed by a majority of its members without a meeting. The Committee may,
by a writing signed by a majority of its members, appoint any member of the Committee to act on
behalf of the Committee. Any person who is a member of the Committee shall not vote or decide upon
any matter relating solely to such member or vote in any case in which the individual right or
claim of such member to any benefit under the Plan is particularly involved. If, in any matter or
case in which a person is so disqualified to act, the remaining persons constituting the Committee
cannot resolve such matter or case, the Board will appoint a temporary substitute to exercise all
the powers of the disqualified person concerning the matter or case in which such person is
disqualified.

     7.3 The Committee may designate in writing other persons to carry out its responsibilities
under the Plan, and may remove any person designated to carry out its responsibilities under the
Plan by notice in writing to that person. The Committee may employ persons to render advice with
regard to any of its responsibilities. All usual and reasonable expenses of the Committee shall be
paid by the Company. The Company shall indemnify and hold harmless each member of the Committee
from and against any and all claims and expenses (including, without limitation, attorneys’ fees
and related costs), in connection with the performance by such member of duties in that capacity,
other than any of the foregoing arising in connection with the willful neglect or willful
misconduct of the person so acting.

     7.4 The Committee shall establish rules and procedures, not contrary to the provisions of the
Plan, for the administration of the Plan and the transaction of its business. The Committee shall
determine the eligibility of any individual to participate in the Plan, shall interpret the Plan in
its sole and absolute discretion, and shall determine all questions arising in the administration,
interpretation and application of the Plan. All determinations of the Committee shall be conclusive
and binding on all employees, Participants and Beneficiaries.

     7.5 Any action to be taken hereunder by the Company shall be taken by resolution adopted by
the Board or by a committee thereof; provided, however, that by resolution, the Board or a
committee thereof may delegate to any officer of the Company the authority to take any such actions
hereunder.

ARTICLE VIII

CLAIMS REVIEW PROCEDURE

 

 

     8.1 In the event that a Participant or Beneficiary is denied a claim for benefits under this
Plan (the “Claimant”), the Committee shall provide to the Claimant written notice of the denial
within 90 days after the claim is filed (45 days in the case of a Disability claim) unless an
extension of time for processing the claim is necessary because more information is needed (or, in
the case of a Disability claim, an extension is necessary for reasons beyond the control of the
Committee), in which case a decision will be rendered not later than 180 days (75 days in the case
of a Disability claim which may be further extended to 105 days if the additional extension is
necessary due to reasons beyond the control of the Committee) after the initial receipt of the
claim. If such an extension of time for processing the claim is required, written notice of the
extension and additional information that is necessary to process the claim will be furnished to
the Claimant prior to the expiration of the initial 90-day (or 45-day) period and will indicate the
special circumstances requiring an extension of time for processing the claim and will indicate the
date the Committee expects to render its decision. In no event will such extension exceed a period
of 90 days from the end of the initial period. The notice shall set forth:

	 	(a)	 	the specific reason or reasons for the denial;
	 
	 	(b)	 	specific references to pertinent Plan provisions on which the Committee based
its denial;
	 
	 	(c)	 	a description of any additional material or information needed for the Claimant
to perfect the claim and an explanation of why the material or information is needed;
	 
	 	(d)	 	if the claim is a claim for a Disability benefit, the Participant will be
notified if an internal rule, guideline, protocol or other similar criterion was relied
on by the Committee and the Participant will be provided with a copy of such rule,
guideline, protocol, or other criterion free of charge on the Participant’s request. If
the claim is a claim for a Disability benefit and the denial is based on a medical
necessity or other similar exclusion or limit, the Participant will be provided, free
of charge at his or her request, an explanation of how that exclusion or limit and any
clinical judgments apply to the Participant’s medical circumstances.
	 
	 	(e)	 	a statement that the Claimant may:

	 	(i)	 	request a review upon written application to the Committee;
	 
	 	(ii)	 	review pertinent Plan documents; and
	 
	 	(iii)	 	submit issues and comments in writing; and

	 	(f)	 	that any appeal the Claimant wishes to make of the adverse determination must
be in writing and received by the Committee within 60 days (180 days in the case of a
Disability claim) after receipt of the Committee’s notice of denial of benefits. The
Committee’s notice must further advise the Claimant that failure to appeal the

 

 

	 	 	 	action to the Committee in writing within the 60-day (or 180-day) period will render
the Committee’s determination final, binding, and conclusive.

     8.2 If the Claimant should appeal to the Committee, the Claimant, or the duly authorized
representative of such Claimant, may submit, in writing, whatever issues and comments such
Claimant, or the duly authorized representative of such Claimant, feels are pertinent. The
Committee shall re-examine all facts related to the appeal and make a final determination as to
whether the denial of benefits is justified under the circumstances. The Committee shall advise
the Claimant in writing of its decision on the appeal, the specific reasons for the decision, and
the specific Plan provisions on which the decision is based. The notice of the decision shall be
given within 60 days (45 days in the case of a Disability claim) of the Claimant’s written request
for review, unless special circumstances (such as a hearing) would make the rendering of a decision
within the 60-day (or 45-day) period infeasible, but in no event shall the Committee render a
decision regarding the denial of a claim for benefits later than 120 days (90 days in the case of a
Disability claim) after its receipt of a request for review. If an extension of time for review is
required because of special circumstances, written notice of the extension shall be furnished to
the Claimant prior to the date the extension period commences. The Claimant will also be entitled
to receive, on request and free of charge, access to and copies of all documents, records, and
other information relevant to the claim. In addition, if the claim is a claim for a Disability
benefit, the Participant will be notified if an internal rule, guideline, protocol or other similar
criterion was relied on by the Committee and will be provided with a copy of such rule, guideline,
protocol, or other criterion free of charge at your request. If the claim is a claim for a
Disability benefit and the denial is based on a medical necessity or other similar exclusion or
limit, the Participant will be provided, free of charge at his or her request, an explanation of
how that exclusion or limit and any clinical judgments apply to the Participant’s medical
circumstances. In the case of a Disability claim, the review on appeal must be made by a different
decision-maker from the Committee and that decision-maker cannot give procedural deference to the
original decision. If the Claimant is dissatisfied with the Committee’s (or other independent
fiduciary’s) review decision, the Claimant has the right to file suit in a federal or state court.

ARTICLE IX

LIMITATION OF RIGHTS

     The establishment of this Plan shall not be construed as giving to any Participant, employee
of the Company or any person whomsoever, any legal, equitable or other rights against the Company,
or its officers, directors, agents or shareholders, or as giving to any Participant or Beneficiary
any equity or other interest in the assets or business of the Company or shares of Company stock or
as giving any employee the right to be retained in the employment of the Company. All employees of
the Company and Participants shall be subject to discharge to the same extent they would have been
if this Plan had never been adopted.

 

 

ARTICLE X

LIMITATION OF ASSIGNMENT AND PAYMENTS

TO LEGALLY INCOMPETENT DISTRIBUTEE

     10.1 No benefits which shall be payable under the Plan to any person shall be subject in any
manner to anticipation, alienation, sale, transfer, assignment, pledge, encumbrance or charge, and
any attempt to anticipate, alienate, sell, transfer, assign, pledge, encumber, charge or otherwise
dispose of the same shall be void. No benefit shall in any manner be subject to the debts,
contracts, liabilities, engagements or torts of any person, nor shall it be subject to attachment
or legal process for or against any person, except to the extent required by law.

     10.2 Whenever any benefit which shall be payable under the Plan is to be paid to or for the
benefit of any person who is then a minor or determined by the Committee, on the basis of qualified
medical advice, to be incompetent, the Committee need not require the appointment of a guardian or
custodian, but shall be authorized to cause the same to be paid over to the person having custody
of the minor or incompetent, or to cause the same to be paid to the minor or incompetent without
the intervention of a guardian or custodian, or to cause the same to be paid to a legal guardian or
custodian of the minor or incompetent, if one has been appointed, or to cause the same to be used
for the benefit of the minor or incompetent.

ARTICLE XI

AMENDMENT TO OR TERMINATION OF THE PLAN

     The Committee and the Board reserve the right at any time to amend or terminate the Plan in
whole or in part. No amendment shall have the effect of retroactively depriving Participants or
Beneficiaries of rights already accrued under the Plan. Upon termination of the Plan, the
Committee may, in its sole and absolute discretion, and notwithstanding any other provision
hereunder to the contrary, direct that all benefits hereunder will be paid as soon as
administratively practicable thereafter.

ARTICLE XII

GENERAL AND MISCELLANEOUS

     12.1 In the event that any provision of this Plan shall be declared illegal or invalid for any
reason, said illegality or invalidity shall not affect the remaining provisions of this Plan but
shall be fully severable and this Plan shall be construed and enforced as if said illegal or
invalid provision had never been inserted herein.

     12.2 The Section headings and numbers are included only for convenience of reference and are
not to be taken as limiting or extending the meaning of any of the terms and provisions of this
Plan. Whenever appropriate, words used in the singular shall include the plural or the plural may
be read as the singular.

 

 

     12.3 The validity and effect of this Plan and the rights and obligations of all persons
affected hereby shall be construed and determined in accordance with the laws of the State of
Illinois unless superseded by federal law.

     12.4 The Company is not required to set aside any assets for payment of the benefits provided
under this Plan. A Participant shall have no security interest in any amounts credited hereunder on
such Participant’s behalf. It is the Company’s intention that this Plan be construed as a plan
which is unfunded and maintained primarily for the purpose of providing deferred compensation for a
select group of highly compensated employees.

     12.5 All amounts payable hereunder shall be reduced by any and all federal, state and local
taxes imposed upon the Participant or a Beneficiary which are required to be paid or withheld by
the Company.

     IN WITNESS WHEREOF, TreeHouse Foods, Inc has caused this document to be executed on this 1st
day of August, 2005.

	 	 	 	 	 
	 	COMPANY:

TREEHOUSE FOODS, INC.

 	 
	 	By:  	/s/ THOMAS E. O’NEILL
 	 
	 	 	Its: General Counsel, Senior Vice      	 
	 	 	President, and Chief Administrative
Officerexv10w6w9

 

Exhibit 10.6.9

STATE OF NEW JERSEY

DEPARTMENT OF HUMAN SERVICES

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES

AND

AMERIGROUP NEW JERSEY, INC.

AGREEMENT TO PROVIDE HMO SERVICES

In accordance with Article 7, section 7.11.2A and 7.11.2B of the contract between AMERIGROUP New
Jersey, Inc. and the State of New Jersey, Department of Human Services, Division of Medical
Assistance and Health Services (DMAHS), effective date October 1, 2000, all parties agree that the
contract shall be amended, effective July 1, 2005, as follows:

 

 

Exhibit 10.6.9

	 	1.	 	Article 1, “Definitions” section — for the following definition:

	 	1.	 	Capitation Summary Record (new definition)

shall be amended as reflected in the relevant page of Article 1 attached hereto and incorporated
herein.

	 	2.	 	Article 2, “Conditions Precedent” Sections H and K.1(b) shall be amended as reflected
in Article 2, Sections H and K.1(b) attached hereto and incorporated herein.
	 
	 	3.	 	Article 3, “Managed Care Management Information System,” Sections 3.2(C); 3.2.1(B);
3.2.5; 3.3.1(A); 3.3.3(A); 3.4.4 (new); 3.9(A); 3.9(C); 3.9.1(A) (new); 3.9.1(B); 3.9.1(C)
(deleted); 3.9.2(A); 3.9.2(B); 3.9.3(C); 3.9.3(D) (deleted), re-number remaining; 3.9.3(E)
(new); 3.9.4(A) and 3.9.4(B) shall be amended as reflected in Article 3, Sections 3.2(C),
3.2.1(B), 3.2.5, 3.3.1(A), 3.3.3(A), 3.4.4, 3.9(A), 3.9(C), 3.9.3(D), 3.9.3(E), 3.9.4(A)
and 3.9.4(B) attached hereto and incorporated herein.
	 
	 	4.	 	Article 4, “Provision of Health Care Services” Sections 4.1.1(G)4 (new); 4.1.2(A)18;
4.2.1(K)3 (new); 4.2.6(A)6 (deleted); 4.2.6(B)1(c); 4.2.6(B)7(f); 4.2.6(B)7(f)ii. 1);
4.3.3(A); 4.5.2(B); 4.5.4(B); 4.6.1(C)8 (new) 4.6.2(P); 4.6.2(X) (new) (deleted previous);
4.6.2(AA)1 (new); 4.6.4(C); 4.6.4(C)6(c); 4.6.4(C)6(d); 4.7.1(K) (new); 4.7.2(A)1; 4.8.3;
4.8.3(A), 4.8.3(A)3 (new); 4.8.3(C)1(new); 4.8.7(D) and 4.8.8(G)1 shall be amended as
reflected in Article 4, Sections 4.1.1(G)4, 4.1.2(A)18, 4.2.1(K)3, 4.2.6(A)6, 4.2.6(B)1(c),
4.2.6(B)7(f)ii.1), 4.3.3(A), 4.5.2(B), 4.5.4(B), 4.6.1(C)8, 4.6.2(P), 4.6.2(X), 4.6.2(AA)1,
4.6.4(C), 4.6.4(C)6(c), 4.6.4(C)6(d), 4.7.1(K), 4.7.2(A)1, 4.8.3, 4.8.3(A), 4.8.3(A)3,
4.8.3(C)1, 4.8.7(D) and 4.8.8(G)1 attached hereto and incorporated herein.
	 
	 	5.	 	Article 5, “Enrollee Services” Sections 5.8.2(S); 5.8.2(NN); 5.10.2(A)1; 5. 14.2(B)8
and 5.15.3(D) shall be amended as reflected in article 5, Sections 5.8.2(S), 5.8.2(NN),
5.10.2(A)1, 5.15.2(B)8 and 5.15.3(D) attached hereto and incorporated herein.
	 
	 	6.	 	Article 7, “Terms and Conditions” Sections 7.3(A); 7.16.4; 7.16.5; 7.16.7(B)2 (new);
7.16.7(B)3 (new); 7.26(F); 7.27.1(B) and 7.38.2(A)1 shall be amended as reflected in
Article 7,

 

 

Exhibit 10.6.9

	 	 	 	Sections 7.3(A), 7.16.4, 7.16.5, 7.16.7(B)2, 7.16.7(B)3, 7.26(F), 7.27.1(B) and
7.38.2(A)1 attached hereto and incorporated herein.
	 
	 	7.	 	Article 8, “Financial Provisions”, Sections 8.4.1(A); 8.4.1(A)1; 8.4.1(A)2; 8.4.1(A)3;
8.5.2.1; 8.5.2.4; 8.5.4 (Heading) 8.5.8 (deleted) (Reserved) and 8.7(H)3 shall be amended
as reflected in Article 8, Sections 8.4.1(A), 8.4.1(A)1, 8.4.1(A)2, 8.4.1(A)3, 8.5.2.1,
8.5.2.4, 8.5.4, 8.5.5 and 8.7(H)3 attached hereto and incorporated herein.
	 
	 	8.	 	Appendix, Section A, “Reports”
	 
	 	•	 	A.3.1 — Reserved (deleted previous);
	 
	 	•	 	A.4.1 — Provider Network File: Attachment A, #13, #18, #19, #20, #21, #22, #33, #36
(new); Attachment B, #16, #18 (new); Attachment E (revised);
	 
	 	•	 	A.4.3 — Network Accessibility Analysis for New Jersey Medicaid/NJ FamilyCare, B.3 #1, 2,
3, 8, 10, 11, 12 (footnote added to define “na”);
	 
	 	•	 	A.7.1 — Certifications, A.7.1(A); A.7.1(B); A.7.1(C) revised language; A.7.1(E) (new);
	 
	 	•	 	A.7.2 — Fraud and Abuse (deleted Section C);
	 
	 	•	 	A.7.3 — Table 1; (revised);
	 
	 	•	 	A.7.4 — Reserved (deleted previous);
	 
	 	•	 	A.7.6 — Reserved (Table 4 moved to HMO Financial Reporting Manual);
	 
	 	•	 	A.7.7 — Table 5; narrative revised;
	 
	 	•	 	A.7.8 — Table 6: 6a, 6b, 6d and 6e moved to HMO Financial Reporting Manual; 6c renamed;
	 
	 	•	 	A.7.9 — Reserved (Table 7 moved to HMO Financial Reporting Manual);
	 
	 	•	 	A.7.10 — Reserved (deleted previous);
	 
	 	•	 	A.7.11 — Table 9: Semi-Annual Utilization and Medical Expenditure Summary (new),
(deleted previous);
	 
	 	•	 	A.7.13 — Reserved (deleted previous);
	 
	 	•	 	A.7.16 — Reserved (deleted previous);
	 
	 	•	 	A.7.18 — Table 16 (revised);
	 
	 	•	 	A.7.21 — HMO Financial Reporting Manual for Medicaid/NJ FamilyCare Rate Cell Grouping
Costs, (revised) (moved from B.7.3, incorporates revised Table 19;

 

 

Exhibit 10.6.9

	 	•	 	A.7.22 — Reserved (Table 20 moved to Financial Reporting Manual);
	 
	 	•	 	A.7.23 — Reserved (Table 21 moved to Financial Reporting Manual);
	 
	 	•	 	A.8.3 — Estate Referral Form — (report separated from previous A.8.2)

shall be amended as reflected in Appendix, Section A, A.3.1, A.4.1, A.4.3, A.7.1, A.7.2, A.7.3,
A.7.4, A.7.6, A.7.7, A.7.9, A.7.9, A.7.10, A.7.11, A.7.12, A.7.13, A.7.16, A.7.18, A.7.21,
A.7.22, A.7.23 and A.8.3 attached hereto and incorporated herein.

	 	9.	 	Appendix, Section B, “Reference Materials”
	 
	 	•	 	B.3.1 — Reserved (deleted previous);
	 
	 	•	 	B.3.2 — Data Files Resources Guide (new) (deleted previous);
	 
	 	•	 	B.4.6 — School-Based Youth Services Programs — list replaced with web site address;
	 
	 	•	 	B.4.7 — Local Health Departments — list replaced with web site address;
	 
	 	•	 	B.4.9 — Mental Health/Substance Abuse Screening Tool
	 
	 	•	 	B.4.11—Special Child Health Services Network — list replaced with web site address;
	 
	 	•	 	B.4.13 — Statewide Family Centered HIV Care network (Ryan White Title IV) — list
replaced with web site address;
	 
	 	•	 	B.5.2 — Cost sharing Requirements for NJ FamilyCare Plan H:#4 deleted, renumber remaining;
	 
	 	•	 	B.57.3 — Reserved (previous moved to A.7.21), and
	 
	 	•	 	B.7.4 — Reserved

shall be amended as reflected in Appendix, Section B, B.3.1, B.3.2, B.4.6, B.4.7, B.4.9, B.4.11,
B.4.13, B.5.2, B.7.3 and B.7.4 attached hereto and incorporated herein.

	 	10.	 	Appendix, Section C, “Capitation Rates” shall be revised as reflected in SFY 2005
Capitation Rates attached hereto and incorporated herein.
	 
	 	11.	 	Appendix, Section E, “Managed Care Service Administrator (MCSA) Administrative Fees”
shall be revised as reflected in the SFY 2005 Administrative Fees attached hereto and
incorporated herein.

 

 

Exhibit 10.6.9

	 	12.	 	All other terms and conditions of the October 1, 2000 contract and subsequent amendments
remain unchanged except as noted above.

The contracting parties indicate their agreement by their signatures.

	 	 	 	 	 	 	 	 
	 	Amerigroup

New Jersey, Inc	 	          State of New Jersey

Department of Human Services
	 	 
	 	 	 	 	 	 
	 	BY:

	 	/s/      TBD
	 	BY:
	 	/s/ Ann Clemency Kohler
	 	 

	 	 
	 	 	 	 
	 	 
	 	 	 	 	 	 
	 	TITLE: President and CEO	 	TITLE: Director, DMAHS
	 	DATE: /s/ April 28, 2005	 	DATE: /s/ 5/2/05
	 	 
	 	 	 	 	 	 
	 	APPROVED AS TO FORM ONLY

Attorney General

State of New Jersey	 	 	 	 
	 	 
	 	 	 	 	 	 
	 	BY:

	 	/s/      TBD	 	 	 	 
	 	 

	 	 	 	 	 	 
	 	Deputy Attorney General	 	 	 	 
	 	 
	 	 	 	 	 	 
	 	DATE: /s/ 4/29/05	 	 	 	 

 

 

Exhibit 10.6.9

C. The Bureau of Guardianship Services (BGS); or

D. A person or agency who has been duly designated by a power of attorney for medical decisions
made on behalf of an enrollee.

Throughout the contract, information regarding enrollee rights and responsibilities can be taken
to include authorized person, whether stated as such or not.

Automatic Assignment — The enrollment of an eligible person, for whom enrollment is mandatory,
in a managed care plan chosen by the New Jersey Department of Human Services pursuant to the
provisions of Article 5.4 of this contract.

Basic Service Area — the geographic area in which the contractor is obligated to provide covered
services for its Medicaid/NJ FamilyCare enrollees under this contract.

Beneficiary — any person eligible to receive services in the New Jersey Medicaid/NJ FamilyCare
program

Benefits Package — the health care services set forth in this contract, for which the contractor
has agreed to provide, arrange, and be held fiscally responsible.

Bilingual — see “Multilingual”

Bonus — a payment the contractor makes to a physician or physician group beyond any salary,
fee-for-service payments, capitation or returned withholding amount.

Capitated Service — any covered service for which the contractor receives capitation payment

Capitation — a contractual agreement through which a contractor agrees to provide specified
health care services to enrollees for a fixed amount per month.

Capitation Payments — the amount prepaid monthly by DMAHS to the contractor in exchange for the
delivery of covered services to enrollees based on a fixed Capitation
Rate per

 

 

Exhibit 10.6.9

enrollee, notwithstanding (a) the actual number of enrollees who receive services from
the contractor, or (b) the amount of services provided to any enrollee.

Capitation Rate — the fixed monthly amount that the contractor is prepaid by the Department for
each enrollee for which the contractor provides the services included in the Benefits Package
described in this contract.

Capitation Summary Record — pseudo-encounters that are reported in addition to normal
encounters. They represent a financial summary of the reported services rendered by HMO network
providers, where the contractual relationship between the HMO and the network provider is based
on a periodic capitation payment, and not on a pre-determined fee for a rendered service.

 

 

Exhibit 10.6.9

2. The contractor shall comply with and remain in compliance with minimum net worth and fiscal
solvency and reporting requirements of the Department of Banking and Insurance, the Department
of Human Services, the federal government, and this contract.

3. The contractor shall provide written certification of new written contracts for all providers
other than FQHCs and shall provide copies of fully executed contracts for new contracts with
FQHCs on a quarterly basis.

4. If solvency protection arrangements change, the contractor shall notify the DMAHS sixty (60)
days before such change takes effect and provide written copy of DOBI approval.

2.H. County Expansion Phase-In Plan. If the contractor does not have an approved COA for each of
the counties in a designated region, the contractor shall submit to DMAHS a county expansion
phase-in plan for review and approval by DMAHS prior to the execution of this contract. The plan
shall include detailed information of:

	 	•	 	The region and names of the counties targeted for expansion;
	 
	 	•	 	Anticipated dates of the submission of the COA modification to DOBI and DHSS (with
copies to DMAHS);
	 
	 	•	 	Anticipated date of approval of the COA;
	 
	 	•	 	Anticipated date for full operations in the region;
	 
	 	•	 	Anticipated date for initial beneficiary enrollment in each county

The
phase-in plan shall indicate that when full expansion into a region shall be complete by
June 30, 2004. All expansions are subject to approval by DMAHS. The contractor shall
maintain full coverage for each county in each region in which the contractor operates for
the duration of this contract.

I. No court order, administrative decision, or action by any other instrumentality of the
United State Government or the State of New Jersey or any other state is outstanding which
prevents implementation of this contract.

J. Net Worth

 

 

Exhibit 10.6.9

          1. The contractor shall maintain a minimum net worth in accordance with N.J.A.C. Title
8:38-11 et seq.

          2. The Department shall have the right to conduct targeted financial audits of the
contractor’s Medicaid/NJ FamilyCare line of business. The contractor shall provide the
Department with financial data, as requested by the Department, within a time frame
specified by the Department.

2K. The contractor shall comply with the following financial operations requirements:

	 	1.	 	A contractor shall establish and maintain:

	 	a.	 	An office in New Jersey, and
	 
	 	b.	 	Premium and claims accounts in a New
Jersey qualified bank with a principal office in New Jersey as
approved by DOBI.

	 	2.	 	The contractor shall have a fiscally sound operation as demonstrated
by:

	 	a.	 	Maintenance of a minimum net worth in
accordance with DOBI requirements (total line of business) and the
requirements outlined in G and J above and Article 8.2.
	 
	 	b.	 	Maintenance of a net operating surplus
for Medicaid/NJ FamilyCare line of business. If the contractor fails
to earn a net operating surplus during the most recent calendar year
or does not maintain minimum net worth requirements on a quarterly
basis, it shall submit a plan of action to DMAHS within the time
fram especified by the Department. The plan is subject to the
approval of DMAHS. It shall demonstrate how and when minimum net
worth will be replenished and present marketing and financial
projections. These shall be supported by suitable back-up material.
The discussion shall include possible alternate funding sources,
including invoking of corporate parental guarantee. The plan will
include:

	 	i.	 	A
detailed marketing plan with enrollment
projections for the next two years.
	 
	 	ii.	 	A
projected balance sheet for the next two years.
	 
	 	iii.	 	A
projected statement of revenues and expenses on an
accrual basis for the next two years.

 

 

Exhibit 10.6.9

	 	iv.	 	A
statement of cash flow projected for the next two
years.
	 
	 	v.	 	A
description of how to maintain capital
requirements and replenish net worth.
	 
	 	vi.	 	Sources and timing of capital shall be
specifically identified.

	 	3.	 	The contractor may be required to obtain prior to this contract and
maintain “Stop-Loss” insurance, pursuant to provisions in Article 8.3.2.

 

 

Exhibit 10.6.9

frames and format requirements are in Section A of the Appendices.

B. Ad Hoc Reporting. The contractor shall have the capability to support ad hoc
reporting requests, in addition to those listed in this contract, both from its own
organization and from the State in a reasonable time frame. The time frame for
submission of the report will be determined by DMAHS with input from the contractor
based on the nature of the report. DMAHS shall at its option request six (6) to eight
(8) reports per year, hardcopy or electronic reports and/or file extracts. This does not
preclude or prevent DMAHS from requiring, or the contractor from providing, additional
reports that are required by State or federal governmental entities or any court of
competent jurisdiction.

C. System Documentation. The contractor shall update documentation on its system(s)
within 30 days of implementation of the changes. The contractor’s documentation must
include a system introduction, program overviews, operating environment, external
interfaces, and data element dictionary. For each of the functional components, the
documentation should include where applicable program narratives, processing flow
diagrams, forms, screens, reports, files, detailed logic such as claims pricing
algorithms and system edits. The documentation should also include job descriptions and
operations instructions. The contractor shall have available current documentation
on-site for Staet audit as requested.

3.1.4 OTHER REQUIREMENTS

     Future Changes. The system shall be easily modifiable to accommodate future system
changes/enhancements to claims processing or other related systems at the same time as
changes take place in the State’s MMIS. In addition, the system shall be able to
accommodate all future requirements based upon federal and State statues, policies and
regulations. Unless otherwise agreed by the State, the contractor shall be responsible
for the costs of these changes.

3.2 ENROLLEE SERVICES

 

 

Exhibit 10.6.9

The MCMIS shall support all of the enrollee services as specified in Article 5 of this
contract. The system shall:

	 	A.	 	Capture and maintain contractor enrollment data electronically.
	 
	 	B.	 	Provide information so that the contractor can send plan materials and
information to enrollees.
	 
	 	C.	 	Capture electronically the Primary Care Provider (PCP) selections name
provided by enrollees as well as enrollee health profiles from the Health Benefits
Coordinator and/or the State.
	 
	 	D.	 	Provide contractor enrollment and Medicaid information to providers.
	 
	 	E.	 	Maintain an enrollee complaint and grievance tracking system for
Medicaid and NJ FamilyCare enrollees.
	 
	 	F.	 	Produce the required enrollee data reports.

The enrollee module(s) shall interface with all other required modules and permit the access,
search, and retrieval of enrollee data by key fields, including date-sensitive information.

3.2.1 CONTRACTOR ENROLLMENT DATA

A. Enrollee Data. The contractor shall maintain a complete history of enrollee information,
including contractor enrollment , primary care provider selection or assignment, third party
liability coverage, and Medicare coverage. In addition, the contractor shall capture demographic
information relating to the enrollee (age, sex, county, etc.), information related to family
linkages, information relating to benefit and service limitations, and information related to
health care for enrollees with special needs.

B. Updates. The contractor shall accept and process a weekly enrollment and eligibility file
information according to HIPPA standards (the managed care register files; See section B.3.2 of the
Appendices) within 48 hours of receipt from the Department. Details of the 834 daily, weekly, and
monthly files are available in the HIPAA Implementation and New Jersey Medicaid Companion Guides.
The system shall provide reports that identify all errors encountered, count all transactions
processed, and provide for a complete audit trail of the update processes. The MCMIS shall
accommodate the following specific Medicaid/NJ FamilyCare requirements.

 

 

Exhibit 10.6.9

     1. The contractor shall be able to access and identify all enrollees by their Medicaid/NJ
FamilyCare Identification Number. This number shall be readily cross-referenced to the contractor’s
enrollment number and the enrollee’s social security number. For DYFS cases, it is important that
the contractor’s system be able to distinguish the DYFS enrolled children not be consolidated based
on the first 10 digits of the Medicaid ID number because the family members may not be residing
together.

2. The system shall be able to link family members for on-line inquiry access and for consolidated
mailings based on the first ten-digits of the Medicaid ID number.

3. The system shall be able to identify newborns from the date of birth, submit the proper
eligibility form to the State, and link the newborn record to the NJ FamilyCare/Medicaid
eligibility and enrollment data when these data are received back from the State.

	 	4.	 	The system shall capture and maintain all of the data elements provided
by the Department on the weekly update files.

 

 

Exhibit 10.6.9

	 	2.	 	Generation of correspondence to enrollees based on variable criteria., including PCP and
demographic information.

3.2.3 CONTRACTOR ENROLLMENT VERIFICATION

A. Electronic Verification System. The contractor shall provide a system that supports the
electronic verification of contractor enrollment to network providers via the telephone 24
hours a day and 365 days a year or on a schedule approved by the State. This capability
should require the enrollee’s contractor Identification Number, the Medicaid/NJ FamilyCare
Identification Number, or the Social Security Number. The system should provide information
on the enrollee’s current PCP as well as the enrollment information.

B. Telephone Enrollment Inquiry. The contractor shall provide telephone operator personnel
(both member services and provider services) to verify contractor enrollment during normal
business hours. The contractor’s telephone operator personnel should have the capability to
electronically verify contractor enrollment based on a variety of fields, including
contractor Identification Number, the Medicaid/NJ FamilyCare Identification Number, Social
Security Number, Enrollee Name, Date of Birth.

The contractor shall ensure that a recorded message is available to providers when
enrollment capability is unavailable for any reason.

3.2.4 ENROLLEECOMPLAINT AND GRIEVANCE TRACKING SYSTEM

The contractor shall develop an electronic system to capture and track the content and
resolution of enrollee complains or grievances.

A. Data Requirements. The system shall capture, at a minimum, the enrollee, the reason
for the complaint or grievance, the date the complaint or grievance was reported, the
operator who talked to the enrollee, the explanation of the resolution, the date the
complaint or grievance was resolved, the person who resolved the complaint or grievance,
referrals to other departments, and comments including general information and/or
observations. See Article 5.15.

3.2.5 ENROLLEE REPORTING

The contractor shall produce all of the reports according to the timeframes and specifications
outlined in Section A of the Appendices.

 

 

Exhibit 10.6.9

The contractor shall provide the State with a monthly file of enrollees (see section A.3.1 of the
Appendices). The State’s fiscal agent will reconcile this file with the State’s Recipient File. The
contractor shall provide for reconciling any differences and taking the appropriate corrective
action.

3.3 PROVIDER SERVICES

The contractor’s System shall collect, process, and maintain current and historical data on program
providers. This information shall be accessible to all parts of the MCMIS for editing and
reporting.

3.3.1 PROVIDER INFORMATION AND PROCESSING REQUIREMENTS

A. Provider Data. The contractor shall maintain individual and group provider network information
with basic demographics, EIN or tax identification number, professional credentials, license and/or
certification numbers and dates, sites, risk arrangements (i.e., individual and group risk pools),
services provided, payment methodology and/or reimbursement schedules, group/individual provider
relationships, facility linkages, number of grievances and/or complaints.

For PCPs, the contractor shall maintain identification as traditional or safety net provider,
specialties, enrollees with beginning and ending effective dates, capacity, emergency arrangements
or contact, other limitations or restrictions, languages spoken, address, office hours, disability
access. See Articles 4.8 and 5.

The contractor shall maintain provider history files and provide for easy data retrieval. The
system should maintain audit trails of key updates.

Providers should be identified with a unique number. The contractor shall be able to
cross-reference it provider number with the provider’s EIN or tax number, the provider’s license
number, UPIN, Medicaid provider number or Medicaid-assigned number, as provided by the State in
response to the contractor’s monthly Provider Network
submission, and Medicare provider number where applicable. The contractor shall comply with the
HIPAA requirements for provider identification.

B. Updates. The contractor shall apply updates to the provider file daily.

 

 

Exhibit 10.6.9

C. Complaint Tracking System. The system shall provide for the capabilities to track and report
provider complaints as specified in Article 6.5. The contractor shall provide detail reports
identifying open complaints and summary statistics by provider on the types of complaints,
resolution, and average time for resolution.

3.3.2 PROVIDER CREDENTIALING

A. Credentialing. The contractor shall credential and re-credential each network provider as
specified in Article 4.6.1. The system should provide a tracking and reporting system to support
this process.

B. Review. The contractor shall be able to flag providers for review based on problems identified
during credentialing, information received from the State, information received from CMS,
complaints, and in-house utilization review results. Flagging providers should cause all claims to
deny as appropriate.

3.3.3 PROVIDER/ENROLLEE LINKAGE

A. Enrollee Rosters. The contractor shall generate electronic (and/or hard copy if provider lacks
capability to accept electronic files) enrollee rosters to its PCPs each month by the second
business day of the month. The rosters shall indicate all enrollees that are assigned to the PCP
and should provide the provider with basic demographic and enrollment information related to the
enrollee.

B. Provider Capacity. The contractor’s system shall support the provider network requirements
described in Article 4.8.

3.3.4 PROVIDER MONITORING

The contractor’s system shall support monitoring and tracking of provider/enrollee complaints,
grievances and appeals from receipt to disposition. The system shall be able
to produce provider reports for quality of medical and dental care analysis, flag and identify
providers with restrictive conditions (e.g., fraud monitoring), and identify the confidentiality
level of information (i.e., to manage who has access to the information).

3.3.5 REPORTING REQUIREMENTS

 

 

Exhibit 10.6.9

The contractor shall produce all of the reports identified in Section A of the Appendices. In
addition, the system shall provide ongoing and periodic reports to monitor provider activity,
support provider contracting, and provide administrative and management information as required for
the contractor to effectively operate.

3.4 CLAIMS/ENCOUNTER PROCESSING

The system shall capture and adjudicate all claims and encounters submitted by providers. The major
function of this module (s) include enrollee enrollment verification, provider enrollment
verification, claims and encounter edits, benefit determination, pricing, medical review and claims
adjudication, and claims payment. Once claims and encounters are processed, the system shall
maintain the claims/encounter history file that supports the State’s encounter reporting
requirements as well as all of the utilization management and quality assurance functions and other
reporting requirements of the contractor.

3. 5 GENERAL REQUIREMENTS

The contractor shall have an automated claims and encounter processing system that will support the
requirements of this contract and ensure the accurate and timely processing of claims and
encounters. The contractor shall offer its providers an electronic payment option.

 

 

Exhibit 10.6.9

4. Contested Claims and Encounters

5. Aged Claims and encounters

6. Checks and EOB(s)

7. Lag Factors and IBNR

B. The contractor shall produce reports according to the timeframes and specification outlined in
Section A of the Appendices.

3.4.4 REMITTANCE ADVICE AND CAPITATION LISTS

     The contractor shall provide federally qualified health centers with electronic remittance
advices and electronic capitation lists of enrollees. In addition, the contractor shall provide
copies of or a report of the data elements of the electronic remittance advices and capitation
lists in Excel format to the DMAHS.

3.5 PRIOR AUTHORIZATION, REFERRAL AND UTILIZATION MANAGEMENT

The prior authorization/referral and utilization management functions shall be an integrated
component of the MCMIS. It shall allow for effective management of delivery of care. It shall
provide a sophisticated environment for managing the monitoring of both inpatient and outpatient
care on a proactive basis.

3.5.1 FUNCTIONS AND CAPABILITIES

A. Prior Authorizations. The contractor shall provide an automated system that includes the
following:

1. Enrollee eligibility, utilization, and case management information.

2. Edits to ensure enrollee is eligible, provider is eligible, and service is covered.

3. Predefined treatment criteria to aid in adjudicating the requests.

4. Notification to provider of approval or denial.

5. Notification to enrollees of any denials or cutbacks of service.

6. Interface with claims processing system for editing.

B. Referrals. The contractor shall provide an automated system that includes the following:

     1. Ability for providers to enter referral information directly, fax information to the
contractor or call in on dedicated phone lines.

 

 

Exhibit 10.6.9

2. Interface with claims processing system for editing.

C. Utilization Management. The contractor should provide an automated system that includes the
following:

1. Provides case tracking, notifies the case worker of outstanding actions.

2. Provide case history of all activity.

3. Provide online access to cases by enrollee and provider numbers.

 

 

Exhibit 10.6.9

D. The contractor shall acquire the capability to receive and transmit data in a secure manner
electronically to and from the State’s data centers, which are operated by OIT. The standard data
transfer software that OIT utilizes for electronic data exchange is Connect: Direct. Both mainframe
and PC versions are available. A dedicated line is preferred, but at a minimum connectivity
software can be used for the connection.

3.8.2 QUERY CAPABILITIES

The contractor’s MCMIS should have a sophisticated query tool with access to all major files for
the users.

A. General. The system should provide a user-friendly, online query language to construct
database queries to data available across all of the database(s), down to raw data elements. It
should provide options to select query output to be displayed on-line, in a formatted, hard-copy
report, or downloaded to the disk for PC-based analysis.

B. Unduplicated Counts. The system should provide the capability to execute queries that
perform unduplicated counts (e.g., unduplicated count of original beneficiary ID number),
duplicated counts (e.g., total number of services provided for a given aid category), or a
combination of unduplicated and duplicated counts.

3.8.3 REPORTING CAPABILITIES

The contractor should provide reporting tools with its MCMIS that facilitate ad hoc, user, and
special reporting. The MCMIS should provide flexible report formatting/editing capabilities that
meet the contractor’s business requirements and support the Department’s information needs. For
example, it should provide the ability to import, export and manipulate data files from
spreadsheet, work processing and database management tools as well as the database(s) and should
provide the capability to indicate header information, date and run time, and page numbers on
reports. The system should provide multiple pre-defined report types and formats that are easily
selected by users.

3.9 ENCOUNTER DATA REPORTING

A. The contractor shall collect, process, format, and submit electronic encounter data for all
services delivered for which the contractor is responsible. The contractor shall capture all
required encounter data elements using coding structures recognized by; the
Department. The contractor

 

 

Exhibit 10.6.9

shall process the encounter data, integrating any manual or automated
systems to validate the adjudicated encounter date. The contractor shall interface with any systems
or modules within its organization to obtain the required encounter data elements. The contractor
shall submit the encounter data to the Department’s fiscal agent electronically via diskette, tape
or electronic transmission, according to specifications in the HIPPA Implementation and Companion
Guides (HICG) Division’s Electronic Media Claims (EMC) Manual which will be distributed with
regular updates may be periodically updated, and which are available at www.wpc-edi.com/hipaa and
www.njmmis.com respectively. The encounter data processing system shall have a data quality
assurance plan to include timely data capture, accurate and complete encounter records, and
internal data quality audit procedures. If DMAHS determines that changes are required, the
contractor shall e given advance notice and time to make the change according to the extent and
nature of the required change.

B. The contractor shall ensure that data received from providers is accurate and complete by:

1. Verifying the accuracy and timeliness of reported data;

2. Screening the data for completeness, logic, and consistency; and

3. Collecting service information in standardized formats to the extent feasible and appropriate.

C. Regardless of whether the contractor is considered a covered entity under HIPAA, the contractor
shall use the HIPAA Transaction and Code Sets as the exclusive format for the electronic
communication of health care claims and encounter data for data with dates of service on or after
October 16, 2003.submitted on or after January 1, 2005, regardless of date of service. The
contractor shall adhere to all HIPAA transaction set requirements as specified in the national
HIPAA Implementation Guide and the New Jersey Medicaid HIPAA Companion Guide when submitting
encounters.

3.9.1 REQUIRED ENCOUNTER DATA ELEMENTS

A. the contractor must report encounter data at least quarterly and no more frequently than
monthly. The data shall be enrollee specific, listing all encounter data elements of the services
provided. Encounter report files will be used to create a database that can be used in a manner
similar to fee-for-service history files to analyze plan utilization,
reimburse the contractor for supplemental payments, and calculate capitation premiums. DMAHS will
edit the data to assure

 

 

Exhibit 10.6.9

consistency and readability. If data are not of an acceptable quality or
submitted timely; the contractor will not be considered in compliance with this contract
requirement until an acceptable file is submitted. All Types of Claims. The contractor shall
capture all required encounter data elements for each of the eight claim types: Inpatient,
Outpatient, Professional, Home Health, Transportation, Vision, Dental, and Pharmacy.

B. Data Elements. The required data elements shall be in compliance with HIPAA transaction set
requirements (see 3.9.C) are provided in Section A.7.11. note that New Jersey specific Medicaid
codes are required in some fields. Provides shall be identified using the provider’s EIN or
tax-identification number. Inpatient hospital claims and encounters shall be combined into a single
stay when the enrollee’s dates of services are consecutive.

C. Contractor Encounter. The contractor shall submit encounter data for claims and encounter
received by the contractor. The contractor shall identify a capitated arrangement versus a “fee for
service” arrangement for its network providers. For noncapitated arrangements, the contractor shall
report the actual payment made to the provider for each encounter. For capitated arrangements the
contractor may reports a zero payment for each encounter. However, a monthly “Capitation Summary
Record” shall be required for each provider type, beneficiary capitation category, and service
month combination. The specifications for the submission of monthly capitation summary records is
further detailed in the EMC Manual issued by the Division.

3.9.2 SUBMISSION OF TEST ENCOUNTER DATA

A. Submitter ID. The contractor shall make application in order to obtain a Submitter
Identification Number, according to the instructions listed in the EMC Manual issued by the
Division. HIPAA Implementation and Companion Guides.

B. Test Requirement. The contractor shall be required to pass a testing phase for each of the eight
encounter claim types before production encounter data will be accepted. The contractor shall pass
the testing phase for all encounter claim type submissions within twelve (12) calendar weeks from
the effective date of the contract. Contractors with prior
contracting experience with DHS who have successfully submitted approved production data may be
exempted at DHS’s option.

 

 

Exhibit 10.6.9

The contractor shall submit the test encounter data to the Department’s fiscal agent
electronically, via diskette, tape, or electronic
transmission according to the specifications of
the Electronic Media Claims Manual issued by the Division HIPAA Implementation and Companion
Guides.

The contractor shall be responsible for passing a two-phased test for each encounter claim type.
The first phase requires that each submitted file follows the prescribed format that header and
trailer records are present and correctly located within the file, and that the key fields are
present. The second phase requires that the required data elements are present and properly valued.
The contractor shall be responsible for passing a phased-in test process prior to submitting
production encounter data. The details of the testing process and handling of errors are provided
in the New Jersey Medicaid Companion Guide.

Following each submission and error report will be forwarded to the contractor identifying the file
and record location of each error encountered for both testing phases. The contractor shall analyze
the report, complete the necessary corrections, and re-submit the encounter data test file(s).

The contractor shall utilize production encounter data, systems, tables, and programs when
processing encounter test files. The contractor shall submit error-free production data once
testing has been approved for all of the encounter claims types.

3.9.3 SUBMISSION OF PRODUCTION ENCOUNTER DATA

A. Adjudicated Claims and Encounters. The contractor shall submit all adjudicated encounter data
for all services provided for which the contractor is responsible. Adjudicated encounter data are
defined as data from claims and encounters that the contractor has processed as paid or denied. The
contractor is not responsible for submitting contested claims or encounters until final
adjudication has been determined.

B. Schedule. Encounter data shall be submitted per the schedule established by the Department. Each
Submission shall include encounter data that were adjudicated in the prior period and any
adjustments for encounter data previously submitted.

 

 

Exhibit 10.6.9

C. Two-Phased Phased-in Process. Similar to testing, the contractor shall be responsible for
passing a two phased-in test process for all production encounter data submitted. The details of
production tests and handling of errors is are found in the New Jersey Medicaid Companion Guide.
The first phase requires each submitted file follow the prescribed format, that header and trailer
records are present and correctly located within the file and that the key fields are present. The
second phase requires that the required data elements are present and
properly valued.

D. Phase One Errors. If all or part of a production encounter file(s) rejects during phase one, an
error report will be forwarded to the contractor identifying the file and record location of each
error encountered. The contractor shall analyze the report, complete the necessary corrections, and
re-submit the “rejected” encounter production data within forty-five (45) calendar days from the
date the contractor receives the notice of error(S).

E. D. The contractor shall not be permitted to provide services under this contract nor shall the
contractor receive capitation payment until it has passed the testing and production submission of
encounter data.

E. Contractor Encounter. The contractor shall submit encounter data for claims and encounters
received by the contractor. The contractor shall identify a capitated arrangement versus a
“fee-for-service” arrangement for its network providers. For noncapitated arrangements, the
contractor shall report the actual payment made to the provider for each encounter. For capitated
arrangements, the contractor may report a zero payment for each encounter. However, a monthly
“Capitation Summary Record” shall be required for each provider type beneficiary capitation
category, and service month combination. The specifications for the submission of monthly
capitation summary records is further detailed in the HIPAA Implementation and Companion Guides.

3.9.4 REMITTANCE ADVICE

     a. Remittance Advice File Processing Report. The Department’s fiscal agent shall produce a
Remittance Advice File on a monthly basis that itemizes all processed encounters. The contractor
shall be responsible for the acceptance and processing of a Remittance Advice (RA) File according
to the specifications listed in the Division’s EMC Manual HIPAA Implementation and Companion
Guides. The Remittance Advice File is produced on magnetic tape and contains all submitted

 

 

Exhibit 10.6.9

encounter
data that passed phase one testing. The disposition (paid or denied) shall be reported
for each encounter along with the “phase two” errors for those claims that the Division denied.

B. Reconciliation. The contractor shall be responsible for matching the encounters on the
Remittance Advice File against the contractor’s data file(s). The contractor shall correct any
encounters that denied improperly and/or any other discrepancies noted on the file. Corrections
shall be resubmitted within thirty (30) calendar days from the date the contractor receives the
Remittance Advice File.

All corrections to “Denied” encounter data, as reported on the Remittance Advice File, shall be
resubmitted as “full record” adjustments, according to the requirements listed in the Division’s
EMC Manual HIPAA Implementation and Companion Guides.

3.9.5 SUBCONTRACTS AND ENCOUNTER DATA REPORTING FUNCTION

A. Interfaces. All encounter data shall be submitted to the department directly by the contractor.
DMAHS shall not accept any encounter data submissions or correspondence directly from any
subcontractors, and DMAHS shall not forward any electronic media, reports or correspondence
directly to a subcontractor. The contractor shall be required to receive all electronic fields and
hardcopy material from the Department, or its appointed fiscal agent, and distribute them within
its organization or to its subcontractors appropriately.

B. Communication. The contractor and its subcontractors shall be represented at all DMAHS meetings
scheduled to discuss any issue related to the encounter function requirements.

3.9.6 FUTURE ELECTRONIC ENCOUNTER SUBMISSION REQUIREMENTS

At the present time, the Centers for Medicare and Medicaid Services (CMS) is pursuing a
standardization of all electronic health care information, including encounter data. The contractor
shall be responsible for completing and paying for any modifications required to submit encounter
data electronically, according to the same specifications and timeframes outlined by CMS for the
New Jersey MMIS.

 

 

Exhibit 10.6.9

with the contractor with respect to payment. Further, the contractor shall ensure that the cost to
the enrollee is no greater than it would be if the services were furnished within the network.

4.1.1.G.4 Protecting Managed Care Enrollees Against Liability for Payment.

As a general rule, if a participating or non-participating provider renders a covered service to a
managed are enrollee, the provider’s sole recourse for payment, other than collection of any
authorized cost-sharing and/or third party liability, is the contractor, not the enrollee. A
provider may not seek payment from, and may not institute or cause the initiation of collection
proceedings or litigation against, an enrollee, an enrollee’s family member, any legal
representative of the enrollee, or anyone else acting on the enrollee’s behalf unless subsections
(a) through and including (f) or subsection (g) below apply:

     (a) (1) The service is not a covered service; or (2) the service is determined to be medically
unnecessary before it is rendered; or (3) the provider does not participate in the program
either generally or for that service.

     (b) The enrollee is informed in writing before the service is rendered that one or more of the
conditions listed in subsection (a) above exist, and voluntarily agrees in writing before the
service is rendered to pay for all or part of the provider’s charges; and

     (c) The service is not an emergency or related service covered by the provisions of 42 USC
1396u-2(bb)(2)(A)(ii), 42 CFR 438.114 and/or NJAC 10:74-9.1; and

     (d) The service is not a trauma service covered by the provisions of the NJAC
8:38-6.3(a)3.i; and

     (e) The protections afforded to enrollees under 42 USC 1396u-2(b)(6), 42 CFR438.106, NJAC
8:38-9.1(d)9, and/or NJAC 8:38-15.2(b)7.ii do not apply; and

     (f) The provider has received no program payments from either DMAHS or the contractor for the
service; or

(g) the enrollee has been paid for the service by a health insurance company or other third party
(as defined in NJSA 30:4D-3.m), and the enrollee has failed or refused to remit to the provider
that portion of the third party’s payment to which the provider is entitled by law.

H. The contractor shall have policies and procedures on the use of enrollee self-referred services.

I. The contractor shall have policies and procedures on how it will provide for genetic testing and
counseling.

 

 

Exhibit 10.6.9

11. Audiology

12. Inpatient Rehabilitation services

13. Podiatrist Services

14. Chiropractor Services

15. Optometrist Services

16. Optical Appliances

17. Hearing Aid Services

4.1.2.A..18 Home Health Agency Services — Not a contractor-covered benefit for the ABD population.
All other services provided to any enrollee in the home, including but not limited to pharmacy (not
applicable to the ABD population) and DME services, are the contractor’s fiscal and medical
management responsibility.

	 	19.	 	Hospice Services — are covered in the community as well as in institutional settings.
Room and board services are included only when services are delivered in an institutional
(non-private residential) setting.
	 
	 	20.	 	Durable Medical Equipment (DME)/Assistive Technology Devices in accordance with
existing Medicaid regulations.
	 
	 	21.	 	Medical Supplies
	 
	 	22.	 	Prosthetics and Orthotics including certified shoe provider
	 
	 	23.	 	Dental Services
	 
	 	24.	 	Organ Transplants — includes donor and recipient costs. Exception: the contractor will
not be responsible for transplant-related donor and recipient inpatient hospital costs for
an individual placed on a transplant list while in the Medicaid FFS program prior to
initial enrollment into the contractor’s plan.

 

 

Exhibit 10.6.9

	 	25.	 	Transportation Services for any contractor-covered service or non-contractor covered
service including ambulance, mobile intensive care units (MICUs) and invalid coach
(including lift equipped vehicles)
	 
	 	26.	 	Post-acute Care

 

 

Exhibit 10.6.9

4.2.1.K.3. Late notification of Emergent Inpatient Hospital Admissions. If the contractor
receives late notification from participating hospitals of emergent hospital admissions because
of the participating hospital’s inability to identify the patient’s HMO due to extenuating
circumstances, the contractor may require proof from the participating hospital that it could
not identify the patient through eligibility verification or because of the medical condition or
the patient. The following procedure shall be followed:

     a. If the contractor receives notification of an emergent inpatient hospital admission from
its participating hospital later than one business day, but no later than seven (7) business
days following the emergent inpatient admission at the participating hospital due to the
hospital’s inability to identify the patient as the contractor’s member, the contractor shall
review the hospital stay for medical necessity for each inpatient day. The review will utilize
the usual and customary concurrent review process agreed to by both parties. The contractor
shall complete its medical necessity review within seven (7) business days of receiving all of
the requested information from the participating hospital.

     b. Participating hospitals shall notify the contractor within one (1) business day once
they have identified the patient’s HMO.

     c. If the contractor receives the notification from the participating hospital later than
seven (7 business days following an emergent inpatient admission at the participating hospital
due to the hospital’s inability to identify the patient as the contractor’s member, the
contractor shall review the case for medical necessity for each inpatient day. With these
cases, the contractor may reserve the right to conduct a more extensive review than the usual
and customary concurrent review process. The contractor shall also complete its review within
seven (7) business days of receiving all of the requested information from the participating
hospital.

     d. If the contractor determines that a participating hospital routinely notifies the
contractor of a member admission beyond one business day, the contractor will work with the
participating hospital to resolve the issues and re-educate the staff of the notice of the
admission requirements and member eligibility verification procedures.

L. The contractor shall establish and maintain policies and procedures for emergency dental
services for all enrollees.

     1. Within the contractor’s Enrollment/Service Area, the contractor will ensure that:

 

 

Exhibit 10.6.9

2. NJ FamilyCare Plans B and C. For children eligible solely through NJ FamilyCare Plans B and C,
coverage includes all preventative screening and diagnostic services, medical examinations,
immunizations, dental, vision, lead screening and hearing services. Includes only those treatment
services identified through the examination that are included under the contractor’s benefit
package or specified services through the FFS program. Other services identified through an EPSDT
examination that are not included in the New Jersey Care 2000+ covered benefits package are not
covered.

	 	3.	 	Enrollee Notification. The contractor shall provide written notification to its
enrollees under twenty-one (21) years of age when appropriate periodic assessments or
needed services are due and must coordinate appointments for care.
	 
	 	4.	 	Missed Appointments. The contractor shall implement policies and procedures and
shall monitor its providers to provide follow up on missed appointments and referrals
from problems identified through the EPSDT exams. Reasonable outreach shall be
documented and must consist of: mailers, certified mail as necessary; use of MEDM
system provided by the State; and contact with the Medical Assistance Customer Center
(MACC), DDD, or DYFS regional offices in the case of DYFS enrollees to confirm
addresses and/or to request assistance in locating an enrollee.
	 
	 	5.	 	PCP Notification. The contractor shall provide each PCP, on a calendar quarter
basis, as list of the PCP’s enrollees who have not had an encounter during the past
year and/or who have not complied with the EPSDT periodicity and immunization schedules
for children. Primary care sites/PCPs and/or the contractor shall be required to
contact these enrollees to arrange an appointment. Documentation of the outreach
efforts and responses is required.

4.2.6.A.6. Reporting Standards. The contractor shall submit quarterly reports, hard copy
and on diskette, of the EPSDT services. See Section A.7.16 of
the Appendices (Table 14).

B. Section 1905(r) of the Social Security Act (42 USC § 1396(d) and federal regulation 42
C.F.R. § 441.50 et. Seq. requires EPSDT services to include:

1. EPSDT Services which include:

     a. A comprehensive health and developmental history including assessments of both
physical and mental health development and the provision of all diagnostic and treatment

 

 

Exhibit 10.6.9

services that are medically necessary to correct or ameliorate a physical or mental
condition identified during a screening visit. The contractor shall have procedures in place
for referral to the State or its agent for non-covered mental health/substance abuse
services.

b. A comprehensive unclothed physical examination including:

	 	•	 	Vision and hearing screening;
	 
	 	•	 	Dental inspection; and
	 
	 	•	 	Nutritional assessment

4.2.6.B.1.c. Appropriate immunizations according to age, health history and the schedule
established by the Advisory Committee on Immunization Practices (ACIP) for pediatric
vaccines (See Section B.4.3 of the Appendices). Contractor and its providers must
adjust for periodic changes in recommended types and schedule of vaccines. Immunizations
must be reviewed at each screening examination as well as during acute care visits and
necessary immunizations must be administered when not contraindicated. Deferral of
administration of a vaccine for any reason must be documented.

d. Appropriate laboratory tests: A recommended sequence of screening laboratory
examinations must be provided by the contractor. The following list of screening tests
is not all inclusive:

	 	•	 	Hemoglobin/hematocrit/EP
	 
	 	•	 	Urinalysis
	 
	 	•	 	Tuberculin test — intradermal, administered annually and when medically indicated
	 
	 	•	 	Lead screening using blood lead level determinations must be
done for every Medicaid-eligible and NJ FamilyCare child:

	 	o	 	between nine (9) months and eighteen (18)
months, preferably at twelve (12) months of age
	 
	 	o	 	at 18-26 months, preferably at twenty-four (24)
months of age
	 
	 	o	 	test any child between twenty-seven (27) to
seventy-two (72) months of age not previously tested

 

 

Exhibit 10.6.9

	 	•	 	Additional laboratory tests may be appropriate and medically; indicated
(e.g., for ova an parasites) and shall be obtained as necessary.

e. Health education/anticipatory guidance.

f. Referral for further diagnosis and treatment or follow-up of all abnormalities which are
treatable/correctable or require maintenance therapy uncovered or suspected (referral may be to

 

 

Exhibit 10.6.9

ii. The contractor shall implement plans for corrective action with those identified PCPs that
describe interventions to be taken to identify and correct deficiencies and impediments to the
screening and how the effectiveness of its interventions will be measured.

e. On a quarterly basis, the contractor shall submit to DMAHS a report of all lead-burdened
children who are receiving treatment and case management services.

4.2.6.B.7.f. Lead Case Management Program. The contractor shall establish a Lead Case Management
Program (LCMP) and have written policies and procedures for the enrollment of children with blood
lead levels 310 μg/dl and other contractor enrollees who are members of the same household and who
are between six months and six years of age, into the contractor’s LCMP.

i. Lead Case Management shall consist of, at a minimum:

1) Follow-up of a child in need of lead screening, or who has been identified with an elevated
blood lead level 310 μg/dl. At minimum follow-up shall include:

     A) For a child with an elevated blood lead level 310 μg/dl, the Plan’s LCM shall ascertain if
the blood lead level has been confirmed by a venous blood determination. In the absence of
confirmatory test results, the LCM will arrange for a test.

     B) For a child with a confirmed blood (venous) lead level of 310 μg/dl, the contractor’s LCM
shall notify and provide to the local health department the child’s name, primary health provider’s
name, the confirmed blood lead level, and any other pertinent information.

2) Education of the family about all aspects of lead hazard and toxicity. Materials shall explain
the sources of lead exposure, the consequences of elevated blood levels, preventative measures,
including housekeeping hygiene, and appropriate nutrition. The reasons why it is necessary to
follow a prescribed medical regimen shall also be explained.

3) Communication among all interested parties.

4) Development of a written case management plan with the PCP and the child’s family and other
interested parties. The case management plan shall be reviewed and updated on an ongoing basis.

 

 

Exhibit 10.6.9

5) Coordination of the various aspects of the affected child’s care, e.g., WIC, support groups, and
community resources, and

6) Aggressively pursuing non-compliance with follow-up tests and appointments, and document these
activities in the LCMP.

4.2.6.B.7.f.ii. Active case management may be discontinued if one of the following criteria has
been met:

1) The child has one confirmed blood lead level <10 μg/dl drawn and all other children under the
age of six years living in the household who are also contractor enrollees and who have been tested
and their blood levels are <10 μg/dl, and the sources of lead have been identified and reduced,
or

2) The family has been permanently relocated to a lead-safe house, or

3) The parent/guardian has given a written refusal of service, or

4) The LCM is unable to locate the child after a minimum of three documented attempts, using the
assistance of County Board of Social Services, and the LHD. The child’s PCP will be notified in
writing.

4.2.7 IMMUNIZATIONS

A. General. The contractor shall ensure that its providers furnish immunizations to its enrollees
in accordance with the most current recommendations for vaccines and periodicity schedule of the
Advisory Committee on Immunization Practices (ACIP) and any subsequent revision to the schedule as
formally recommended by the ACIP, whether or not included as a contract amendment. To the extent
possible, the State will provide copies of updated schedules and vaccine recommendations.

 

 

Exhibit 10.6.9

Need for an examination based on a Head Start referral if the enrollee has had an age-appropriate
EPSDT examination (for infants) or an EPSDT examination (for children two (2) to five (5) years
old) within six (6) months of the referral date.

9. Policies and Procedures for Head Start’s role in prevention activities or programs developed by
the contractor.

B. The contractor shall evaluate referred Head Start patients to determine the need for
treatment/therapies for problems identified by staff of those programs. The contractor/PCP shall be
responsible for providing treatment and follow-up information for medically necessary care.

C. The contractor shall review referrals and provide appointments in accordance with Article 5.12.
Denials of service requests or reduction in level of service only after an evaluation is completed,
shall be in writing, following the requirements in Article 4.6.4.

SCHOOL-BASED YOUTH PROGRAMS

A. The contractor shall demonstrate to DMAHS that is has established a working linkage with
school-based youth services programs (SBYSP) that meet credentialing and scope of service
requirements for services offered by these programs which are covered MCE services. (See section
B.4.6 of the Appendixees fro a list of SBYSPs).

1. SBYSP service provision must meet MCE contract requirements, e.g., twenty-four (24)-hour
coverage.

2. SBYSP employees must meet credentialing requirements.

B. Such working linkages shall include, at minimum, and exchange of information on the following:

1. Policies and procedures for referrals for routine, urgent and emergent care, and standing
referrals.

2. Policies and procedures for scheduling appointments for routine and urgent care.

3. Policies and procedures for the exchange of information of SBYSP participants who are contractor
enrollees.

 

 

Exhibit 10.6.9

4. Policies and procedures for follow-up and assuring the provision of health care services.

5. Policies and procedures for appealing denials of service and/or reductions in the level of
service.

 

 

Exhibit 10.6.9

3. Care management systems to ensure all required services, as identified through a Complex Needs
Assessment, are furnished on a timely basis, and that communication occurs between participating
and nonparticipating providers (to the extent the latter are used). Articles 4.5.4 and 4.6.5
contain additional information on care managements.

4. Policies and procedures to allow for the continuation of existing relationships with
non-participating providers, when appropriate providers are not available within network or it is
otherwise considered by the contractor to be in the best medical interest of the enrollee with
special needs. Articles 4.5.2D and 4.8.7G contain more specific standards for use of
non-participating providers.

5. Methods to assure that access to all contractor-covered services, including transportation, is
available for enrollees with special needs whose disabilities substantially impede activities of
daily living. The contractor shall reasonably accommodate enrollees with disabilities and shall
ensure that physical and communication barriers do not prohibit enrollees with disabilities from
obtaining services from the contractor.

6. Services for enrollees with special needs must be provided in a manner responsive to the nature
of a person’s disability/specific health care need and include adequate time for the provision of
the service.

4.5.2.B. The contractor shall ensure that any new enrollee identified (either by the information on
the Medical Information form Plan Selection Form at the time of enrollment or by contractor
providers after enrollment) as having complex/chronic conditions receives immediate transition
planning. The planning shall be completed within a timeframe appropriate to the enrollee’s
condition, but in no case later than ten (10) business days from the effective date of enrollment
when the Medical Information form Plan Selection Form has an indication of special health care
needs or within thirty (30) days after special conditions are identified by a provider. This
transition planning shall not constitute the IHCP described in Sections 4.5.4 and 4.6.5. Transition
planning
shall provide for a brief, interim plan to ensure uninterrupted services until a more detailed plan
of care is developed. The transition planning process includes, but is not limited to:

1. Review of existing care plans.

 

 

Exhibit 10.6.9

2. Preparation of a transition plan that ensures continuous care during the transfer into the
contractor’s network.

3. If durable medical equipment has been ordered prior to enrollment but not received by the time
of enrollment, the contractor must coordinate and follow-through to ensure that the enrollee
receives necessary equipment.

C. Outreach and Enrollment Staff. The contractor shall have outreach and enrollment staff who are
trained to work with enrollees with special needs, are

 

 

Exhibit 10.6.9

4.5.4.B. Complex Needs Assessment. For enrollees with special needs, the contractor shall perform a
Complex Needs Assessment no later than forty-five (45) days (or earlier, if urgent) from initial
enrollment if special needs are indicated on the Medical Information form Plan Selection Form or
from the point of identification of special needs. See 4.6.5 for a description of the CNA.
Additional time will be permitted if the contractor demonstrates a good faith level of effort in
developing the CNA, and the contractor has in place a continuum of care while assessment is being
completed.

C. Experience and Caseload. Care managers for enrollees who require a higher level of care
management will have the same role and responsibilities as the care manager for the lower intensity
care management and additionally will address the complex intensive needs of the enrollee
identified as being at “high risk” of adverse medical outcomes absent active intervention by the
contractor. For example, a visually-impaired, insulin-dependent diabetic who requires frequent
glucose monitoring, nutritional guidance, vision checks, and assistance in coordination with visits
with multiple providers, therapeutic regimen, etc. The contractor shall provide intensive acute
care services to treat individual with multiple complex conditions. The number of medical and
social services required by an enrollee in this level of care management will generally be greater,
thus the number of linkages to be created, maintained, and monitored, including the promotion of
communication among providers and the consumer and of continuity of care, will be greater. The
contractor shall provide these enrollees greater assistance with scheduling appointments/visits.
The intensity and frequency of interaction with the enrollee and other members of the treatment
team will also be greater. The care manager shall contact the enrollee bi-weekly or as needed.

1. At a minimum, the care manager for this level of care management shall include, but is not
limited to, individual who hold current RN licenses with at least three (3) years experience
serving enrollees with special needs or a graduate degree in social work with at least two (2)
years experience serving enrollees with special needs.

2. The contractor shall ensure that the care manager’s caseload is adjusted, as needed, to
accommodate the work and level of effort needed to meet the needs of the entire case mix of
assigned enrollees including those determined to be high risk:

3. The contractor should include care managers with experience working with pediatric as well as
adult enrollees with special needs.

 

 

Exhibit 10.6.9

D. IHCPs. The contractor through its care manager shall ensure that an Individual Health care Plan
(IHCP) is developed and implemented as soon as possible, according to the circumstances of the
enrollee. The contractor shall ensure the full participation and consent of the enrollee or, where
applicable, authorized person and participation of the enrollee’s PCP, consultation with any
specialists.

 

 

Exhibit 10.6.9

j. The review and approval of studies and responses to DMAHS concerning QM matters.

3. Enrollee Rights and Responsibilities. Shall include the right to the Medicaid Fair Hearing
Process for Medicaid enrollees.

4. Medical Record standards shall address both Medical and Dental records. Records shall also
contain notation of any cultural/linguistic needs of the enrollee.

5. Provider Credentialing. Before any provider may become part of the contractor’s network, that
provider shall be credentialed by the contractor. The contractor must comply with N.J.A.C. 8:38C-1
et seq. and Standard IX of NJ modified QARI/QISMC (Section B.4.14 of the Appendices). Additionally,
the contractor’s credentialing procedures shall include verification that providers and
subcontractors have not been suspended, debarred, disqualified, terminated or otherwise excluded
from Medicaid, Medicare, or any other federal or state health care program. The contractor shall
obtain federal and State lists of suspended/debarred providers from the appropriate agencies.

6. Institutional and Agency Provider Credentialing. The contractor shall have written policies and
procedures for the initial quality assessment of institutional and agency providers with which it
intends to contract. At a minimum, such procedures shall include confirmation that a provider has
been reviewed and approved by a recognized accrediting body and is in good standing with State and
federal regulatory bodies. If a provider has not been approved by a recognized accrediting body,
the contractor shall develop and implement standards of participation. For home health agency and
hospice agency providers, the contractor shall verify that the providers are licensed and meet
Medicare certification participation requirements.

7. Delegation/subcontracting of QAPI activities shall not relieve the contractor of its obligation
to perform all QAPI functions. The contractor shall submit a written request and a plan for active
oversight of the QAPI activities to DMAHS for review and approval prior to
subcontracting/delegating any QAPI responsibilities.

4.6.1.C.8. Dental Service Coordinator. The contractor shall have on staff a Dental Service
Coordinator who shall be responsible for:

 

 

Exhibit 10.6.9

a. Coordinating of all dental activities of the contractor;

b. Monitoring activities to review the performance of dental providers in their provision of health
care to enrollees.

c. Responses to DMAHS concerning dental related QM matters; and

d. If the contractor contracts with a dental subcontractor, the contractor’s Dental Services
Coordinator shall monitor vendor performance; provide direction to the dental subcontractor; ensure
that decisions are made in a clinically appropriate and timely manner; and address dental issues at
the contractor level.

4.6.2 QAPI ACTIVITIES

The contractor shall carry out the activities described in its QAPI. The contractor shall develop
and submit to DMAHS annually an annual work plan of expected accomplishments which includes a
schedule of clinical standards to be developed, medical care evaluations to be completed, and other
key quality assurance activities to be completed. The contractor shall also prepare and submit to
DMAHS an annual report on quality assurance activities which demonstrate the contractor’s
accomplishments, compliance and/or deficiencies in meeting its previous year’s work plan and should
include studies undertaken, subsequent actions, and aggregate data on utilization and clinical
quality of medical care rendered.

The contractor’s quality assurance activities shall include, at a minimum:

A. Guidelines. The contractor shall develop guidelines that meet the requirements of 42 CFR 438 for
the management of selected diagnoses and basic health maintenance, and shall distribute all
standards, protocols, and guidelines to all providers and upon request to enrollees.

B. Treatment Protocols. The contractor may use treatment protocols, however, such protocols shall
allow for adjustments based on the enrollee’s medical condition and contributing family and social
factors.

C. Monitoring. The contractor shall have procedures for monitoring the quality and adequacy of
medical care including: 1) assessing use of the distributed guidelines and 2) assessing possible
under-treatment/under-utilization of services.

D. Focused Evaluations. The contractor shall have procedures for focused medical care evaluations
to be employed when indicators suggest that quality may need to be studied. The contractor shall
also have procedures for conducting problem-oriented clinical studies of individual care.

 

 

Exhibit 10.6.9

E. Follow-up. The contractor shall have procedures for prompt follow-up of reported problems and
complaints involving quality care issues.

F. Reserved.

 

 

Exhibit 10.6.9

appropriate use of new medical technologies or new applications of established technologies
including medical procedures, drugs, devices, assistive technology devices, and DME.

N. Informed Consent. The contractor is required and shall require all participating providers to
comply with the informed consent forms and procedures for hysterectomy and sterilization as
specified in 42 C.F.R. Part 441, Sub-part B, and shall include the annual audit for such compliance
in its quality assurance reviews of participating providers. Copies of the forms are included in
Section B.4.15 of the Appendices.

O. Continuity of Care. The contractor’s Quality Management Plan shall include a continuity of care
system including a mechanism for tracking issues over time with an emphasis on improving health
outcomes, as well as preventive services and maintenance of function for enrollees with special
needs.

4.6.2.P. HEDIS. The contractor shall submit annually, on a date specified by the State, HEDIS 3.0
data or more updated version, aggregate population data as well as, if available, the contractor’s
commercial and Medicare enrollment HEDIS data for its aggregate, enrolled commercial and Medicare
population in the State or region (if these data are collected and reported to DHSS, a copy of the
report should be submitted also to DMAHS) the following clinical indicator measures:

	 	 	 
	HEDIS	 	Report Period
	Reporting Set Measures	 	by Contract Year
	 
	*Childhood Immunization Status

	 	Annually
	*Adolescent Immunization Status

	 	Annually
	*Well-Child visits in first 15 months of life

	 	Annually
	* Well-Child visits in the 3rd,
4th, 5th, and 6th
year of life

	 	annually
	Adolescent Well-Care Visits

	 	annually
	*Prenatal and Postpartum care

	 	annually
	Breast Cancer Screening

	 	annually
	Cervical Cancer Screening

	 	annually
	*Use of Appropriate Medication for People with Asthma

	 	annually
	Comprehensive Diabetes Care

	 	annually

 

 

Exhibit 10.6.9

Childhood & Adolescent Immunization *NOTE: HEDIS data for NJ FamilyCare enrollees up to the age of
19 years must be reported separately.

Q. Quality Improvement Projects (QIPs). The contractor shall participate in QIPs defined annually
by the State with input from the contractor. The State will, with input from the contractor and
possibly other MCEs define measurable improvement goals and QIP-specific measures which shall serve
as the focus for each QIP. The contractor shall be responsible for designing and implementing
strategies for achieving each QIP’s objectives. At the beginning of each contract year the
contractor shall present a plan for designing and implementing such strategies, which shall receive
approval from the State prior to implementation.

 

 

Exhibit 10.6.9

2. Clinical performance measures on outcomes of care;

3. Maintenance and preventive services;

4. Enrollee experience and perceptions of service delivery; and

5. Access.

For MH/SA services provided to enrollees who are clients of DDD the contractor shall report MH/SA
utilization data to its providers.

W. Member Satisfaction. The State will assess member satisfaction of contractor services by
conducting surveys employing the Consumer Assessments of Health Plans Study (CAHPS) survey, or
another survey instrument specified by the State. The survey shall be stratified to capture
statistically significant results for all categories of New Jersey Care 2000+ enrollees including
AFDC/TANF, DYFS, SSI and New Jersey Care Aged, Blind and Disabled, NJ FamilyCare, pregnant and
parenting women, and racial and linguistic minorities. Sample size, sample selection, and
implementation methodology shall be determined by the State, with contractor input, to assure
comparability of results across State contractors.

The contractor shall fully cooperate with the State and the independent survey administrator such
that final, analyzed survey results shall be available from the survey administrator to the State,
in a format approved by the State, by a date specified by the State of each contract year. Within
sixty (60) days of receipt of the final analyzed survey results sent to the contractor, it shall
identify leading sources of enrollee dissatisfaction, specify additional measurement or
intervention efforts developed to address enrollee dissatisfaction, and a timeline, subject to
State approval, indicating when such activities will be completed. A status report on the
additional measurement or intervention efforts shall be submitted to the State by a date specified
by DMAHS. The contractor shall respond to and submit a corrective action to address and correct
problems and deficiencies found through the survey.

If the contractor conducts a member satisfaction survey of its own, it shall send to DMAHS the
results of the survey.

4.6.2.X. Enrollee Outreach and Education Assessment. The State will conduct a needs assessment to
determine the areas of service provision that require additional enrollee outreach and education.
The assessment will evaluate member understanding of the managed care system, ability to access

 

 

Exhibit 10.6.9

appropriate and needed services, effectiveness of enrollee communication methods, and areas of
difficulty for enrollees. The assessment will comprise various informal enrollee surveys conducted
by the State throughout the year. The surveys may be conducted in person, by telephone, mail or
other means, and will ascertain information on areas that require additional enrollee outreach and
education by the State and/or the contractor. The contractor shall cooperate with the State in
identifying target groups to survey, topics and materials to survey, and opportunities for revised
and/or additional enrollee outreach and education activities as a result of the surveys.

The State shall not divulge the names or other identifying information of those surveyed to the
contractor or any other party except in the case where an enrollee gives permission to the State to
be contacted for assistance with a stated question or problem. The State will annually summarize
and provide to the contractor, its findings and recommendations for future enrollee outreach and
education activities.

X. Focus Groups. The State will annually conduct four focus groups with enrolled populations
identified by the State and communicated in writing to the contractor. Objectives for the focus
groups will be collaboratively developed by the State and the contractor. For the first contract
year, two focus groups each will be conducted with enrollees who have communication affecting
disorders and with enrollees who are elderly.

Focus groups results will be reported by the State. The contractor shall identify opportunities for
improvement identified through the focus groups, specify additional measurement or intervention
efforts developed to address the opportunities for improvement, and a timeline, subject to State
approval., indicating when such activities will be completed. A status report on the additional
measurement or intervention efforts shall be submitted annually to the State by a date specified by
DMAHS.

Y. ERO. Other “areas of concern” shall be monitored through the external review process. The
External Review Organization (ERO) shall, in its monitoring activities, validate the contractor’s
protocols, sampling, and review methodologies.

Z. Community /Health Education Advisory Committee. The contractor shall establish and maintain a
community advisory committee, consisting of persons being served by the contractor, including

 

 

Exhibit 10.6.9

enrollees or authorized persons, individual and providers with knowledge of and experience with
serving elderly people or people with disabilities; and representatives from community agencies
that do not provide contractor-covered services but are important to the health and well-being of
members. The committee shall meet at least quarterly and its input and recommendations shall be
employed to inform and direct contractor quality management activities and policy and operations
changes. The DMAHS shall conduct on-site review of the membership of this committee, as well as the
committee’s activities throughout the year.

AA. Provider Advisory Committee. The contractor shall establish and maintain a provider advisory
committee, consisting of providers contracting with the contractor to serve enrollees. At least two
providers on the committee shall maintain practices that predominantly serve Medicaid beneficiaries
and other indigent populations. In addition to at least one other practicing provider on the
committee who has experience and expertise in serving enrollees with special needs. The committee
shall meet at least quarterly and its input and recommendations shall be employed to inform and
direct contractor quality management activities and policy and operations changes. The DMAHS shall
conduct on-site review of the membership of this committee, as well as the committee’s activities
throughout the year.

4.6.2.AA.1. The contractor shall have a Dental Affairs Advisory subcommittee to give participating
dental providers the opportunity to provide input to the HMO in improving dental screening
performance rates and quality of care.

4.6.3 REFERRAL SYSTEMS

A. The contractor shall have a system whereby enrollees needing specialty medical and dental care
will be referred timely and appropriately. The system shall address authorization for specific
services with specific limits or authorization of treatment and management of a case when medically
indicated (e.g., treatment of a terminally ill cancer patient requiring significant specialist
care). The contractor shall maintain and submit a flow chart accurately describing the contractor’s
referral system, including the title of the person(s) responsible for approving referrals. The
following items shall be contained within the referral system:

1. Procedures for recording and tracking each authorized referral.

2. Documentation and assurance of completion of referrals.

 

 

Exhibit 10.6.9

3. Policies and procedures for identifying and rescheduling broken referral appointments with the
providers and/or contractor as appropriate (e.g., EPSDT services).

4. Policies and procedures for accepting, resolving, and responding to verbal and written enrollee
requests for referrals made to the PCP and/or contractor as appropriate. Such requests shall be
logged and documented. Requests that cannot be decided upon immediately shall be responded to in
writing no later than five (5) business days from the date of receipt of the request (with a call
made to the enrollee on final disposition) and postmarked the next day.

5. Policies and procedure for proper notification of the enrollee and where applicable, authorized
person, the enrollee’s provider, and the enrollee’s care manager, including notice of right to
appeal and/or right to request a second opinion when services are denied.

6. A referral form which can be given to the enrollee or, where applicable, an authorized person to
take a specialist.

7. Referral form mailed, faxed, or sent by electronic means directly to the referral provider.

 

 

Exhibit 10.6.9

d. The action taken or intended to be taken by the contractor on the request for prior
authorization and the reason for such action including clinical rationale and the underlying
contractual basis or Medicaid authority;

e. The name and address of the contractor;

f. Notice of internal (contractor) appeal rights and instructions on how to initiate such appeal;

g. Notice of the availability, upon request, of the clinical review criteria relied upon to make
the determination;

h. the notice to the enrollee shall inform the enrollee that he or she may file an appeal
concerning the contractor’s action using the contractor’s appeal procedure prior to or concurrent
with the initiation of the State hearing process.

i. The contractor shall notify enrollees, and/or authorized persons within the time frames set
forth in this contract and in 42 CFR 438.404(c);

j. The enrollee’s right to have benefits continue (see Article 4.6.4C) pending resolution of the
appeal and how to request that benefits be continued.

9. In no instance shall the contractor apply prior authorization requirements and utilization
controls that effectively withhold or limit medically necessary services, or establish prior
authorization requirements and utilization controls that would result in a reduced scope of
benefits for any enrollee.

4.6.4C. Appeal Process of UM Determinations. The contractor shall have policies and procedures for
the appeal of utilization management determinations and similar determinations. In the case of an
enrollee who was receiving a covered service (from the contractor, another contractor, or the
Medicaid Fee-for-Service program) prior to the determination, the contractor shall continue to
provide the same level of service while the determination is in appeal. However, the contractor may
require the enrollee to receive the service from within the contractor’s provider network, if
equivalent care can be provided within network.

1. The contractor shall provide that an enrollee, and any provider acting on behalf of the enrollee
with the enrollee’s consent (enrollee’s consent shall not be require in the case of a deceased
patient, or when an enrollee has relocated and cannot be found), may appeal any UM decision
resulting in a denial, termination, or other limitation in the coverage of and access to health
care services in accordance with this contract and as defined in C.2.

 

 

Exhibit 10.6.9

4.6.4.G.6. Continuation of benefits. The MCO shall continue the enrollee’s benefits if —

a. the enrollee or the provider files the appeal timely;

b. the appeal involves the termination suspension, or reduction of a previously authorized course
of treatment;

c. The services were ordered by an authorized provider (i.e. a network provider); and

d. the original period covered by the original authorization has not expired, unless inadequate
notice was given to allow an enrollee a timely appeal.

7. Duration of continued or reinstated benefits. The contractor shall continue the enrollee’s
benefits while an appeal is pending. The benefits must be continued until one of the following
occurs:

a. the enrollee withdraws the appeal,

b. Ten days pass after the contractor mails the notice, providing the resolution of the appeal
against the enrollee, unless the enrollee, within the 10-day timeframe has requested a State fair
hearing with continuation of benefits until a State fair hearing decision is reached.

c. A State fair hearing Office issues a hearing decision adverse to the enrollee.

d. The time period or service limits of a previously authorized service has been met.

8. Effectuation of reversed appeal resolutions.

a. Services not furnished while the appeal is pending. If the contractor or the State fair hearing
officer reverses a decision to deny, limit or delay services that were not furnished while the
appeal was pending, the contractor must authorize or provide the disputed services promptly, and as
expeditiously as the enrollee’s health condition requires.

b. Services furnished while the appeal is pending. If the contractor or the State fair hearing
officer reverses a decision to deny authorization of services, and the enrollee received the
disputed services while the appeal was pending, the contractor must pay for those services, in
accordance with this contract.

9. Expedited Resolution of Appeals. The contractor shall establish and maintain an expedited review
process for appeals when the contractor determines (for a request from the enrollee) or the
provider indicates (in making the request on the enrollee’s behalf or supporting the enrollee’s
request) that taking the time for a standard resolution could seriously jeopardize the enrollee’s
life or health or

 

 

Exhibit 10.6.9

ability to attain, maintain or regain maximum function.

 

 

Exhibit 10.6.9

C. The contractor hereby agrees to medical audits in accordance with the protocols for care
specified in this contract, in accordance with medical community standards for care, and of the
quality of car provided all enrollees, as may be required by appropriate regulatory agencies.

D. The contractor shall cooperate with DMAHS in carrying out the provisions of applicable statutes,
regulations, and guidelines affecting the administration of this contract.

E. The contractor shall distribute to all subcontractors providing services to enrollees,
informational materials approved by DMAHS that outlines the nature, scope, and requirements of this
contract.

F. The contractor, with the prior written approval of DMAHS, shall print and distribute reporting
forms and instructions, as necessary whenever such forms are required by this contract.

G. The contractor shall make available to DMAHS copies of all standards, protocols, manuals and
other documents used to arrive at decisions on the provision of care to its DMAHS enrollees.

H. The contractor shall use appropriate clinicians to evaluate the clinical data, and must use
multi-disciplinary teams to analyze and address systems issues.

I. contractor shall develop an incentive system for providers to assure submission of encounter
data. At a minimum, the system shall include:

     1. Mandatory provider profiling that includes complete and timely submissions of encounter
data. Contractor shall set specific requirements for profile elements based on data from encounter
submissions.

     2. Contractor shall set up data submission requirements based on encounter data elements for
which compliance performance will be both rewarded and/or sanctioned.

J. The contractor shall include in its quality management system reviews/audits which focus on the
special dental needs of enrollees with developmental disabilities. Using encounter data reflecting
the utilization of dental services and other data sources, the contractor shall measure clinical
outcomes, have these outcomes evaluated by clinical experts; identify quality management tools to
be applied; and recommend changes in clinical practices intended to improve the quality of dental
care to enrollees with developmental disabilities.

4.7.1.K. The contractor shall produce reports of all PCPs in its network (regardless of panel
size), who are treating children under 21 years old, that provide information to the PCPs of
underutilization or no utilization of their enrollee panel members as compared to EPSDT utilization
requirements.

 

 

Exhibit 10.6.9

4.7.2 EVALUATION AND REPORTING — CONTRACTOR RESPONSIBILITIES

A. The contractor shall collect data and report tot eh State its findings on the following:

1. Encounter Data: the contractor shall prepare and submit encounter data to DMAHS in accordance
with Article 3.9.Instructions and formats for this report are specified in Section B.3.3 of the
Appendices of this contract.

2. Grievance Reports: the contractor shall provide to DMAHS quarterly reports of all grievances in
accordance with Articles 5.15 and the contractor’s approved grievance process included in this
contract. See Section A.7.5 of the Appendices (Table 3).

3. Appointment Availability Studies: The contractor shall conduct a review of appointment
availability and submit a report to DMAHS annually. The report must list the average time that
enrollees wait for appointments to be scheduled in each of the following categories: baseline
physical, routine, specialty, and urgent care appointments. DMAHS must approve the methodology for
this review in advance in writing. The contractor shall assess the impact of appointment waiting
times on the health status of enrollees with special needs.

4. Twenty-four (24) Hour Access Report: the contractor shall submit to DMAHS an annual report
describing its twenty-four (24) hour access procedures for enrollees. The report must include the
names and addresses of any answering services that the contractor uses to provide twenty-four (24)
hour access.

5. The contractor shall submit to DMAHS, on a quarterly basis, the number of early discharges that
pertain to hospital stays for newborns and mothers.

6. The contractor shall monitor, evaluate and submit an annual report to DMAHS on the incidence of
HIV/AIDS patients, the impact of the contractor’s program to promote HIV prevention (Article
4.5.7), counseling, treatment and quality of life outcomes, mortality rates.

7. Additional Reports: The contractor shall prepare and submit such other reports as DMAHS may
request. Unless otherwise required by law or regulation, DMAHS shall determine the timeframe for
submission based on the nature of the report and give the contractor the opportunity to discuss and
comment on the proposed requirements before the contractor is required to submit such additional
reports.

 

 

Exhibit 10.6.9

understanding that the contractor may permit a more liberal, direct specialty access (See section
4.5.2) to a specific specialist for the explicit purpose of meeting those specific specialty
service needs. The PCP shall in this case retain all responsibility for provision of primary care
services and for overall coordination of care, including specialty care.

5. If the enrollees’ existing PCP is a participating provider in the contractor’s network, and if
the enrollee wishes to retain the PCP, contractor shall ensure that the PCP is assigned, even if
the PCP’s panel is otherwise closed at the time of the enrollee’s enrollment.

C. In addition to offering, at a minimum, a choice of two or more primary care physicians, the
contractor shall also offer an enrollee, or where applicable, and authorized person the option of
choosing a certified nurse midwife, certified nurse practitioner or clinical nurse specialist whose
services must be provided within the scope of his/her license. The contractor shall submit to DMAHS
for review a detailed description of the CNP/CNS’s responsibilities and health care delivery system
within the contractor’s plan.

4.8.3 PROVIDER NETWORKFILE REQUIREMENTS

The contractor shall provide a certified [See appendix A.4.4 for form] provider network file
monthly, to be reported by hard copy and electronically in a format and software application system
determined by DMAHS that will include the names and addresses of every provider in the contractor’s
network. The file shall be submitted electronically by the close of business on the fourth Monday
of every month. This includes all contracted providers and required established relationships. It
excludes all non-participating providers. The format for computer diskette electronic submission is
found in Section A.4.1 of the Appendices.

A. The contractor shall provide the DMAHS a full network, monthly, on computer diskette
electronically in accordance with the specifications provided in Section A.4.1 of the Appendices.
The contractor shall phase-in use of HIPAA Taxonomy Specialty Codes with full implementation by
January 2007. The network file shall include an indicator for new additions and deletions and shall
include:

     1. Any and all changes in participating primary care providers, including, for example,
additions, deletions, or closed panels, must be reported monthly to DMAHS.

 

 

Exhibit 10.6.9

     2. Any and all changes in participating physician specialists, health care providers,
CNPs/CNSs, ancillary providers, and other subcontractors must be reported to DMAHS on a monthly
basis.

     3. The contractor shall not allow enrollment freezes for any provider unless the same
limitations apply to all non-Medicaid/NJ FamilyCare members as well, or contract capacity limits
have been reached.

 

 

Exhibit 10.6.9

B. DMAHS review of provider network deficiencies will be conducted on a quarterly basis or more
frequently as may be required.

C. The contractor shall provide the HBC with a full network on a monthly basis in accordance with
the specifications found in Section A.4.1 of the Appendices. The electronic files shall be sent to
DMAHS, and a hard copy to the DMAHS’ designee for distribution.

1. The contractor will receive an electronic “HMO Provider Network Response” file from the State in
response to the monthly provider network file submitted to the State by the contractor. The file
will contain the pre-existing Medicaid ID or the assigned pseudo-Medicaid ID for each network
provider. This response file will contain the same fields and records submitted to the State by the
contractor and the State will value the Medicaid or pseudo-Medicaid Provider ID field for each
record. The contractor shall use the Medicaid or pseudo-Medicaid Provider IDs as a secondary
identifier on all encounter data submitted to the State.

4.8.4 PROVIDER DIRECTORY REQUIREMENTS

The contractor shall prepare a provider director which shall be presented in the following manner.
Fifty (50) copies of the provider directory, and any updates, shall be provided to the HBC, and ten
(10) copies shall be provided to DMAHS at least every six months or within 30 days of an update.

A. Primary care providers who will serve enrollees listed by

	 	•	 	County, by city by specialty
	 
	 	•	 	Provider name and degree; specialty board eligibility/certification status; office
address(es) (actual street address); telephone number; fax number if available; office
hours at each location; indicate if a provider services enrollees with disabilities and how
to receive additional information such as type of disability; hospital affiliations,
transportation availability; special appointment instructions if any; languages spoken;
disability access; and any other pertinent information that would assist the enrollee in
choosing a PCP.

B. Contracted specialists and ancillary services providers who will service enrollees
Listed by county, by city, by physician specialty, by non-physician specialty, and by adult
specialist and by pediatric specialist for those specialties indicated in Section 4.8.8.C.

C. Subcontractors

 

 

Exhibit 10.6.9

Contracting, as a consultant, or on a referral basis. Payment mechanism and rates shall be
negotiated directly with the center.

C. The contractor shall include primary care providers experienced in caring for enrollees with
special needs (See A.4.1 provider network file).

4.8.7.D. The contractor shall include providers who have knowledge and experience in identifying
child abuse and neglect and should include Child Abuse Regional Diagnostic Centers (Section B.4.16
of the Appendix) or their equivalent through either direct contracting, as a consultant or on a
referral basis. A list of Child Abuse Regional Diagnostic Centers is in Section B.4.16 of the
Appendices.

E. The contractor shall have a procedure by which an enrollee who needs ongoing care from a
specialist may receive a standing referral to such specialist. If the contractor or the primary
care provider in consultation with the contractor’s medical director and specialist, if any,
determines that such a standing referral is appropriate, the organization shall make such a
referral to a specialist. The contractor shall not be required to permit an enrollee to elect to
have a non-participating specialist if a network provider of equivalent expertise is available.
Such referral shall be pursuant to a treatment plan approved by the contractor in consultation with
the primary care provider, the specialist, the care manager, and the enrollee, or , where
applicable, authorized person. Such treatment plan may limit the number of visits or the period
during which such visits are authorized and may require the specialist to provide the primary care
provider with regular updates on the specialty care provided, as well as all necessary medical
information.

F. The contractor shall have a procedure by which an enrollee as described in Articles 4.5.2.D may
receive a referral to a specialist or specialty care center with expertise in treating such
conditions in lieu of a traditional PCP.

G. If
the contractor determines that it does not have a health care provider with appropriate
training and experience in its panel or network to meet the particular health care needs of an
enrollee, the contractor shall make a referral to an appropriate out-of-network provider, pursuant
to a treatment plan approved by the contractor in consultation with the primary care provider, the
non- contractor participating provider and the enrollee or where applicable, authorized person, at
no additional cost

 

 

Exhibit 10.6.9

to the enrollee. The contractor shall provide for a review by a specialist of the same or similar
specialty as the type of physician or provider to whom a referral is required before the contractor
may deny a referral.

4.8.8 PROVIDER NETWORK REQUIREMENTS

Provider networks and all provider types within the network shall be reviewed on a county basis,
i.e., must be located within the county except where indicated, (See also Section 4.8.8M.). The
contractor shall monitor the capacity of each of its providers and decrease ratio limits as needed
to maintain appointment availability standards.

 

 

Exhibit 10.6.9

F. The contractor shall also establish relationships with physician specialist and subspecialists
[Non-Institutional file] through a contract, as a consultant, or on a referral basis for:

1. Dental Specialists — Required relationships for dental conditions that require specialists for

a. Prosthodontia

b. Endodontia

c. Periodontia

2. Pain Management

3. Medical Genetics

4. Developmental-Behavioral Pediatrics

G. Specialty Centers (Centers of excellence) shall be included in the network either through a
contract, as a consultant, or on a referral basis [Institutional File].

1. Providers and health care facilities for the care and treatment of HIV/AID (list of for
available centers, found in see section B.4.13 of the Appendices Appendix).

2. Special Child Health services Network Agencies for:

a. Pediatric Ambulatory Tertiary Centers

b. Regional Cleft Lip/Palate Centers

c. Pediatric HIV Treatment Centers

d. Comprehensive Regional Sickly Cell/Hemoglobinpathies Treatment Centers

e. PKU Treatment Centers

f. Other as designated from time to time by the Department of Health and Senior Services.

3. Other

a. Genetic Testing and Counseling Centers

b. Hemophilia Treatment Centers

H. Other Specialty Centers/Providers [Institutional File]

Contractor should establish relationships with the following providers/centers on a consultant or
referral basis.

1. Spinal bifida Centers/providers

2. Adult Scoliosis

 

 

Exhibit 10.6.9

3. Autism and Attention Deficits

4. Spinal Cord Injury

5. Lead Poisoning Treatment Centers

6. Child Abuse Regional Diagnostic Centers

 

 

Exhibit 10.6.9

family planning services outside the contractor’s provider network are
not covered services

N. A description of the process for referral to specialty and ancillary care providers and second
opinions;

O. An explanation of the reasons for which an enrollee may request a change of PCP, the process of
effectuating that change, and the circumstances under which such a request may be denied;

P. The reasons and process by which provider may request an enrollee to change to a different PCP.

Q. An explanation of an enrollee’s rights to disenroll or transfer at any time for cause; disenroll
or transfer in the first 90 days after the latter of the date the individual enrolled or the date
they receive notice of enrollment and at least every twelve (12) months thereafter without cause
and that the lock-in period does not apply to ABD, DDD or DYFS individuals;

R. Complaints and Grievances/Appeals

1. Procedures for resolving complaints, as approved by the DMAHS;

2. A description of the grievance/appeal procedures to be used to resolve disputes between a
contractor and an enrollee, including: the name, title, or department, address, and telephone
number of the person(s) responsible for assisting enrollees in grievance/appeal resolutions; the
time frames and circumstances for expedited and standard grievances; the right to appeal a
grievance determination and the procedures for filing such an appeal; the time frames and
circumstances for expedited and standard appeals; the right to designate a representative; a notice
that all disputes involving clinical decisions will be made by a qualified clinical personnel; and
that all notices of determination will include information about the basis of the decision and
further appeal rights, if any;

3. The contractor shall notify all enrollees in their primary language of their rights to file
grievances and appeal grievance decisions by the contractor;

5.8.2.S. An explanation that in addition to the HMO Appeal process, Medicaid/NY FamilyCare Plan A
enrollees, and Plans D and H enrollees with a program status code of 380, have the right to a
Medicaid Fair Hearing (which must be requested withink20 days of the date of the adverse action)
with DMAHS and the appeal process through the DHSS for Medicaid and NJ FamilyCare enrollees,
including instructions on the procedures involved in making such a request;

 

 

Exhibit 10.6.9

specialized medical care over a prolonged period of time may request a specialist or specialty care
center responsible for providing or coordinating the enrollee’s medical care and the procedure for
requesting and obtaining such a specialist or access to the center;

HH. A notice of all appropriate mailing addresses and telephone numbers to be utilized by enrollees
seeking information or authorization;

II. A notice of pharmacy Lock-In program and procedure:

JJ. An explanation of the time delay of thirty (30) to forty-five (45) days between the date of
initial application and the effective date of enrollment; however, during this interim period,
prospective Medicaid enrollees will continue to receive health care benefits under the regular
fee-for-service Medicaid program or the HMO with which the person is currently enrolled. Enrollment
is subject to verification of the applicant’s eligibility for the Medicaid program and New Jersey
Care 2000+ enrollment; and the time delay of thirty (30) to forty five (45 days between the date of
request for disenrollment and the effective date of disenrollment.

KK. An explanation of the appropriate uses of the Medicaid/NJ FamilyCare identification card and
the contractor identification card. ;

LL. A notification, whenever applicable, that some primary care physicians may employ other health
care practitioners, such as nurse practitioners or physician assistants, who may participate in the
patient’s care;

MM. The enrollee’s or, where applicable, an authorized person’s signed authorization on the
enrollment application allows release of medical records.

5.8.2.NN. Notification that the enrollees’ health status survey information on the Plan Selection
Form will be sent to the contractor by the enrollee Health Benefits Coordinator.

OO. A notice that enrollment and disenrollment is subject to verification and approval by DMAHS;

PP. An explanation of procedures to follow if enrollees receive bills from providers of services,
in or out of network;

 

 

Exhibit 10.6.9

QQ. An explanation of the enrollee’s financial responsibility for payment when services are
provided by a health care provider who is not part of the contractor’s organization or when a
procedure , treatment or service is not a covered health care benefit by the contractor and/or by
Medicaid;

 

 

Exhibit 10.6.9

Person of the enrollee’s disenrollment rights at least sixty (60) days prior to the end of his/her
twelve (12) — month enrollment period. The contractor shall notify the enrollee of the effective
disenrollment date.

D. Release of Medical Records. The contractor shall transfer or facilitate the transfer of the
medical record (or copies of the medical record) upon the enrollee’s or, where applicable, and
authorized person’s request, to either the enrollee, to the receiving provider, or, in the case of
a child eligible through the Division of Youth and Family Services, to a representative of the
Division of Youth and Famaly Services or to an adoptive parent receiving subsidy through DYFS, at
no charge, in a timely fashion, i.e., no later than ten days prior to the effective date of
transfer. The contractor shall release medical records of the enrollee, and/or facilitate the
release of medical records in the possession of participating providers as may be directed by DMAHS
authorized personnel and other appropriate agencies of the State of New Jersey, or the federal
government. Release of medical records shall be consistent with the provision of confidentiality as
expressed in Article 7.40 of this contract and the provisions of 42 C.F.R. 431.300. For individual
being served through the Division of Youth and Family Services, release of medical records must be
in accordance with the provisions under JNSA 9:6-8.10a and 9:6-8:40 and consistent with the need to
protect the individual’s confidentiality.

E. in the event the contract, or any portion thereof, is terminated, or expires, the contractor
shall assist DMAHS in the transition of enrollees to other contractors. Such assistance and
coordination shall include, but not belimited to, the forwarding of medical and other records and
the facilitation and scheduling of medically necessary appointments for care and services. The cost
of reproducing and forwarding medical charts and other materials shall be borne by the contractor.
Contractor shall be responsible for providing all reports set forth in this contract. The
contractor shall make provision for continuing all management and administrative services until the
transition of enrollees is completed and all other requirements of this contract are satisfied. The
contractor shall be responsible for the following:

1. Identification and transition of chronically ill, high risk and hospitalized enrollees, and
enrollees in their last four weeks of pregnancy.

2. Transfer of requested medical records.

 

 

Exhibit 10.6.9

5.10.2 DISENROLLMENT FROM THE CONTRACTOR’S PLAN AT THE ENROLLEE’S REQUEST

A. An individual enrolled in a contractor’s plan may be subject to the enrollment Lock-in period
provided for in this Article. The enrollment Lock-In provision does not apply to SSI and New Jersey
Care ABD individual, clients of DD or to individuals eligible to participate through the Division
of Youth and Family Services.

1. An Medicaid and NJ FamilyCare Plan A enrollees are subject to the enrollment Lock In period and
may initiate disenrollment or transfer for any reason during the first ninety days after the latter
of the date the individual is enrolled or the date they receive notice of enrollment with a new
contractor and at least every twelve (12) months thereafter without cause. NJ FamilyCare Plans B,
C, D, and H enrollees will be subject to a twelve (12) month Lock In period.

a. The period during which an individual has the right to disenroll from the contractor’s plan
without cause applies to an individual’s initial period of enrollment with the contractor. If that
individual chooses to re-enroll with the contractor, his/her initial date of enrollment with the
contractor will apply.

b. Upon automatic re-enrollment of an individual who is disenrolled solely because he or she loses
Medicaid eligibility for a period of 2 months or less, if the temporary loss of Medicaid
eligibility has caused the individual to miss the annual disenrollment opportunity.

2. An enrollee subject to the Lock in Period may initiate disenrollment for good cause at any time

a. Good cause reasons for disenrollment or transfer shall include unless otherwise defined by
DMAHS:

i. Failure of the contractor to provide services including physical access to the enrollee in
accordance with the terms of this contract;

ii. Enrollee has filed a grievance/appeal with the contractor pursuant to the applicable
grievance/appeal procedure and has not received a response within the specified time period stated
herein, or in a shorter time period required by federal law;

iii. Documented grievance/appeal by the enrollee against the contractor’s plan without
satisfaction.

iv. Enrollee is subject to enrollment exemption as set forth in Article 5.3.2. If an exemption
situation exists within the contractor’s plan but another contractor can accommodate the
individual’s needs, a transfer may be granted.

 

 

Exhibit 10.6.9

6. Expected timeframes for disposition of grievances/appeals in accordance with NJAC8:38 et seq.
and 42 CFR 438.408

7. Extensions of the grievance/appeal process if needed and time frames in accordance with
5.15.2.B.8 Fair hearing procedures including the Medicaid enrollee’s right to access the also file
for a Medicaid Fair Hearing process at any time in addition to the HMO appeal to request resolution
of a grievance/appeal

9. DHSS process for use of Independent Utilization Review Organization (IURO)

C. A description of the process under which an enrollee may file an appeal shall include at a
minimum:

1. Title of person responsible for processing appeal

2. Title of person(s) responsible for resolution of appeal

3. Time deadlines for notifying enrollee of appeal resolution

4. The right to request a Medicaid Fair Hearing/DHSS IURO processes where applicable to specific
enrollee eligibility categories

5.15.3 GRIEVANCE/APPEAL PROCEDURES

A. Availability. The contractor’s grievance/appeal procedure shall be available to all enrollees,
or where applicable, an authorized person or permit a provider acting on behalf of an enrollee and
with the enrollee’s consent. The procedure shall assure that grievance/appeals may be filed
verbally directly wit the contractor.

B. The grievance/appeal procedure shall be in accordance with NJAC 8:38 et seq. and 42 CFR 438.438
subpart F.

C. DMAHS shall have the right to submit comments to the contractor regarding the merits or
suggested resolution of any grievance/appeal.

By the fifteenth of every month the contractor shall submit electronically reports of all UM
and non-UM enrollee grievance/appeal requests and dispositions directly to the DMAHS on the
database format provided by DMAHS. The information submitted to DMAHS shall include information for
the reporting month and all open cases to date and indicate the enrollee’s name, Medicaid/NJ
FamilyCare number, date of birth, age, eligibility category, as well as the date of the
grievance/appeal, resolution and the date of resolution.

 

 

Exhibit 10.6.9

D. Time limits to File. The contractor may provide reasonable time limits within which enrollees
must file grievance/appeals, but such time period shall not e less than sixty (60) days and not to
exceed 90 days from the date of the contractor’s notice of action. (Within that timeframe, the
enrollee may file an appeal or request a State fair hearing). In the case of a Medicaid Fair
Hearing, the enrollee must file a request within 20 days of the adverse action.

5.15.4 PROCESSING GRIEVANCES/APPEALS

A. Staffing. The contractor shall have an adequate number of staff to receive and assist with
enrollee grievance/appeals by phone, in person and by mail. All staff involved in the receipt,
investigation and resolution of complaints shall be trained on the contractor’s policies and
procedures and shall treat all enrollees with dignity and respect.

B. grievance/appeal Forms. If the contractor uses a grievance/appeal form, the contractor must make
available written grievance/appeal forms in the enrollee’s primary language in accordance with the
multilingual definition. Such forms shall be readily available through the contractor upon request
by telephone or in writing. The contractor shall mail the form within five (5) work days of
receiving a telephone or written request. The contract shall permit grievance/appeals to be filed
in writing, either on the contractor’s form ir in any other written format, by fax, or verbally.
For appeals, an oral filing must be followed with a written, signed appeal except when the request
is for expedited translation service to translate grievance/appeal forms in an enrollee’s primary
language in order to meet the timeframes of this contract provision. A copy of the translated form
shall be sent to DMAHS for post review.

C. Confidentiality. The contractor shall have written policies and procedures to assure enrollee
confidentiality and reasonable privacy throughout the complaint and grievance/appeal process.

D. Non — Discrimination. The contractor shall have written policies to assure that the contractor or
any provider or agent of the contractor shall not discriminate against an enrollee or attempt to
disenrolll an enrollee for filing a complaint or grievance/appeal against the contractor.

E. Documentation. Upon receipt of a grievance/appeal, the contractor’s staff shall record the date

of receipt, a written summary of the problem, the response given, the resolution effected, if any,
and the department or staff personnel to whom the grievance/appeal has been routed. See article
5.15.5 for further information on records maintenance.

F. Tracking System. The contractor shall maintain a separate complaint log as well as a
grievance/appeal tracking and resolution for Medicaid/NJ

 

 

Exhibit 10.6.9

Commission, percentage, brokerage or contingent fee, except bona fide employees or bona fide
established commercial or selling agencies maintained by the contractor for the purpose of securing
business. The penalty for breach or violation of this provision may result in termination of the
contract without the State being liable for damages, cost and/or attorney fees or, in the
Department’s discretion, a deduction from the contract price or consideration the full amount of
such commission, percentage, brokerage or contingent fee.

K. MacBride Principles. The contractor shall comply with the MacBride principles of
nondiscrimination in employment and have no business operations in Northern Ireland as set forth in
NJSA 52:34-12.1.

L. Ownership of Documents. All documents and records, regardless of form, prepared by the
contractor in fulfillment of the contract shall be submitted to the State and shall become the
property of the State

M. Publicity. Publicity and/or public announcements pertaining to the project shall be approved by
the State prior to release. See Article 5.16 regarding Marketing

N. Taxes. Contractor shall maintain and produce to the Department upon request, proof that all
appropriate federal and State taxes are paid.

7.3 STAFFING

In addition to complying with the specific administrative requirements specified in Articles Two
through Six and Eight, the contractor shall adhere to the standards delineated below:

A. The contractor shall have in place the organization, management and administrative systems
necessary to fulfill all contractual arrangements. The contractor shall demonstrate to DMAHS’
satisfaction that it has the necessary staffing, by function and qualifications, to fulfill its
obligations under this contract which include at a minimum:

	 	•	 	A designated administrative liaison for the Medicaid/NJ FamilyCare contract who shall be
the main point of contact responsible for coordinating all administrative activities for
this contract (“contractor’s Representative”; See also Article 7.5 below)
	 
	 	•	 	A medical director who shall be a New Jersey licensed physician (M.D. or D.O).
	 
	 	•	 	A dental service coordinator
	 
	 	•	 	Financial Officer(s) or accounting and budgeting officer

 

 

Exhibit 10.6.9

Liquidated Damages:

If the contractor does not provide or perform the requirement within fifteen (15) business days
of the written notice, or longer if allowed by the Department, or through an approved corrective
action plan, the Department may impose liquidated damages of $250 per requirement per day for
each day the requirement continues not to be provided or performed. If after fifteen (15)
additional days from the date the Department imposes liquidated damages, the requirement has
still not been provided or performed, the Department, after written notice to the contractor,
may increase the liquidated damages to $500 per requirement per day for each day the requirement
continues to be unprovided or unperformed.

7.16.3 TIMELY REPORTING REQUIREMENTS

The contractor shall produce and deliver timely reports within the specified timeframes and
descriptions in the contract including information required by the ERO. Reports shall be
produced and delivered on both a scheduled and mutually agreed upon on-request basis according
to the schedule established by DMAHS.

Liquidated Damages:

For each late report, the Department may impose liquidated damages of $250 per report per day
until the report is provided. For any late report that is not delivered after thirty (30) days
or such longer period as the Department shall allow, the Department, after written notice, shall
have the right to increase the liquidated damages to $500 per day per report until the report is
provided.

7.16.4 ACCURATE REPORTING REQUIREMENTS

Every report due the State shall contain sufficient and accurate information and in the approved
media format to fulfill the State’s purpose for which the report was generated.

If the Department imposes liquidated damages, it shall give the contractor written notice of a
report that is either insufficient or in accurate and that liquidated damages will be assessed
accordingly. After such notice, the contractor shall have fifteen (15) business days, or such
longer period as the Department may allow, to correct the report.

Encounter data shall be accurate and complete, i.e., have not missing encounters or required
data elements, and shall have no more than 5% edit errors.

 

 

Exhibit 10.6.9

Liquidated Damages:

If the contractor fails to correct the report within the fifteen (15) business days, or such
longer period as the Department may allow, the Department shall have the right to impose
liquidated damages of $250 per day per report until the corrected report is delivered. If the
report remains uncorrected for more than thirty (30) days from the date liquidated damages are
imposed, the Department, after written notice, shall have the right to increase the liquidated
damages assessment to $500 per day per report until the report is corrected.

The State will use encounter data completeness benchmarks to identify areas where encounter data
appear to have been underreported. These benchmarks will be periodically revised to ensure that
they are reasonable, and accurately reflect minimum reporting expectations. If the contractor
falls outside of encounter data completeness benchmarks for any Managed Care Category of
Service, the contractor will be notified that reporting deficiencies may have occurred for
specified date ranges. In this event, the State may require documentation regarding the
potential deficiency and/or a plan of corrective action from the contractor . If the contractor
is unable to demonstrate that encounter data reports are complete, the State will conduct
reviews of medical records, or utilize other means to determine reporting compliance. The State
reserves the right to consider utilization rates reported via encounter data in the process of
calculating capitation rates. Additionally the State reserves the right to reconsider the use of
the benchmarks to measure reporting completeness.

In addition to conducting routine monitoring, the DMAHS will conduct, on a calendar year basis,
annual reviews of encounter data to determine compliance performance. Encounter data will be
reviewed for missing or omitted encounter data and for pending encounters or edit errors. An
amount of $1 may be assessed for each missing or omitted encounter. Id addition, $1 per
encounter or encounter data element may be assessed for any pending encounter or error that is
not corrected and returned to DMAHS within thirty (30) days after notification by DMAHS that the
data are incomplete or incorrect. The Department shall have the right to calculate the total
number of missing or omitted encounters and encounter data by extrapolating from a sample of
missing or omitted encounters and encounter data.

 

 

Exhibit 10.6.9

7.16.5 TIMELY PAYMENTS TO MEDICAL PROVIDERS

The contractor shall process claims in accordance with New Jersey laws and regulations and shall
be subject to damages pursuant to such laws and regulations. In addition, pursuant to this
contract the Department may assess liquidated damages if the contractor does not process (pay
or deny) claims within the following timeframes: ninety (90) percent of all claims (the totality
of claims received whether contested or uncontested) submitted manually by medical providers
within thirty (30) days of receipt; ninety (90) percent of all claims filed electronically
within forty (40) days of receipt; ninety-nine (99) percent of all claims , whether submitted
electronically or manually, within sixty (60) days of receipt; and one hundred (100) percent of
all claims within ninety (90) days of receipt. Claims processed for providers under
investigation for fraud or abuse and claims suppressed pursuant to Article 8.9 (regarding PIPs)
are not subject to these requirements.

The amount of time required to process a paid claim shall be computed in days by comparing the
initial date of receipt with the check mailing date. The amount of time required to process a
denied claim (whether all or part of the claim is denied) shall be computed in days by comparing
the date of initial receipt with the denial notice mailing date. Claims processed during the
quarter shall be reported in required categories through the Claims Lag report (see Section
A.7.621 of the Appendices (Tables 4A and B)). Table 4A shall be used to report claims submitted
manually and Table 4B shall be used to report claims submitted electronically.

 

 

Exhibit 10.6.9

Liquidated Damages

Liquidated damages may be assessed if the contractor does not meet the above requirements on a
quarterly basis. Based on the contractor-reported information n the claims lag report, the
Department shall determine for each time period (thirty (30)/forty (40), sixty (60), and ninety
(90) days) the actual percentage of claims processed (electronic and manual claims shall be
added together). This number shall be subtracted from the percentage of claims the contractor

should have processed in the particular time period. The difference shall be expressed in
points. For example, if the contractor only processed eighty-eight (88) percent of manual claims
within forty days, it shall be considered to be two (20 pointes short for that time period. The
points that the contractor is short for each of the three time periods shall be added together.
This sum shall then be multiplied times .0004 times the compensation received by the contractor
during the quarter at issue to arrive at the liquidation damages amount.

No offset shall be given if a criterion is exceeded. DMAHS reserves the right to audit and/or
request detail and validation of reported information. DMAHS shall have the right to accept or
reject the contractor report and may substitute reports created by DMAHS if contractor fails to
submit reports or the contractor’s reports are found to be unacceptable.

7.16.6 CONDITIONS FOR TERMINATION OF LIQUIDATED DAMAGES

Except as waived by the Contracting Officer, no liquidated damages imposed on the contractor
shall be terminated or suspended until the contractor issues a written notice of correction to
the Contracting Officer certifying the correction of condition(s) for which liquidated damages
were imposed and until all contractor corrections have been subjected to system testing or other
verification at the discretion of the Contracting Officer. Liquidated damages shall cease on the
day of the contractor’s certification only if subsequent testing of the correction establishes
that, indeed, the correction has been made in the manner and at the time certified to by the
contractor.

A. the contractor shall provide the necessary system time to system test any correction the
Contracting Officer deems necessary.

 

 

Exhibit 10.6.9

Iv Achievement of less than 30 percent lead screening rate: refund of $5 per enrollee for all
enrollees under age 3 not screened.

b. Discretionary sanction. The DMAHS shall have the right to impose a financial or
administrative sanction if the contractor’s performance screening rate is between sixty (60) and
seventy (70) percent. The DMAHS, in its sole discretion, may impose a sanction after review of
the contractor’s corrective action plan and ability to demonstrate good faith efforts to improve
compliance.

7.16.7.B.2. Failure to achieve and maintain the required screening rate shall result in the
Local Health Departments being permitted to screen the contractor’s pediatric members. The cost
of these screening shall be paid by the DMAHS to the LHD, and the screening cost shall be
deducted from the contractor’s capitation rate in addition to the damages imposed as a result of
failure to achieve lead screening performance standards.

3. Mandatory sanctions may be offset when the contractor demonstrates improved compliance. The
division, in is sole discretion, may reduce the sanction amount by $1 for each twelve (12) point
improvement over prior reporting period performance rate. Offsets shall not reduce the financial
sanction amount to below $1 per enrollee not screened.

C. The contractor must deomonstrate continuous quality improvement in achieving the performance
standard for EPSDT and elad screenings as stated in Article 4. The Division shall, in its sole
discretion, determine the appropriateness of v imposed corrective action and the imposition of
any other financial or administrative sanction in addition to those set out above.

7.16.8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CIVIL MONEY PENALITIES

7.16.8.1 FEDERAL STATUTES

Pursuant to 42 U.S.C§ 1396B(m)(5)(A), the Secretary of the Department of Health and Human
Services may impose substantial monetary and/or criminal penalties on the contractor when the
contractor:

A. fails to substantially provide an enrollee with required medically necessary items and
services, required under law or under contract to be provided to an enrolled beneficiary, and
the failure has adversely affected the enrollee or has substantial likelihood of adversely
affecting the enrollees.

 

 

Exhibit 10.6.9

B. Imposes premiums or charges on enrollees in violation of this contract, which provides that
no premiums, deductibles, co-payments or fees of any kind may be charged to Medicaid enrollees.

 

 

Exhibit 10.6.9

Quality assurance studies or projects; prospective, concurrent, and retrospective utilization
reviews of inpatient hospital stays and denials of off-formulary drug requests.

7.26.F. the contractor shall prepare and submit to DMAHS quarterly reports to be submitted
reported electronically (e.g., email) in report-ready form by hard copy and diskette in a format
and software application system determined by DMAHS, containing summary information on the
contractor’s operations for each quarter of the program. (See Section A.7 of the Appendices,
Tables 1 though 2122. Exceptions — Tables 3A and 3B shall be submitted monthly by the fifteenth
(15th ) of every month; Tables 5 and 7 shall be submitted annually). These reports
shall be receive by DMAHS no later than forty-five (45 ) calendar days after the end of the
quarter. After a grace period of five (5) days, for each calendar day after a due date the DMAHS
has not yet received at a prescribed location a report that fulfills the requirements of any one
item, assessment for damages equal to one half month’s negotiated blended capitation rate that
would normally be owed by the DMAHS to the contractor for one recipient shall be applied. The
damages shall be applied as an offset to the subsequent payments to the contractor.

The contractor shall be responsible for continued reporting beyond the term of the
contract because of lag time in submitting source documents by providers.

g. The contractor may submit encounter reports daily but must submit encounter reports at least
quarterly . However, encounter reports will be processed by DMAHS’ fiscal agent no more
frequently than monthly. All encounters shall be reported to DMAHS within seventy-five (75) days
of the end of the quarter in which they are received by the contractor and within one year plus
seventy-five days from the date of service.

H. The contractor shall annually and at the time changes are made report its staffing position
including the names of supervisory personnel (Director level and above and the QM/UR personnel),
organizational chart, and any position vacancies in tehse major areas.

I. DMAHS shall have the right to create additional reporting requirements at any time as they
are required by applicable federal or State laws and regulations, as they exist or may
hereafter be amended and incorporated into this contract.

 

 

Exhibit 10.6.9

J. Reports that shall be submitted on an annual or semi-annual basis, as specified in this
contract, shall be due within sixty (60) days of the close of the reporting period, unless
specified otherwise.

K. MCSA Paid Claims Reconciliation. On a quarterly basis, the contractor shall provide paid
claims data, via an encounter data file or separate paid claims file, that meet the HIPAA format
requirements for audit and reconciliation purposes.

 

 

Exhibit 10.6.9

The contractor shall provide documentation that demonstrates a 100% reconciliation of the
amounts paid to the amounts billed to the DMAHS. The paid claims data shall include at a
minimum, claim type, provider type, category of service, diagnosis code (5 digits),
procedure/revenue code, Internal Control Number or Patient Account Number under HIPAA, provider
ID, dates of services, that will allow the DMAHS to price claims in comparison to Medicaid fee
schedules for evaluation purposes.

L. Encounter Data Submissions. The contractor shall cooperate with the DMAHS in its review of
the status of encounter data submissions to determine needed improvements for accuracy and
completeness of encounter data submissions. With the contract period beginning July 2005, the
contractor will be subject to additional sanction if not in full compliance with encounter data
submission standards.

7.27. FINANCIAL STATEMENTS

7.27.1 AUDITED FINANCIAL STATEMENTS (SAP BASIS)

A. Annual Audit. The contractor shall submit its audited annual financial statements prepared in
accordance with Statutory Accounting Principles (SAP) certified by an independent public
accountant no later than June 1 of each year, for the immediately preceding calendar year as
well as for any company that is a financial guarantor for the contractor in accordance with NJSA
8:38-11.6.

B. Audit of Income Statements by Rate Cell Grouping Costs

The contractor shall submit quarterly, reports found in Appendix, Section A in accordance with
the “HMO Financial Guide for Reporting Manual for Medicaid/NJ FamilyCare Rate Cell Grouping
Costs” (appendix, Section B7.3A7.21). these reports shall be reviewed by an independent public
accountant in accordance with the standard “Agreed Upon Procedures” procedures and for the cost
categories that will be detailed by DMAHS on or before December 31 each year, to be effective
the following July. (Appendix, Section BA).

The contractor shall require its independent public accountant to prepare a letter and report of
finding which shall be submitted to DMAHS by June 1 of each year. Only the fourth quarter report
(period October through December 31) of each calendar year will be subject to this agreed upon
procedures a Audit of Income Statements by Rate Cell Grouping.

 

 

Exhibit 10.6.9

The contractor shall require its independent public accountant to explain any differences
between the Statewide Income Statement by Rate Cell Grouping Cost Reports (Report 2 – Parts S1
through S3) and the annual audit statements in the letter.

 

 

Exhibit 10.6.9

4. Has been convicted for an offense that occurred after the date of the enactment of the Health
Insurance Portability and Accountability Act of 1996 of a criminal offense consisting of a
felony relating to the unlawful manufacture, distribution, prescription, or dispensing of a
controlled substance.

7.38 FRAUD AND ABUSE

The contractor shall have arrangements and procedures that comply with all state and federal
statutes and regulations, including 42 CFR 438.608 governing fraud and abuse requirements.

7.38.1 ENROLLEES

A. Policies and procedures. The contractor shall establish written policies and procedures for
identifying potential enrollee fraud and abuse. Proven cases are to be referred to the
Department for screening for advice and/or assistance on follow-up actions to be taken.
Referrals are to be accompanied by all supporting case documentation.

B. Typical Cases. The most typical cases of fraud or abuse include but are not limited to: the
alteration of an identification card for possible expansion of benefits, the loaning of an
identification card to others; use of forged or altered prescriptions; and mis-utilization of
services.

7.38.3 PROVIDERS

A. Policies and Procedures. The contractor shall establish written policies and procedures for
identifying, investigating, and taking appropriate corrective action against fraud and abuse (as
defined in 42 CFR§ 455.2) in the provision of health care services. The policies and procedures
will include, at a minimum:

1. Written notification must be sent by the contractor to DMAHS within 5 business days of the
contractor’s intent to conduct an investigation or to recover funds and approval must e obtained
by the contractor from DMAHS prior to conducting the investigation or attempting to recover
funds. Details of potential investigations shall be provided to DMAHS and include the data
elements in Section A72B of the Appendices. Representatives of the contractor may be required to
present the case to DMAHS. DMAHS in consultation with the contractor will then determine the
appropriate course of action to be taken.

 

 

Exhibit 10.6.9

Written notification must be sent by the contractor to DMAHS within five (50 business days of
the contractor’s intent to recover fund, and approval must be obtained by the contractor from
DMAHS prior to collection of those funds.

2. Incorporation of the use of claims and encounter data for detecting potential fraud and abuse
of services.

3. A means to verify services were actually provided.

4. Reporting investigation results within twenty (20) business days to DMAHS.

5. Specifications of, and reports generated by, the contractor’s prepayment and postpayment
surveillance and utilization review systems, including prepayment and postpayment edits.

B. Distinct Unit. The contractor shall establish a distinct fraud and abuse unit, solely
dedicated to the detection and investigation of fraud and abuse by its New Jersey Medicaid/NJ
FamilyCare beneficiaries and providers It shall be separate from the contractor’s utilization
review and quality of care functions. The unit can either be part of the contractor’s corporate
structure, or operate under contract with the contractor.

1. The unit shall be staffed with investigators who shall have at least one of the following:
(1) a Bachelor’s degree; (2) an Associate’s degree plus a minimum of two years experience with
health care related employment; (3) a minimum of four years experience with health care related
employment; or (4) a minimum of five years of law enforcement experience. When approved by
DMASH, the contractor shall be permitted to employ a limited number of specialist who shall
possess unique qualifications by way of training, technical skill and/or experience to
investigate and identify cases of fraud, but who lack the specific educational requirements set
forth above to be investigators. The unit shall have an investigator to beneficiary ratio for
the New Jersey Medicaid/NJ FamilyCare enrollment of at least one investigator per 60,000 or
fewer New Jersey enrollees or a greater ratio as needed to meet the investigative demands. The
requirement of at least on investigator per 60,000 or fewer New Jersey enrollees can be
satisfied by the use of full-

 

 

Exhibit 10.6.9

time equivalents rather than dedicated investigators, but only if the contractor submits to
DMAHS on a quarterly basis the statistics ask for in Section A.7.2 of the Appendix documenting
that at least one full-time equivalent investigator per 60,000 or fewer enrollees is being
devoted to DMAHS-related fraud and abuse cases.

2. Claims analysts who are reviewing claims specifically for trends of fraud and/or abuse can be
counted toward the FTEs. However, reviewing claims primarily for quality of care may not be
counted. Exclusive use of

 

 

Exhibit 10.6.9

8.4 MEDICAL COST RATIO

8.4.1 MEDICAL COST RATIO STANDARD

The contractor shall maintain direct medical expenditures for enrollees equal to or greater than
eighty (80) percent of premiums paid in all forms from the State. This medical cost ratio (MCR)
shall apply to annual periods from the contractor effective date (if the contract ends before
the completion of an annual period, the MCR shall apply to that shorter period). The MCR shall
be based on reports completed by the contractor and acceptable to the Department.

A. Direct
Medical Expenditures. Direct medical expenditures are the incurred cots of providing
direct care to enrollees for covered health care services as stated in Article 4.1 (Report on
Table 19s 6a and 6b6). Costs related to information and materials for general education and
outreach and/or administration are not considered direct medical
expenditures.

Personnel costs are generally considered to be administrative in nature and must be reported as
an administrative expense to Table 19s 6a and 6b6 (Income statement by Rate Cell Grouping of
Revenues and Expenses) on line 3029 for (compensation). However, a portion of these costs may
qualify as direct medical expenditures, subject to prior review and approval by the State. Those
activities that the contractor expects to generate these costs must be specified and detailed in
a Medical Cost Ratio-Direct Medical Expenditures Plan which must be reviewed and approved by
the State. At the end of the reporting period, the contractor’s reporting shall be based only on
the approved Medical Cost Ratio- Direct Medical Expenditures Plan. In order to consider these
costs as Direct Medical Expenditures, the contractor must complete Table 6e, entitled “Allowable
Direct Medical Expenditures,” which will be used by the State to determine the allowable portion
of the costs. The allowable components of these personnel costs include the following
activities:

1. Care Management. Allowable direct medical expenditures for care management include: 1)
assessment(s) of an enrollee’s risk factors; and 2)development of Individual Health Care Plans.
The costs of performing these two allowable components may be considered a direct medical
expenditure for purposes of calculating MCR and must be reported on Table 6c.

2. The cost associated with the provision of a face-to-face home visit by the contractor’s
clinical personnel for the purpose of medical education or anticipatory guidance can be
considered a direct medical expenditure (Report on Table 6c.

 

 

Exhibit 10.6.9

3. Costs for activities required to achieve compliance standards for EPSDT participation, lead

screening, and prenatal care as specified in Article IV may be considered direct medical
expenditures. The contractor’s reporting shall be based only on the approved Medical Cost Ratio-
Direct Medical Expenditures Plan (report on Table 6c).

Calculation of MCR. The calculation of MCR will be made using information submitted by each
contractor on the quarterly reports — Income Statement by Rate Cell Grouping of Revenues and
Expenses (Section A.7.8 21 of the Appendices, (Tables 6a, 6b and 6c 19)). The costs related to
8.4.1.A 1 -3 are to be reported on Table 6c and the allowable amount will be added to the
calculation of Medical and Hospital Expenses (lines 28) less Coordination of Benefits (COB)
(line 6) and less reinsurance recoveries (line 7) will be divided by the sum of all applicable
quarter of Medicaid/NJ FamilyCare premiums (line 4) to arrive at the ratio.

8.4.2 RESERVED

8.4.3 DAMAGES

The Department shall have the right to impose damages on a contractor that has failed to
maintain an appropriate MCR. The damages shall be assessed when MCR is below 80% and an
underexpenditure occurs. The formula for imposing damages follows:

	 	 	 	 	 
	ACTUAL MCR	 	1st OFFENSE	 	2ND OFFENSE
	 
	80% or above

	 	NONE
	 	NONE
	 
	 	 	 	 
	78.00% — 79.99%

	 	.15 times
underexpenditure
	 	.15 times
underexpenditure
	 
	 	 	 	 
	75.00 — 77.99%

	 	.50 times
underexpenditure
	 	.50 times
underexpenditure
	 
	 	 	 	 
	74.99 or below

	 	.90 times
underexpenditure
	 	.90 times
underexpenditure

If the contractor fails to meet the MCR requirement and a penalty is applied, a plan of
corrective action shall be required.

 

 

Exhibit 10.6.9

8.5 REGIONS, PREMIUM GROUPS, AND SPECIAL PAYMENT PROVISIONS

8.5.1 REGIONS

Capitation rates for DYFS NJ FamilyCare Plans B, C, and D and the non risk-adjusted rates for
AIDS and clients of DD are statewide. Rates for all other premium groups are regional in each of
the following regions:

	 	•	 	Region 1: Bergen, Hudson, Hunterdon, Morris, Passaic, Somerset, Sussex, and Warren
counties
	 
	 	•	 	Region 2: Essex, Union, Middlesex, and Mercer counties
	 
	 	•	 	Region 3: Altantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Monmouth,
Ocean, and Salem Counties

Contractors may contract for one or more regions but, except as provided in Article 2, may not
contract for part of a region.

8.5.2 MAJOR PREMIUM GROUPS

The following is a list of the major premium groups. The individual rate groups (e.g. children
under 2 years, etc.) with their respective rates are presented in the rates tables in the appendix.

8.5.2.1 AFDC/TANF, NJJC PREGNANT WOMEN, AND NJ FAMILYCARE PLAN A CHILDREN

This grouping includes capitation rates for Aid to Families with Dependent Children
(AFDC)/Temporary Assistance for Needy Families (TANF), New Jersey Care Pregnant Woman and Children,
and NJ FamilyCare Plan A children (includes individual under 21 in PSC 380), but excludes
individual who have AIDS or are clients of DDD, as well as AFCD/TANF restricted alien individual
over the age of 20.99 years old.

8.5.2.2 NJ FAMILYCARE PLANS B &C

This grouping includes capitation rates for NJ FamilyCare Plans B and C enrollees, excluding
individuals with AIDS and/or DDD Clients.

8.5.2.3
NJ FamilyCare PLAN D CHILDREN

This grouping includes capitation rates for NJ FamilyCare Plan D children excluding individuals
with AIDS.

 

 

Exhibit 10.6.9

8.5.2.4 NJ FamilyCare PLAN D PARENTS/CARETAKERS

This grouping includes capitation rates for NJ FamilyCare Plan D parents/caretakers, excluding
individuals with AIDS, and restricted alien individuals, and include only enrollees 19 years of age
or older.

 

 

Exhibit 10.6.9

8.5.4 SUPPLEMENTAL PAYMENT PER PREGNANCY OUTCOME (Not applicable to Plan H).

Because cost for pregnancy outcomes were not included in the capitation rates, the contractor shall
be paid supplemental payments for pregnancy outcomes for all eligibility categories.

Payment for pregnancy outcome shall be a single, predetermined lump sum payment. This amount shall
supplement the existing capitation rate paid. The Department will make a supplemental payment to
contractors following pregnancy outcome. For purposes of this Article, pregnancy outcome shall mean
each live birth, still birth or miscarriage occurring at the thirteenth (13th) or
greater week of gestation. This supplemental payment shall reimburse the contractor for its
inpatient hospital, antepartum, and postpartum costs incurred in connection with delivery. Costs
for care of the baby for the first 60 days after the birth plus through the end of the month in
which the 60th day falls are included (see Section 8.5.3). Regional payment shall be
made by the State to the contractor based on submission of a financial summary report of hospital
and/or birthing center claims paid for final pregnancy outcomes. No other services, in patient
hospital or otherwise, rendered prior to final pregnancy outcome shall qualify or be payable for a
maternity supplement.

The report shall be accompanied by a signed certification form and an electronic file to
include:

1. Paid inpatient hospital/birthing center claims;

2. Name of mother;

3 Mothers Medicaid identification number;

4. Newborn’s name, if known;

5. Diagnosis and five-digit ICD-9 codes, including V-codes, specified by DMAHS, and

6. Place of service.

The contractor shall continue to submit encounter data that will document each paid claim reported
on the financial summary report. The DMAHS will conduct a reconciliation of these paid claims
utilizing encounter data.

8.5.5 PAYMENT FOR CERTAIN BLOOD CLOTTING FACTORS

The contractor shall be paid separately for factor VIII and IX blood clotting factors. Payment will
be made by DMAHS to the contractor based on; 1) submission of appropriate encounter data; and 2)
notification from the contractor to DMAHS within 12 months of the date of service of

 

 

Exhibit 10.6.9

identification of individual with factor VIII or IX hemophilia. Payment for these products will be
lesser of 1)Average Wholesale Price (AWP) minus 12.5% and 2)rates paid by the contractor.

8.5.6 PAYMENT FOR HIV/AIDS DRUGS

The contractor shall be paid separately for protease inhibitors and other anti-retroviral agents
(First Data Bank Specific Therapeutic Class Codes W5C, W5B, W5I, W5J, W5K, W5L, W5M, W5N). Payment
for protease inhibitors shall be made by DMAHS to the contractor based on 1)submission of
appropriate encounter data; and 2) notification from the contractor to DMAHS within 12 months of
the date of service of identification of individuals with HIV/AIDS. Payment for these products will
be the lesser of 1)Average Wholesale Price (AWP) minus 12.5% and 2) rates paid by the contractor.

Individuals eligible through NJ FamilyCare Plans A, B, C and only those Plan D enrollees with a
program status code of 380 and all children groups shall receive protease inhibitors and other
anti-retroviral agents under the contractor’s plan. All other individual eligible through NJ
FamilyCare P with program status codes of 497-498, 300-301, 700-701, and 763, and all Plan H
individuals shall receive protease inhibitors and other anti-retrovirals (First Date Bank Specific
Therapeutic Class Codes W5C, W5B, W5I, W5J, W5K, W5L, W5M, and W5N) through Medicaid fee for
service and/or the AIDS Drug Distribution Program (ADDP).

8.5.7 EPSDT INCENTIVE PAYMENT

     the contractor shall be paid separately, $10 for every documented encounter record for a
contractor-approved EPSDT screening examination. The contractor shall be required to pass the $10
amount directly to screening provider.

The incentive payment shall be reimbursed for EPSDT encounter records submitted in accordance with
1) procedure codes specified by DMAHS, and 2) EPSDT periodicity schedule.

8.5.8
ADMINISTRATIVE COSTS RESERVED

The capitation rates, effective July 1, 2003 recognize costs for anticipated contractor
administrative expenditures due to Balanced Budge Act regulations.

8.5.9 NJ FAMILYCARE PLAN H ADULTS

 

 

Exhibit 10.6.9

The contractor shall be paid an administrative fee for NJ FamilyCare Plan H adults without
dependent children, and restricted alien parents excluding pregnant women as defined in Article
One.

8.6 HEALTH BASED PAYMENT SYSTEM (HBPS) FOR THE ABD POPULATION WITHOUT MEDICARE

The DMAHS shall utilize a Health-Based Payment System (HBPS) for reimbursements for the ABD
population without Medicare to recognize larger average health care costs and the greater
dispersion around the average than other DMAHS populations. The contractor shall be reimbursed not
only on the basis of the demographic cells into which individuals fall, but also on the basis of
individual health status.

 

 

Exhibit 10.6.9

Number, date of accident/incident, nature of injury, name and address of enrollee’s legal
representative, copies of pleadings, and nay other documents related to the action in the
contractor’s possession or control. This shall include, but not limited to (for each service date
on or subsequent to the date of the accident/incident), the name of the provider, practitioner or
subcontractor, the enrollee’s diagnosis, the nature of the service provided to the enrollee, and
the amount paid to the provider (or to a provider’s authorized subcontractor) by the contractor for
each service. A form is available for this purpose and is included in Section A.8.2 of the
Appendices.

8.7.H.3. The contractor shall notify the State within thirty (30) days of the date it becomes aware
of the death of one of its Medicaid enrollees age fifty-five (55) or older, giving the enrollees
full name, Social Security Number, Medicaid identification number, and the date of death. The State
will then determine whether it can recover correctly paid Medicaid benefits from the enrollee’s
estate. (See Appendix A.8.3, Estate Referral Form)

4. The contractor agrees to cooperate with the State’s efforts to maximize the collection of third
party payments by providing to the State updates to the information required by this Article.

I. Enrollment Exclusions and Contractor Liability for the Costs of Care.

1. Any Medicaid beneficiary enrolled in or covered by either a Medicare or commercial HMO will not
re enrolled by the contractor. The only exception to this exclusion from enrollment is when the
contractor and the beneficiary’s Medicare/commercial HMO are the same. When beneficiaries are
enrolled under this exception, appropriate reductions will be made in the State’s capitation
payments to the contractor.

2. If the contractor and the Medicaid beneficiary’s Medicare or commercial HMO are the same, the
contractor will be responsible for either:

a. Paying all cost-sharing expenses of the Medicaid beneficiary; or

b. Addressing cost sharing in the contracts with its providers in such a way that the Medicaid
beneficiary is not liable for any cost sharing expenses, subject to the subarticle 3 below.

 

 

Exhibit 10.6.9

3. If a Medicaid beneficiary otherwise covered by the provisions of subarticle 2 above wishes to
utilize a provider outside of the Medicare or commercial HMO’s network, the HMO’s rules apply.
Failure to follow the HMO’s rules relieves both the contractor and the State of any liability for

 

 

Exhibit 10.6.9

A.3.1 Monthly HMO Reconciliation Rile Reserved

The following is submitted by the contractor to DMAHS fiscal agent.

 

 

Exhibit 10.6.9

4.

State of New Jersey

Department of Human Services

Division of Medical Assistance and Health Services

Office of Management Information Systems

File Layout

	 	 	 
	HMO Reconciliation File

	 	Effective Date
	File Name
	 	 

	 	 	 	 	 
	Data Set Name

	 	      Record Size – Bytes
	Block Size	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Element	 	Field Name	 	Chars	 	Bytes	 	Bytes # rel to 1	 	Format	 	Cobol Picture	 	Description and/or Remarks
	1

	 	Medicaid Number
	 	12	 	12	 	1-12
	 	Num
	 	9(12)	 	Enrollee’s Medicaid
Number
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	Last Name
	 	12	 	12	 	13-24
	 	AN
	 	X(12)	 	Enrollee’s Last Name
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3

	 	First Name
	 	7	 	7	 	25-31
	 	AN
	 	X(7)	 	Enrollee’s First Name
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	DOB
	 	8	 	8	 	32-39
	 	Num
	 	9(8)	 	Enrollee’s Date of Birth
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	SSN
	 	9	 	9	 	40-48
	 	An
	 	X(9)	 	Enrollee’s Social
Security No.
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	Effect Enrollee
	 	8	 	8	 	49-56
	 	Num
	 	9(8)	 	Effective date of
enrollment mmddyyyy
format
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7

	 	Disenroll Date
	 	8	 	8	 	57-64
	 	Num
	 	9(8)	 	Disenrollment Date
mmddyyyy format
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8

	 	Filler
	 	33	 	33	 	65-97
	 	An
	 	X(33)	 	As Needed/If Needed
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9

	 	Plan Code
	 	3	 	3	 	98-100
	 	An
	 	X(3)	 	###(078-098)

 

			
	Format: Num – Numeric
	 
	An – alpha numeric
	 
	PD = Packed Decimal

 

 

Exhibit 10.6.9

			
	BI = Binary

 

 

Exhibit 10.6.9

ATTACHMENT A

New Jersey Department of Human Services, Division of Medical Assistance and Health Services, Office of Managed

Health Care

HMO Non-Institutional Provider Network File Specifications

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	When	 	 	 	 
	Field	 	Field Name	 	Size	 	Required	 	Definition	 	Example
	1

	 	Last Name
	 	 	22	 	 	 	A	 	 	Individual Provider’s Surname; may include R. or
III. Name of group or medical school is
unacceptable
	 	Jones, Jr.

	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	First Name
	 	 	15	 	 	 	A	 	 	Providers First Name. should include middle
initial. Name of group or medical schools is
unacceptable
	 	Tom T.

	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3

	 	SSN
	 	 	9	 	 	 	A	 	 	Provider’s Social Security Number. Do not use
hyphens or spaces
	 	150999999
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	Tax ID
	 	 	9	 	 	 	B	 	 	Provider’s Tax ID Number. Do not use hyphens or
spaces
	 	229999999
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	Degree
	 	 	5	 	 	 	A	 	 	MD, DO, etc. Do not use periods
	 	DO

	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	Primary
	 	 	1	 	 	 	A	 	 	Is this a primary care provider? (y Or N)
Do not indicate Y for dental providers
	 	Y
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7

	 	Practice Name
	 	 	45	 	 	 	B	 	 	Name of Practice if different than provider’s
last name
	 	Jones Family
Practice

	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8

	 	Address 1
	 	 	60	 	 	 	A	 	 	Place where services are rendered. Always start
with street number if one is contained in the
actual address of the practice. “Serving This
Area” is not acceptable.
	 	225 Main St

	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9

	 	Address 2
	 	 	30	 	 	 	B	 	 	Building Name, PO Box etc.
	 	Suite 3

	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10

	 	City
	 	 	22	 	 	 	A	 	 	Proper Name for Municipality in which practice
office is located. No abbreviations
	 	South Orange

	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11

	 	State
	 	 	2	 	 	 	A	 	 	Two Character State Abbreviation, NJ or other
with rare exceptions
	 	NJ

	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12

	 	Zip
	 	 	5	 	 	 	A	 	 	5 digit zip code
	 	08888
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13

	 	Phone
	 	 	15	 	 	 	A	 	 	For service address, include Area Code, prefix,
and Number No spaces or dashes.
	 	6095882705
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14

	 	County
	 	 	2	 	 	 	A	 	 	Two digit code for county in which office is
actually located
	 	07
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15

	 	Office Hours
	 	 	60	 	 	 	A	 	 	List days and hours when patients can be seen at
this site.
	 	M9-5, T1-5, Th1-7

	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16

	 	Specialty Code
	 	 	3	 	 	 	A	 	 	See List. List only one per record
	 	213
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17

	 	Age Restrictions
	 	 	4	 	 	 	B	 	 	Speciality code in string field 16,
1st 2 = min age, 2nd 2 = max
age, 0000 if none for a specialty. Omit if no
specialty is limited
	 	1234
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18

	 	Hosp Affl1
	 	 	355	 	 	 	B	 	 	Code for Hhospital where provider has admitting
privileges. *required for physicians, podiatrists
&Oral Surgeons.
	 	Newark-Beth Israel

A1234

	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	19

	 	Hosp Affl2
	 	 	355	 	 	 	B	 	 	If more than One
	 	A1234
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	20

	 	Hosp Affl3
	 	 	355	 	 	 	B	 	 	If more than Two
	 	A1234
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	21

	 	Hosp Affl4
	 	 	355	 	 	 	B	 	 	If more than Three
	 	A1234

 

 

Exhibit 10.6.9

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	When	 	 	 	 
	Field	 	Field Name	 	Size	 	Required	 	Definition	 	Example
	22

	 	Hosp Affl5
	 	 	355	 	 	 	B	 	 	If more than Four
	 	A1234
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	23

	 	Languages
	 	 	10	 	 	 	A	 	 	Must be at least one, even if English; See code
list. No spaces/commas/Slashes/Hyphens, etc
	 	EFG9

	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	24

	 	Plan Code
	 	 	3	 	 	 	1	 	 	Three digit plan code
	 	099
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	25

	 	Panel Status
	 	 	1	 	 	 	A	 	 	O = Open, F = Frozen (no new patients)
	 	O
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26

	 	Specialty Name
	 	 	30	 	 	 	A	 	 	Show one narrative specialty name per record
	 	Family Practice

	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	27

	 	Panel Capacity
	 	 	4	 	 	 	B	 	 	Potential Number of Members: PCPs & General
Dentists, should not exceed 1500 unless
authorized by DMAHS
	 	1500
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	28

	 	Members Assigned
	 	 	4	 	 	 	B	 	 	Actual number of Members Assigned; PCPs & Dentists
	 	900
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	29

	 	Record Type
	 	 	3	 	 	 	B	 	 	a = addition of record to file (excludes d)

d = deletion of record from file (excludes a & c)

s = multiple listing of provider, unique specialty

l = multiple listing of provider, unique location

Use all that apply. No commas. Spaces allowed.
	 	s a
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	30

	 	Date
	 	 	10	 	 	 	A	 	 	Fill with date Network Update File
or Application Network

File was submitted to DMAHS mm/dd/yyyy
	 	06/01/2000
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	31

	 	Servicing County
	 	 	4	 	 	 	B	 	 	If other than actual county; include a record for
each county served. Out-of-county physicians may
not be considered in applications except where
specified in the contract	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	32

	 	Total Hours
	 	 	2	 	 	 	A	 	 	Total number of hours for record. Round down
	 	20
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	33

	 	Medicaid ID
	 	 	7	 	 	 	A	 	 	Provider’s Medicaid assigned ID
	 	1234567
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	34

	 	Special Needs

Indicator
	 	 	5	 	 	 	A	 	 	Indicates provider has expertise serving specific
populations. Use all OMHS special needs codes
that apply to provider.	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	35

	 	Handicapped

Accessible
	 	 	1	 	 	 	C	 	 	Use Y if facility is Handicapped Accessible	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	36

	 	Taxonomy Coe
	 	 	10	 	 	 	B	 	 	Health Care Provider Taxonomy Code
	 	Alpha-Numeric

according to

instructions.

 

			
	A = Always Required
	 
	B = Required When Applicable
	 
	C = Optional

 

 

Exhibit 10.6.9

ATTACHMENT B

NEW JERSEY DEPARTMENT of Human Services, Division of Medical Assistance and Health

Services,

Office of Managed Health Care

HMO Institutional Provider Network File Specifications

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	When	 	 	 	 
	Field	 	Field Name	 	Size	 	Required	 	Definition	 	Example
	1

	 	Provider Name
	 	 	45	 	 	A
	 	 	 	Doc’s Drugs

	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	Provider Type
	 	 	30	 	 	A
	 	 	 	Pharmacy

	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3

	 	Provider Tax ID
	 	 	9	 	 	A
	 	Provider’s Tax ID Number
	 	22999999
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	Address 1
	 	 	60	 	 	A
	 	Always start with street number if one is
contained in the actual address of the
practice. “Serving This Area” is not
acceptable.
	 	22 Main St.

	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	Address 2
	 	 	30	 	 	B
	 	Building Name, PO Box, Etc
	 	Suite 3

	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	City
	 	 	22	 	 	A
	 	Proper Name for Municipality in which
practice office is located. No
abbreviations
	 	South Orange

	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7

	 	State
	 	 	2	 	 	A
	 	Two Character State Abbreviation, NJ or

other with rare exceptions
	 	NJ

	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8

	 	Zip
	 	 	5	 	 	A
	 	5 digit zip code
	 	08888
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9

	 	Phone
	 	 	15	 	 	A
	 	For service address, include Area Code,
prefix, and Number No spaces or dashes.
	 	6095882705
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10

	 	County
	 	 	2	 	 	A
	 	Two digit code for county in which office
is actually located
	 	07
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11

	 	Plan Code
	 	 	3	 	 	A
	 	Three Digit Plan Code
	 	099
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12

	 	Specialty Code
	 	 	3	 	 	A
	 	See Code List. Use one.
	 	500
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13

	 	Servicing County
	 	 	4	 	 	B
	 	If other than actual county; Include a
record for each county served.
Out-of-county institutions may not be
considered in application except where
specified in the contract.	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14

	 	Date
	 	 	10	 	 	A
	 	Fill with date Network Update File or
Application Network File was submitted to
DMAHS mm/dd/yyyy
	 	06/01/2000
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15

	 	Record Type
	 	 	1	 	 	B
	 	A = addition of record to file (excludes d)
D = Deletion of record from file
(excludes a)
	 	a
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16

	 	Medicaid Id
	 	 	7	 	 	B
	 	Provider’s Medicaid assigned Id
	 	1234567
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17

	 	Hospital Code
	 	 	5	 	 	B
	 	Unique Hospital Code
	 	99999
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18

	 	Taxonomy code
	 	 	10	 	 	B
	 	Health care Provider Taxonomy Code
	 	Alpha Numeric

according to

specifications.

 

			
	A = Always required
	 
	B = Required when applicable

 

 

Exhibit 10.6.9

ATTACHMENT E

Hospital Code List

	 	 	 	 	 
	Hospital Name	 	County Location	 	Codes
	Ancora Psychiatric Hospital

	 	Atlantic
	 	P0101
	Atlantic City Medical Center — City Division

	 	Atlantic
	 	H0102
	Atlantic City Medical Center — Mainland Division

	 	Atlantic
	 	H0103
	Bacharach Institute for Rehabilitation

	 	Atlantic
	 	R0104
	Shore Medical Hospital

	 	Atlantic
	 	H0105
	William B. Kessler Memorial Hospital

	 	Atlantic
	 	R0106
	Bergen Regional Medical Center

	 	Bergen
	 	H0201
	Christian Health Care Center

	 	Bergen
	 	P0202
	Englewood Hospital and Medical Center

	 	Bergen
	 	H0203
	Hackensack University Medical Center

	 	Bergen
	 	H0204
	Holy Name Hospital

	 	Bergen
	 	H0205
	Kessler Institution for Rehabilitation — Kessler North

	 	Bergen
	 	R0206
	Pascack Valley Hospital

	 	Bergen
	 	H0207
	The Valley Hospital

	 	Bergen
	 	H0208
	Lourdes Medical Center of Burlington County

	 	Burlington
	 	H0301
	Deborah Heart and Lung Center

	 	Burlington
	 	S0302
	Hampton Behavioral Health Center

	 	Burlington
	 	P0303
	Marlton Rehabilitation Hospital

	 	Burlington
	 	R0304
	Virtua Memorial Hospital Burlington

	 	Burlington
	 	H0305
	Virtua-West Jersey Hospital Marlton

	 	Burlington
	 	H0306
	Weisman Children’s Rehabilitation Hospital

	 	Burlington
	 	R0307
	The Cooper Health System

	 	Camden
	 	H0401
	Kennedy Memorial Hospital — UMC Cherry Hill

	 	Camden
	 	H0402
	Kennedy Memorial Hospital — UMC Stratford

	 	Camden
	 	H0403
	Our Lady of Lourdes Medical Center

	 	Camden
	 	H0404
	Virtua West Jersey Hospital — Berlin

	 	Camden
	 	H0405
	Virtua West Jersey Hospital — Voorhees

	 	Camden
	 	H0406
	Burdette Tomlin Memorial Hospital

	 	Cape May
	 	H0501

 

 

Exhibit 10.6.9

	 	 	 	 	 
	Hospital Name	 	County Location	 	Codes
	Rehabilitation Hospital of South Jersey

	 	Cumberland
	 	R0601
	South Jersey Healthcare — Regional Medical Center

	 	Cumberland
	 	H0602
	Clara Maas Medical Center

	 	Essex
	 	H0701
	Columbus Hospital

	 	Essex
	 	H0702
	East Orange General Hospital

	 	Essex
	 	H0703
	Irvington General Hospital

	 	Essex
	 	H0704
	Kessler Institution for Rehabilitation — Kessler East

	 	Essex
	 	R0705
	Kessler Institution for Rehabilitation — Kessler West

	 	Essex
	 	R0706
	Newark Beth Israel Medical Center

	 	Essex
	 	H0707
	St. Barnabas Medical Center

	 	Essex
	 	H0708
	St. James Hospital

	 	Essex
	 	H0709
	St. Michael’s Medical Center

	 	Essex
	 	H0710
	The Mountainside Hospital

	 	Essex
	 	H0711
	UMDNJ — University Hospital

	 	Essex
	 	H0712
	VA New Jersey Health care System — East Orange

	 	Essex
	 	V0713
	Kennedy Memorial Hospitals — UMC Washington Township

	 	Gloucester
	 	H0801
	Underwood Memorial Hospital

	 	Gloucester
	 	H0802
	Bayonne Medical Center

	 	Hudson
	 	H0901
	Christ Hospital

	 	Hudson
	 	H0902
	Hudson County Meadowview Hospital

	 	Hudson
	 	P0903
	Liberty Health Care System — Greenview Hospital Campus

	 	Hudson
	 	H0904
	Liberty Health Care System — Jersey City Medical Center
Campus

	 	Hudson
	 	H0905
	Liberty Health Care System — Meadowlands Hospital Campus

	 	Hudson
	 	H0906
	Palisades Medical Center — New York Presbyterian Health
Care System

	 	Hudson
	 	H0907
	St. Mary’s Hospital

	 	Hudson
	 	H0908
	Hunterdown Medical Center

	 	Hunterdon
	 	H1001
	Senator Garrett W Hagedorn Gero-Psychiatric Hospital

	 	Hunterdon
	 	P1002
	Capital Health System — Fuld Campus

	 	Mercer
	 	H1101

 

 

Exhibit 10.6.9

	 	 	 	 	 
	Hospital Name	 	County Location	 	Codes
	Capital Health System — Mercer Campus

	 	Mercer
	 	H1102
	University Medical Center at Princeton

	 	Mercer
	 	H1103
	Robert Wood Johnson University Hospital At Hamilton

	 	Mercer
	 	H1104
	St. Francis Medical Center

	 	Mercer
	 	H1105
	St. Lawrence Rehabilitation center

	 	Mercer
	 	R1106
	Trenton Psychiatric Hospital

	 	Mercer
	 	P1107
	JFK Medical Center

	 	Middlesex
	 	H1201
	Raritan Bay Medical Center — Old Bridge

	 	Middlesex
	 	H1212
	Raritan Bay Medical Center — Perth Amboy

	 	Middlesex
	 	H1203
	Robert Wood Johnson University Hospital — New Brunswick

	 	Middlesex
	 	H1204
	St. Peter’s University Hospital

	 	Middlesex
	 	H1205
	JFK Johnson Rehabilitation Hospital

	 	Middlesex
	 	R1206
	University Behavioral HealthCare

	 	Middlesex
	 	P1207
	Bayshore Community Hospital

	 	Monmouth
	 	H1301
	CentraState Healthcare System

	 	Monmouth
	 	H1302
	Jersey Shore University Medical Center

	 	Monmouth
	 	H1303
	Monmouth Medical Center

	 	Monmouth
	 	H1304
	Riverview Medical Center

	 	Monmouth
	 	H1305
	HEALTHSOUTH Rehabilitation Hospital at Tinton Falls

	 	Monmouth
	 	R1306
	Chilton Memorial Hospital

	 	Morris
	 	H1401
	Morristown Memorial Hospital

	 	Morris
	 	H1402
	St. Clare’s Health Services — Denville

	 	Morris
	 	H1403
	Greystone Park Psychiatric Hospital

	 	Morris
	 	P1404
	Kessler Institute for Rehabilitation
Corporation-Kessler Welkind

	 	Morris
	 	R1405
	St. Clare’s Hospital Boonton Township

	 	Morris
	 	P1406
	Community Medical Center

	 	Ocean
	 	H1501
	Kimball Medical Center

	 	Ocean
	 	H1502
	Meridian Health Ocean Medical Center

	 	Ocean
	 	H1503
	Southern Ocean County Hospital

	 	Ocean
	 	H1504
	HEALTHSOUTH Rehabilitation Hospital of Toms River

	 	Ocean
	 	H1505

 

 

Exhibit 10.6.9

	 	 	 	 	 
	Hospital Name	 	County Location	 	Codes
	St. Barnabas Behavioral Health Network

	 	Ocean
	 	P1506
	Barnert Hospital

	 	Passaic
	 	H1601
	Passaic Beth Israel Regional Health Network

	 	Passaic
	 	H1602
	St. Joseph’s Hospital and Medical Center — Paterson

	 	Passaic
	 	H1603
	St. Joseph’s Wayne Hospital

	 	Passaic
	 	H1604
	St. Mary’s Hospital Passaic

	 	Passaic
	 	H1605
	South Jersey Healthcare — Elmer Hospital

	 	Salem
	 	H1701
	The Memorial Hospital of Salem county

	 	Salem
	 	H1702
	Carrier Clinic

	 	Somerset
	 	P1801
	The Matheny School and Hospital

	 	Somerset
	 	S1802
	Somerset Medical Center

	 	Somerset
	 	H1803
	VA New Jersey Health Care System Lyons

	 	Somerset
	 	V1804
	Newton Memorial Hospital

	 	Sussex
	 	H1901
	St. Clare’s Hospital /Sussex

	 	Sussex
	 	H1902
	Muhlenburg Regional Medical Center

	 	Union
	 	H2001
	Overlook Hospital

	 	Union
	 	H2002
	Robert Wood Johnson University Hospital at Rahway

	 	Union
	 	H2003
	Trinitas Hospital Williamson Street Campus

	 	Union
	 	H2004
	Union Hospital

	 	Union
	 	H2005
	Children’s Specialized Hospital

	 	Union
	 	R2006
	Runnells Specialized Hospital

	 	Union
	 	S2007
	Summit Hospital

	 	Union
	 	P2008
	Hackettstown Community Hospital

	 	Warren
	 	H2101
	Warren Hospital

	 	Warren
	 	H2102

 

 

Exhibit 10.6.9

	 	 	 	 	 
	HOSPITAL NAME	 	COUNTY LOCATION	 	CODES
	Ancora Psychiatric Hospital

	 	Atlantic
	 	P0101
	Atlantic City Medical Center — City Division

	 	Atlantic
	 	H0102
	Atlantic City Medical Center — Mainland Division

	 	Atlantic
	 	H0103
	Bacharach Institute for Rehabilitation

	 	Atlantic
	 	R0104
	Shore Medical Hospital

	 	Atlantic
	 	H0105
	William B. Kessler Memorial Hospital

	 	Atlantic
	 	R0106
	Bergen Regional Medical Center

	 	Bergen
	 	H0201
	Christian Health Care Center

	 	Bergen
	 	P0202
	Englewood Hospital and Medical Center

	 	Bergen
	 	H0203
	Hackensack University Medical Center

	 	Bergen
	 	H0204
	Holy Name Hospital 

	 	Bergen
	 	H0205
	Kessler Institution for Rehabilitation — Kessler North

	 	Bergen
	 	R0206
	Pascack Valley Hospital 

	 	Bergen
	 	H0207
	Valley Health System — The Valley Hospital 

	 	Bergen
	 	H0208
	Lourdes Medical Center of Burlington County

	 	Burlington
	 	H0301
	Deborah Heart and Lung Center

	 	Burlington
	 	S0302
	Hampton Hospital

	 	Burlington
	 	P0303
	Mediplex Rehabilitation Hospital 

	 	Burlington
	 	R0304
	Virtua Health — Virtua Memorial Hospital Burlington

	 	Burlington
	 	H0305
	Virtua Health — Virtua West Jersey Hospital Marlton

	 	Burlington
	 	H0306
	Voorhees Pediatric Rehabilitation Hospital 

	 	Burlington
	 	R0307
	The Cooper Health System

	 	Camden 
	 	H0401
	Kennedy Memorial Hospital- Cherry Hill

	 	Camden 
	 	H0402
	Kennedy Memorial Hospital- Stratford

	 	Camden 
	 	H0403
	Lourdes Health System-Our Lady of Lourdes Medical
Center

	 	Camden 
	 	H0404
	Virtua West Jersey Hospital — Berlin

	 	Camden 
	 	H0405
	Virtua West Jersey Hospital  — Voorhees

	 	Camden 
	 	H0406
	Burdette Tomlin Memorial Hospital 

	 	Cape May
	 	H0501
	South Jersey Health System- South Jersey Hospital
Bridgeton 

	 	Cumerland
	 	H0601

 

 

Exhibit 10.6.9

	 	 	 	 	 
	HOSPITAL NAME	 	COUNTY LOCATION	 	CODES
	South Jersey Health system South Jersey Hospital - Vineland

	 	Cumberland
	 	H0602
	Clara Maas Medical Center

	 	Essex
	 	H0701
	Columbus Hospital

	 	Essex
	 	H0702
	East Orange General Hospital

	 	Essex
	 	H0703
	Hospital Center at Orange

	 	Essex
	 	H0704
	Irvington General Hospital 

	 	Essex
	 	H0705
	Kessler Institution for Rehabilitation — Kessler East

	 	Essex
	 	R0706
	Kessler Institution for Rehabilitation — Kessler West

	 	Essex
	 	R0707
	Newark Beth Israel Medical Center 

	 	Essex
	 	H0708
	St. Barnabas Medical Center 

	 	Essex
	 	H0709
	St. James Hospital

	 	Essex
	 	H0710
	St. Michael’s Medical Center 

	 	Essex
	 	H0711
	The Mountainside Hospital 

	 	Essex
	 	H0712
	UMDNJ — University Hospital 

	 	Essex
	 	H0713
	VA New Jersey Health care System — East Orange

	 	Essex
	 	V0714
	Essex County Hospital Center

	 	Essex
	 	P0715
	Kennedy Memorial Hospitals — UMC Washington Township

	 	Gloucester
	 	H0801
	Underwood Memorial Hospital 

	 	Gloucester
	 	H0802
	Bayonne Medical Center 

	 	Hudson 
	 	H0901
	Christ Hospital 

	 	Hudson 
	 	H0902
	Liberty Health Care System — Greenview Hospital Campus

	 	Hudson 
	 	H0903
	Liberty Health Care System — Jersey City Medical Center
Campus

	 	Hudson 
	 	H0904
	Liberty Health Care System — Meadowlands Hospital
Campus

	 	Hudson 
	 	H0905
	Palisades Medical Center — New York Presbyterian Health
Care System

	 	Hudson 
	 	H0906
	St. Mary’s Hospital

	 	Hudson 
	 	H0907
	West Hudson Hospital 

	 	Hudson
	 	H0908
	Hunterdon Medical Center 

	 	Hunterdon
	 	H1001
	Senator Garrett W Hagedorn Gero-Psychiatric Hospital 

	 	Hunterdon
	 	P1002
	Capital Health System — Fuld Campus

	 	Mercer
	 	H1101
	Capital Health System — Mercer Campus

	 	Mercer
	 	H1102

 

 

Exhibit 10.6.9

	 	 	 	 	 
	HOSPITAL NAME	 	COUNTY LOCATION	 	CODES
	The Medical Center at Princeton

	 	Mercer
	 	H1103
	Robert Wood Johnson University Hospital Hamilton

	 	Mercer
	 	H1104
	St. Francis Medical Center 

	 	Mercer
	 	H1105
	St. Lawrence Rehabilitation center 

	 	Mercer
	 	R1106
	Trenton Psychiatric Hospital 

	 	Mercer
	 	P1107
	JFK Medical Center 

	 	Middlesex
	 	H1201
	Raritan Bay Medical Center — Old Bridge

	 	Middlesex
	 	H1212
	Raritan Bay Medical Center — Perth Amboy

	 	Middlesex
	 	H1203
	Robert Wood Johnson University Hospital — New
Brunswick

	 	Middlesex
	 	H1204
	St. Peter’s University Hospital 

	 	Middlesex
	 	H1205
	JFK Johnson Rehabilitation Hospital 

	 	Middlesex
	 	R1206
	University Behavioral HealthCare

	 	Middlesex
	 	P1207
	Bayshore Community Hospital 

	 	Monmouth
	 	H1301
	CentraState Healthcare System

	 	Monmouth
	 	H1302
	Jersey Shore University Medical Center 

	 	Monmouth
	 	H1303
	Monmouth Medical Center 

	 	Monmouth
	 	H1304
	Riverview Medical Center 

	 	Monmouth
	 	H1305
	HEALTHSOUTH Rehabilitation Hospital at Tinton Falls

	 	Monmouth
	 	R1306
	Chilton Memorial Hospital 

	 	Morris 
	 	H1401
	Morristown Memorial Hospital 

	 	Morris 
	 	H1402
	St. Clare’s Health Services — Denville

	 	Morris 
	 	H1403
	Greystone Park Psychiatric Hospital 

	 	Morris 
	 	P1404
	Kessler Rehabilitation Corporation- Kessler Welkind

	 	Morris 
	 	R1405
	St. Clare’s Health Services Boonton

	 	Morris 
	 	P1406
	St Barnabas Health Care System Community Medical Center

	 	Ocean 
	 	H1501
	St Barnabas Health Care System Kimbal Medical Center

	 	Ocean
	 	H1502
	Meridian Health Ocean Medical Center 

	 	Ocean
	 	H1503
	Southern Ocean County Hospital 

	 	Ocean
	 	H1504
	HEALTHSOUTH Rehabilitation Hospital of Toms River

	 	Ocean
	 	H1505
	St. Barnabas Behavioral Health Network

	 	Ocean
	 	P1506
	Barnert Hospital 

	 	Passaic
	 	H1601

 

 

Exhibit 10.6.9

	 	 	 	 	 
	HOSPITAL NAME	 	COUNTY LOCATION	 	CODES
	Beth Israel Hospital 

	 	Passaic
	 	H1602
	St. Joseph’s Hospital and Medical Center — Paterson

	 	Passaic
	 	H1603
	St. Joseph’s Wayne Hospital 

	 	Passaic
	 	H1604
	St. Mary’s Hospital Passaic

	 	Passaic
	 	H1605
	The General Hospital Center At Passaic

	 	Passaic 
	 	H1606
	South Jersey Healthcare — Elmer Hospital 

	 	Salem
	 	H1701
	The Memorial Hospital of Salem county 

	 	Salem
	 	H1702
	Carrier Clinic

	 	Somerset
	 	P1801
	The Matheny School and Hospital 

	 	Somerset
	 	S1802
	Somerset Medical Center 

	 	Somerset
	 	H1803
	VA New Jersey Health Care System VA Medical Center 

	 	Somerset
	 	V1804
	Newton Memorial Hospital 

	 	Sussex
	 	H1901
	St. Clare’s Health Services/Sussex

	 	Sussex
	 	H1902
	Solaris Health System — Muhlenburg Regional Medical
Center

	 	Union
	 	H2001
	Atlantic Health System Overlook Hospital 

	 	Union
	 	H2002
	Rahway Hospital 

	 	Union
	 	H2003
	RJW Health Systems Children’s Specialized Hospital

	 	Union
	 	H2003
	Runnells Specialized Hospital 

	 	Union
	 	S2007
	Summit Hospital 

	 	Union
	 	P2008
	Hackettstown Community Hospital 

	 	Warren
	 	H2101
	Warren Hospital 

	 	Warren 
	 	H2102

 

 

Exhibit 10.6.9

B — Report Specifications

1) Prepare a separate geographic accessibility analysis for each county. Restrict provider groups
to service area equal to county. Separate analyses are required for each of the following:

	 	 	 	 	 	 	 
	 	 	Beneficiaries - Include all AFDC, DYFS, NJ FamilyCare, SSI-ABD
	Provider Type	 	All Ages	 	Children under 21	 	Adults 21 and up
	Adult PCPs (FP, FP,

IM OB/GYN-women

only

	 	 	 	 	 	Page Codes 1-9
	Pediatric PCPs (FP,
Ped., GP)
	 	 	 	 	 	 
	General Dentists

	 	Page Codes 1-9	 	 	 	 
	Hospitals

	 	Page Codes 1-10 & 12	 	 	 	 
	Blood Drawing
Centers and Labs
that Draw Blood

	 	Page Codes 11 & 12	 	 	 	 

2) See Article 4.8.8 for standards A and B for each provider type. For example, eligibles
living in urban areas should have two PCPs within six miles. Mileage should be calculated on an
estimated driving distance basis.

3). Each of the analyses should consist of the pages indicated above.

	 	 	 	 	 
	Page	 	Access	 	 
	Code	 	Standard	 	Description
	1

	 	na*
	 	This cover page of each report includes plan name, county
beneficiary group and date.
	 
	2

	 	na*
	 	This page uses a graph to illustrate the percentage of
beneficiaries who have access to a group of providers at various
distances. It includes a table showing the average distances to
the nearest choices of one, two, three, four and five providers.
	 
	3

	 	na*
	 	This page shows, by zip code, the average distance for
beneficiaries to two providers and the percentage of
beneficiaries having two providers within 2, 6, 10 and 15 miles
	 
	4

	 	A
	 	This page shows the number of providers, the number of
beneficiaries with access to two providers and the average
distance to up to five providers for beneficiaries with access.
It also analyzes beneficiary accessibility in ten key cities.
	 
	5

	 	A
	 	This page shows, by zip code, the number and percentage of
beneficiaries who do not have access to a choice of two
providers and the average distance to one and two providers.
	 
	6

	 	B
	 	This page shows the number of providers the number of
beneficiaries with access to one provider and the average
distance to up to five providers for beneficiaries with access.
It also analyzes beneficiary

 

 

Exhibit 10.6.9

	 	 	 	 	 
	Page	 	Access	 	 
	Code	 	Standard	 	Description
	 

	 	 	 	accessibility in ten key cities.
	 
	7

	 	B
	 	This page shows, by zip code, the number and percentage of
beneficiaries who do not have access to one provider and their
average distance to one provider.
	 
	8

	 	na*
	 	This includes documentation about the report and its data sources
	 
	9

	 	A
	 	This county map shows beneficiary locations for those who do not
have access to two providers. Use 2 point black circles for
beneficiaries.
	 
	10

	 	na*
	 	This county map shows provider locations. Use 12 point light
gray circles for individual and 12 point black triangles for
multiple provider locations.
	 
	11

	 	na*
	 	This county map shows all beneficiaries and a five mile radius
circle around each provider location. The map should show only
“Radius 1” which should be transparent. Use provider and
beneficiary symbol specifications from page codes 9 and 10.
	 
	12

	 	na*
	 	This should be a hard copy of the geocoded provider file, which
must include name, specialty/type, address, zip code, individual
capacity (where applicable), geographic coordinates and
geocoding method return code.

 

	
	* na = no access standard applicable; information required

4) Save to dBASE file the geocoded provider file according to the specifications indicated in Figure
1.

Figure 1

	 	 	 
	Field Name	 	Description
	NAME1

	 	Last name for individual providers (include suffix, e.g., Jr. Sr.)

Entire name for institution
	NAME2

	 	First name and middle initial with period for individuals
	ADDRESS1

	 	Street number first then street name where medical care is actually provided
	ADDRESS2

	 	Additional information (e.g., suite #, building)
	STDCITY

	 	Standard city name according to geocoder output field
	STATE

	 	State
	ZIP

	 	Full zip codes in character or text format to show leading zeros
	SPECIALTY

	 	Primary specialty only for individual providers Provider type for institutions
	LONGITUDE

	 	Geocoded Longitude
	LATITUDE

	 	Geocoded Latitude
	GEOMETHOD

	 	Return codes from geocoder
	CAPACITY

	 	Individual capacity used for access analysis when applicable

Report specifications, calculations and supporting data files for geographic analysis reports
submitted to DMAHS must be retained in accordance with 45 CFR. Part 74 and made available on
request

 

 

Exhibit 10.6.9

A.7.1.A CERTIFICAION OF ENROLLMENT INFORMATION RELATING TO PAYMENT UNDER THE Medicaid/NJ FAMILYCARE
PROGRAM.

 

 

Exhibit 10.6.9

 A

(Sample Certification Form)

This certification includes the State of New Jersey’s proposed language for data submission
certification for the New Jersey Medicaid/NJ FamilyCare Program.

CERTIFICATION OF ENROLLMENT INFORMATION RELATING TO PAYMENT UNDER THE MEDICAID/NJ FAMILYCARE PROGRAM

CERTIFICATION

Pursuant to the contract(s) between the Department of Human services and the (name of managed
care organization (MCO), provider certifies that; the business entity named on this form is a
qualified provider enrolled with and authorized to participate in the New Jersey Medical Assistance
Program as an MCO designated as Plan number (insert Plan identification number(s) here).
(Name of MCO) acknowledges that if payment is based on enrollment data, Federal regulations at 42
CFR 438.600 (et.al.) require that the data submitted must be certified by a Chief Financial
Officer, Chief Executive Officer, or a person who reports directly to and who is authorized to sign
for the Chief Financial Officer or Chief Executive Officer.

(Name of MCO) hereby requests payment from the New Jersey Medical Assistance Program under
contracts based on enrollment data submitted and in doing so makes the following certification to
the Department of Human Services (DHS) as required by the Federal regulations at 42 CFR 438.600
(et.al.)

	 	 	(Name of MCO) has reported to the DHS for the month of (indicate month and
year) all new enrollments, disenrollments, and any changes in the enrollee’s status.
(Name of MCO) has reviewed the monthly membership report for the month of
(indicate month and year) and I, (enter Name of Chief Financial Officer, Chief
Executive Officer or Name of Person who Reports Directly to and Who is Authorized to Sign
for Chief Financial Officer or Chief Executive Officer) attest that based on best knowledge,
information, and belief as of the date indicated below, all information submitted to DHS in
this report is accurate, complete, and truthful, and I hereby certify that NO MATERIAL FACT
HAS BEEN OMITTED FROM THIS FORM AND/OR THE DATA SUBMISSION.

 

 

Exhibit 10.6.9

	 	 	I, (enter Name of Chief Financial Officer, Chief Executive Officer or Name of Person who
Reports Directly to and Who is Authorized to Sign for Chief Financial Officer or Chief
Executive Officer), ACKNOWLEDGE THAT THE INFORMATION DESCRIBED ABOVE MAY DIRECTLY AFFECT THE
CALCULATION OF PAYMENTS TO (Name of MCO). I UNDERSTAND THAT I MUST COMPLY WITH ALL
APPLICABLE FEDERAL AND STATE LAWS FOR ANY FALSE CLAIMS, STATEMENTS, OR DOCUMENTS, OR
CONCEALMENT OF A MATERIAL FACT. I HAVE READ AND AM FAMILIAR WITH THE CONTENTS OF THIS
SUBMISSION.

	 	 	 
	 

	 	 
	 

	 	(INDICATE NAME AND TILTE
	 

	 	CFO, CEO OR DELGATE))
	 

	 	On behalf of
	 
	 	 
	 

	 	 
	 

	 	(INDICATE NAME OF BUSINESS ENTITY)
	 
	 	 
	 

	 	 
	 

	 	DATE

 

 

Exhibit 10.6.9

A.7.1.B CERTIFICATION OF ECOUNTER INFORMATION RELATING TO PAYMENT UNDER THE MEDICAID/NJ FAMILYCARE PROGRAM

 

 

Exhibit 10.6.9

 B

(Sample Certification Form)

This certification includes the State of New Jersey’s proposed language for data submission
certification for the New Jersey Medicaid/NJ FamilyCare Program.

CERTIFICATION OF ENCOUNTER INFORMATION RELATING TO PAYMENT UNDER THE MEDICAID/NJ FAMILYCARE PROGRAM

CERTIFICATION

Pursuant to the contract(s) between the Department of Human Services and the (name of managed
care organization (MCO), provider certifies that; the business entity named on this form is a
qualified provider enrolled with and authorized to participate in the New Jersey Medical Assistance
Program as an MCO designated as Plan number (insert Plan identification number(s) here).
(Name of MCO) acknowledges that if payment is based on encounter data, Federal regulations
at 42 CFR 438.600 (et.al.) require that the data submitted must be certified by a Chief Financial
Officer, Chief Executive Officer, or a person who reports directly to and who is authorized to sign
for the Chief Financial Officer or Chief Executive Officer.

(Name of MCO) hereby requests payment from the New Jersey Medical Assistance Program under
contracts based on encounter data submitted and in doing so makes the following certification to
the Department of Human Services (DHS) as required by the Federal regulations at 42 CFR 438.600
(et.al.)

	 	 	(Name of MCO) has reported to the DHS for the month of (indicate month and
year) all new encounters, (indicate type of data — inpatient hospital, outpatient hospital,
physician, etc.). (Name of MCO) has reviewed the encounter data for the month of
(indicate month and year) and I, (enter Name of Chief Financial Officer, Chief
Executive Officer or Name of Person who Reports Directly to and Who is Authorized to Sign
for Chief Financial Officer or Chief Executive Officer) attest that based on best knowledge,
information, and belief as of the date indicated below, all information submitted to DHS in
this report is accurate, complete, and truthful, and I hereby certify that NO
MATERIAL FACT HAS BEEN OMITTED FROM THIS FORM AND/OR THE DATA SUBMISSION.

 

 

Exhibit 10.6.9

	 	 	I, (enter Name of Chief Financial Officer, Chief Executive Officer or Name of Person who
Reports Directly to and Who is Authorized to Sign for Chief Financial Officer or Chief
Executive Officer), ACKNOWLEDGE THAT THE INFORMATION DESCRIBED ABOVE MAY DIRECTLY AFFECT THE
CALCULATION OF PAYMENTS TO (Name of MCO). I UNDERSTAND THAT I MUST COMPLY WITH ALL
APPLICABLE FEDERAL AND STATE LAWS FOR ANY FALSE CLAIMS, STATEMENTS, OR DOCUMENTS, OR
CONCEALMENT OF A MATERIAL FACT. I HAVE READ AND AM FAMILIAR WITH THE CONTENTS OF THIS
SUBMISSION.

	 	 	 
	 

	 	 
	 

	 	(INDICATE NAME AND TILTE
	 

	 	CFO, CEO OR DELGATE))
	 

	 	On behalf of
	 
	 	 
	 

	 	 
	 

	 	(INDICATE NAME OF BUSINESS ENTITY)
	 
	 	 
	 

	 	 
	 

	 	DATE

 

 

Exhibit 10.6.9

A.7.1.C CERTIFICATION OF ANY INFORMATION REQUIRED BY THE STATE AND CONTAINED IN
CONTRACTS, PROPOSALS, AND RELATED DOCUMENTS RELATING TO PAYMENT UNDER THE MEDICAID/NJ
FAMILYCARE PROGRAM.

 

 

Exhibit 10.6.9

 C

(Sample Certification Form)

This certification includes the State of New Jersey’s proposed language for data submission
certification for the New Jersey Medicaid/NJ FamilyCare Program.

CERTIFICATION OF ANY INFORMATION REQUIRED BY THE STATE AND CONTAINED IN CONTRACTS, PROPOSALS, AND RELATED DOCUMENTS RELATING TO PAYMENT UNDER THE MEDICAID/NJ FAMILYCARE PROGRAM

CERTIFICATION

Pursuant to the contract(s) between the Department of Human services and the (name of managed
care organization (MCO), provider certifies that; the business entity named on this form is a
qualified provider enrolled with and authorized to participate in the New Jersey Medical Assistance
Program as an MCO designated as Plan number (insert Plan identification number(s) here).
(Name of MCO) acknowledges that if payment is based on any information required by the State and
contained in contracts, proposals, and related documents, Federal regulations at 42 CFR 438.600
(et.al.) require that the data submitted must be certified by a Chief Financial Officer, Chief
Executive Officer, or a person who reports directly to and who is authorized to sign for the Chief
Financial Officer or Chief Executive Officer.

(Name of MCO) hereby requests payment from the New Jersey Medical Assistance Program under
contracts based on any information required by the State and contained in contracts, proposals, and
related documents submitted and in doing so makes the following certification to the Department of
Human Services (DHS) as required by the Federal regulations at 42 CFR 438.600 (et.al.)

	 	 	(Name of MCO) has reported to the DHS for the period of (indicate dates) all
information required by the State and contained in contracts, proposals, and related
documents submitted. (Name of MCO) has reviewed the monthly membership report for
the period of (indicate dates) and I, (enter Name of Chief Financial Officer,
Chief Executive Officer or Name of Person who Reports Directly to and Who is
Authorized to Sign for Chief Financial Officer or Chief Executive Officer) attest that
based on best knowledge, information, and belief as of the date indicated below, all
information submitted to DHS in this report is

 

 

Exhibit 10.6.9

	 	 	accurate, complete, and truthful, and I hereby certify that NO MATERIAL FACT HAS BEEN
OMITTED FROM THIS FORM AND/OR THE DATA SUBMISSION.

	 	 	I, (enter Name of Chief Financial Officer, Chief Executive Officer or Name of Person who
Reports Directly to and Who is Authorized to Sign for Chief Financial Officer or Chief
Executive Officer), ACKNOWLEDGE THAT THE INFORMATION DESCRIBED ABOVE MAY DIRECTLY AFFECT
THE CALCULATION OF PAYMENTS TO (Name of MCO). I UNDERSTAND THAT I MUST COMPLY WITH ALL
APPLICABLE FEDERAL AND STATE LAWS FOR ANY FALSE CLAIMS, STATEMENTS, OR DOCUMENTS, OR
CONCEALMENT OF A MATERIAL FACT. I HAVE READ AND AM FAMILIAR WITH THE CONTENTS OF THIS
SUBMISSION.

	 	 	 
	 

	 	 
	 

	 	(INDICATE NAME AND TILTE
	 

	 	CFO, CEO OR DELGATE))
	 

	 	On behalf of
	 
	 	 
	 

	 	 
	 

	 	(INDICATE NAME OF BUSINESS ENTITY)
	 
	 	 
	 

	 	 
	 

	 	DATE

 

 

Exhibit 10.6.9

A.7.1.E. Certification of HIV/AIDS/Hemophilia

 

 

Exhibit 10.6.9

E.

HIV/AIDS/Hemophilia

	 	 	 
	 

	 	Month of Certification                                        
	 

	 	Run Date                                                            

I,                                          , hereby certify on behalf of                                                             

Name of Medical Director                                                            Name of HMO

that                                         , Medicaid ID number                
                                       
      

           Name of Member

a member of said HMO, has been diagnosed by his/her treating physician with and/or is being
treated for HIV or AIDS or Hemophilia requiring Factors VIII or IX (circle any that apply).
If including more than one member, you may attach a written list of members specifying the
diagnosis of each individual.

The number of members with HIV is                     ; AIDS                     ; Factor VIII                    ; Factor IX                     
I certify that the foregoing statements are true, and attest that based on best knowledge,
information, and belief as of the date indicated below, all information submitted to DMAHS
is accurate, complete and truthful, and certify that no material fact has been omitted from
this form. I am aware that if any foregoing statements made by me are willfully false,
                                        , may be subject to the imposition

	 	 	 
	Name of HMO

of sanctions and/or liquidated damages. I understand that I must abide by all applicable
Federal and State laws for any false claims, statements, or documents, or concealment of a
material fact. I have read and am familiar with the contents of this submission.

Signature of Medical Director:

Print Name:

Title:

Date:

 

 

Exhibit 10.6.9

A.7.2 Fraud and Abuse

A. the contractor shall report to the Department all identified instances (proven or
suspected) of provider, subcontractor, and enrollee fraud and abuse with supporting case
documentation attached to the report.

The contractor must submit quarterly the following report with monthly data identified by
reporting month:
Month

Year

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Beginning of month	 	Added during the month	 	Completed/Closed	 	End of Month
	 	 	Provider	 	Enrollee	 	Provider	 	Enrollee	 	Provider	 	Enrollee	 	Provider	 	Enrollee
	# of Cases
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Totals
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

B. The contractor must report in detail to DMAHS the following information for cases
involving providers, subcontractors, and enrollees:

Case Name

Date Opened

Reason for initiating case

Date of notification to DMAHS

Date of approval from DMAHS

Personnel assigned to case

Date of completion

Findings

Date of screening with DMAHS

Actions

 

 

Exhibit 10.6.9

C. The contractor must submit quarterly the following report of FTE hours devoted solely
to DMAHS related fraud and abuse cases, reviews and initiatives. The contractor shall report
the data by employee.

	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	TOTAL HOURS
	 	 	 	 	 	 	 	 	DEVOTED
	 	 	 	 	DMAHS RELATED FRAUD AND	 	SOLELY TO
	 	 	 	 	ABUSE CASE(S), REVIEWS, AND	 	DMAHS
	EMPLOYEE	 	INITIATIVE(S0	 	FRAUD/ABUSE
	 	 	 	 	Name/Description(List 	 	 	 	 
	 	 	 	 	each case, review or	 	 	 	 
	 	 	 	 	initiative separately,	 	 	 	 
	 	 	 	 	along with hours 	 	 	 	 
	 	 	 	 	devoted solely to	 	 	 	 
	Last Name	 	First Name	 	DMAHS for each)	 	Sub total Hours	 	Total Hours
	 
	 	 	 	 	 	 	 	 

 

 

Exhibit 10.6.9

A.7.3

Table 1 Medicaid Enrollment by Primary Care Providers

Listed alphabetically by provider type and for each primary care physician, primary care
dentist, primary care CNP/CNS, and primary care physician assistant, the contractor shall
enter the total number of enrollees at the end of the prior quarter and for the
reporting period and any member months for the quarter. 

 

 

Exhibit 10.6.9

	 	 	 
	STATE OF NEW JERSEY
	 	 
	Plan Name                                                                                 

	 	Quarter Ending                                         

TABLE 1

MEDICAID ENROLLMENT BY PRIMARY CARE PROVIDERS

	 	 	 	 	 	 	 	 	 	 	 
	Primary Care Providers	 	 	 	 	 	 	 	 	 	 
	List, by type of provider,	 	 	 	 	 	 	 	 	 	 
	alphabetically by last	 	 	 	 	 	 	 	 	 	 
	name with one line for	 	 	 	 	 	# of Enrollees	 	Total # of	 	Total Member
	each county in which	 	 	 	 	 	at End of Prior	 	Enrollees for	 	Months for
	provider practices	 	Specialty	 	County	 	Quarter	 	Reporting Period	 	Quarter
	Primary Care Physicians
	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Dentists
	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	CNP/CNSs
	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Physician Assistants
	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Total
	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Total # PCPs
	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Total # PCPs with Enrollees
	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Total # PCPs without Enrollees
	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Total # Dentists
	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Total # Dentists with Enrollees
	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Total # Dentists without Enrollees
	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Total # CNP/CNSs
	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Total # CNP/CNSs with Enrollees
	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Total # CNP/CNSs without Enrollees
	 	 	 	 	 	 	 	 	 	 

 

 

Exhibit 10.6.9

	 	 	 	 	 	 	 	 	 	 	 
	Primary Care Providers	 	 	 	 	 	 	 	 	 	 
	List, by type of provider,	 	 	 	 	 	 	 	 	 	 
	alphabetically by last	 	 	 	 	 	 	 	 	 	 
	name with one line for	 	 	 	 	 	# of Enrollees	 	Total # of	 	Total Member
	each county in which	 	 	 	 	 	at End of Prior	 	Enrollees for	 	Months for
	provider practices	 	Specialty	 	County	 	Quarter	 	Reporting Period	 	Quarter
	Total # Pas
	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Total # PAs with Enrollees
	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Total # PAs without Enrollees
	 	 	 	 	 	 	 	 	 	 

 

 

Exhibit 10.6.9

A.7.4 Reserved

Table 2 Disenrollment Form Plan

The contractor shall aggregate the disenrollment from the plan of the number of enrollees
(not cases/families) by eligibility category and reason for disenrollment by identifying
involuntary (Section A) and voluntary (Section B) disenrollments. All reasons must be
explained in the appropriate space provided.

“NJ FamilyCare” in this and other tables includes Plans B, C, D and H. 

 

 

Exhibit 10.6.9

STATE OF NEW JERSEY

Plan Name                                                            Quarter Ending

TABLE 2

DISENROLLMENT FORM PLAZN

A. Involuntary Disenrollment By Reason

	 	 	 	 	 	 	 	 	 	 	 
	 	 	A	 	D	 	SSI	 	NJ	 	T
	 	 	FDC	 	YFS	 	ABD	 	FamilyCare	 	QTAL
	Death
	 	 	 	 	 	 	 	 	 	 
	Institutionalized
	 	 	 	 	 	 	 	 	 	 
	Moved from Enrollment Areas
	 	 	 	 	 	 	 	 	 	 
	Loss of Medicaid Eligibility
	 	 	 	 	 	 	 	 	 	 
	Change in Medicaid Aid Category
	 	 	 	 	 	 	 	 	 	 
	Termination By Plan
	 	 	 	 	 	 	 	 	 	 
	Other*
	 	 	 	 	 	 	 	 	 	 
	TOTAL
	 	 	 	 	 	 	 	 	 	 

 

*Explanation of Other

B. Voluntary Disenrollment By Reason

	 	 	 	 	 	 	 	 	 	 	 
	 	 	A	 	D	 	SSI	 	NJ	 	T
	 	 	FDC	 	YFS	 	ABD	 	FamilyCare	 	QTAL
	Closed Panel of Providers
	 	 	 	 	 	 	 	 	 	 
	Emergency Treatment Procedures
	 	 	 	 	 	 	 	 	 	 
	Delay in securing Appointments
	 	 	 	 	 	 	 	 	 	 
	Dissatisfaction with PCP
	 	 	 	 	 	 	 	 	 	 
	Other*
	 	 	 	 	 	 	 	 	 	 
	TOTAL
	 	 	 	 	 	 	 	 	 	 

 

*Explanation of Other

 

 

Exhibit 10.6.9

A.7.6 Reserved

Table 4 Claims Lag Report

 

 

Exhibit 10.6.9

A.7.6

Table 4 Claims Lag Report

Table 4A

Note: Use this form to report manually submitted claims that were processed
during the quarterly period. Claims submitted and processed electronically must be reported
separately on Table 4B. Manual claims submission shall be processed within 40 days of
receipt.

Report amounts for each category of service and total listed in column 1 in
the following columns:

Non-Processed Claims from Prior Quarters (column 2). Enter the number of
manually submitted claims on hand that were unprocessed as of the closing date of the last
quarterly period. The number should be the same as was reported in Column 16 of the prior
quarterly report.

Claims Rec’d During Quarter (Column 3) Enter the amount of all manually
submitted claims that were received during the quarterly period being reported.

Total Claims (Column 4). Enter the total of Columns 2 and 3.

Claims Processed This Quarter (Column 5) — Enter the amount of all manually
submitted claims processed (both paid and denied) during the quarterly period being
reported. Do not count pended claims.

1-40 Days (Column 6) Enter the number of manually submitted claims that were processed
(either paid or denied) within 40 days of their receipt. Note: The number of days required
to process a claim is calculated by comparing the date the claim was received by the
contractor to the date the claim was paid or denied by the contractor (See Article 7.16.5 of
this contract for further details.).

% of Total (Column 7) Enter the percentage of manually submitted claims
processed within 40 days (Compared to the total claims processed. Divide Column 6 by Column
5 to arrive at percent).

41-60 Days (Column 8) Enter the number of manually submitted claims that were
processed (either paid or denied) between 41-60 days of their receipt

 

 

Exhibit 10.6.9

% of Total (Column 9) Enter the percentage of manually submitted claims
processed within between 41-60 days (Compared to the total claims processed. Divide Column 8
by Column 5 to arrive at percent).

61-90 Days (Column 10) Enter the number of manually submitted claims that were
processed (either paid or denied) between 61-90 days of their receipt

% of Total (Column 11) Enter the percentage of manually submitted claims processed within
between 61-90 days (Compared to the total claims processed. Divide Column 12 by Column 5 to
arrive at percent).

91-120 Days (Column 8) Enter the number of manually submitted claims that were
processed (either paid or denied) between 90-120 days of their receipt

% of Total (Column 9) Enter the percentage of manually submitted claims
processed within between 90-120 days (Compared to the total claims processed. Divide Column
14 by Column 5 to arrive at percent).

Non Processed Claims on Hand at End of Quarter (Column 16). Enter the number
of manually submitted claims on hand that were not processed as of closing date of the last
report period. (Should be the difference of Column 4 minus Column 5). Same number should
match number of claims entered in column 2 of next quarter reports.

% of Claims Not Processed at End of Quarter (Column 17). Divide Column 16 by
Column 4 to arrive at percent.

 

 

Exhibit 10.6.9

>120 Days (Column 8) Enter the number of manually submitted claims that
were processed (either paid or denied) after 120 days of their receipt

 

 

Exhibit 10.6.9

Table 4B

Note: Use this form to report electronically submitted claims that were
processed during the quarterly period. Claims submitted and processed electronically must be
reported separately on Table 4A. Electronic Claims submission shall be processed within 30
days of receipt.

Report amounts for each category of service and total listed in Column 1 in
the following columns:

Non-Processed Claims from Prior Quarters (Column 2). Enter the number of
electronically submitted claims on hand that were unprocessed as of the closing date of the
last quarterly period. The number should be the same as was reported in Column 16 of the
prior quarterly report.

Claims Rec’d During Quarter (Column 3) Enter the amount of all electronically
submitted claims that were received during the quarterly period being reported.

Total Claims (Column 4). Enter the total of Columns 2 and 3.

Claims Processed This Quarter (Column 5) — Enter the amount of all
electronically submitted claims processed (both paid and denied) during the quarterly period
being reported. Do not count pended claims.

1-30 Days (Column 6) Enter the number of electronically submitted claims that
were processed (either paid or denied) within 30 days of their receipt. Note: The number of
days required to process a claim is calculated by comparing the date the claim was received
by the contractor to the date the claim was paid or denied by the contractor (See Article
7.16.5 of this contract for further details.).

% of Total (Column 7) Enter the percentage of electronically submitted claims
processed within 30 days (Compared to the total claims processed. Divide Column 6 by Column
5 to arrive at percent).

31-60 Days (Column 8) Enter the number of electronically submitted claims that
were processed (either paid or denied) between 31-60 days of their receipt

% of Total (Column 9) Enter the percentage of electronically submitted claims
processed within between 31-60 days (Compared to the total claims processed. Divide Column 8
by Column 5 to arrive at percent).

61-90 Days (Column 10) Enter the number of electronically submitted claims
that were processed (either paid or denied) between 61-90 days of their receipt

 

 

Exhibit 10.6.9

% of Total (Column 11) Enter the percentage of electronically submitted claims
processed within between 61-90 days (Compared to the total claims processed. Divide Column
12 by Column 5 to arrive at percent).

91-120 Days (Column 8) Enter the number of electronically submitted claims
that were processed (either paid or denied) between 91-120 days of their receipt

% of Total (Column 9) Enter the percentage of electronically submitted claims
processed within between 91-120 days (Compared to the total claims processed. Divide Column
14 by Column 5 to arrive at percent).

Non Processed Claims on Hand at End of Quarter (Column 16). Enter the number
of electronically submitted claims on hand that were not processed as of closing date of the
last report period. (Should be the difference of Column 4 minus Column 5). Same number
should match number of claims entered in column 2 of next quarter reports.

% of Claims Not Processed at End of Quarter (Column 17). Divide Column 16 by
Column 4 to arrive at percent. 

 

 

Exhibit 10.6.9

STATE OF NEW JERSEY

	 	 	 
	Plan Name

	 	Quarter
Ending

Table 4A

CLAIMS LAG REPORT FOR MANUALLY SUBMITTED CLAIMS

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1	 	2	 	 	3	 	 	4	 	 	5	 	 	Claims Processed During Quarter	 
	 	 	Non	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Processed	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Non	 	 	% of Claims	 
	 	 	claims	 	 	Claims	 	 	Total	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Processed	 	 	not	 
	 	 	from	 	 	Rec’d	 	 	Claims	 	 	Claims processed this	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Claims on	 	 	Processed	 
	 	 	prior	 	 	 During	 	 	(cols	 	 	quarter (cols	 	 	1-40	 	 	Of	 	 	1-60	 	 	Of	 	 	1-90	 	 	0f-1-120	 	 	Of	 	 	120	 	 	Of	 	 	Hand at End	 	 	at End of	 
	Category of services	 	quarter	 	 	Quarter	 	 	2+3)	 	 	6+8+10+12+14)	 	 	ays	 	 	etal	 	 	ays	 	 	etal	 	 	ays	 	 	etal	 	 	ays	 	 	etal	 	 	ays	 	 	of Quarter	 	 	Quarter	 
	Inpatient Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Primary Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Physician Specialty Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Hospital Outpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Other Professional Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Emergency Room
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	DME/Medical Supplies
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prosthetics
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Dental
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Pharmacy
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

 

Exhibit 10.6.9

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1	 	2	 	 	3	 	 	4	 	 	5	 	 	Claims Processed During Quarter	 
	 	 	Non	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Processed	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Non	 	 	% of Claims	 
	 	 	claims	 	 	Claims	 	 	Total	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Processed	 	 	not	 
	 	 	from	 	 	Rec’d	 	 	Claims	 	 	Claims processed this	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Claims on	 	 	Processed	 
	 	 	prior	 	 	 During	 	 	(cols	 	 	quarter (cols	 	 	1-40	 	 	Of	 	 	1-60	 	 	Of	 	 	1-90	 	 	0f-1-120	 	 	Of	 	 	120	 	 	Of	 	 	Hand at End	 	 	at End of	 
	Category of services	 	quarter	 	 	Quarter	 	 	2+3)	 	 	6+8+10+12+14)	 	 	ays	 	 	etal	 	 	ays	 	 	etal	 	 	ays	 	 	etal	 	 	ays	 	 	etal	 	 	ays	 	 	of Quarter	 	 	Quarter	 
	AIDS/HIV Reimbursable Drugs
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Home Health Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Lab and X-Ray
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Vision Care & Eyeglasses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Mental Health/Substance Abuse
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Other Medical
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

 

Exhibit 10.6.9

STATE OF NEW JERSEY

	 	 	 
	Plan Name

	 	Quarter
Ending

Table 4B

CLAIMS LAG REPORT FOR ELECTRONICALLY SUBMITTED CLAIMS

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1	 	2	 	 	3	 	 	4	 	 	5	 	 	Claims Processed During Quarter	 
	 	 	Non	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Processed	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Non	 	 	% of Claims	 
	 	 	claims	 	 	Claims	 	 	Total	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Processed	 	 	not	 
	 	 	from	 	 	Rec’d	 	 	Claims	 	 	Claims processed this	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Claims on	 	 	Processed	 
	 	 	prior	 	 	 During	 	 	(cols	 	 	quarter (cols	 	 	1-30	 	 	Of	 	 	1-60	 	 	Of	 	 	1-90	 	 	0f-1-120	 	 	Of	 	 	120	 	 	Of	 	 	Hand at End	 	 	at End of	 
	Category of services	 	quarter	 	 	Quarter	 	 	2+3)	 	 	6+8+10+12+14)	 	 	ays	 	 	etal	 	 	ays	 	 	etal	 	 	ays	 	 	etal	 	 	ays	 	 	etal	 	 	ays	 	 	of Quarter	 	 	Quarter	 
	Inpatient Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Primary Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Physician Specialty Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Hospital Outpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Other Professional Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Emergency Room
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	DME/Medical Supplies
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prosthetics
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Dental
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Pharmacy
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

 

Exhibit 10.6.9

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1	 	2	 	 	3	 	 	4	 	 	5	 	 	Claims Processed During Quarter	 
	 	 	Non	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Processed	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Non	 	 	% of Claims	 
	 	 	claims	 	 	Claims	 	 	Total	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Processed	 	 	not	 
	 	 	from	 	 	Rec’d	 	 	Claims	 	 	Claims processed this	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Claims on	 	 	Processed	 
	 	 	prior	 	 	 During	 	 	(cols	 	 	quarter (cols	 	 	1-30	 	 	Of	 	 	1-60	 	 	Of	 	 	1-90	 	 	0f-1-120	 	 	Of	 	 	120	 	 	Of	 	 	Hand at End	 	 	at End of	 
	Category of services	 	quarter	 	 	Quarter	 	 	2+3)	 	 	6+8+10+12+14)	 	 	ays	 	 	etal	 	 	ays	 	 	etal	 	 	ays	 	 	etal	 	 	ays	 	 	etal	 	 	ays	 	 	of Quarter	 	 	Quarter	 
	AIDS/HIV Reimbursable Drugs
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Home Health Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Lab and X-Ray
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Vision Care & Eyeglasses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Mental Health/Substance Abuse
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Other Medical
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

 

Exhibit 10.6.9

 

 

Exhibit 10.6.9

A.7.7

Table 5 Hospital Specific Data

Table 5

In Table 5, the contractor shall report on an annual basis, hospital-specific data for
Medicaid and NJ FamilyCare enrollees for whom hospital services were rendered during the
year. The first year to be reported shall be calendar year 2001, due by March 1, 2003.
Subsequent reporting shall follow this model. The contractor must provide data in Excel
format, (hard copy and electronically), only for those
hospitals listed on the spreadsheet. The contractor must combine data for hospitals to which
the contractor has assigned multiple provider numbers. The data elements required for each
hospital include:

Number of discharges

Patient Days

Outpatient visits

Inpatient charges

Inpatient payments

Outpatient charges

Outpatient payments

Use discharge date as service date for inpatient services.

For an updated list of hospitals, the contractor shall utilize the DHSS website:

www.state.nj.us/health/hcsa/hospitalsearch/index.html.

Click on “General Acute Care Hospital” and “Start Search”.

 

 

Exhibit 10.6.9

A.7.8

Table 6 Statement of Revenues and Expenses Allowable Direct
Medical Expenditures

The Contractor shall report quarterly its expenditures for allowable direct medical
activities for purposes of calculating the medical cost ratio.

The contractor shall report revenues and expenses for all Medicaid premium
groups on an accrual basis for each quarter of the calendar year (Table 6A). A cumulative
year to date report is also required in the second, third, and fourth quarters of the
calendar year (Table 6B).

Note: Shaded blocks are not required to be completed.

1. Member months

REVENUE

2. Capitated Premiums — Revenue recognized on a prepaid basis for enrollees
for provision of a specified range of health services over a defined period of time,
normally one month. If Advance payments are made to the plan for m ore than one reporting
period, the portion of payment that has not been earned must be treated as a liability
(unearned Premiums).

3. Supplemental Premiums — Revenue paid to the pal in addition to capitated
premiums for certain services provided. .See a, b and c below.

a. Maternity (See Article 8)

b. HIV/AIDS Reimbursable Drugs

c. Other — Any other revenue paid by DMAHS to the plan in addition to
capitation for covered services that is not a or b above.

4. Total Premium — All Medicaid premiums paid to the plan reported on lines 2,
3a, 3b and 3c.

5 . Interest — Interest earned from all sources including escrow and reserve
accounts.

6. COB Income from Coordination of Benefits and Subrogation

7. Reinsurance Recoveries — income from the settlement of claims resulting
from a policy with a private reinsurance carrier.

8. Other Revenue. Revenue from sources not covered in the previous revenue
accounts

9. Total Revenue — Total revenue (the sum of lines 2 through 8).

 

 

Exhibit 10.6.9

EXPENSES: Report total actual expense on an accrual basis for each of the
medical and hospital categories below in column d. Report the applicable amounts for each of
the categories in columns a, b, and c as defined below.

Paid Claims (Column a) — Enter amounts of paid claims (claims for which checks
have actually been mailed) during the quarter for each medical and hospital category.

Reported by Unpaid Claims (RBUSs) (Column b) Enter the amount of all claims
which are received during the quarter by the plan for which a check has not yet been issued
for services during the quarter.

Incurred But Not Reported (IBNR) (column c) Enter estimated amounts of the
obligation for claims which have not yet been received by the plan for services rendered
during the quarter.

Actual PMPM (Column e). Enter the actual cost per member per month for each
line category. Divide the amount in column d by total member months online1 to arrive a the
dollar and cents number (use two decimal places, e.g. $14.25)

Medical and Hospital

10. Inpatient Hospital — Inpatient hospital costs including ancillary services
for enrollees while confined to an acute care hospital, including out of area
hospitalization.

11. Primary care — Includes all costs associated with medical services
provided in any setting by a primary care provider, including physicians and other
practitioners

12. Physician specialty services — All costs associated with medical services
provided by a physician other than a primary care physician.

13. Outpatient Hospital. Includes the facility component of the outpatient
visit. The visit can be free standing or a hospital outpatient department. The professional
component should be billed separately and reported in the appropriate service category line
item, e.g., physician specialty services.

14. Other Professional Services — Compensation paid by the contractor to non
physician providers engaged in the delivery of medical services.

15. Emergency Room — Includes the facility component of the emergency room
visit asd well as out of area emergency room costs. Professional components that are billed
separately should be reported in the appropriate service category line item.

16. DME/Medical Supplies ___include the cost of durable medical equipment and
supplies

 

 

Exhibit 10.6.9

17. Prosthetics and Orthotics — includes the cost of Prosthetics and Orthotics

18. Dental Expenses for all dental services provided.

19. Pharmacy — Expenses for legend and non-legend pharmacy services provided
that includes both ingredient costs and dispensing fees. Excludes expenses reported as
HIV/AIDS Reimbursable Drugs on line 20.

20. HIV/AIDS Reimbursable Drugs

21. Home Health Care — Expenses for home health services provided including
nurses, aides, hospice costs private duty nursing.

22. Transportation — Expenses for all ambulance, medical intensive care Units
(MICUs) and invalid coach services.

23. Lab & X-Ray. The cost of all laboratory and radiology (diagnostic
andtherpeutic) services for which the contractor is separately billed.

24. Vision Care including Eyeglasses — The cost of routine exams (by
non-physicians) and dispensing glasses to correct eye defects. This category includes the
cost of eyeglasses but excludes ophthalmologist costs related to the treatment of disease or
injury to the eye: the latter should be included in physician specialty or Other
professional Services.

25. Mental Health/Substance Abuse — Include the cost of all mental health and
substance abuse services including inpatient, physician services, outpatient hospital, other
professional services and other services associated with mental health or substance abuse
treatment.

26. Reinsurance Expense — Expenses for reinsurance or “stop loss” insurance

27. Incentive Pool Adjustment — A reduction to medical expense for adjusting
the full medial expenses reported.

28. Other Medical — medical expenses not included in lines 10-27.

29Total Medical and Hospital  — The total of all medical and hospital expenses
(the sum of lines 10 through 28).

ADMINISTRATION: Costs associated with the overall management and operation of
the plan including the following components:

30. Compensation ___all expenses for administrative services including
compensation and fringe benefits for personnel time devoted to or in direct support of
administration. Include expenses for management contracts. Do not include marketing expenses
here.

31. Interest Expense — Interest on loans paid during the period.

 

 

Exhibit 10.6.9

32. Occupancy, Depreciation, and Amortization

33. Education and Outreach — Expenses incurred for education and outreach
activities

34. Marketing — Expenses directly related to marketing activities including
advertising, printing, marketing, salaries, and fringe benefits, commissions, broker fees,
travel, occupancy, and other expenses allocated to the marketing activity.

35. Other. Costs which are not appropriately assigned to the health plan
administration categories defined above.

36. Total Administration- The total of costs of administration ( the sum of
lines 30 through 35).

37. Total Expenses: the sum of Total Medical and Hospital Expenses (line 29)
and total Administration (line 36)

38. Operation Income (Loss) — Excess or deficiency of Total Revenu (line 9)
minus Total Expenses (line 37).

39. Extraordinary Item — A non-recurring gain or loss

40. Adjustments for prior period IBNR estimates — should include a
reconciliation and explanation of prior period (BNY estimates. A contra expense would be
reported if IBNR estimates exceeded actual expenses. )

42. Net Income (loss) — Operation Income (Loss) (line 38) minus lines 39, 40
and 41.

 

 

Exhibit 10.6.9

STATE OF NEW JERSEY

			
	 	 	 
	Plan Name
	 	Quarter
Ending                   

MEDICAID DATA ONLY

TABLE 6A

Quarter Only

STATEMENT OF REVENUES AND EXPENSES

Summary of All Eligibility groups on Claims Incurred

During the Current Quarter

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	PAID	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	CLAIMS	 	 	RBUCs	 	 	IBNR	 	 	 	 	 	 	 	 
	 	 	For services received	 	 	 	 	 	 	ACTUAL	 
	 	 	during this quarter	 	 	ACTUAL TOTAL	 	 	PMPM	 
	Member Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUE:
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2. Capitated Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3. Supplemental Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	a. Maternity
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	b.
HIV/AIDs Reimbursable Drugs
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	c. Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4. Total Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5. Interest
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6. COB
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7. Reinsurance Recoveries
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8. Other Revenue
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total REVENUE
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Medical & Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10. Inpatient Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11. Primary Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12. Physician Specialty
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13. Outpatient Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14. Other Professional Service
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15. Emergency Room
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16.
DME/Medical supplies
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17. Prosthetics & Orthotics
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18. Dental
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	19. Pharmacy
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	20. HIV/AIDS Reimbursable Drugs
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	21. Home Health care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	22. Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	23. Labs & X-ray
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	24. Vision Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	25 Mental Health/Substance Abuse
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26. Reinsurance Expenses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	27. Incentive Pool Adjustment
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	28. Other Medical
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	29. TOTAL MEDICAL AND HOSPITAL
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

 

Exhibit 10.6.9

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	PAID	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	CLAIMS	 	 	RBUCs	 	 	IBNR	 	 	 	 	 	 	 	 
	 	 	For services received	 	 	 	 	 	 	ACTUAL	 
	 	 	during this quarter	 	 	ACTUAL TOTAL	 	 	PMPM	 
	30. Compensation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	31. Interest Expense
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	32. Occupancy, Depre. & Amortiz.
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	33. Education and outreach
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	34. Marketing
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	35. Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	36.TOTAL ADMINISTRATION
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	37.TOTAL EXPENSES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	38. OPERATION INCOME (LOSS)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	39. Extraordinary Item
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	40 Provision for Taxes
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	41. Adj for Prior period IBNR est.
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	42. NET INCOME (LOSS)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

 

Exhibit 10.6.9

STATE OF NEW JERSEY

			
	 	 	 
	Plan Name
	 	Quarter Ending

MEDICAID DATA ONLY

TABLE 6B

STATEMENT OF REVENUES AND EXPENSES

Summary of All Eligibility groups on Claims Incurred

Year to Date

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	PAID	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	CLAIMS	 	 	RBUCs	 	 	IBNR	 	 	ACTUAL TOTAL	 	 	ACTUAL	 
	 	 	For services received year	 	 	 	 	 	 	 	 
	 	 	to date	 	 	 	 	 	 	 
	Member Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUE:
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2. Capitated Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3. Supplemental Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	a. Maternity
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	b. HIV/AIDs Reimbursable Drugs
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	c. Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4. Total Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5. Interest
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6. COB
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7. Reinsurance Recoveries
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8. Other Revenue
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total REVENUE
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Medical & Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10. Inpatient Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11. Primary Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12. Physician Specialty
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13. Outpatient Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14. Other Professional Service
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15. Emergency Room
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16. DME/Medical supplies
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17. Prosthetics & Orthotics
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18. Dental
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	19. Pharmacy
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	20. HIV/AIDS Reimbursable Drugs
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	21. Home Health care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	22. Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	23. Labs & X-ray
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	24. Vision Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	25 Mental Health/Substance Abuse
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26. Reinsurance Expenses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	27. Incentive Pool Adjustment
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	28. Other Medical
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	29. TOTAL MEDICAL AND HOSPITAL
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	30. Compensation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

 

Exhibit 10.6.9

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	PAID	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	CLAIMS	 	 	RBUCs	 	 	IBNR	 	 	 	 	 	 	 	 
	 	 	For services received year	 	 	 	 	 	 	ACTUAL	 
	 	 	to date	 	 	ACTUAL TOTAL	 	 	PMPM	 
	31. Interest Expense
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	32. Occupancy, Depre. & Amortiz.
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	33. Education and outreach
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	34. Marketing
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	35. Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	36.TOTAL ADMINISTRATION
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	37.TOTAL EXPENSES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	38. OPERATION INCOME (LOSS)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	39. Extraordinary Item
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	40 Provision for Taxes
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	41. Adj for Prior period IBNR est.
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	42. NET INCOME (LOSS)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

 

Exhibit 10.6.9

Table 6c

Allowable DIRECT MEDICAL EXPENSES

For purposes of calculating Medical Cost Ratio

For the Quarter Ending

List the employee name or employee number of salaried individual who have performed
Allowable Direct Medical Expenditure functions during the quarter. Allowable Direct Medical
Expenditures are the salary costs of performing function related to the following
categories: 1) assessment(s) of an enrollee’s risk factor; 2)development of Individual
Health care Plans; 3)provision of face-to-face medical education or anticipatory guidance;
and4) activities required to maintain compliance with EPSDT, lead screening and pre-natal
care. Reporting of direct medical expenditures shall reflect only those activities approved
by the State in the Medical Cost Ratio — Direct Medical Expenditure Plan. Other Care
Management functions are considered administrative and are allowable.

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Category	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	(Care Management,	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Face-to-face,	 	 	 	 
	Employee Name	 	 	 	 	 	 	 	 	 	 	 	 	 	Compliance with	 	 	 	 
	Or Number	 	Employee Title	 	 	Salary This quarter	 	 	Allowable Amount	 	 	EPSDT, et.al)	 	 	%	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total*
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	(attach
additional sheets,
if necessary)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

I certify the expenses reported as allowable are the true and accurate salary costs of
the individuals listed above and meet the definition of an Allowable Direct Medical
Expenditure defined in Section 8.4.1.A of the managed care contract. Further, I certify
these costs are included and have been reported as Administrative costs on Tables 6a and 6b
online 30 (Compensation).

	 	 	 	 	 	 	 
	 

	 	(Signature)	 	 	 	 
	 

	 	 	 	 

	 	 
	 

	 	Name and Title	 	 	 	 
	 

	 	 	 	 
	 	 

 

 

Exhibit 10.6.9

A.7.9 Reserved

Table 7 Stop Loss Summary

The contractor shall identify reinsurance coverage in effect during the quarterly
report period. For each of the designated eligibility categories, the contractor shall report the
total number of enrollees that exceeded the stop loss threshold and the total net expenditures
exceeding the stop loss threshold during the period.

 

 

Exhibit 10.6.9

STATE OF NEW JERSEY

Plan Name                 Quarter Ending 

Medicaid Data Only 

Table 7 

STOP LOSS SUMMARY 

 A. COVERAGE

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	Maximum	 	 	Includes	 	 	 	 	 	 	 	 
	Aggregate	 	Maximum	 	 	Aggregate	 	 	Insolvency	 	 	 	 	 	 	Cost of	 
	Stop Loss	 	Per Enrollee	 	 	Lifetime Per	 	 	Insurance	 	 	 	 	 	 	Premiums	 
	threshold	 	Per Year	 	 	Enrollee	 	 	(Y/N)	 	 	Deductable	 	 	PMPM	 
	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

Policy Expiration Date

B.

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Category of Eligibility	 	AFDC/TA NF	 	 	DYFS	 	 	ABD	 	 	NJ FamilyCare	 	 	TOTAL	 
	 
	Number
of Enrollees
Exceeding Stop
Loss
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Net
Expenditures
Above Stop
Loss
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 C. List Details for Each Individual (Name or ID Not Required) 

	 	 	 	 	 
	 	 	Net Expenditures Above Stop Loss	 	Primary Diagnosis/Major Procedure
	 	 	 
	1
	 	 	 	 
	2
	 	 	 	 
	3
	 	 	 	 
	4
	 	 	 	 
	5
	 	 	 	 
	6
	 	 	 	 
	7
	 	 	 	 
	8
	 	 	 	 
	9
	 	 	 	 
	10
	 	 	 	 
	11
	 	 	 	 
	12
	 	 	 	 
	13
	 	 	 	 
	14
	 	 	 	 
	15
	 	 	 	 

 

 

 

Exhibit 10.6.9

A.7.10 reserved 

Table 8 Medicaid Claims Analysis 

Part A. Claims Incurred During Current Period (quarter).

Total Expense (Column A): Enter the accrued amounts in each respective medical
expense category in Column A. Amount reported as line 6. Total should agree with Table 6a, line 29.
total medical and Hospital Expenses. Column A — amounts should equal the sum of Columns B, C,and D
for each respective medical expense category.

Claims Paid (Column B): Enter the amount of all claims actually processed (checks
mailed) related to services incurred during the quarter. Prior period claims processed during this
quarter but related to services incurred during prior quarters must be reflected in Part B, Column
B.

Claims Reported — But Not Paid (Column C): Enter the amount of claims received by the
contractor related to services incurred during the quarter but for which checks have not yet been
issued. Do not include amounts for claims paid or IBNY amounts in this column

Claims Incurred — but not Reported (Column D): Enter the amount estimated for
services incurred during the quarter for which the contractor has not yet received a claim. (Should
be same as Part A, Column D).

Part B: Unpaid Claims

Reported Claims that are Unpaid:

On Claims Incurred During Prior Periods (Column A): Enter the amount of claims
received by the contractor related to services incurred during all periods prior to this quarter
for which checks have not yet been issued.

On Claims Incurred During Current Period (Column B): Enter the amount of claims
received by the contractor related to services incurred during the quarter for which checks have
not been issued.

Incurred — but not Reported

On Claims Incurred During Prior Periods (Column C): Enter the amount estimated for
services incurred during all periods prior to this quarter for which the contractor has not yet
received a claim.

On Claims Incurred During Current Period (Column D) Enter the amount estimated for
services incurred during the quarter for which the contractor has not yet received a claim.

(Should be the same as Part A, Column D).

Total Unpaid Claims (Column E): Enter the sum of Part B, Columns A, B, C, and D.

 

 

Exhibit 10.6.9

Plan
Name                                                 
                                                                           STATE OF NEW JERSEY 

Quarter Ending 

TABLE 8 

MEDICAID CLIAMS ANALYSIS

A. Claims incurred during Current Period

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	(D)	 
	 	 	 	 	 	 	 	 	 	 	(C)	 	 	Claims Incurred	 
	Category of Service	 	 	 	 	 	 	 	 	 	Claims 	 	 	 But Not 	 
	Revenue & Expense 	 	(A)	 	 	(B)	 	 	Reported But 	 	 	Reported 	 
	Statement (Table 6a)	 	Total Expenses	 	 	Claims Paid	 	 	Not Paid	 	 	(IBNR)	 
	1.
Inpatient.... (line
10)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2.
Primary Care ...
(line
11)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3.
Physician Specialty
Services
(line12)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4.
Emergency Room
(line
15)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5.
All other medical
services (line
28)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6.
TOTAL (line
29)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 B. Claims Unpaid

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	(A)	 	 	(B)	 	 	(C)	 	 	(D)	 	 	(E)	 
	 	 	Reported Claims that are Unpaid	 	 	Incurred But Not Reported	 	 	 	 	 	 	 
	 	 	On Claims 	 	 	On Claim
Incurred 	 	 	On Claims 	 	 	On Claims
Incurred 	 	 	 	 
	 	 	Incurred 	 	 	During 	 	 	Incurred 	 	 	During 	 	 	Total Unpaid 	 
	 	 	During Prior 	 	 	Current 	 	 	During Prior 	 	 	Current 	 	 	Claims 	 
	Category of Service 	 	Periods	 	 	Period	 	 	Periods	 	 	Period	 	 	(A+B+C+D)	 
	1.
Inpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2.
Primary Care

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3.
Physician Specialty
Services

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4.
Emergency Room

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5.
All other medical
services

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6.
TOTAL

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

 

Exhibit 10.6.9

	 	 	 	 	 	 	 	 	 	 	 
	A.7.11	 	 
	Table 9

Health
Care Data Elements Semi-Annual Utilization and Medical Expenditure Summary

The contractor shall report utilization and expenditure data every six months, by calendar year.
The report will summarize all claims adjudicated, encounters received, and capitations and other
medical expenditures paid as of six and twelve months after the end of each period. The required
utilization and expenditure statistics shall be reported according to date of service and grouped
using the Managed Care Category of Service Matrix. The report shall be submitted in an electronic
format defined by DMAHS.

Managed care categories of Service

Inpatient Hospital (01) — services for enrollees while confined to an acute care, specialty or
rehab hospital, including out of area hospitalization.

Outpatient Hospital, except emergency Room and EPSDT(04N) — services associated with the facility
component of ambulatory surgery visits. The visit can be free standing or a hospital outpatient
department. The professional component should be reported in the appropriate service category line
item, e.g. physician specialty services.

Outpatient Hospital, Emergency Room (04E) — services associated with the facility component of
emergency room visits as well as out of area emergency room costs. Professional components that are
billed separately should be reported in the appropriate service category line item.

EPSDT Private Duty Nurse (08D) — PDN services defined by procedures, diagnosis, and recipients’ age
that are provided by a private duty nurse.

EPSDT Dental (EPD) — dental services defined by procedures, diagnosis, and recipients’ age that are
provided in any setting by a dental provider.

Optical Appliances (09) non-physician services associated with the dispensing of corrective lenses,
ocular implants and prostheses to correct eye defects. (This category includes the cost of
eyeglasses and other corrective lenses, implants, and prostheses. It excludes ophthalmologist and
optometrist data related to the treatment of disease or injury to the eye; the former should be
included in Specialty Physician; and the latter in Optometrist Services)

Primary Care Physician, Nurse Practitioner, Physician Assistant (10P) — medical services provided
by a primary care provider , including physicians and other practitioners (excludes EPSDT).

Specialty Physician (10S) Medical services provided by a physician other than a primary care
physician (Excludes EPSDT)

Dental (11) — All dental services except EPSDT

Optomestrist Services (13) — optical services by non-physicians. (this category includes
optometrist data related to the treatment of disease or injury to the eye. It excludes
ophthalmologist data related to the treatment of disease or injury to the eye and the cost of
eyeglasses and other optical

 

 

Exhibit 10.6.9

appliances; the former should be included in Specialty Physician and
the latter in Optical Appliances).

Chiropractic Services (14) — All chiropractic services

Nurse Practitioner Specialty (15S0 — units and compensation related to Nurse Practitioners
practicing within a medical specialty and engaged in the delivery of medical services and paid by
the contractor.

Podiatrist Services (17)

Prosthetics and Orthotics (a8)

Pharmacy, HIV/AIDS Drugs (20H) — reimbursable HIV/AIDS Drugs.

Pharmacy, excluding HIV/AIDS drugs (20N) — legend and non-legend pharmacy services provided that
includes both ingredient costs and dispensing fees.

Medical Supplies (30)

DME (31) — Durable Medical Equipment

Hearing Aids (32) — units and compensation related to hearing aid providers engaged in the delivery
of medical services and paid by the contractor

Home Health (33) — home health services provided by nurses and aides.

Private Duty Nursing (PDN) — PDN services other than EPSDT that are provided by a private duty
nurse

Hospice Services (50) — Hospice Services for which the contractor is separately billed

Lab (60) — Laboratory services for which the contractor is separately billed

Radiology (65) — The units and costs of all x-rays (diagnostic and therapeutic) for which the
contractor is separately billed

Transportation (70) — ambulance, mobile intensive care units (MCIU) and invalid coach services for
which the contractor is separately billed

Family Planning (FP) — certain services defined by procedure, diagnosis and recipient’s age
provided in any setting by a primary care provider, including physicians and other practitioners.

Mental
Health (MH)— inpatient or outpatient hospital , physician services, and other services
associated with mental health treatment

Physician Assistant Specialty (PAS) services other than primary care provided by physician
assistants

 

 

Exhibit 10.6.9

Substance Abuse (SA) inpatient or outpatient hospital, physician services, and other services
associated with treatment for substance abuse

Other Medical (XM) — medical services and/or expenditures that are not reported in any other
category.

Required Statistics

Unduplicated Enrollees Served — the unduplicated number of enrollees receiving one or more services
in the category during the report period

Units/Days/Prescription — Report the number of applicable units for each service category. Report
the total number of days for Inpatient Hospital and the Number of prescriptions for pharmacy.

FFS Amount Paid — the amount paid by the contractor to its fee-for-service providers

Capitation Amount Paid — the amount paid by the contractor to its providers in capitation payments

Other
Amount Paid — any expenditure for medical services that is not considered a fee for service
or a capitation payment

The contractor must report encounter data at least quarterly and no more
frequently than monthly. The data shall be enrollee specific, listing all encounter data elements
of the services provided. The data reporting medium shall be a tape or diskette in a configuration
specified by DMAHS. Encounter report files will be used to create a data base which can be used in
a manner similar to fee for service history files to analyze plan utilization, reimburse the
contractor for supplemental payments (e.g. Pregnancy outcome) and calculate capitation premiums.
DMAHS will edit the data to assure consistency and readability. If data are not of an acceptable
quality or submitted timely, the contractor will not be considered in compliance with this contract
requirement until an acceptable file is submitted. All enrollee specific encounter data must be
submitted in accordance with the EMC manual.

The encounter list indicates the “required “data elements for Inpatient and Ambulatory Care
encounters. In addition, “optional” data elements are also listed. These elements are optional in
the sense that they can be used to custom fit the reporting to the needs of a particular program,
enhance data validity checking, or allow more flexibility in the use of mandatory data elements.

 

 

Exhibit 10.6.9

Table 9

Semi-Annual Utilization and Medical Expenditure Summary

MCO Name            Paid Through            June 30,

Calendar
Year

Enter the year in the appropriate cell to the right of month and
day.

December 31,

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Medical Center	 	Medical Center DOS	 	Unduplicated	 	Units/Days/Prescri	 	 	 	Capitation	 	Other Amount	 	 	 	 
	COS Code	 	DESC	 	Enrollees Served	 	ptions	 	FFS Amount Paid	 	Amount	 	Paid	 	 	 	 
	01

	 	Inpatient Hospital	 	 	 	 	 	 	 	 	 	 
	04N

	 	Outpatient Hospital- Not ER	 	 	 	 	 	 	 	 	 	 
	04E

	 	Outpatient Hospital- ER	 	 	 	 	 	 	 	 	 	 
	08D

	 	EPSDT-PDN	 	 	 	 	 	 	 	 	 	 
	EPM

	 	EPSDT- Medical	 	 	 	 	 	 	 	 	 	 
	EPD

	 	EPSDT- Dental	 	 	 	 	 	 	 	 	 	 
	09

	 	Optical Appliances	 	 	 	 	 	 	 	 	 	 
	10P

	 	Primary Care Physician,

Nurse Practitioner,

Physician Assistant	 	 	 	 	 	 	 	 	 	 
	10S

	 	Specialty Physician	 	 	 	 	 	 	 	 	 	 
	11

	 	Dental	 	 	 	 	 	 	 	 	 	 
	13

	 	Optomestrist Services	 	 	 	 	 	 	 	 	 	 
	14

	 	Chiropractic Services	 	 	 	 	 	 	 	 	 	 
	15S

	 	Nurse Practitioner -

Specialty	 	 	 	 	 	 	 	 	 	 
	17

	 	Podiatrist Services	 	 	 	 	 	 	 	 	 	 
	18

	 	Prosthetics and Orthotics	 	 	 	 	 	 	 	 	 	 
	20H

	 	Pharmacy, HIV/AIDS Drugs	 	 	 	 	 	 	 	 	 	 
	20N

	 	Pharmacy, Not HIV/AIDS Drugs	 	 	 	 	 	 	 	 	 	 
	30

	 	Medical supplies	 	 	 	 	 	 	 	 	 	 

 

 

Exhibit 10.6.9

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Medical Center	 	Medical Center DOS	 	Unduplicated	 	Units/Days/Prescri	 	 	 	Capitation	 	Other Amount	 	 	 	 
	COS Code	 	DESC	 	Enrollees Served	 	ptions	 	FFS Amount Paid	 	Amount	 	Paid	 	 	 	 
	31

	 	DME	 	 	 	 	 	 	 	 	 	 
	32

	 	Hearing Aids	 	 	 	 	 	 	 	 	 	 
	40

	 	Home Health	 	 	 	 	 	 	 	 	 	 
	PDN

	 	Private Duty Nursing — Not
EPSDT	 	 	 	 	 	 	 	 	 	 
	50

	 	Hospice Services	 	 	 	 	 	 	 	 	 	 
	60

	 	Lab	 	 	 	 	 	 	 	 	 	 
	65

	 	Radiology	 	 	 	 	 	 	 	 	 	 
	70

	 	Transportation	 	 	 	 	 	 	 	 	 	 
	FP

	 	Family Planning	 	 	 	 	 	 	 	 	 	 
	MH

	 	Mental Health	 	 	 	 	 	 	 	 	 	 
	PAS

	 	Physician Assistant Specialty	 	 	 	 	 	 	 	 	 	 
	SA

	 	Substance Abuse	 	 	 	 	 	 	 	 	 	 
	XM

	 	Other Medical	 	 	 	 	 	 	 	 	 	 

S

 

 

Exhibit 10.6.9

TABLE 9

HEALTH CARE ELEMENTS

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Professional	 	Dental	 	Transportation	 	Vision	 	Description 
	 

	 	COMMON

DATA	 	 	 	 	 	 	 	 	 	 
	 

	 	HMO ID
	 	X
	 	 	 	X
	 	 	 	HMO ID number assigned by

Medicaid
	 

	 	Record

ID
	 	X
	 	 	 	X
	 	 	 	HMO Number assigned to
the record
	 

	 	Patient

Medicaid ID
	 	X
	 	 	 	X
	 	 	 	Recipient ID

Number
	 

	 	Workers

Comp
	 	X
	 	 	 	X
	 	 	 	Y/N indicator that
service is subject to workers
comp or related
	 

	 	Payment

amount
	 	X
	 	 	 	X
	 	 	 	Total amount paid by

HMO
	 

	 	Patient

DOB
	 	O
	 	 	 	X
	 	 	 	Patient’s DOB
	 

	 	Date Claim

received 
	 	X
	 	 	 	X
	 	 	 	Date Claim received by

HMO
	 

	 	Date of
payment
	 	X
	 	 	 	X
	 	 	 	Date of payment by
HMO
	 

	 	Status

code
	 	X
	 	 	 	X
	 	 	 	Status code p = paid, d =

denied
	 

	 	DETAIL

AREA
	 	X
	 	 	 	X	 	 	 	 
	0

	 	Capitation

Service

Category
	 	X
	 	 	 	X
	 	 	 	Classification of
services according to list

	1

	 	Service Date

From
	 	X
	 	 	 	X
	 	 	 	Date service

started
	2

	 	Service Date to

	 	X
	 	 	 	 	 	 	 	Date Service

Ended
	3

	 	Procedure

Code
	 	X
	 	 	 	X
	 	 	 	HCPCS procedure

code
	4

	 	1 Procedure

Code Modifier
	 	X
	 	 	 	 	 	 	 	First modifier, if

applicable
	5

	 	2 Procedure

Code modifier 
	 	X
	 	 	 	 	 	 	 	Second modifier, if

applicable 
	6

	 	Place of
Service
	 	X
	 	 	 	 	 	 	 	Place of Service
1=Office, 2=inpatient hospital, 3
= outpatient hospital/ER
	7.

	 	Diagnosis

Codes
	 	X
	 	 	 	 	 	 	 	ICD 9 CM diagnosis

code
	8

	 	Units of
Service
	 	X
	 	 	 	X
	 	 	 	Units of service
rendered
	9

	 	Servicing

Provider Number
	 	X
	 	 	 	X
	 	 	 	Provider SSN or Tax

ID
	0

	 	Referring

Provider Number
	 	X
	 	 	 	X
	 	 	 	Individual group from who

the patient was referred

	 	 
	 	X = Required

O= Optional

 

 

Exhibit 10.6.9

TABLE 9B

HEALTH CARE ELEMENTS

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Inpatient	 	Outpatient	 	Home Health	 	Description 
	 

	 	COMMON DATA	 	 	 	 	 	 	 	 
	 

	 	HMO ID
	 	X
	 	X
	 	 	 	HMO ID number assigned by

Medicaid
	 

	 	Record ID
	 	X
	 	X
	 	 	 	HMO Number assigned to the
record
	 

	 	Patient Medicaid ID
	 	X
	 	X
	 	 	 	Recipient ID Number
	 

	 	Workers Comp
	 	X
	 	X
	 	 	 	Y/N indicator that service is
subject to workers comp or
related
	 

	 	Payment amount
	 	X
	 	X
	 	 	 	Total paid by HMO
	 

	 	Capitation Service Category
	 	O
	 	O
	 	 	 	Classification of service,
according to list
	 

	 	Patient DOB 
	 	X
	 	X
	 	 	 	Patient’s DOB
	 

	 	Admit Date/Service From Date
	 	X
	 	X
	 	 	 	Date admitted to hospital

	 

	 	Discharge Date
	 	X
	 	X
	 	 	 	Date discharged from hospital

	0

	 	DRG Code
	 	X
	 	 	 	 	 	DRG Code
	1

	 	Patient Status
	 	X
	 	 	 	 	 	Status of patient at end of
stay 1= discharged to home,
2=discharged to LTC facility, 3=death,
4=other
	 

	 	Surgery Data (Up to 3 times)	 	 	 	 	 	 	 	 
	2

	 	Procedure Code
	 	X
	 	 	 	 	 	CPT/HCPCS Codes
	3

	 	Surgery Date
	 	X
	 	 	 	 	 	Surgery Date, if

applicable
	4

	 	Admitting Diagnosis Code
	 	X
	 	 	 	 	 	ICD 9CM diagnosis on

admittance
	5

	 	Discharge Diagnosis
	 	X
	 	 	 	 	 	ICD 9CM diagnosis on

discharge
	6

	 	Attending Physician Code
	 	X
	 	 	 	 	 	Attending Physician SSN or Tax

ID
	7

	 	Servicing provider Number
	 	X
	 	 	 	 	 	Facility/agency rendering care

tax id
	8

	 	Referring provider number
	 	X
	 	 	 	 	 	Individual/group from whom the

patient was referred, SSN or tax

id
	9

	 	Date claim received 
	 	X
	 	 	 	 	 	Date Claim received by

HMO
	0

	 	Date of Payment
	 	X
	 	 	 	 	 	Date of payment by HMO
	1

	 	Status Code 
	 	X
	 	 	 	 	 	Status code p = paid, d =

denied
	 

	 	DETAIL AREA	 	 	 	 	 	 	 	 
	2

	 	Capitation Service Category
	 	 	 	 	 	 	 	Classification of services
according to list 
	3

	 	Service Date From
	 	 	 	 	 	 	 	Date service started
	4

	 	Service Date to 
	 	 	 	 	 	 	 	Date Service Ended
	5

	 	Procedure Code
	 	 	 	 	 	 	 	HCPCS procedure code
	6

	 	Procedure Code Modifier
	 	 	 	 	 	 	 	modifier, if

applicable
	7

	 	Units of Service
	 	 	 	 	 	 	 	Units of service
rendered
	8

	 	Revenue Code
	 	 	 	 	 	 	 	Identifies the services

rendered in these settings
	9

	 	Clinic Code
	 	 	 	 	 	 	 	Identifies specialty clinic in

the outpatient hospital

setting

X = Required

O= Optional

 

 

Exhibit 10.6.9

TABLE 9C 

HEALTH CARE DATA ELEMENTS 

	 	 	 	 	 	 	 
	 	 	 	 	DRUG	 	 
	 

	 	HMO ID
	 	X
	 	HMO ID number assigned by Medicaid
	 

	 	Record ID
	 	X
	 	HMO Number assigned to the record
	 

	 	Patient Medicaid ID
	 	X
	 	Recipient ID Number
	 

	 	Workers Comp/Accident

    Ind
	 	X
	 	Y/N indicator that service is subject to
workers comp or related
	 

	 	Payment amount
	 	X
	 	Total paid by HMO
	 

	 	Pharmacy Number
	 	X
	 	Pharmacy provider SSN or Tax ID
	 

	 	Prescribing Provider

    Number
	 	X
	 	Prescribing provider SSN or Tax ID
	 

	 	Recipient DOB
	 	X
	 	Patient date of birth
	 

	 	Date Dispersed
	 	X
	 	Date drug was dispersed 
	 

	 	NDC Number
	 	X
	 	NDC code of the substance dispensed
	 

	 	Metric Quantity
	 	X
	 	Quantity of the substance dispensed and the
units of measure
	 

	 	Days Supply
	 	X
	 	Days supply of the drug dispensed
	 

	 	Refill Indicator
	 	X
	 	Number of available refills after the
dispensing date
	 

	 	Capitation Service

    Category
	 	X
	 	Classification of service according to
list
	 

	 	Date Claim Received

	 	X
	 	Date claim received by HMO
	 

	 	Date of Payment
	 	X
	 	Date payment made by HMO
	 

	 	Status code 
	 	X
	 	Status code p=paid, d= denied

TABLE 9D

CAPITATION SERVICE CATEGORY LIST

	 	 	 
	0

1A

	 	PRIMARY Care Physician, Nurse

Practitioners, Physician Assistant
	01b

	 	Specialty Physician
	02

	 	EPSDT
	03

	 	Inpatient Hospital
	04

	 	Outpatient Hospital
	05

	 	Laboratory
	06

	 	Radiology
	07

	 	Prescription Drugs
	08

	 	Family Planning
	09

	 	Outpatient Therapies
	10

	 	Podiatrist Services
	11

	 	Chiropractic Services
	12

	 	Optometrist Services
	13 

	 	Optical Appliances
	14

	 	Hearing Aids
	15

	 	Home Health Agency Services
	16

	 	Hospice Services

 

 

Exhibit 10.6.9

	 	 	 
	17

	 	Durable Medical Equipment
	18

	 	Medical Supplies
	19

	 	Prosthetics and
Orthotics
	20

	 	Dental Services
	21

	 	Transportation

 

 

Exhibit 10.6.9

A.7.12 Reserved

Table 10 Third Party Liability Collections

The contractor shall report quarterly the categories of all third party liability
collections to DMAHS and shall include a complete disclosure demonstrating its efforts to obtain
payment from liable third parties and the amounts and nature of all third party payments recovered
for Title XIX and NJ FamilyCare enrollees including but not limited to payments for services ad
condition which are:

	 	•	 	
· Covered through coordination of benefits;
	 
	 	•	 	Employment related injuries or illnesses;
	 
	 	•	 	Related to motor vehicle accidents, whether injured
as pedestrians, drivers, passengers or bicyclists; and
	 
	 	•	 	Contained in diagnosis Codes 800 through 999 (ICD9CM)
with the exception of Code 994.6.
	 
	 	 	 	 

 

 

Exhibit 10.6.9

STATE OF NEW JERSEY

PLAN
NAME                                                                                                                                                      Quarter Ending

TABLE 10

THIRD PARTY LIABILITY COLLECTIONS *

	 	 	 	 	 	 	 
	 	 	Casualty Insurance	Health Insurance
	 	 	Employment 	 	Motor Vehicle 	 	 
	Eligibility Category	 	Related	 	Related	 	Other 
	AFDC **
	 	 	 	 	 	 
	DYFS
	 	 	 	 	 	 
	SSI AGED W/MEDICARE+
	 	 	 	 	 	 
	SSI AGED W/O MEDICARE+
	 	 	 	 	 	 
	SSI DISABLED & BLIND W/ MEDICARE
	 	 	 	 	 	 
	SSI DISABLED & BLIND W/O MEDICARE
	 	 	 	 	 	 
	NJ FAMILYCARE
	 	 	 	 	 	 
	Total
	 	 	 	 	 	 

 

			
	*	 	Enter total amount collected for each eligibility category,
	 
	**	 	Include New Jersey care children and pregnant women
	 
	+	 	Include essential spouses

 

 

Exhibit 10.6.9

A.7.13 Reserved

 Table 11 Provider Additions and Deletions

The contractor shall report, on a quarterly and annual basis, all additions and deletions to the
provider network as well as closed panels. Report closed panels under the deletions portion of the
table and state under the “Reason for change’ column: “Closed Provider Panel”. Include the names
and locations of all new providers and subcontractors; decreases in the provider network;
identified by provider type, name and location; an all PCPs, PCDs, CNPs/CNSs, physician assistants,
physician specialists, and other subcontractors who are not accepting new patients. The contractor
shall not allow enrollment freezes for any provider unless the same limitations apply to all
commercially insured members as well or contract capacity limits have been reached. 

 

 

Exhibit 10.6.9

STATE OF NEW JERSEY 

Plan
Name

                       
                       
                       
               
               Quarter Ending 

 TABLE 11

PROVIDER ADDITIONS AND DELETIONS 

	 
	A) Total Physicians at Start of Quarter

	b)Total Additions this quarter

	c) Total Deletions this Quarter

	d) Total Physicians at End of Quarter

	 	 	 
	Recruitment Rate

	 	%
	Disenrollment Rate

	 	%
	Growth Rate

	 	%

 =a+b+c 

A. Listing of changes in Non Hospital Providers During Quarter

	 	 	 	 	 	 	 	 	 
	Name of Additions	 	Provider Type	 	Address & City	 	County	 	Reason for Change
	Total Additions
	 	 	 	 	 	 	 	 
	Name of Deletions
	 	 	 	 	 	 	 	 
	 
	Total Deletions
	 	 	 	 	 	 	 	 

B. Listing of Contracted Hospital Changes

	 	 	 	 	 
	Name of Additions	 	Address & City	 	Reason for Change
	Total Additions
	 	 	 	 
	Name of Deletions
	 	 	 	 
	 
	Total Deletions
	 	 	 	 

 

 

Exhibit 10.6.9

A.7.12 Reserved

Table 14 EPSDT Services

1. EPSDT Services

the following EPSDT Services reports sorted by age group (0-11.99 months, 1-2 years, 3-5

years, 6-9 years, 10-14 years, 15-18 years, and 19-20 years) and separated by Medicaid/NJ

FamilyCare Plan A and Medicaid/NJ FamilyCare Plans B, C, and D must
be submitted quarterly:

a. Number of Enrollees Receiving at least One Initial or Periodic Screening Services. This

is an unduplicated count of individual who received one or more documented initial or

periodic screenings during the quarter. 

b. Actual Number of Initial and Periodic Screening Services by Age. This includes combined

number of initial and periodic EPSDT child health screening examinations during the quarter.

Do not enter data for incomplete or inter-periodic screenings, or for vision, dental, or

hearing services.

2. Referrals to Specialists

a. Number of Referrals for Vision Assessments

b.
Number of Referrals for Dental Assessments

c.
Number of Referrals for Hearing Assessments

d. Number of Referrals for Mental Health Assessments
e. Number of Referrals for Other Health Assessments

3. Appropriate Immunizations according to Age (Report only newly identified Cases).

Number of enrollees Receiving Immunizations Sorted by Age Group (0-11.99 months, 1-2 years, 3-5
years, 6-9 years, and 10+ years).

4. Lead Screenings and Treatments

a. total number of enrollees screened for Lead Toxicity (all ages).

b. Number of enrollees Screened Sorted by Age Group (9-18 months, 19-26 months, and 27-72 months).

c. Number of newly identified Lead Positive Enrollees with Blood Lead Level Between 10-14 μg/dl
(low Toxicity).

d. Number of newly identified Lead Positive Enrollees with Blood Lead Level Between 15-19 μg/dl
(Mild Toxicity).

e. Number of newly identified Lead Positive Enrollees with Blood Lead Level 20 μg/dl and Over
(Moderate, High and Severe Toxicity).

f. Number of Enrollees Referred to Local Health Departments with Blood Lead level of 10 μg/dl and
over

g. Number of Enrollees Receiving Treatments with chelation.

h. Number of Enrollees with Blood Lead level of 10 μg/dl and over placed in HMO Case Management
Program.

 

 

Exhibit 10.6.9

STATE OF NEW JERSEY 

Plan
Name

                       
                       
                       
               
               Quarter Ending 

TABLE 14

EPSDT SERVICES

	 	 	 	 	 
	 	 	Medicaid/NJ 	 	 
	1. EPSDT Services	 	FamilyCare A	 	FamilyCare B, C & D
	unduplicated count of children screened
	 	 	 	 
	b.
Number of screens by
age:                                                                     
<1
	 	 	 	 
	1-2
	 	 	 	 
	3-5
	 	 	 	 
	6-9
	 	 	 	 
	10-14
	 	 	 	 
	15-18
	 	 	 	 
	19-20
	 	 	 	 
	Total number of screens
	 	 	 	 

	 	 	 	 	 
	 	 	Medicaid/NJ 	 	FamilyCare B, C
	2. Referrals to Specialist	 	FamilyCare A	 	& D
	a. Vision referrals
	 	 	 	 
	b. Dental referrals
	 	 	 	 
	c. Hearing referrals
	 	 	 	 
	d. Mental health referrals
	 	 	 	 
	e. Other referrals
	 	 	 	 

	 	 	 	 	 
	 	 	Medicaid/NJ 	 	FamilyCare B, C
	3. Appropriate Immunizations According to Age	 	FamilyCare A	 	& D
	a. Number of enrollees receiving immunizations by
age:       <1 
	 	 	 	 
	1
	 	 	 	 
	1-2
	 	 	 	 
	3-5
	 	 	 	 
	6-9
	 	 	 	 
	10+
	 	 	 	 
	Total number of enrollees receiving immunizations
	 	 	 	 

	 	 	 	 	 
	4. Lead screenings and Treatments	 	Medicaid/NJ	 	FamilyCare B, C
	Report only newly identified Cases	 	FamilyCare A	 	 & D
	a. Total No. of enrollees screened (all ages)
	 	 	 	 
	b. No. of enrollees screened by age:
	 	 	 	 
	19-18 months
	 	 	 	 
	 19-26 months 
	 	 	 	 
	27-72 months
	 	 	 	 
	c No. of enrollees with low toxicity (BLL 10-14 μg/dl)
Ages
	 	 	 	 
	19-18 months
	 	 	 	 
	 19-26 months 
	 	 	 	 
	27-72 months
	 	 	 	 
	c No. of enrollees with mild toxicity (BLL 15-19 μg/dl)
Ages
	 	 	 	 
	19-18 months
	 	 	 	 

 

 

Exhibit 10.6.9

	 	 	 	 	 
	4. Lead screenings and Treatments	 	Medicaid/NJ	 	FamilyCare B, C
	Report only newly identified Cases	 	FamilyCare A	 	 & D
	 19-26 months 
	 	 	 	 
	27-72 months
	 	 	 	 
	e No. of enrollees with high toxicity (BLL = 20 μg/dl)
Ages
	 	 	 	 
	19-18 months
	 	 	 	 
	 19-26 months 
	 	 	 	 
	27-72 months
	 	 	 	 
	f. no. of enrollees referred to LHDs (BLL = 10 μg/dl) 
	 	 	 	 
	g. . no. of enrollees being treated with chelation 
	 	 	 	 
	h. . no. of enrollees with BLL = 10 μg/dl placed in HMO case management 
	 	 	 	 

NOTE: if a response is 0, provide explanation

 

 

Exhibit 10.6.9

A.7.18

Table 16 Ratio of Prior Authorizations Denied to Requested

The contractor shall report the number of prior authorizations requested and denied each quarter by
category of service. If prior authorization is not required, indicate “NA” for not applicable.

 

 

Exhibit 10.6.9

STATE OF NEW JERSEY

Plan Name                                                                                                                                       
                       Quarter Ending

TABLE 16

RATE OF PRIOR AUTHORIZATIONS DENIED TO REQUESTED

	 	 	 	 	 	 	 
	 	 	Number of PAs	 	Number of PAs	 	 
	Category of Service	 	    requested	 	       denied	 	% of PAs Denied
	Inpatient Hospital
	 	 	 	 	 	 
	Primary Care
	 	 	 	 	 	 
	Physician Specialty Services
	 	 	 	 	 	 
	Outpatient Hospital
	 	 	 	 	 	 
	Other Professional Services
	 	 	 	 	 	 
	Emergency Room
	 	 	 	 	 	 
	DME/Medical Supplies
	 	 	 	 	 	 
	Prosthetics & Orthotics
	 	 	 	 	 	 
	Dental
	 	 	 	 	 	 
	Pharmacy
	 	 	 	 	 	 
	    Formulary
	 	 	 	 	 	 
	    Off-Formulary
	 	 	 	 	 	 
	HIV/AIDS Reimbursable Drugs
	 	 	 	 	 	 
	Home Health Care
	 	 	 	 	 	 
	Transportation
	 	 	 	 	 	 
	Lab & X-Ray
	 	 	 	 	 	 
	Vision Care & Eyeglasses
	 	 	 	 	 	 
	Mental Health 
	 	 	 	 	 	 
	Substance Abuse
	 	 	 	 	 	 
	Hospice
	 	 	 	 	 	 
	Private Duty Nursing
	 	 	 	 	 	 
	Other Medical
	 	 	 	 	 	 
	Total
	 	 	 	 	 	 

 

 

Exhibit 10.6.9

A.7.21 HMO Financial Reporting Manual for Medicaid/NJ FamilyCare Rate Cell Grouping Costs
Table 19A, Parts A through V.

 

 

Exhibit
10.9

HMO Financial

Guide Reporting Manual

for Reporting Medicaid/NJ FamilyCare Rate

Cell Grouping Costs

State of New Jersey

Revised Date: March – January 2004

Effective Date: State Fiscal Year 2005

 

 

Contents

	 	 	 	 	 
	1. Introductions

	 	 	2	 
	2. General Instructions

	 	 	7	 
	3. Report Guidelines Specifications

	 	 	9	 

	 	•	 	Report # 1: Lag Report (Table 20, Parts A—E)      
                                                                   
   	9	 
	 					
	 	•	 	Report # 2: Income Statements by Rate Cell Grouping (Table
19, Parts A—V) 16 13		

	 	o	 	Table 19, Parts A—S3: Medicaid/NJ FamilyCare At-Risk Groupings
	 
	 	o	 	Table 19, Part T: Non-State Plan Services
	 
	 	o	 	Table 19, Parts U and V: Managed Care Service Administrator Groupings

	•	 	Report # 3: Maternity Outcome Counts (Table 21)                	2922424

	•	 	Report # 4: Claims Processing Lag Reports (Parts
A—B)               	302525  

	•	 	Report # 7: Stop Loss Summary (Parts A—C)                	352929  

	•	 	Report # 10: Third Party Liability Collections                	363030  

	•	 	Report # 3: Maternity
Outcome            Counts
(Table
21)	22          

	 	 	 
	4. Incurred — But Not Reported (IBNR) Methodology

	 	Appendix A
	 
	5. Report Forms

	 	Appendix B

	 	 	 
	HMO Financial Guide for Reporting Specifications
	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Introduction

Purpose

The objective of this Financial Guide 
Reporting Specifications is to ensure uniformity, accuracy and completeness in reporting
Medicaid/NJ FamilyCare rate cell groupings. In addition, the provision of this Guide

Reporting Specifications to the HMOs will help to eliminate inconsistencies, and reports can vary
in the presentation of items such as allocation of expense, accrual of incurred-but-not-reported
(IBNR) claims, handling of maternity claims, and other items. All reports
should
shall be submitted as outlined in the general instructions. The financial reports submitted
from this Guide 
Financial 
Reporting Specifications will be used in future rate setting and to better assess the financial
performance of HMOs.

The reports in this Guide 
Financial Reporting Specifications are to supplement, not replace, the reporting requirements
currently required in the Division of Medical Assistance and Health Services (DMAHS) Managed Care
Contract (please refer to Section A of the contract). Key differences between this
Guide 
Financial Reporting Specifications and the reports currently submitted to the State are as follows:

	 	•	 	Rate cell grouping detail;
	 
	 	•	 	Regional detail;
	 
	 	•	 	IBNR calculation detail;
	 
	 	•	 	Timing of submissions.

Rate Cell Groupings

This Guide  Financial  Reporting Specifications requires key cost reporting by rate cell grouping. Rate cells have been
combined into nineteen rate cell groupings for these reporting purposes (seventeen rate cell
groupings for Medicaid/NJ FamilyCare Managed Care at-risk populations and two rate cell groupings
for Managed Care Service Administrator (MCSA) populations). Please note where Acquired
Immunodeficiency Syndrome (AIDS) individuals are included or excluded in the rate cell groupings.
Also note that maternity and newborn costs are reported as a
separate rate cell groupings and should
shall be excluded from other rate cell groupings. The rate cell groupings are as follows:

	 	 	 
	HMO Financial Guide for Reporting Specifications 
	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

	 	 	 	 	 	 	 	 	 
	 	 	 	 	Capitation	 	 
	Rate Cell Reference	 	Rate Cell Grouping	 	Code	 	Description
	Table # 19 — Parts A, B, C

	 	AFDC/NJCPW/NJ KidCare A

 (Excluding AIDS)
	 	125R1-125R3

143R1-143R3

171R1-171R3

172R1-172R3

183R1-183R3	 	Individual eligible for Aid to Families with
Dependent Children (AFDC) New Jersey Care
Pregnant Women (NJCPW), or NJ KidCare A
(children below the age of 19 with family
incomes up to and including 133% of the
federal poverty level (FPL)), excluding
individuals with AIDS.
	Table # 19 — Part D

	 	DFYS Clients

(Excluding AIDS)
	 	 	32599,34399	 	 	Individuals eligible through the Division of
Youth and Family services (DYFS),
also known as 
including Foster Care children and children
with Adoption Assistance, excluding
individuals with AIDS.
	Table # 19 — Part E

	 	ABD with Medicare — DDD
(Excluding AIDS)
	 	 	48399	 	 	ABD (Aged, Blind, and/or Disabled)
individuals who receive Medicare and are
eligible for services through the Division of
Developmental Disabilities (DDD), excluding
individuals with AIDS.
	Table # 19 — Part F

	 	ABD with Medicare
Non- DDD
(Excluding AIDS)
	 	711R1-711R3

813R1-813R3

823R1-823R3

	 	ABD individual who receive Medicare and are
not eligible for services through the DDD,
excluding individuals with AIDS.

	Table # 19 — Part G

	 	Non-ABD  — DDD
(Excluding AIDS)
	 	47399
	 	Non-ABD individual eligible for services
through the DDD, excluding individuals with
AIDS.
	Table # 19 — Part H

	 	ABD without Medicare —

DDD

(including AIDS)
	 	 	49399	 	 	ABD individuals not receiving Medicare and
eligible for services through the DDD,
including individuals with AIDS.
	Table # 19 — Part I

	 	ABD without Medicare —

Non-DDD

(including AIDS)
	 	 	71099, 81099	 	 	ABD individuals not receiving Medicare and
not eligible for services through the DDD,
including individuals with AIDS
	Table # 19 — Part J

	 	NJ KidCare B7C

(excluding AIDS)
	 	 	62599, 6399	 	 	Eligible children under age 19 with family
income above 133% and up to and including
200% FPL, excluding individuals with AIDS.
	Table # 19 — Part K

	 	NJ KidCare D

(excluding AIDS)
	 	 	92599, 93399	 	 	Eligible children under age 19 with family
income above 201% and up to and including
350% FPL, excluding individuals with AIDS.
	Table # 19 — Part M

	 	NJ FamilyCare Parents

0-133% FPL (excluding

AIDS)
	 	57199, 57899,

58499             
	 	Parents with dependent children with family
income between 0 and 133% FPL, excluding
individuals with AIDS
	Table # 19 — Part O

	 	NJ FamilyCare Parents

134-2050% FPL (excluding

AIDS)
	 	 	95499, 97499,

98499	 	 	Parents with dependent children with family
income between 134% and 200% FPL,
Parents/Caretakers with children below 23,
and children from the age of 19 through 22
years who are fulltime students who do not
qualify for AFDC Medicaid with family incomes
up to and including 250% of FPL, excluding
individuals with AIDS.

	 	 	 
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Financial Guide for Reporting Specifications 
	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

	 	 	 	 	 	 	 
	 	 	 	 	Capitation	 	 
	Rate Cell Reference	 	Rate Cell Grouping	 	Code	 	Description
	 
	 	 	 	 	 	250% of FPL, excluding individuals
with AIDS.
	 	 	 	 	 	 	 
	Special Populations Data
	 	 	 	 	 	 
	Table # 19 — Part P

	 	ABD with Medicare —

AIDS
	 	28499, 48499
	 	ABD individuals with AIDS who receive
Medicare, including those eligible for DDD,
excluding the risk-adjusted populations.
	Table # 19 — Part Q

	 	Non-ABD — AIDS
	 	27499, 47499,

27699
	 	Non-ABD individuals with AIDS including AFDC,
NJCPW, NJ KidCare, DYFS, and NJ FamilyCare
Parents, excluding the risk-adjusted
populations.
	Table # 19 — Part R1

	 	Maternity
	 	N/A
	 	Please refer to criteria outlined in the
instructions for Report # 2R1
and#3(Table 21)
in the Report Guidelines
Specifications section.
	Table # 19 — Part R2

	 	Newborn
	 	Includes

newborn claims

costs

associated

within: 103R1-

103r3, 30399, 

60399, 80399, 

90399
	 	Please refer to criteria outlined in the
instructions for Report # 2R2, in the Report
Guidelines
Specifications section.
	Table # 19 — Part U

	 	NJ Familycare Adults

0—100% FPL (excluding

AIDS)
	 	65499, 67499, 

68499
	 	Single Adults and couples without dependent
children with family income between 0% and
100% FPL, adults and couples without
dependent children under the age of 23 with
family incomes up to and including 250% FPL,
excluding individuals with AIDS. Includes
Health Access individuals without dependent
children.
	Table # 19 — Part V

	 	Adult Restricted Aliens
	 	40199, 40299,

40399
	 	Classification based on restricted alien
status PSCs 310—330, 410-47
30, 470 and 380 over the age of 20, or NJ
FamilyCare PSCs 763, and 497 and 498 with
corresponding cap codes.

	 	 	 
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	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Introduction

Geographic Regions

Some of the reports in this Guide
HMO Reporting Specifications request information from the three geographic regions
corresponding to those used in rate setting. Listed below are the counties included in each
geographic region.

	 	 	 	 	 
	Northern (Region 1)	 	Central (Region 2)	 	Southern (Region 3)
	Bergen

	 	Essex
	 	Atlantic
	Hudson

	 	Mercer
	 	Burlington
	Hunterdon

	 	Middlesex
	 	Camden
	Morris

	 	Union
	 	Cape May
	Passaic

	 	 	 	Cumberland
	Somerset

	 	 	 	Gloucester
	Sussex

	 	 	 	Monmouth
	Warren

	 	 	 	Ocean
	 

	 	 	 	Salem

	 	 	 
	HMO Financial Guide for Reporting Specifications
	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

General Instructions

The following are general guideline
general instructions for completing the various reports required to be submitted by the HMOs
to the State. These instructions are designed to promote uniformity in reporting.

Due Dates

All Medicaid/NJ FamilyCare revenues and expenses must be reported using the accrual basis of
accounting except for Report# 2 Parts T-V (non-State Plan Services by rate cell grouping and MCSA
groupings). Report # 2 Parts T-V should

shall be reported on a paid basis. Reports shall be submitted quarterly and are due 45 days
following each quarter end.

Quarterly Reports

	 	 	 
	Quarter Ending:	 	Due Date
	March 31

	 	May 15
	June 30

	 	August 15
	September 30

	 	November 15
	December 31

	 	February 15

If a due date falls on a weekend or state holiday, reports will be due the next business day.
Please submit the completed reports to:

State of New Jersey

Director, HMO Financial Reporting

Daved.Moran@dhs.state.nj.us

and

Tanti.Dararutana@dhs.state.nj.us

and

Mercer Government Human Services Consulting

Actuarial Services

Mike.Nordstrom@mercer.com

Format

The HMO will submit these reports electronically versions of these
reports
 , including notes to the financial statements, in the formula specified, to the e-mail addresses
listed above. Copies of the reports are included in Appendix B of this manual.

	 	 	 
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General Instructions

Annual Audit Requirement

Please refer to Section 7.27 for the audit requirements in the current
DMAHS managed care contract.

Other Instructions

Line titles and columnar headings of the various reports are, in general, self-explanatory.
Specific instructions are provided for items that may have some question as to content. Any entry
for which no specific instructions are included should
shall be made in accordance with sound accounting principles and in a manner consistent with
related items covered by specific instructions.

Incorporate adjustments to prior data in the current reporting period. Adjustments for prior period
IBNR estimates should
shall be included on Report # 2, Table 19, Parts S1 and S2, in Line 402, and a detailed
reconciliation shall be included on Report # 2, Table 19, Part S3. Information about any adjustments
that pertain to prior periods should
shall be explained in a note t the reports. However, if there was material error in
preparation of the prior period report, a revised report should
shall be submitted.

Unanswered questions or blank lines on any report or schedule will render the report or schedule
incomplete and may result in a resubmission request. Any resubmission must be clearly identified as
such. If no answers or entries are to be made, write “Non”, “not Applicable (N/A)”, or “0” in the
space provided. Always use predefined categories or classifications before reporting an amount as
“other”.

Dollar amounts should
shall be reported to the nearest dollar. Per member per month (PMPM) amounts, however,
should
shall be shown with two digits to the right of the decimal point.

Additional sheets referencing the applicable reports can
must be attached for further explanation. You may also the contractor shall use “notes To
Financial Reports” in Appendix B for write-ins and explanations.

	 	 	 	 	 
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Report Guidelines Specifications

Report # 1: Lag Reports (Table 20, Parts A-E)

Analyzing the accuracy of historical medical claims liability estimates is
helpful
necessary in assessing the adequacy of current liabilities. In addition, valid IBNR liability
estimates are crucial when utilizing financial statements in the managed care rate setting process.
The schedule provides the necessary information to make this analysis.

Information is provided on Inpatient Hospital, Physician, Pharmacy, and Other Medical Payments on
Parts A through D, respectively with all rate cell groupings combined, excluding the Managed Care
Service Administrator (MCSA) rate cell groupings. Lag report see below for

information shall be provided for services that are included in 
each Medical Cost Grouping as defined below and map to the corresponding consolidated category of
service for the corresponding incurral period within Report # 2, Table 19, Parts S1 and S2. A
detailed reconciliation of the lag report information and Income Statements by Rate Cell Group
shall be included on Report # 2, Table 19, Part S3. Information about any adjustments that pertain
shall be explained in a not to the reports.

	 	 	 	 	 	 	 	 	 
	Consolidated	 	Income Statement	 	Managed Care Category	 	Medical Cost	 	Lag Report
	Category of Service	 	Reference	 	of Service Codes	 	Grouping	 	Reference
	 	 	 	 	Description	 	 	 	 
	Inpatient Hospital

	 	Table # 19 — Parts
S1 & S2, Line 9
	 	Inpatient hospital costs
including ancillary services for
enrollees while confined to an acute
care hospital , including out of area
(OOA) hospitalization.
01
	 	Inpatient Hospital
	 	Table # 20 — Part A
	 
	 	 	 	 	 	 	 	 
	Primary Care

	 	Table # 19 — parts
S2 & S2, Line 10
	 	All costs associated with
medical services provided in any
setting by a primary care provider,
including physicians and other
practitioners.
10P
	 	Physician
	 	Table # 20 — Part B
	 
	 	 	 	 	 	 	 	 
	Physician Specialty Services

	 	Table # 19 — parts
S2 & S2, Line 11
	 	All costs associated with

medical services provided by a

physician other than a primary care

physician (PCP) 
10S
	 	Physician
	 	Table # 20 — Part B
	 Pharmacy
(not to include
Reimbursable HIV/AIDS Drugs
and Blood Products)

	 	Table # 19 — parts
S2 & S2, Line 18
	 	Expenses for legend and
non-legend drugs provided that include
both ingredient costs and dispensing
fees. Exclude expense reported to Human
Immunodeficiency Virus (HIV/AIDS
Reimbursable Drugs
20N
	 	Pharmacy
	 	Table # 20 — Part C

	 	 	 	 	 
	HMO Financial Guide for Reporting Specifications

	 	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

	 	 	 	 	 	 	 	 	 
	Consolidated	 	Income Statement	 	Managed Care Category	 	Medical Cost	 	Lag Report
	Category of Service	 	Reference	 	of Service Codes	 	Grouping	 	Reference
	 	 	 	 	Description	 	 	 	 
	Reimbursable HIV/AIDS Drugs
and Blood Products

	 	Table # 19 — parts
S2 & S2, Line 19
	 	Specifically, protease
inhibitors and certain other
anti-retrovirals and factor VIII and IX
blood clotting factors.
20H
	 	Pharmacy
	 	Table # 20 — Part C
	 
	 	 	 	 	 	 	 	 
	Outpatient Hospital

(excludes ER)

	 	Table # 19 — parts
S2 & S2, Line 12
	 	The facility component of
the outpatient visit. The visit can be
to a free standing clinic or to a
hospital outpatient department

04N
	 	Pharmacy
	 	Table # 20 — Part D
	 
	 Other
Professional Services

	 	Table # 19 — parts
S2 & S2, Line 13
	 	Compensation paid by the
HMO to non-physician providers engaged
in the delivery of medical
services
14, 15S, 17, PAS
	 	Other
	 	Table # 20 — Part D
	 
	 Emergency
Room

	 	Table # 19 — parts
S2 & S2, Line 14
	 	The facility component of
the emergency room visit as well as OOA
emergency rooms costs. 
04E
	 	Other
	 	Table # 20 — Part D
	 
	 DME/Medical
Supplies

	 	Table # 19 — parts
S2 & S2, Line 15
	 	The cost of durable
medical Equipment (DME) and supplies

30, 31, 32.
	 	Other
	 	Table # 20 — Part D
	 
	 Prosthetics
and Orthotics

	 	Table # 19 — parts
S2 & S2, Line 16
	 	The cost of Prosthetics
and Orthotics
	 	Other
	 	Table # 20 — Part D
	 
	 
Dental

	 	Table # 19 — parts
S2 & S2, Line 17
	 	Expenses for all dental

services provided
	 	Other
	 	Table # 20 — Part D
	 
	 Home
Health, Hospice, and
PDN
Care

	 	Table # 19 — parts
S2 & S2, Line 20
	 	Expenses for home health
services provided, including nurses,
aides and hospice costs and private
duty nursing (PDN
). 40, 50, PDN
	 	Other
	 	Table # 20 — Part D
	 
	 	 	 	 	 	 	 	 
	Transportation

	 	Table # 19 — parts
S2 & S2, Line 21
	 	Expenses for all
ambulance, medical intensive care units
(MICUs) and invalid coach
services
	 	Other
	 	Table # 20 — Part D
	 
	 Lab
& X-ray

	 	Table # 19 — parts
S2 & S2, Line 22
	 	The cost of all
laboratory and radiology (diagnostic
and therapeutic) services for which the
HMO is separately billed.

60, 65.
	 	Other
	 	Table # 20 — Part D

	 	 	 	 	 
	HMO Financial Guide for Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

	 	 	 	 	 	 	 	 	 
	Consolidated	 	Income Statement	 	Managed Care Category	 	Medical Cost	 	Lag Report
	Category of Service	 	Reference	 	of Service Codes	 	Grouping	 	Reference
	 	 	 	 	Description	 	 	 	 
	Vision Care including

eyeglasses

	 	Table # 19 — parts
S2 & S2, Line 23
	 	The cost of routine exams
(by non-physicians) and dispensing
glasses to correct eye defects. This
category includes the cost of
eyeglasses but excludes ophthalmologist
costs related to the treatment of
disease or injury to the eye.

09, 13.
	 	Other
	 	Table # 20 — Part D
	 
	 	 	 	 	 	 	 	 
	Mental Health/substance

Abuse

	 	Table # 19 — parts
S2 & S2, Line 24
	 	The cost of mental health
and substance abuse services including
inpatient, physician services,
outpatient hospital, other professional
services, and other services associated
with mental health or substance abuse
treatment. 
MH, SA. 
	 	Other
	 	Table # 20 — Part D
	 
	 	 	 	 	 	 	 	 
	EPSDT Medical and PDN

	 	Table # 19 — parts
S2 & S2, Line 26a
	 	08D, EPM
	 	Other
	 	Table # 20 — Part D
	 
	 	 	 	 	 	 	 	 
	EPSDT Dental

	 	Table # 19 — parts
S2 & S2, Line 26b
	 	EPD
	 	Other
	 	Table # 20 — Part D
	 
	 Family
Planning

	 	Table # 19 — parts
S2 & S2, Line 27
	 	The cost of family
planning services, including medical
history and physical examinations
(including pelvic and breast),
diagnostic and laboratory tests, drugs
and biologicals, medical supplies and
devices, counseling, continuing
medical supervision, continuity of care
and genetic counseling
, FP
	 	Other
	 	Table # 20 — Part D
	 
	 	 	 	 	 	 	 	 
	Other Medical

	 	Table # 19 — parts
S2 & S2, Line 28
	 	Medical expenses not
included above. 
XM
	 	Other
	 	Table # 20 — Part D

The schedules are arranged with the month of service horizontally and the month of payment
vertically. Therefore, payments made during the current month for services rendered during the
current month would be reported in Line 1, Column 3, while payments made during the current month
for services rendered in prior months would be reported on Line 1, Columns 4 through 39. Please
note that columns 13 through 38 and rows 11 through 36 are hidden in the sample worksheet. Lines 1
through 3 contain data for payments made in the current period. Earlier data on

	 	 	 	 	 
	HMO Financial Guide for Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

Lines 4 through 37
should
shall match data on appropriate lines on the prior period’s submission. If Lines 4 through 37
change from the prior period’s submission, include an explanation. The current month is the last
month of the period that is being reported. For example, in the report for the period ended June
30, 2003, the current month would be June 2003, and the first prior month would be May 2003. Do not
include risk pool distributions as payments in this schedule.

Report # 1 must provide data for the period beginning with the first month the MO is responsible for
providing medical benefits to Medicaid/NJ FamilyCare recipients, and ending with the current month.

Line 39
— Subcapitation payments should
shall be reported here, by month of payment. They should
are not to be included above line 39. For the current period, Line 39
should
shall contain new data in Columns 3 through 5. Data in columns 6 through 38
should
shall match data in appropriate columns on the prior period’s submission. If columns 6 through
38 change from the prior period’s submission, include an explanation.

Line 40 — Report pharmacy rebates anticipated for drugs dispensed this period. Adjust as
appropriate any adjustment applicable to a prior period. Only complete for the Pharmacy Payment
report, Part C.

Line 41 — the HMO should
shall report payments on Lines 1—36. If the HMO makes a settlement or other payment that
cannot be reported on Lines 1—36 due to lack of data, the amount
should
shall be reported on Line 41. If the service month(s) can be determined, the settlement
dollars can be allocated to the service month. Otherwise, with
the payment month can be used as a substitute for the service month. If an amount is shown on
Line 41, in columns 3 through 5, include an explanation. If columns 6 and greater change from the
prior submission, also include an explanation.

Line 42 — This line is the total amount paid to date for services rendered. Line 42
should
shall equal the sum of Lines 38, 39 and 41. For the Pharmacy Payment report, Part C, also
include Line 40.

Line 43 — This line provides the current estimate of remaining liability for unpaid claims for each
month of service. The amount in each column on this line must be updated each period. The
amount in Column 40 is the sum of amounts in Columns 3 through 39. The sum of the amounts in Column
40, in parts A through D, is the unpaid claim liability (IBNR and reported-but-unpaid-claims
(RBUC)). Please refer to Attachment A for a methodology for calculating IBNR.

Line 44. The total incurred claims is the sum of Lines 42 (the amounts paid to date) and Line 43
(estimate of unpaid claims liability). Amounts on Line 44 are shown for each month.

The State recognizes that claims liabilities may include the administrative portion of claim
settlement expenses. Any liability for future claim settlement expense must be disclosed in the
notes in the reports.

The Family Care Adults 0—100 percent of FPL, Health Access individual without dependent children,
and Adult Restricted Aliens (excluding pregnant women) populations are classified into two groups
under the MCSA program. As the State has assumed the responsibility for financial risk for medical
costs of these populations, the medical expenses for these populations
should
shall be excluded from Parts A—D of the Lag Report. All medical expenses for these populations
must be reported within Part E of the Lag Report.

	 	 	 	 	 
	HMO Financial Guide for Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

	 	 	 	 	 
	HMO Financial Guide for Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

Report Guidelines Specifications

Report # 2: Income Statement by Rate Cell Groupings (Table 19, Parts A—V)

This report is meant to provide detailed summary information on revenues and expenses. A separate
report is to be completed for each of the seventeen
fifteen rate cell groupings and for Maternity and Newborn with Report #2, Part S1 and S2 being
the summations of Parts A-R2 respectively. For quarter end and calendar year-to-date end. For
reporting purposes, AIDS revenues and expenses are included or excluded from the rate cell
groupings as indicated on the report forms and in the chart defining the rate cell groupings
provided on page 2.

Additionally, State fiscal year-end information will be provided on the first fiscal quarter ending
reports (September 30). This information shall include all data with incurred dates through the
most recent completed state fiscal year, with paid data through September 30 (incurred in 12
months, paid in 15 months) Reports are to be completed for each of the fifteen rate cell groupings
and for Maternity and Newborn categories. Besides quarter ending September 30, this information is
not required for any other quarter ending time periods.

The Family Care Adults 0—100 percent of FPL, Health Access individual without dependent children,
and Adult Restricted Aliens (excluding pregnant women) populations are classified into two groups
under the MCSA program. As the State has assumed the responsibility for financial risk for medical
costs of these populations, the medical and administrative expenses and premiums for these
populations should
shall be excluded from all rate cell groupings in Parts A—T and reported separately in Parts U
and V. Part V has been created to provide information on services for the non-risk Adult Restricted
Aliens (excluding pregnant women). The Adult Restricted Aliens (excluding pregnant women) expenses
and revenues, which have been scattered across several COAs should
shall now only be included in Part V. Revenue and expenses for non-risk FamilyCare Adults
0—100 percent of FPL will be reported within Part U.

Do not include maternity or newborn revenues or expenses in Part A—Q. Only include maternity or
newborn revenues and maternity expenses on the Income Statement for Maternity, Part R1, and for all
Rate Cell Groupings, Parts S1 and S2. Include newborn expenses on the Income Statement for Newborn,
Part R2, and for all Rate Cell Groupings, Parts S1 and S2. Include Maternity costs associated with
the following codes for still births or live births after the twelfth week of gestation, excluding
elective abortions:

ICG—9 Diagnosis Codes:

	 	•	 	640.01, 640.81, 640.91
	 
	 	•	 	641.01, 641.11, 641.21, 641.31, 641.81, 641.91,
	 
	 	•	 	642.01, 642.11, 642.21, 642.21, 642.31, 642.41, 642.51, 642.64, 642.71, 642.91, 642.02,
642.12, 642.22, 642.21, 642.31, 642.41, 642.51, 642.61, 642.71, 642.91, 642.92
	 
	 	•	 	643.01, 643.11, 643.21, 643.81, 643.91,
	 
	 	•	 	645.01
	 
	 	•	 	646.01, 646.11, 646.12, 646.21, 646.22, 646.31, 646.41, 646.42, 646.51, 646.52, 646.61,
646.62, 646.71, 646.81, 646.82, 646.91

	 	 	 	 	 
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	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

	 	•	 	647.01, 647.11, 647.21, 647.31, 647.41, 647.51, 647.61, 647.61, 647.81, 647.91, 647.02,
647.12, 647.11, 647.21, 647.32, 647.42, 647.52, 647.62, 647.82, 647.92
	 
	 	•	 	648.01, 648.11, 648.21, 648.31, 648.41, 648.51, 648.61, 648.71, 648.81, 648.91, 648.02,
648.12, 648.22, 648.32, 648.62, 648.52, 648.62, 648.82, 648.92
	 
	 	•	 	650 (and any or no trailing characters)
	 
	 	•	 	651.01, 651.11, 651.21, 651.31, 651.41, 651.51, 651.61, 651.81, 651.91
	 
	 	•	 	652.01, 652.11, 652.21, 652.31, 562.41, 652.51, 652.61, 652.71, 652.81, 652.91
	 
	 	•	 	653.01, 653.11, 653.21, 653.31, 563.41, 653.51, 653.61, 653.71, 653.81, 653.91
	 
	 	•	 	654.01, 654.11, 654.21, 654.31, 564.41, 654.51, 654.61, 654.71, 654.81, 654.91, 654.02,
654.12, 654.22, 654.32, 564.42, 654.52, 654.62, 654.72, 654.82, 654.92
	 
	 	•	 	655.01, 655.11, 655.21, 655.31, 565.41, 655.51, 655.61, 655.71, 655.81, 655.91
	 
	 	•	 	656.01, 656.11, 656.21, 656.31, 566.41, 656.51, 656.61, 656.71, 656.81, 656.91
	 
	 	•	 	657.01
	 
	 	•	 	658.01, 658.11, 658.21, 658.31, 568.41, 658.81, 658.91
	 
	 	•	 	659.01, 659.11, 659.21, 659.31, 569.41, 659.51, 659.61, 659.71, 659.81, 659.91
	 
	 	•	 	660.01, 660.11, 660.21, 660.31, 660.41, 660.51, 660.61, 660.71, 660.81, 660.91
	 
	 	•	 	661.01, 661.11, 661.21, 661.31, 661.41, 661.91
	 
	 	•	 	662.01, 662.11, 662.21, 662.31,
	 
	 	•	 	663.01, 663.11, 663.21, 663.31, 663.41, 663.51, 663.61, 663.81, 663.91
	 
	 	•	 	664 (and any or no trailing characters)
	 
	 	•	 	665.01, 665.11, 665.31, 665.41, 665.51, 665.61, 665.71, 665.81, 665.91, 665.22, 665.72,
665.92, 665.92
	 
	 	•	 	666.02, 666.12, 666.22, 666.32
	 
	 	•	 	667.02, 667.12
	 
	 	•	 	668.01, 668.11, 668.21, 66.881, 668.02, 668.12, 668.22, 668.82
	 
	 	•	 	669.01, 669.11, 669.21, 669.31, 669.41, 669.51, 669.61, 669.71, 669.81, 669.91, 669.02,
669.12, 669.22, 669.32, 669.42, 669.82, 669.92
	 
	 	•	 	670.02
	 
	 	•	 	671.01, 671.11, 671.21, 671.31, 671.42, 671.51, 671.81, 671.91, 671.01,671.12, 671.22,
671.52, 671.82, 671.92
	 
	 	•	 	672.02
	 
	 	•	 	673.01, 673.11, 673.21, 673.31, 673.81, 673.02, 673.12, 673.22, 673.32, 673.82
	 
	 	•	 	674.01, 674.02, 674.12, 674.22, 674.32, 674.42, 674.82, 674.92
	 
	 	•	 	675.01, 675.11, 675.21, 675.81, 675.91, 675.02, 675.12, 675.22, 675.82, 675.92
	 
	 	•	 	676.01, 676.11, 676.21, 676.31, 676.41, 676.51, 676.61, 676.81, 676.91, 676.02, 676.12,
676.22, 676.32, 676.42, 676.52, 676.62, 676.82, 676.92, 677 (no other characters)
	 
	 	•	 	V27, V27.0, V27.2, V27.3, V27.4, V27.5, V27.6, V27.7, V27.9

    CPT-4 Codes

	 	•	 	59400, 59409, 59410, 59412, 59414, 59430, 59510, 59510, 59514, 59515, 59525, 59610,
59612, 59614, 59618, 59620, 59622, 59821

Revenue Codes

	 	 	 	 	 
	HMO Financial Guide for Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

	 	•	 	720, 722, 724, 729

Additionally, Report R2 (Income Statement for Newborn) includes newborn claims for the partial
month of birth and the first two (2) months therefter, previously reported in the
AFCD/NJCPW/KidCare A, NJ KidCareB, C, and D, DYFS, and Blind/Disabled rate cell groupings — Age
should
shall be determined by counting the child’s age as of their last birthday, on the first of the
month in which the claim is incurred.

Except for non-State Plan services (Part T) and MCSA reports (Parts U — V), all revenues and
expenses must e reported on Report # 2 using the accrual basis of accounting for the requested
period of the calendar year. Cumulative YTD revenues and expenses are also required in this report.
Each report is based on statewide reporting except for the rate cell grouping AFDC/NJCPW/NJ KidCare
A, which is to be reported for each of the Northern, Central and
Southern region (Report # 2). Each
report must provide total dollar amounts and PMPM amounts. Cells shaded are not to be filled out.
Report # 2 Part S must reconcile to reports #6A and #6B for the Medicaid managed care
at rsik populations. Report # 2 Parts U and V must reconcile to reports #6D and #6E (reports #6D and
#6E on a paid basis) respectively, for the MCSA groups.

The non-State Plan services (See: supplemental Benefits, Article 4.8.1 of the contract) report
(Part T) has been created to provide information on
benefits/services reported within Report # 2,
Parts A—S2 in excess of the State Plan. All medical and administrative expenses must be reported
using actual incurred and paid data for the current period of the calendar year. Unit cost expenses
for the non-State Plan services must also be provided. An
E examples
of non-State Plan approved medical expense would be child car seat

enhanced eyeglass allowance and over the counter drugs for adults.

All medical and administrative expenses within the MCSA reports (Parts U — V) must be reported
using paid data for the current period of the calendar year.

Member Months

A member month is equivalent to the one member for whom the HMO has recognized capitation-based
revenue for the entire month. Where the revenue is recognized for only part of a month for a given
individual, a partial, pro-rated member month should
shall be counted. A partial member month is pro-rated based on the actual number of days in a
particular month. The member months should
shall be reported on a cumulative basis by the rate cell grouping as shown on the report.
Enter the number of member months for the current period in the second column of the member months
line and the member months for the year to date in the fourth column.

The Maternity Income Statement, Part R1 should
shall list number of deliveries, rather than member months. Newborn member months, as defined
in the previous section, will be reported within Part R2 and are not to be included with Parts
S1—S2.

Revenue

Line 1
— Capitated Premiums — revenue recognized on a prepaid basis for enrollees for provision of
a specified range of health services over a defined period of time,
normally
generally one month. If advance payments are made to the HMO, for more than one reporting
period, the portion of the

	 	 	 	 	 
	HMO Financial Guide for Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

payment that has not been earned must be treated as a liability
(Unearned Premiums). Refer to Part S3 for reconciliations.

Line 2 — supplemental Premiums — Revenue paid to the HMO in addition to capitated premiums for
certain services provided. See Lines 2a through 2f below.

Line 2a — Maternity 1— Supplemental payment per pregnancy outcome. This line item should
shall only be included in Part R1 (Maternity) and Parts S1 and S2 (all rate cell groupings).

Line 2b — Reimbursable HIV/AIDS Drugs and blood Products — Supplemental payment for HIV/AIDS Drugs
(protease inhibitors and effective 7/1/01 other anti-retrovirals) and clotting factor VIII and IX
blood products.

Line 2c
— early and Periodic Screening, Diagnosis and Treatment (EPSDT) Incentive Payment — Supplemental payment for EPSDT services.

Line 2d — Reimbursable Medical and Hospital — Supplemental payment for medical and hospital
expenses for FamilyCare Adults 1—100 percent of FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations who are under a MCSA
program. This revenue should
shall only be included in Part U (FamilyCare Adults 0—100 percent FPL) and part V (Adult Restricted
Aliens) and should
is not be included in Parts S1 and S2 (all Rate Cell Groupings).

Line 2e — Managed Care service Administrator Premium — supplemental payment for administrative
expenses for FamilyCare Adults 1—100 percent of FPL, Health Access individuals without dependent
 children, and Adult Restricted Aliens (excluding pregnant women) populations who are under a MCSA
program. This revenue should shall only be included
in Part U (FamilyCare Adults 1—100 percent of FPL) and Part V
(Adult Restricted Aliens), and shoule is not be included in Parts S1
and S2 (All rate cell groupings).

Line 2f — Other — Any other revenue paid by DMAHS to the HMO in addition to capitation for covered
services that is not included in lines 2a, 2b, 2c, 2d, or 2e above.

Line 3 — Total Premiums — All Medicaid/NJ FamilyCare premiums paid to the HMO reported on lines 1,
2a, 2b, 2c, 2d, 2e, and 2f. A detailed reconciliation of total premiums received and reported on
the Income Statement in Part S1 shall be included on Report # 2, Table 19, Part S3. Information
about any differences shall be explained in a note to the reports.

Line 4 — interest — Interest earned from all sources including escrow and reserve accounts.

Line 5 — C.O.B. — Income from Coordination of Benefits and Subrogation. Alternatively, COB for a
particular claim may be recognized as a negative claim expense.

 

			
	1	 	Because costs for pregnancy outcomes were not included in the capitation rates, a separate maternity premium
payment is paid for pregnancy outcomes (each live birth, still birth, or miscarriage occurring at after or after
the twelfth thirteenth (12
13th) week of gestation). This supplemental payment reimburses HMOs for its inpatient
hospital, antepartum, and postpartum costs incurred in connection with delivery. Costs for care of the baby are
included only for the first two months of newborn claims in the AFDC/NJCPW/NJ KidCare A, NJKidCare B, C, and D,
DYFS, and Blind/Disabled rate cell groupings.

	 	 	 	 	 
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Line 6 — Reinsurance Recoveries — Income from the settlement of claims resulting from a policy with
a private reinsurance carrier.

Line 7 — Other Revenue — Revenue from sources not covered in the previous revenue accounts.

Line 8 — Total Revenue — Total revenue (the sum of lines 3 through 7).

Expenses

Medical and Hospital

Line 9 — Inpatient Hospital — code 01 — for description, see Medicaid/NJ FamilyCare Managed Care
Contract.

Inpatient hospital costs including ancillary services for enrollees while confined to
an acute care hospital, including OOA hospitalization.

Line 10 — Primary Care — Code 10P — For description, see Medicaid/NJ FamilyCare Managed Care
Contract.

Includes all costs associated with medical services provided in any setting by a
primary care provider, including physicians and other practitioners.

Line 11 — Physician Specialty Services — Code 10S — For description, see Medicaid/NJ FamilyCare
Managed Care Contract.

All costs associated with medical services provided by a physician other than a PCP.

Line 12 — Outpatient Hospital (excludes ER) — Code 04N — For description, see Medicaid/NJ
FamilyCare Managed Care Contract.

Includes the facility component of the outpatient visit to a free standing clinic or
to a hospital outpatient department should shall be billed separately and reported in the
appropriate service category line item, e.g. physician specialty services.

Lines 13 — Other Professional Services — Codes 14, 15S, 16, PAS — For description, see Medicaid/NJ
FamilyCare Managed Care Contract.

Compensation paid by the HMO to non-physician providers engaged in the delivery of
medical services

Line 14 — Emergency Room — Code 04E — For description, see Medicaid/NJ FamilyCare Managed Care
Contract.

The facility component of the emergency room visit as well as OOA emergency rooms
costs. 

Line 15 — DME/Medical Supplies — codes 30, 31, 32 — For description, see Medicaid/NJ FamilyCare
Managed Care Contract.

The cost of durable medical Equipment (DME) and supplies

	 	 	 	 	 
	HMO Financial Guide for Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

Line 16
— Prosthetics and Orthotics — Code 18 — For description, see Medicaid/NJ FamilyCare Managed
Care Contract.

Includes the cost of Prosthetics and Orthotics

Line 17 — Covered Dental — code 11 — For description, see Medicaid/NJ FamilyCare Managed Care
Contract.

Expenses for all covered dental services.

Line 18 — Pharmacy (not to include Reimbursable HIV/AIDS Drugs and Blood Products)- Code 20N — For
description, see Medicaid/NJ FamilyCare Managed Care Contract.

Expenses for legend and non-legend drugs provided that include both ingredient costs
and dispensing fees. Exclude expense reported to Human Immunodeficiency Virus (HIV/AIDS
Reimbursable Drugs on line 19.

Line 19 — Reimbursable HIV/AIDS Drugs and Blood Products Reimbursable HIV/AIDS Drugs

Code 20H — For description, see Medicaid/NJ FamilyCare Managed Care Contract.

HIV/AIDS Drugs (protease inhibitors and other anti-retrovirals) and clotting factor
VIII and IX blood products. This expense should shall equal the amount on Revenue Line 2b.

Line 20 — Home Health, Hospice, PDN Care
 — codes 40, 50, PDN- For description, see Medicaid/NJ FamilyCare Managed Care Contract.

Expenses for home health services provided, including nurses, aides and hospice costs
and private duty nursing (PDN).

Line 21 — Transportation — Code 70 — For description, see Medicaid/NJ FamilyCare Managed Care
Contract.

Expenses for all ambulance, medical intensive care units (MICUs) and invalid coach
services

Line 22 — Lab & E-Ray — Codes 60, 65 — For description, see Medicaid/NJ FamilyCare Managed Care
Contract.

The cost of all laboratory and radiology (diagnostic and therapeutic) services for
which the HMO is separately billed.

Line 23 — Vision Care including Eyeglasses — Codes 09, 13 — For description, see Medicaid/NJ
FamilyCare Managed Care Contract.

The cost of routine exams (by non-physicians) and dispensing glasses to correct eye
defects. This category includes the cost of eyeglasses but excludes ophthalmologist costs related
to the treatment of disease or injury to the eye.

Line 24 — Mental Health/Substance Abuse — Code MH, SA — For description, see Medicaid/NJ FamilyCare
Managed Care Contract.

The cost of mental health and substance abuse services including inpatient, physician
services, outpatient hospital, other professional services, and other services associated with
mental health or substance abuse treatment.

Line 25 — Reinsurance Expenses — Expenses for reinsurance or “stop loss” insurance made to a
contracted reinsurer.

	 	 	 	 	 
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Line 26a — EPSDT Medical & PDN — codes 08D, EPM —  For description, see Medicaid/NJ FamilyCare
Managed Care Contract.

Line 26b — EPSDT Dental — code EPD — For description, see Medicaid/NJ FamilyCare Managed Care
Contract.

Line 26 — Incentive Pool Adjustment — A reduction to medical expenses for adjusting
the full medical expenses reported. For example, physician withholds retained by the HMO should
shall be included here.

Line 27 — Family Planning — Code FP — For description, see Medicaid/NJ FamilyCare Managed Care
Contract. The cost of family planning services, including medical history and
physical examinations (including pelvic and breast), diagnostic and laboratory tests, drugs and
biologicals, medical supplies and devices, counseling, continuing medical supervision, continuity
of care genetic counseling.

Line 27
8 — Other Medical — Code XM — For description, see Medicaid/NJ FamilyCare Managed Care Contract.

Medical expenses not included in lines 9 through 267.

Line 28
9— Total Medical and Hospital — the total of all medical and hospital expense (sum of lines 9
through 27
8)

Administration

Administration expenses should
shall only be reported on the
designated forms for the MCSA populations (Parts U andV) and the forms for all rate cell
groupings (Parts S1—S2). Except for the MCSA rate cell groupings , this eliminates the need to
allocate these costs across the remaining rate cell groupings. As the State has the responsibility
for financial risk for medical costs of the NJ FamilyCare Adults 1-100 percent of FPL, Health
Access individuals without dependent children, and Adult Restricted Aliens (excluding pregnant
women) populations , the administrative expenses for these populations
should
shall be excluded from Parts S1-S2. The administration expenses for these populations
should
shall be reported separately in Parts U — V. Administration must also be reported on Part T if
the HMO provides any non-State Plan services. Costs associated with the overall management and
operation of the HMO including the following components.

Line 29
30 — Compensation — All expenses for administrative services including compensation and fringe
benefits for personnel time devoted to or in direct support of administration. Include expenses for
management contracts. Do not include marketing expenses here.

Line 30
1 — Occupancy, Depreciation, and Amortization

Line 3210 
Interest Expense. Interest paid during the period on loans.

Line 31 — Occupancy, Depreciation, and Amortization

Line 32
3 — Education/and
Outreach Marketing — Expenses incurred for education and outreach activities for enrollees.
Expenses directly related to marketing activities including advertising,

	 	 	 	 	 
	HMO Financial Guide for Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

printing, marketing
salaries, and fringe benefits, commissions, broker fees, travel, occupancy, and other expenses
allocated to the marketing activity.

Line 33
4 — Sanctions — Expenses related to events where DMAHS finds the contractor to be out of compliance
with the program standards, performance standards, or the terms and conditions of the Medicaid
managed care contract.

Line 33 — Marketing Expenses directly related to marketing activities including
advertising, printing, marketing salaries, and fringe benefits, commissions, broker fees, travel,
occupancy, and other expenses allocated to the marketing activity.

Line 35 44 — Corporate Overhead Allocations — all expenses for management fees, and other
allocations of corporate expenses. Methodologies for allocated expenses may include PMPM, percent
of revenue, percent of head counts and/or full-time equivalents (FTE), etc. Include an explanation
of the expenses included and the basis of methodology in the notes to the financial reports.

Line 36 — Subcontracted/Delegated Administrative Services — Administrative portion of Delegated
Administrative expenses such as Pharmacy Benefits Manager (PBM) or Third Party Administrator (TPA)
payments that cover costs such as claims processing and medical management of the PBM/TPA. An
example of TPA expenses includes dental subcontractors and delegated case management administrative
expenses.

Line 34
7 — Other — Costs which are not appropriately assigned to the health plan administration categories
defined in lines 30 to 36 above. An explanation for this expense must be detailed on Table 19, Part
S3 for categories where the expense is greater than $250,000.

Line 35
8 — Total Administration — The total of costs of administration (the sum of line
28
9 through 34
7)

Line 36
9 — Total Expenses — The sum of Total Medical and Hospital expenses (Line
28
9) and total Administration (Line 35
8).

Line 3740 — Operation Income (Loss) Excess or deficiency of Total Revenue (line 8) minus Total Expenses
Line 36
9).

Line 38
41 — Extraordinary Item — A non-recurring gain or loss.

Line 39
42 — Provision for State, Federal , and o
Other g
Governmental Income Taxes — All income taxes for the period.

Line 42
3 — Other than Income taxes — Expenses other than the state or federal income taxes (i.e. state
assessments irrespective of profit position).

Line 44 032
 — Adjustment for prior period IBNR estimates — should
shall include a reconciliation within Part S3 and
an explanation of prior period IBNR estimates and a detailed
calculation within Report # 2,
Table 20, Parts A through D. A contra-expense would be reported if IBNR estimates exceeded actual
expenses.

	 	 	 	 	 
	HMO Financial Guide for Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

Report Guidelines Specifications

In the explanation below, the term “IBNR” is used to represent all claims incurred, but
unpaid. In statutory accounting for HMOs the incurred claims for a period are calculated as
follows:

	 	 	 	 	 	 	 	 	 	 	 
	 	 	Example for Quarter Ending	 	Example Using Dollars
	 	 	06/30/2003xx Reporting	 	 	 	 	 	 	 	 
	 	 	Period	 	 
	Claims paid in the period
	 	Claims Paid in quarter ending06/30/2003  xx	 	 	 	 	 	$	48,000,000	 
	+IBNR
at the end of the period
	 	+ IBNR as of 06/30/2003xx	 	 	 	 	 	$	11,000,000	 
	- IBNR at
the end of the prior period
	 	- IBNR as of 03/31/2003xx	 	 	 	 	 	–$	9,000,000	 
	+Subcapitation Payments,Pharmacy Rebates, settlements at the end of the period
	 	+Subcapitation Payments, Pharmacy Rebates, settlements as of 06/30/20xx	 	 	 	 	 	+$	500,000	 
	- Subcapitation Payments, Pharmacy Rebates, settlements at the end of the prior period
	 	- Subcapitation Payments, Pharmacy Rebates, settlements as of 3/31/20xx	 	 	 	 	 	–$	450,000	 
	Claims incurred in the period
	 	Claims incurred in quarter ending 06/30/20xx	 	 	 	 	 	$	50,0050,000	 

	 	 	 	 	 
	HMO Financial Guide for Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

Report GuidelinesSpecifications

The above calculation can be split into two components — the first for services rendered in
the period and the second for services rendered prior to the period, as follows:

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Incurred in Quarter	 	Incurred in	 	Total
	 	 	Ending	 	03/31/2003xx &	 	 	 	 
	 	 	06/30/2003xx	 	Prior	 	 
	Claims paid in QTR
ending
06/30/20
03
xx
	 	$	39,500,000	 	 	 	 	 	 	$	8,500,000	 	 	$	48,000,000	 
	+IBNR as of
06/30/20
03
xx
	 	$	10,900,000	 	 	 	 	 	 	$	100,000	 	 	$	11,000,000	 
	-IBNR as of
03/31/20
03
xx
	 	 	None	 	 	 	 	 	$	9,000,000	 	 	$	9,000,000	 
	+ Subcapitation
Payments, Pharmacy
Rebates,
Settlements as of
06/30/20xx
	 	$	50,000	 	 	 	 	 	 	$	450,000	 	 	$	500,000	 
	- Subcapitation
Payments, Pharmacy
Rebates,
Settlements as of
03/31/20xx
	 	 	None	 	 	 	 	 	$	450,000	 	 	$	450,000	 
	Recognized in QTR
Ending
06/30/20
03xx
	 	$	50,4050,000	 	 	 	—	 	 	$	400,000	 	 	$	50,0050,000	 

In the example, claims incurred in the quarter ending 06/30/2003
xx are $50.45 million. This is the amount that would be shown on
Report # 2S Line
28
9; the Statewide Total hospital and Medical Expense for the 3 months ended
06/30/2003
xx. The negative $0.4 million would be reported on line 44032
Adjustment for prior period IBNR estimates. This is the effect of the estimation error for the
prior year end IBNR. Such Estimation errors are to be expected, since the actual amount of unpaid
claims will never exactly match the estimate made earlier.

The sum of the amounts on lines 28
9 and 44032 should
shall be consistent with the statutory accounting amount of claims recognized as incurred in
the period, $50 million in the example above. Information about a
Any non-claim adjustments for prior periods which are not to be grouped into Line
44032, but not in Report #1, in line 4543, and should
shall be explained in a note to the reports. A detailed reconciliation of prior period IBNR
shall be included on Report # 2, Table 19, Part S3.

Line 45 43 — Non Cliam adjustments for Prior periods.

Line 46 541 — Net Income (loss) — Operation Income (Loss) (line 37
40) minus Lines 38, 39,
41, 42, 423, and 434
and 45043

	 	 	 	 	 
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	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

Report Guidelines Specifications

Report # 3 (Table 21): Maternity Outcome Counts

This
report provides counts of second and third trimester maternity outcomes2 for the
current period and year-to-date.

The HMO will provide counts for the following:

Live Births

	 	-	 	Cesarean section deliveries
	 
	 	-	 	Vaginal deliveries

Non-Live Births

These counts will be reported for the following rate cell groupings and geographic areas.

	 	 	 
	Rate Cell Grouping

	 	Geographic Area
	AVDC/NJCPW/NJ KidCare A

	 	Northern
	AVDC/NJCPW/NJ KidCare A

	 	Central
	AVDC/NJCPW/NJ KidCare A

	 	Southern
	All Other

	 	Statewide

Multiple births should be counted as one maternity outcome.

 

		
	2  	Still or live births at or after the twelfth
thirteenth week of gestation, excluding elective abortions.

			
	HMO Financial Guide for Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Report Guidelines Specifications

Report # 4: Claims Processing Lag Report (Tables 4A & 4B)

This report is meant to provide a detailed summary of manual and electronic submitted claims that
were processed during the quarter.

Table 4A

Use Table 4A to report manually submitted claims that were processed during the quarterly period.
Claims submitted and processed electronically must be reported separately on Table 4b. Manual
claims submission shall be processed within 40 days of receipt. Report amounts for each
consolidated category of service and listed in Column 1 in the following columns:

Column 2 — Non-Processed Claims from Prior Quarters — Enter the number manually submitted claims
on-hand that were unprocessed as of the closing date of the last quarterly period. The number shall
be the same as was reported in Column 16 of the prior quarterly report.

Column 3 — Claims Received During Quarter  — Enter the amount of all manually submitted claims that
were received during the quarterly period being reported.

Column 4 — Total Claims — Enter the sum of Columns 2 and 3

Column 5 — Claims Processed This Quarter — Enter the amount of all manually submitted claims
processed (both paid and denied) during the quarterly period being reported. Do not count pended
claims.

Column 6 — 01—40 Days. Enter the number of all manually submitted claims processed (both paid and
denied) within 40 days of their receipt. Note: The number of days required to process a claim is
calculated by comparing the date the claim was received by the contractor to the date the claim was
paid or denied by the contractor (See Article 7.16.5 of the contractor for further detail).

Column 7 — Percent of Total — enter the percentage of manually submitted claims processed (both
paid and denied) within 40 days of their receipt (Compared to total claims processed. Divide Column
6 by 5).

Column 8 — 41—60 Days Enter the number of all manually submitted claims processed (both paid and
denied) between 41—60 days of their receipt

Column 9 — Percent of Total — enter the percentage of manually submitted claims processed (both
paid and denied) between 41—60 days of their receipt. (Compared to total claims processed. Divide
Column 8 by 5).

Column 10 — 61—90 Days — Enter the number of all manually submitted claims processed (both paid and
denied) between 61—90 days of their receipt

      

			
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	 	State of New Jersey

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Column 11 — Percent of Total — enter the percentage of manually submitted claims processed (both
paid and denied) between 61—90 days of their receipt. (Compared to total claims processed. Divide
Column 10 by 5).

Column 12 — 91—120 Days —  Enter the number of all manually submitted claims processed (both paid
and denied) between 91—120 days of their receipt

Column 13 — Percent of Total — enter the percentage of manually submitted claims processed (both
paid and denied) between 91—120 days of their receipt. (Compared to total claims processed. Divide
Column 12 by 5).

Column 14 — > 120 days  — Enter the number of all manually submitted claims processed (both paid
and denied) after 120 days of their receipt

Column 15 — Percent of Total — enter the percentage of manually submitted claims processed (both
paid and denied) after 120 days of their receipt. (Compared to total claims processed. Divide
Column 14 by 5).

Column 16 — Non-Processed Claims on Hand at End of Quarter — Enter the number of manually submitted
claims on hand that were not processed as of closing date of the last report period. (Should be the
difference of Column 4 minus Column 5). Same number should match number of claims entered in Column
2 of next quarter Report.

Column 17 —  Percent of Claims Not Processed at End of Quarter — Divide Column 16 by Column 4 to
arrive at percent.

Table 4B

Use Table 4B to report electronically submitted claims that were processed during the quarterly
period. Claims submitted and processed manually must be reported separately on Table 4A. Electronic
claims submission shall be processed within 30 days of receipt. Report amounts for each
consolidated category of service and total listed in Column 1 in the following columns:

Column 2 — Non-Processed Claims from Prior Quarters — Enter the number electronically submitted
claims on-hand that were unprocessed as of the closing date of the last quarterly period. The
number shall be the same as was reported in Column 16 of the prior quarterly report.

Column 3 — Claims Received During Quarter  — Enter the amount of all electronically submitted
claims that were received during the quarterly period being reported.

Column 4 —  Total Claims — Enter the sum of Columns 2 and 3.

Column 5 — Claims Processed This Quarter — Enter the amount of all electronically submitted claims
processed (both paid and denied) during the quarterly period being reported. Do not count pended
claims.

      

			
	HMO Financial Guide for Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Column 6 — 01—30 Days. Enter the number of all electronically submitted claims processed (both paid
and denied) within 30 days of their receipt. Note: The number of days required to process a claim
is calculated by comparing the date the claim was received by the contractor to the date the claim
was paid or denied by the contractor (See Article 7.16.5 of the contractor for further detail).

Column 7 — Percent of Total — enter the percentage of electronically submitted claims processed
(both paid and denied) within 30 days of their receipt (Compared to total claims processed. Divide
Column 6 by 5).

Column 8 — 31—60 Days Enter the number of all electronically submitted claims processed (both paid
and denied) between 31—60 days of their receipt

Column 9 — Percent of Total — enter the percentage of electronically submitted claims processed
(both paid and denied) between 31—60 days of their receipt. (Compared to total claims processed.
Divide Column 8 by 5).

Column 10 — 61—90 Days — Enter the number of all electronically submitted claims processed (both
paid and denied) between 61—90 days of their receipt

Column 11 — Percent of Total — enter the percentage of electronically submitted claims processed
(both paid and denied) between 61—90 days of their receipt. (Compared to total claims processed.
Divide Column 10 by 5).

Column 12 — 91—120 Days —  Enter the number of all electronically submitted claims processed (both
paid and denied) between 91—120 days of their receipt

Column 13 — Percent of Total — enter the percentage of electronically submitted claims processed
(both paid and denied) between 91—120 days of their receipt. (Compared to total claims processed.
Divide Column 12 by 5).

Column 14 — > 120 days  — Enter the number of all electronically submitted claims processed
(both paid and denied) after 120 days of their receipt

Column 15 — Percent of Total — enter the percentage of electronically submitted claims processed
(both paid and denied) after 120 days of their receipt. (Compared to total claims processed. Divide
Column 14 by 5).

Column 16 — Non-Processed Claims on Hand at End of Quarter — Enter the number of electronically
submitted claims on hand that were not processed as of closing date of the last report period.
(Should be the difference of Column 4 minus Column 5). Same number should match number of claims
entered in Column 2 of next quarter Report.

Column 17 — Percent of Claims Not Processed at End of Quarter — Divide Column 16 by Column 4 to
arrive at percent.

      

			
	HMO Financial Guide for Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Report  Guidelines  Specifications

Report
# 3 (Table 21) :Maternity Outcome Counts

This
report provides counts of second and third trimester maternity outcomes3 for the
current period and year-to-date.

The HMO will provide counts for the following:

Live Births

	 	 	 	Cesarean section deliveries
	 
	 	 	 	Vaginal deliveries

Non-Live Births

These counts will be reported for the following rate cell groupings and geographic areas.

	 	 	 
	Rate Cell Grouping 

	 	 Geographic Area
	AVDC/NJCPW/NJ KidCare A

	 	 Northern
	AVDC/NJCPW/NJ KidCare A

	 	Central
	AVDC/NJCPW/NJ KidCare A

	 	Southern
	All Other

	 	Statewide

 

		
	3  	Still or live births at or after the twelfth
thirteenth week of gestation, excluding elective abortions.

	 		
	HMO Financial Guide for Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Report Guidelines Specifications

Report # 7: Stop Loss Summary (Table 7, Parts A-C)

The contractor shall identify reinsurance coverage in effect during the calendar year for the
reporting period ending December 31 of each year. For each of the designated eligibility
categories, the contractor shall report the total number of enrollees that exceeded the stop-loss
threshold and the total net expenditures exceeding the stop-loss threshold during the period.

      

			
	HMO Financial Guide for Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Report Guidelines Specifications

Report # 10: Third Party Liability Collections (Table 10)

The contractor shall report quarterly the categories of all third party liability collections and
shall include the amounts and nature of all third party payments recovered for Medicaid/NJ
FamilyCare enrollees, included but not limited to, payments for services and conditions which are:

	 	•	 	Covered through coordination of benefits;
	 
	 	•	 	Employment related injuries or illnesses;
	 
	 	•	 	Related to motor vehicle accidents, whether injured as pedestrians, drivers,
passengers, or bicyclists; and
	 
	 	•	 	Contained in diagnosis Codes 800 through 999 (ICD9CM) with the exception of Code
994.6.

Multiple births should be counted as one maternity outcome.

      

			
	HMO Financial Guide for Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Appendix A — IBNR Methodology

IBNR Methodology

IBNRs are difficult to estimate because of the quantity of service and exact service cost are not
always known until claims are actually received. Since medical claims are the major expenses
incurred by the HMOs, it is extremely important to accurately identify costs for outstanding
unbilled services. To accomplish this, a reliable claims system and a logical IBNR methodology are
required.

Selection of the most appropriate system for estimating IBNR claims expense requires judgment based
on an HMO’s own circumstances, characteristics, and the availability and reliability of various
data sources. A primary estimation methodology along with supplementary analysis usually produces
the most accurate IBNR estimates. Other common elements needed for successful IBNR systems are:

	 	•	 	An IBNR system must function as part of the overall financial management and claims
system. These systems combine to collect, analyze, and share claims data. They require
effective referral, prior authorization, utilization review, and discharge planning
functions. Also, the HMO must have a full accrual accounting system. Full accrual
accounting systems help properly identify and record the expense, together with the related
liability, for all unpaid and unbilled medical services provided to HMO members.
	 
	 	•	 	An effective IBNR system requires the development of reliable lag tables that identify
the length of time between provision of service, receipt of claims, and processing and
payment of claims by major provider type (inpatient hospital, physician, pharmacy, and
other medical). Reliable claims/cash disbursement systems generally produce most of the

necessary data. Lag tables, and the projections developed from them, are most useful when
there is sufficient, accurate claims history, which show stable claims lag patterns.
Otherwise, the tables will need modification, on a pro forma basis, to reflect corrections
for known errors or skewed payment patterns. The data included in the lag schedules should
shall include all information received to date in order to take advantage of all known
amounts (i.e., RBUCs and paid claims).

Accurate, complete, and timely claims data should shall be monitored, collected, compiled, and
evaluated as early as possible. Whenever practical, claims data collection and analysis should
shall begin before the service is provided (i.e. prior authorization records). This prospective
claims data, together with claims data collected as the services are provided, should shall be used
to identify claims liabilities. Claims data should shall also be segregated to permit analysis by
major rate code, region/county, and consolidated category of service.

Subcontractor agreements should shall clearly state each party’s responsibility for
claims/encounter submission, prior notification, authorization, and reimbursement rates. These
agreements should shall be in writing, clearly understood and followed consistently by each party.

The individual IBNR amounts, once established, should shall be monitored for adequacy and adjusted
as needed. If IBNR estimates are subsequently found to be significantly inaccurate, analysis should
shall be performed to determine the reasons for the inaccuracy. Such an analysis should shall be
used to refine an HMO’s IBNR methodology if applicable.

      

			
	HMO Financial Guide for Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

There are several different methods that can be used to determine the amount of IBNRs. The HMO
should shall employ the one that best meets its needs and accurately estimates its IBNRs. If an HMO
is utilizing a method different from the methods included herein, a detailed description of the
process must be submitted to the State for approval. This process may be described in the “notes to
Financial Reports” section. The IBNR methodology used by the HMO must be evaluated by the HMO’s
independent accountant or actuary for reasonableness.

Case Basis Method

Accruals are based on estimates of individual claims and/or episodes. This method is generally used
for those types of claims where the amount of the cost will be large, requiring prior
authorization. The final estimated cost could be made after the services have been authorized by
the HMO. For example, if an HMO knows how many hospitals days were authorized for a certain time
period, and can incorporate the contracted reimbursement arrangement(s) with the hospital (s), a
reasonable estimate should be attainable. This is also the most common and can be the most accurate
method for small and medium sized organizations.

Average Cost Method

As the name suggests, average costs of services are used to estimate total expense. The expenses
estimated using average costs. Two primary average costs methods are discussed below. It is
important to note that each method may be used by and HMO to estimate different categories of IBNRs
(i.e. hospitalization vs. other medical). Also, either method may be utilized in conjunction with
other IBNR methodologies discussed in this document.

PMPM Averages

Under this method the average costs are based on the population of each rate code (or group of
homogenous rate codes) over a given time period, in this case one month. The average cost may cover
one or more service categories and it multiplied by the number of members in the specific
population to estimate the total expense of the service category. Any claims paid are subtracted
from the expense estimate that results in the IBNR liability estimate for that service category.

Per Diem or Per Service Averages

Averages for this method are of specific occurrences known by the HMO at the time of the
estimation. Therefore, it is first necessary to know how many hospital days, procedure or visits
were authorized as of the date for which the IBNR is being estimated. Again, once the total expense
has been estimated, the amount of related paid claims should shall be subtracted to get the IBNR
liability. This method is primarily used for hospitalization IBNRs as HMOs know the amount of
hospital days authorized at any given time.

Lag Tables

Lag tables are used to track historical payment patterns. When a sufficient history exists and a
regular claims submission pattern has been established, this methodology can be employed. All HMOs
should shall use lag information as a validation test for accruals calculated using other methods.,
if it is not the primary methodology employed. Typically, the information on the

	 		
	HMO Financial Guide for Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

schedules I organized according to the month claims are incurred on the horizontal axis and the
month claims are paid by the HMO on the vertical axis.

Once a number of months becomes “fully developed” (i.e. claims submissions are thought to be
complete for the month of service), the information can be utilized to effectively estimate IBNRs.
Computing the average period over which claims are submitted historically and applying this
information to months that are not yet fully developed does this.

      

			
	HMO Financial Guide for Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Appendix B — Report Forms

Quarterly Report Forms

This section includes copies of the forms to be completed electronically by the HMO for each quarter.

	 	•	 	Quarterly Certification Statement
	 
	 	•	 	Report # 1: Lag Report

	 	o	 	Part A: Lag Report for Inpatient Hospital Payments Excluding MCSA Populations.
	 
	 	o	 	Part B: Lag Report for Physician Payments Excluding MCSA Populations
	 
	 	o	 	Part C: Lag Report for Pharmacy Payments Excluding MCSA Populations
	 
	 	o	 	Part D: Lag Report for Other Medical Payments Excluding MCSA Populations
	 
	 	o	 	Part E: Lag Report for MCSA Populations

	 	•	 	Report # 2: Income Statement by RATE CELL GROUPING

	 	o	 	Part A: AFDC/NJCPW/NJ KidCare A — Northern Region
	 
	 	o	 	Part B: AFDC/NJCPW/NJ KidCare A — Central Region
	 
	 	o	 	Part C: AFDC/NJCPW/NJ KidCare A — Southern Region
	 
	 	o	 	Part D: DYFS — Statewide
	 
	 	o	 	Part E: ABD with Medicare — DDD — Statewide
	 
	 	o	 	Part F: ABD with Medicare — non-DDD — Statewide
	 
	 	o	 	Part G: Non-ABD — DDD — Statewide
	 
	 	o	 	Part H: ABD without Medicare — DDD — Statewide
	 
	 	o	 	Part I: ABD without Medicare — Non DDD — Statewide
	 
	 	o	 	Part J: NJ KidCare B&C Statewide
	 
	 	o	 	Park K: NJ KidCare D Statewide
	 
	 	o	 	Part L: Reserved
	 
	 	o	 	Part M: NJ FamilyCare Parents 0-133% FPL — Statewide
	 
	 	o	 	Part N: (Reserved)
	 
	 	o	 	Part O: NJ FamilyCare Parents 134-200 250% FPL — Statewide
	 
	 	o	 	Part P: ABD with Medicare — AIDS- Statewide
	 
	 	o	 	Part Q: Non- ABD —  AIDS- Statewide
	 
	 	o	 	Part R1: Maternity- Statewide
	 
	 	o	 	Part R2: Newborn — Statewide
	 
	 	o	 	Part S1: All Rate Cell Groupings Current Quarter — Statewide
	 
	 	o	 	Part S2: All Rate Cell Groupings Year  — To -Date — Statewide
	 
	 	o	 	Part S3: Reconciliations
	 
	 	o	 	Part T: Non-State Plan Services
	 
	 	o	 	Part U: NJ FamilyCare Adults 0-100% FPL — Statewide
	 
	 	o	 	Part V: Adult Restricted Aliens — Statewide

	 	•	 	Report # 3: table 21: Maternity Outcome Counts
	 
	 	•	 	Report # 4: Claims Processing Lag Report

	 	o	 	Part A: Claims Processing Lag Report for Manually Submitted Claims
	 
	 	o	 	Part B: Claims Processing Lag Report for Electronically Submitted Claims

	 	•	 	Report # 7: Stop Loss Summary
	 
	 	•	 	Report # 10 : Third Party Liability Collections
	 
	 	•	 	Notes to Financial Reports

      

			
	HMO Financial Guide for Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Appendix B — Report Forms

QUARTERLY CERTIFICATION STATEMENT

OF

 

HMO NAME

TO THE

NEW JERSEY DEPARTMENT OF HUMAN SERVICES

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES

FOR THE PERIOD ENDED

 

(Month/day/year)

Name of Preparer _________________

Title ________________

Phone Number ______________

Please check which reports are included with this packet:

					
	O Report # 1

	 	O Report # 2
	 	O Report # 3
	O Report # 4

	 	O Report # 7
	 	O Report # 10

I hereby attest that the information submitted in the reports herein is current, complete
and accurate to the best of my knowledge. I understand that whoever knowingly and willfully
makes or causes to be made a false statement or representation on the reports may be
prosecuted under applicable state laws. In addition, knowingly and willfully failing to
fully and accurately disclose the information requested may result in denial of a request to
participate, or where the entity already participates, a termination of an HMO’s agreement
or contract with the State.

	 	 	 	 	 
	Date

	 	Chief Financial Officer
	 	Signature

      

			
	HMO Financial Guide for Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Appendix B — Report Forms

NOTES TO FINANCIAL REPORTS

Any notes or further explanation of any items contained in any of the reports or in the
reporting of financial disclosures are to be noted here. Appropriate references and
attachments are to be used as necessary. Space is provided below or you may use a separate
page as necessary.

      

			
	HMO Financial Guide for Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Table # 4  — Part A — claims Processing Lag Report for Manually Submitted Claims

For the Three months ending _______ for _______

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Claims Processed During Quarter	 
	1	 	2	 	 	3	 	 	4	 	 	5	 	 	6	 	 	7	 	 	8	 	 	9	 	 	10	 	 	11	 	 	12	 	 	13	 	 	14	 	 	15	 	 	16	 	 	17	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Percent	 
	 	 	Non	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Non	 	 	of Non	 
	 	 	Processed	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Processed	 	 	Processed	 
	 	 	Claims	 	 	Claims	 	 	 	 	 	 	Claims	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Claims	 	 	Claims	 
	 	 	from	 	 	Received	 	 	 	 	 	 	Processed	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	on Hand	 	 	on Hand	 
	Consolidated	 	Prior	 	 	During	 	 	Total	 	 	this	 	 	01-40	 	 	Percent	 	 	41-60	 	 	Percent	 	 	61-90	 	 	Percent	 	 	91-120	 	 	Percent	 	 	>120	 	 	Percent	 	 	at end of	 	 	at End of	 
	Category of service	 	quarter	 	 	Quarter	 	 	Claims	 	 	Quarter	 	 	Days	 	 	of Total	 	 	Days	 	 	of Total	 	 	Days	 	 	of Total	 	 	Days	 	 	of Total	 	 	days	 	 	of Total	 	 	Quarter	 	 	Quarter	 
	 
	Inpatient Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Primary Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Physician Specialty
Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Other
Professional
Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Emergency Room
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	DME/Medical Supplies
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prosthetics
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Dental
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Pharmacy
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	AIDS/HIV
Reimbursable Drugs
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Home Health Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Lab and X-Ray
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Vision Care &
Eyeglasses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Mental
Health/Substance
Abuse
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Other Medical
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Grand Total
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

      

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Table # 4 — Part B — Claims Processing Lag Report for Electronically Submitted Claims

For the Three months ending __________ for ___________

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Claims Processed During Quarter	 
	1	 	2	 	 	3	 	 	4	 	 	5	 	 	6	 	 	7	 	 	8	 	 	9	 	 	10	 	 	11	 	 	12	 	 	13	 	 	14	 	 	15	 	 	16	 	 	17	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Percent	 
	 	 	Non	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Non	 	 	of Non	 
	 	 	Processed	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Processed	 	 	Processed	 
	 	 	Claims	 	 	Claims	 	 	 	 	 	 	Claims	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Claims	 	 	Claims	 
	 	 	from	 	 	Received	 	 	 	 	 	 	Processed	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	on Hand	 	 	on Hand	 
	Consolidated	 	Prior	 	 	During	 	 	Total	 	 	this	 	 	01-30	 	 	Percent	 	 	31-60	 	 	Percent	 	 	61-90	 	 	Percent	 	 	91-120	 	 	Percent	 	 	>120	 	 	Percent	 	 	at end of	 	 	at End of	 
	Category of service	 	quarter	 	 	Quarter	 	 	Claims	 	 	Quarter	 	 	Days	 	 	of Total	 	 	Days	 	 	of Total	 	 	Days	 	 	of Total	 	 	Days	 	 	of Total	 	 	days	 	 	of Total	 	 	Quarter	 	 	Quarter	 
	 
	Inpatient Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Primary Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Physician Specialty
Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Other
Professional
Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Emergency Room
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	DME/Medical Supplies
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prosthetics
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Dental
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Pharmacy
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	AIDS/HIV
Reimbursable Drugs
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Home Health Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Lab and X-Ray
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Vision Care &
Eyeglasses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Mental
Health/Substance
Abuse
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Other Medical
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Grand Total
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

      

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Table # 7: Parts A—C — Stop Loss Summary

For the Calendar Year ENDING ______________ For _____________________

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	A. Coverage
 	 
	Aggregate Stop Loss	 	Maximum Per Enrollee Per	 	 	Maximum Aggregate	 	 	Includes Insolvency	 	 	 	 	 	 	 
	Threshold	 	Year	 	 	Lifetime Per Enrollee	 	 	Insurance (Y/N)	 	 	Deductible	 	 	Cost of Premiums PMPM	 
	 
	$
	 	$
 
Policy Expiration Date	 	 	 	$	 	 	 	 	 	 	 	$
 
00/00/0000	 	 	 	$	 	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	B
 
	Category of Eligibility	 	AFDC	 	DYFs	 	ABD	 	NJ KidCare	 	FamilyCare	 	TOTAL
	 
	Number of Enrollees
Exceeding Stop Loss
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Net Expenditures Above Stop Loss

	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 

	 	 	 	 	 	 	 	 	 	 	 	 	 
	
C. List Details for Each Individual (Name or ID Not Required)
 	 
	 	 	Net Expenditures Above Stop Loss	 	 	Primary Diagnosis/Major Procedure	 	 	Reinsurance Recoveries	 
	 
	1
	 	 	 	 	 	 	 	 	 	 	 	 
	2
	 	 	 	 	 	 	 	 	 	 	 	 
	3
	 	 	 	 	 	 	 	 	 	 	 	 
	4
	 	 	 	 	 	 	 	 	 	 	 	 
	5
	 	 	 	 	 	 	 	 	 	 	 	 
	6
	 	 	 	 	 	 	 	 	 	 	 	 
	7
	 	 	 	 	 	 	 	 	 	 	 	 
	8
	 	 	 	 	 	 	 	 	 	 	 	 
	9
	 	 	 	 	 	 	 	 	 	 	 	 
	10
	 	 	 	 	 	 	 	 	 	 	 	 
	11
	 	 	 	 	 	 	 	 	 	 	 	 
	12
	 	 	 	 	 	 	 	 	 	 	 	 
	13
	 	 	 	 	 	 	 	 	 	 	 	 
	14
	 	 	 	 	 	 	 	 	 	 	 	 
	15
	 	 	 	 	 	 	 	 	 	 	 	 
	Total (lines 1 through 15)
	 	 	 	 	 	 	 	 	 	 	 	 
	Table # 19, Parts S2, Line 6
	 	 	 	 	 	 	 	 	 	 	 	 
	Difference
	 	 	 	 	 	 	 	 	 	 	 	 

Table # 10 — Third Party Liability *

	 		
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

FOR THE
THREE MONTHS ENDING __________ FOR ___________

	 	 	 	 	 	 	 	 	 
	COA	 	Employment Related	 	Motor Vehicle Related	 	Other	 	Health Insurance
	 
	AFDC**
	 	$	 	$	 	$	 	$
	DYFS
	 	$	 	$	 	$	 	$
	Aged with Medicare
	 	$	 	$	 	$	 	$
	Aged w/o Medicare
	 	$	 	$	 	$	 	$
	Blind and Disabled
with Medicare +
	 	$	 	$	 	$	 	$
	Blind and Disabled
w/o Medicare +
	 	$	 	$	 	$	 	$
	NJ KidCare
	 	$	 	$	 	$	 	$
	NJ FamilyCare
	 	$	 	$	 	$	 	$
	Total
	 	$	 	$	 	$	 	$

 

			
	*	 	Enter total amount collected for each eligibility category.
	 
	**	 	Include New Jersey care children and pregnant women
	 
	+	 	Include essential spouses

      

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

NOTES TO FINANCIAL REPORTS

FOR THE
THREE MONTHS ENDING _________________________
        FOR ________________

Any notes or further explanations of any items contained in any of the
reports or in the reporting of financial disclosures are to be noted here.
Appropriate references and attachments are to be used as necessary. Space is
provided below or you may use a separate page as necessary.

Table # 4

	 	•	 	Part A — Claims Lag report for manually submitted
	 
	 	•	 	Part B — Claims Lag report for electronically submitted

Table # 7

Parts A—C — Stop Loss

Table # 10 — Third Party Liability

Table # 19

Parts A—V — Income Statement by RATE CELL GROUPINGS

Table # 20

Part A — Lag Report for Inpatient hospital Payments

Part B — Lag Report for physician Payments

Part C — Lag Report for pharmacy Payments

Part D —  Lag Report for Other Medical Payments

Part E — Lag Report for MCSA Payments

Table # 21

Maternity Outcome Counts

Table # 21 — Maternity Outcome Counts

      

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

FOR THE THREE MONTHS ENDING ________
        FOR _____________

        (HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Current Period	 	 	Year to Date	 
	 	 	Live Births	 	 	Non-live	 	 	 	Live Births	 	 	Non-live	 
	 	 	C-Section	 	 	Vaginal	 	 	births	 	 	C-Section	 	 	Vaginal	 	 	births	 
	 
	NORTHERN REGION
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	CENTRAL REGION
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SOUTHERN REGION
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	STATEWIDE
ALL OTHER
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	TOTAL
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

Note: Only outcomes on or after the thirteenth week of gestation should be included in this
report, excluding elective abortions.

      

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Table #20 – Part A – Lag Report for Inpatient Hospital Payments

FOR THE THREE MONTHS ENDING ___                FOR ___

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	(1)	 	(2)	 	(3)	 	 	(4)	 	 	(5)	 	 	(6)	 	 	(7)	 	 	(8)	 	 	(9)	 	 	(10)	 	 	(11)	 	 	(12)	 	 	(13)	 	 	(14)	 	 	(15)	 	 	(16)	 	 	(17)	 	 	(18)	 	 	(19)	 	 	(20)	 	 	(21)	 	 	(22)	 	 	(23)	 
	 	 	 	 	Current	 	 	1st Prior	 	 	2nd Prior	 	 	3rd Prior	 	 	4th Prior	 	 	5th Prior	 	 	6th Prior	 	 	7 Prior	 	 	8 Prior	 	 	9 Prior	 	 	10 Prior	 	 	11th Prior	 	 	12thPrior	 	 	13 Prior	 	 	14 Prior	 	 	15 Prior	 	 	16 Prior	 	 	17 Prior	 	 	18 Prior	 	 	19 Prior	 	 	20th Prior	 
	Line	 	Month of Payment	 	Month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 
	1
	 	Current Month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2
	 	1st Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3
	 	2nd Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4
	 	3rd Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5
	 	4th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6
	 	5th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7
	 	6th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8
	 	7 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9
	 	8 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10
	 	9 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11
	 	10 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12
	 	11th  Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13
	 	12th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14
	 	13 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15
	 	14 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16
	 	15 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17
	 	16 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18
	 	17th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	19
	 	18th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	20
	 	19th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	21
	 	20th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	22
	 	21st prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	23
	 	22nd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	24
	 	23rd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	25
	 	24th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26
	 	25th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	27
	 	26th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	28
	 	27th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	29
	 	28th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	30
	 	29th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	31
	 	30th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	32
	 	31st prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	33
	 	32rd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	34
	 	33 prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	35
	 	34 prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	36
	 	35th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	37
	 	Months before	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	35th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	38
	 	Total Claim Payments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	39
	 	Subcapitation payments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	40
	 	Pharmacy Rebates	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	41
	 	Settlements	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	(1)	 	(2)	 	(3)	 	 	(4)	 	 	(5)	 	 	(6)	 	 	(7)	 	 	(8)	 	 	(9)	 	 	(10)	 	 	(11)	 	 	(12)	 	 	(13)	 	 	(14)	 	 	(15)	 	 	(16)	 	 	(17)	 	 	(18)	 	 	(19)	 	 	(20)	 	 	(21)	 	 	(22)	 	 	(23)	 
	 	 	 	 	Current	 	 	1st Prior	 	 	2nd Prior	 	 	3 Prior	 	 	4th Prior	 	 	5th Prior	 	 	6th Prior	 	 	7 Prior	 	 	8 Prior	 	 	9 Prior	 	 	10 Prior	 	 	11th Prior	 	 	12thPrior	 	 	13 Prior	 	 	14 Prior	 	 	15 Prior	 	 	16 Prior	 	 	17 Prior	 	 	18 Prior	 	 	19 Prior	 	 	20th Prior	 
	Line	 	Month of Payment	 	Month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 
	42
	 	Sum of claims,	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	Subcapitation payments, and	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	settlements	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	43
	 	Current estimate of	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	remaining liability	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	44
	 	Total Incurred Claims	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

Table #20 – Part A – Lag Report

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	(1)	 	(2)	 	(24)	 	 	(25)	 	 	(26)	 	 	(27)	 	 	(28)	 	 	(29)	 	 	(30)	 	 	(31)	 	 	(32)	 	 	(33)	 	 	(34)	 	 	(35)	 	 	(36)	 	 	(37)	 	 	(38)	 	 	(39)	 	 	(40)	 	 	 	 	 
	 	 	 	 	Current	 	 	1st Prior	 	 	2nd Prior	 	 	3rd Prior	 	 	4th Prior	 	 	5th Prior	 	 	6th Prior	 	 	7 Prior	 	 	8 Prior	 	 	9 Prior	 	 	10 Prior	 	 	11thPrior	 	 	12th Prior	 	 	13 Prior	 	 	14 Prior	 	 	15 Prior	 	 	 	 	 	 	 	 	 
	Line	 	Month of Payment	 	Month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	 	 	 	 	 	 	 
	1
	 	Current Month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2
	 	1st Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3
	 	2nd Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4
	 	3rd Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5
	 	4th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6
	 	5th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7
	 	6th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8
	 	7 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9
	 	8 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10
	 	9 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11
	 	10 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12
	 	11th  Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13
	 	12th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14
	 	13 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15
	 	14 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16
	 	15 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17
	 	16 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18
	 	17th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	19
	 	18th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	20
	 	19th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	21
	 	20th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	22
	 	21st prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	23
	 	22nd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	24
	 	23rd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	25
	 	24th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26
	 	25th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	27
	 	26th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	28
	 	27th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	29
	 	28th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	30
	 	29th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	31
	 	30th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	32
	 	31st prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	33
	 	32rd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	34
	 	33 prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	35
	 	34 prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	36
	 	35th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	37
	 	Months before	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	35th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	38
	 	Total Claim Payments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	(1)	 	(2)	 	(24)	 	 	(25)	 	 	(26)	 	 	(27)	 	 	(28)	 	 	(29)	 	 	(30)	 	 	(31)	 	 	(32)	 	 	(33)	 	 	(34)	 	 	(35)	 	 	(36)	 	 	(37)	 	 	(38)	 	 	(39)	 	 	(40)	 	 	 	 	 
	 	 	 	 	Current	 	 	1st Prior	 	 	2nd Prior	 	 	3rd Prior	 	 	4th Prior	 	 	5th Prior	 	 	6th Prior	 	 	7 Prior	 	 	8 Prior	 	 	9 Prior	 	 	10 Prior	 	 	11thPrior	 	 	12th Prior	 	 	13 Prior	 	 	14 Prior	 	 	15 Prior	 	 	 	 	 	 	 	 	 
	Line	 	Month of Payment	 	Month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	 	 	 	 	 	 	 
	39
	 	Subcapitation payments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	40
	 	Pharmacy Rebates	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	41
	 	Settlements	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	42
	 	Sum of claims,	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	Subcapitation payments, and settlements	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	43
	 	Current estimate of	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	remaining liability	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	44
	 	Total Incurred Claims	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

Table #20 – Part B – Lag Report for Physician Payments

FOR THE THREE MONTHS ENDING ___                FOR ___

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	(1)	 	(2)	 	(3)	 	 	(4)	 	 	(5)	 	 	(6)	 	 	(7)	 	 	(8)	 	 	(9)	 	 	(10)	 	 	(11)	 	 	(12)	 	 	(13)	 	 	(14)	 	 	(15)	 	 	(16)	 	 	(17)	 	 	(18)	 	 	(19)	 	 	(20)	 	 	(21)	 	 	(22)	 	 	(23)
	 	 	 	 	Current	 	 	1st Prior	 	 	2nd Prior	 	 	3rd Prior	 	 	4th Prior	 	 	5th Prior	 	 	6th Prior	 	 	7 Prior	 	 	8 Prior	 	 	9 Prior	 	 	10 Prior	 	 	11th Prior	 	 	12th Prior	 	 	13 Prior	 	 	14 Prior	 	 	15 Prior	 	 	16 Prior	 	 	17 Prior	 	 	18 Prior	 	 	19 Prior	 	 	20th Prior
	Line	 	Month of Payment	 	Month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month
	1
	 	Current Month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2
	 	1st Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3
	 	2nd Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4
	 	3rd Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5
	 	4th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6
	 	5th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7
	 	6th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8
	 	7 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9
	 	8 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10
	 	9 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11
	 	10 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12
	 	11th  Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13
	 	12th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14
	 	13 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15
	 	14 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16
	 	15 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17
	 	16 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18
	 	17th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	19
	 	18th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	20
	 	19th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	21
	 	20th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	22
	 	21st prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	23
	 	22nd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	24
	 	23rd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	25
	 	24th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26
	 	25th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	27
	 	26th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	28
	 	27th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	29
	 	28th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	30
	 	29th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	31
	 	30th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	32
	 	31st prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	33
	 	32rd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	34
	 	33 prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	35
	 	34 prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	36
	 	35th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	37
	 	Months before 35th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	38
	 	Total Claim Payments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	39
	 	Subcapitation payments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	40
	 	Pharmacy Rebates	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	41
	 	Settlements	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	(1)	 	(2)	 	(3)	 	 	(4)	 	 	(5)	 	 	(6)	 	 	(7)	 	 	(8)	 	 	(9)	 	 	(10)	 	 	(11)	 	 	(12)	 	 	(13)	 	 	(14)	 	 	(15)	 	 	(16)	 	 	(17)	 	 	(18)	 	 	(19)	 	 	(20)	 	 	(21)	 	 	(22)	 	 	(23)	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Current	 	 	1st Prior	 	 	2nd Prior	 	 	3rd Prior	 	 	4th Prior	 	 	5th Prior	 	 	6th Prior	 	 	7 Prior	 	 	8 Prior	 	 	9 Prior	 	 	10 Prior	 	 	11th Prior	 	 	12th Prior	 	 	13 Prior	 	 	14 Prior	 	 	15 Prior	 	 	16 Prior	 	 	17 Prior	 	 	18 Prior	 	 	19 Prior	 	 	20th Prior	 	 	 	 	 	 	 	 	 	 	 	 	 
	Line	 	Month of Payment	 	Month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	 	 	 	 	 	 	 	 	 	 	 
	42
	 	Sum of claims, Subcapitation
payments, and settlements	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	43
	 	Current estimate of remaining liability	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	44
	 	Total Incurred Claims	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

Table #20 – Part B – Lag Report

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	(1)	 	(2)	 	(24)	 	 	(25)	 	 	(26)	 	 	(27)	 	 	(28)	 	 	(29)	 	 	(30)	 	 	(31)	 	 	(32)	 	 	(33)	 	 	(34)	 	 	(35)	 	 	(36)	 	 	(37)	 	 	(38)	 	 	(39)	 	 	(40)	 	 	 	 	 
	 	 	 	 	Current	 	 	1st Prior	 	 	2nd Prior	 	 	3rd Prior	 	 	4th Prior	 	 	5th Prior	 	 	6th Prior	 	 	7 Prior	 	 	8 Prior	 	 	9 Prior	 	 	10 Prior	 	 	11th Prior	 	 	12th Prior	 	 	13 Prior	 	 	14 Prior	 	 	15 Prior	 	 	 	 	 	 	 	 	 
	Line	 	Month of Payment	 	Month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	 	 	 	 	 	 	 
	1
	 	Current Month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2
	 	1st Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3
	 	2nd Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4
	 	3rd Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5
	 	4th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6
	 	5th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7
	 	6th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8
	 	7 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9
	 	8 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10
	 	9 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11
	 	10 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12
	 	11th  Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13
	 	12th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14
	 	13 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15
	 	14 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16
	 	15 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17
	 	16 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18
	 	17th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	19
	 	18th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	20
	 	19th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	21
	 	20th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	22
	 	21st prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	23
	 	22nd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	24
	 	23rd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	25
	 	24th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26
	 	25th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	27
	 	26th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	28
	 	27th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	29
	 	28th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	30
	 	29th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	31
	 	30th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	32
	 	31st prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	33
	 	32rd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	34
	 	33 prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	35
	 	34 prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	36
	 	35th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	37
	 	Months before	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	35th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	38
	 	Total Claim Payments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	(1)	 	(2)	 	(24)	 	 	(25)	 	 	(26)	 	 	(27)	 	 	(28)	 	 	(29)	 	 	(30)	 	 	(31)	 	 	(32)	 	 	(33)	 	 	(34)	 	 	(35)	 	 	(36)	 	 	(37)	 	 	(38)	 	 	(39)	 	 	(40)	 	 	 	 	 
	 	 	 	 	Current	 	 	1st Prior	 	 	2nd Prior	 	 	3rd Prior	 	 	4th Prior	 	 	5th Prior	 	 	6th Prior	 	 	7 Prior	 	 	8 Prior	 	 	9 Prior	 	 	10 Prior	 	 	11th Prior	 	 	12th Prior	 	 	13 Prior	 	 	14 Prior	 	 	15 Prior	 	 	 	 	 	 	 	 	 
	Line	 	Month of Payment	 	Month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	 	 	 	 	 	 	 
	39
	 	Subcapitation payments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	40
	 	Pharmacy Rebates	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	41
	 	Settlements	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	42
	 	Sum of claims,	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	Subcapitation payments, and	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	settlements	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	43
	 	Current estimate of	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	remaining liability	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	44
	 	Total Incurred Claims	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

Table #20 – Part C – Lag Report for Pharmacy Payments

FOR THE
THREE MONTHS ENDING ___ FOR ___

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 
	(1)	 	(2)	 	(3)	 	 	(4)	 	 	(5)	 	 	(6)	 	 	(7)	 	 	(8)	 	 	(9)	 	 	(10)	 	 	(11)	 	 	(12)	 	 	(13)	 	 	(14)	 	 	(15)	 	 	(16)	 	 	(17)	 	 	(18)	 	 	(19)	 	 	(20)	 	 	(21)	 	 	(22)	 	 	(23)	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Current	 	 	1st Prior	 	 	2nd Prior	 	 	3rd Prior	 	 	4th Prior	 	 	5th Prior	 	 	6th Prior	 	 	7 Prior	 	 	8 Prior	 	 	9 Prior	 	 	10 Prior	 	 	11th Prior	 	 	12th Prior	 	 	13 Prior	 	 	14 Prior	 	 	15 Prior	 	 	16 Prior	 	 	17 Prior	 	 	18 Prior	 	 	19 Prior	 	 	20th Prior	 	 	 	 	 	 	 	 	 	 	 	 	 
	Line	 	Month of Payment	 	Month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	 	 	 	 	 	 	 	 	 	 	 
	1
	 	Current Month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2
	 	1st Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3
	 	2nd Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4
	 	3rd Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5
	 	4th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6
	 	5th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7
	 	6th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8
	 	7 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9
	 	8 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10
	 	9 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11
	 	10 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12
	 	11th  Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13
	 	12th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14
	 	13 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15
	 	14 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16
	 	15 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17
	 	16 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18
	 	17th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	19
	 	18th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	20
	 	19th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	21
	 	20th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	22
	 	21st prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	23
	 	22nd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	24
	 	23rd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	25
	 	24th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26
	 	25th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	27
	 	26th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	28
	 	27th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	29
	 	28th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	30
	 	29th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	31
	 	30th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	32
	 	31st prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	33
	 	32rd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	34
	 	33 prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	35
	 	34 prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	36
	 	35th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	37
	 	Months before 35th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	38
	 	Total Claim Payments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	39
	 	Subcapitation payments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	40
	 	Pharmacy Rebates	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	41
	 	Settlements	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	(1)	 	(2)	 	(3)	 	 	(4)	 	 	(5)	 	 	(6)	 	 	(7)	 	 	(8)	 	 	(9)	 	 	(10)	 	 	(11)	 	 	(12)	 	 	(13)	 	 	(14)	 	 	(15)	 	 	(16)	 	 	(17)	 	 	(18)	 	 	(19)	 	 	(20)	 	 	(21)	 	 	(22)	 	 	(23)	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Current	 	 	1st Prior	 	 	2nd Prior	 	 	3rd Prior	 	 	4th Prior	 	 	5th Prior	 	 	6th Prior	 	 	7 Prior	 	 	8 Prior	 	 	9 Prior	 	 	10 Prior	 	 	11th Prior	 	 	12th Prior	 	 	13 Prior	 	 	14 Prior	 	 	15 Prior	 	 	16 Prior	 	 	17 Prior	 	 	18 Prior	 	 	19 Prior	 	 	20th Prior	 	 	 	 	 	 	 	 	 	 	 	 	 
	Line	 	Month of Payment	 	Month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	 	 	 	 	 	 	 	 	 	 	 
	42
	 	Sum of claims,	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	Subcapitation payments, and settlements	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	43
	 	Current estimate of remaining liability	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	44
	 	Total Incurred Claims	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

Table #20 – Part c – Lag Report

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	(1)	 	(2)	 	(24)	 	 	(25)	 	 	(26)	 	 	(27)	 	 	(28)	 	 	(29)	 	 	(30)	 	 	(31)	 	 	(32)	 	 	(33)	 	 	(34)	 	 	(35)	 	 	(36)	 	 	(37)	 	 	(38)	 	 	(39)	 	 	(40)	 	 	 	 	 
	 	 	 	 	Current	 	 	1st Prior	 	 	2nd Prior	 	 	3rd Prior	 	 	4th Prior	 	 	5th Prior	 	 	6th Prior	 	 	7 Prior	 	 	8 Prior	 	 	9 Prior	 	 	10 Prior	 	 	11th Prior	 	 	12th Prior	 	 	13 Prior	 	 	14 Prior	 	 	15 Prior	 	 	 	 	 	 	 	 	 
	Line	 	Month of Payment	 	Month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	 	 	 	 	 	 	 
	1
	 	Current Month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2
	 	1st Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3
	 	2nd Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4
	 	3rd Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5
	 	4th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6
	 	5th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7
	 	6th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8
	 	7 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9
	 	8 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10
	 	9 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11
	 	10 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12
	 	11th  Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13
	 	12th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14
	 	13 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15
	 	14 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16
	 	15 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17
	 	16 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18
	 	17th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	19
	 	18th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	20
	 	19th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	21
	 	20th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	22
	 	21st prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	23
	 	22nd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	24
	 	23rd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	25
	 	24th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26
	 	25th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	27
	 	26th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	28
	 	27th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	29
	 	28th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	30
	 	29th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	31
	 	30th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	32
	 	31st prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	33
	 	32rd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	34
	 	33 prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	35
	 	34 prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	36
	 	35th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	37
	 	Months before 35th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	38
	 	Total Claim Payments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	(1)	 	(2)	 	(24)	 	 	(25)	 	 	(26)	 	 	(27)	 	 	(28)	 	 	(29)	 	 	(30)	 	 	(31)	 	 	(32)	 	 	(33)	 	 	(34)	 	 	(35)	 	 	(36)	 	 	(37)	 	 	(38)	 	 	(39)	 	 	(40)	 	 	 	 	 
	 	 	 	 	Current	 	 	1st Prior	 	 	2nd Prior	 	 	3rd Prior	 	 	4th Prior	 	 	5th Prior	 	 	6th Prior	 	 	7 Prior	 	 	8 Prior	 	 	9 Prior	 	 	10 Prior	 	 	11th Prior	 	 	12th Prior	 	 	13 Prior	 	 	14 Prior	 	 	15 Prior	 	 	 	 	 	 	 	 	 
	Line	 	Month of Payment	 	Month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	 	 	 	 	 	 	 
	39
	 	Subcapitation payments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	40
	 	Pharmacy Rebates	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	41
	 	Settlements	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	42
	 	Sum of claims, Subcapitation
payments, and settlements	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	43
	 	Current estimate of remaining liability	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	44
	 	Total Incurred Claims	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

Table
#20 – Part D – Lag Report for Other Medical Payments

FOR THE
THREE MONTHS ENDING ___ FOR ___

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	(1)	 	(2)	 	(3)	 	 	(4)	 	 	(5)	 	 	(6)	 	 	(7)	 	 	(8)	 	 	(9)	 	 	(10)	 	 	(11)	 	 	(12)	 	 	(13)	 	 	(14)	 	 	(15)	 	 	(16)	 	 	(17)	 	 	(18)	 	 	(19)	 	 	(20)	 	 	(21)	 	 	(22)	 	 	(23)	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Current	 	 	1st Prior	 	 	2nd Prior	 	 	3rd Prior	 	 	4th Prior	 	 	5th Prior	 	 	6th Prior	 	 	7 Prior	 	 	8 Prior	 	 	9 Prior	 	 	10 Prior	 	 	11th Prior	 	 	12th Prior	 	 	13 Prior	 	 	14 Prior	 	 	15 Prior	 	 	16 Prior	 	 	17 Prior	 	 	18 Prior	 	 	19 Prior	 	 	20th Prior	 	 	 	 	 	 	 	 	 	 	 	 	 
	Line	 	Month of Payment	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	 	 	 	 	 	 	 	 	 	 	 
	1
	 	Current Month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2
	 	1st Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3
	 	2nd Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4
	 	3rd Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5
	 	4th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6
	 	5th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7
	 	6th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8
	 	7 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9
	 	8 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10
	 	9 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11
	 	10 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12
	 	11th  Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13
	 	12th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14
	 	13 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15
	 	14 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16
	 	15 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17
	 	16 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18
	 	17th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	19
	 	18th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	20
	 	19th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	21
	 	20th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	22
	 	21st prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	23
	 	22nd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	24
	 	23rd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	25
	 	24th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26
	 	25th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	27
	 	26th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	28
	 	27th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	29
	 	28th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	30
	 	29th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	31
	 	30th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	32
	 	31st prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	33
	 	32rd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	34
	 	33 prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	35
	 	34 prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	36
	 	35th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	37
	 	Months before 35th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	38
	 	Total Claim Payments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	39
	 	Subcapitation payments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	40
	 	Pharmacy Rebates	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	41
	 	Settlements	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	(1)	 	(2)	 	(3)	 	 	(4)	 	 	(5)	 	 	(6)	 	 	(7)	 	 	(8)	 	 	(9)	 	 	(10)	 	 	(11)	 	 	(12)	 	 	(13)	 	 	(14)	 	 	(15)	 	 	(16)	 	 	(17)	 	 	(18)	 	 	(19)	 	 	(20)	 	 	(21)	 	 	(22)	 	 	(23)	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Current	 	 	1st Prior	 	 	2nd Prior	 	 	3rd Prior	 	 	4th Prior	 	 	5th Prior	 	 	6th Prior	 	 	7 Prior	 	 	8 Prior	 	 	9 Prior	 	 	10 Prior	 	 	11th Prior	 	 	12th Prior	 	 	13 Prior	 	 	14 Prior	 	 	15 Prior	 	 	16 Prior	 	 	17 Prior	 	 	18 Prior	 	 	19 Prior	 	 	20th Prior	 	 	 	 	 	 	 	 	 	 	 	 	 
	Line	 	Month of Payment	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	 	 	 	 	 	 	 	 	 	 	 
	42
	 	Sum of claims, Subcapitation payments, and settlements	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	43
	 	Current estimate of remaining liability	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	44
	 	Total Incurred Claims	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

Table #20 – Part D – Lag Report

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	(1)	 	(2)	 	(24)	 	 	(25)	 	 	(26)	 	 	(27)	 	 	(28)	 	 	(29)	 	 	(30)	 	 	(31)	 	 	(32)	 	 	(33)	 	 	(34)	 	 	(35)	 	 	(36)	 	 	(37)	 	 	(38)	 	 	(39)	 	 	(40)	 	 	 	 	 
	 	 	 	 	Current	 	 	1st Prior	 	 	2nd Prior	 	 	3rd Prior	 	 	4th Prior	 	 	5th Prior	 	 	6th Prior	 	 	7 Prior	 	 	8 Prior	 	 	9 Prior	 	 	10 Prior	 	 	11th Prior	 	 	12th Prior	 	 	13 Prior	 	 	14 Prior	 	 	15 Prior	 	 	 	 	 	 	 	 	 
	Line	 	Month of Payment	 	Month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	 	 	 	 	 	 	 
	1
	 	Current Month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2
	 	1st Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3
	 	2nd Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4
	 	3rd Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5
	 	4th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6
	 	5th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7
	 	6th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8
	 	7 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9
	 	8 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10
	 	9 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11
	 	10 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12
	 	11th  Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13
	 	12th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14
	 	13 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15
	 	14 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16
	 	15 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17
	 	16 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18
	 	17th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	19
	 	18th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	20
	 	19th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	21
	 	20th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	22
	 	21st prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	23
	 	22nd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	24
	 	23rd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	25
	 	24th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26
	 	25th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	27
	 	26th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	28
	 	27th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	29
	 	28th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	30
	 	29th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	31
	 	30th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	32
	 	31st prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	33
	 	32rd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	34
	 	33 prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	35
	 	34 prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	36
	 	35th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	37
	 	Months before 35th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	38
	 	Total Claim Payments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	(1)	 	(2)	 	 	(24)	 	 	(25)	 	 	(26)	 	 	(27)	 	 	(28)	 	 	(29)	 	 	(30)	 	 	(31)	 	 	(32)	 	 	(33)	 	 	(34)	 	 	(35)	 	 	(36)	 	 	(37)	 	 	(38)	 	 	(39)	 	 	(40)	 	 	 	 	 
	Line	 	Month of Payment	 	 	Current	 	 	1st Prior	 	 	2nd Prior	 	 	3rd Prior	 	 	4th Prior	 	 	5th Prior	 	 	6th Prior	 	 	7 Prior	 	 	8 Prior	 	 	9 Prior	 	 	10 Prior	 	 	11th Prior	 	 	12th Prior	 	 	13 Prior	 	 	14 Prior	 	 	15 Prior	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	Month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	 	 	 	 	 	 	 
	39
	 	Subcapitation payments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	40
	 	Pharmacy Rebates	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	41
	 	Settlements	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	42
	 	Sum of claims,	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	Subcapitation payments, and	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	settlements	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	43
	 	Current estimate of	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	remaining liability	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	44
	 	Total Incurred Claims	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

Table #20 – Part E – Lag Report for Managed Care Service Administrator Populations

FOR THE THREE MONTHS ENDING ___FOR ___

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	(1)	 	(2)	 	(3)	 	 	(4)	 	 	(5)	 	 	(6)	 	 	(7)	 	 	(8)	 	 	(9)	 	 	(10)	 	 	(11)	 	 	(12)	 	 	(13)	 	 	(14)	 	 	(15)	 	 	(16)	 	 	(17)	 	 	(18)	 	 	(19)	 	 	(20)	 	 	(21)	 	 	(22)	 	 	(23)	 	 	 	 	 	 	 	 	 	 	 	 	 
	Line	 	Month of Payment	 	Current	 	 	1st Prior	 	 	2nd Prior	 	 	3rd Prior	 	 	4th Prior	 	 	5th Prior	 	 	6th Prior	 	 	7 Prior	 	 	8 Prior	 	 	9 Prior	 	 	10 Prior	 	 	11th Prior	 	 	12th Prior	 	 	13 Prior	 	 	14 Prior	 	 	15 Prior	 	 	16 Prior	 	 	17 Prior	 	 	18 Prior	 	 	19 Prior	 	 	20th Prior	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	 	 	 	 	 	 	 	 	 	 	 
	1
	 	Current Month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2
	 	1st Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3
	 	2nd Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4
	 	3rd Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5
	 	4th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6
	 	5th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7
	 	6th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8
	 	7 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9
	 	8 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10
	 	9 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11
	 	10 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12
	 	11th  Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13
	 	12th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14
	 	13 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15
	 	14 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16
	 	15 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17
	 	16 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18
	 	17th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	19
	 	18th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	20
	 	19th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	21
	 	20th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	22
	 	21st prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	23
	 	22nd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	24
	 	23rd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	25
	 	24th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26
	 	25th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	27
	 	26th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	28
	 	27th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	29
	 	28th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	30
	 	29th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	31
	 	30th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	32
	 	31st prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	33
	 	32rd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	34
	 	33 prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	35
	 	34 prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	36
	 	35th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	37
	 	Months before 35th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	38
	 	Total Claim Payments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	39
	 	Subcapitation payments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	40
	 	Pharmacy Rebates	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	41
	 	Settlements	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	(1)	 	(2)	 	(3)	 	 	(4)	 	 	(5)	 	 	(6)	 	 	(7)	 	 	(8)	 	 	(9)	 	 	(10)	 	 	(11)	 	 	(12)	 	 	(13)	 	 	(14)	 	 	(15)	 	 	(16)	 	 	(17)	 	 	(18)	 	 	(19)	 	 	(20)	 	 	(21)	 	 	(22)	 	 	(23)	 	 	 	 	 	 	 	 	 	 	 	 	 
	Line	 	Month of Payment	 	Current	 	 	1st Prior	 	 	2nd Prior	 	 	3rd Prior	 	 	4th Prior	 	 	5th Prior	 	 	6th Prior	 	 	7 Prior	 	 	8 Prior	 	 	9 Prior	 	 	10 Prior	 	 	11th Prior	 	 	12th Prior	 	 	13 Prior	 	 	14 Prior	 	 	15 Prior	 	 	16 Prior	 	 	17 Prior	 	 	18 Prior	 	 	19 Prior	 	 	20th Prior	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	 	 	 	 	 	 	 	 	 	 	 
	42
	 	Sum of claims, Subcapitation
payments, and settlements	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	43
	 	Current estimate of remaining liability	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	44
	 	Total Incurred Claims	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

           Table #20
— Part E — Lag Report

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	(1)	 	(2)	 	(24)	 	 	(25)	 	 	(26)	 	 	(27)	 	 	(28)	 	 	(29)	 	 	(30)	 	 	(31)	 	 	(32)	 	 	(33)	 	 	(34)	 	 	(35)	 	 	(36)	 	 	(37)	 	 	(38)	 	 	(39)	 	 	(40)	 	 	 	 	 
	Line	 	Month of Payment	 	Current	 	 	1st Prior	 	 	2nd Prior	 	 	3rd Prior	 	 	4th Prior	 	 	5th Prior	 	 	6th Prior	 	 	7 Prior	 	 	8 Prior	 	 	9 Prior	 	 	10 Prior	 	 	11th Prior	 	 	12th Prior	 	 	13 Prior	 	 	14 Prior	 	 	15 Prior	 	 	 	 	 	 	 	 	 
	 	 	 	 	Month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	 	 	 	 	 	 
	1
	 	Current Month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2
	 	1st Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3
	 	2nd Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4
	 	3rd Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5
	 	4th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6
	 	5th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7
	 	6th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8
	 	7 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9
	 	8 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10
	 	9 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11
	 	10 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12
	 	11th  Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13
	 	12th Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14
	 	13 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15
	 	14 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16
	 	15 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17
	 	16 Prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18
	 	17th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	19
	 	18th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	20
	 	19th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	21
	 	20th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	22
	 	21st prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	23
	 	22nd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	24
	 	23rd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	25
	 	24th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26
	 	25th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	27
	 	26th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	28
	 	27th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	29
	 	28th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	30
	 	29th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	31
	 	30th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	32
	 	31st prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	33
	 	32rd prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	34
	 	33 prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	35
	 	34 prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	36
	 	35th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	37
	 	Months before 35th prior month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	38
	 	Total Claim Payments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	(1)	 	(2)	 	(24)	 	 	(25)	 	 	(26)	 	 	(27)	 	 	(28)	 	 	(29)	 	 	(30)	 	 	(31)	 	 	(32)	 	 	(33)	 	 	(34)	 	 	(35)	 	 	(36)	 	 	(37)	 	 	(38)	 	 	(39)	 	 	(40)	 	 	 	 	 
	Line	 	Month of Payment	 	Current	 	 	1st Prior	 	 	2nd Prior	 	 	3rd Prior	 	 	4th Prior	 	 	5th Prior	 	 	6th Prior	 	 	7 Prior	 	 	8 Prior	 	 	9 Prior	 	 	10 Prior	 	 	11th Prior	 	 	12th Prior	 	 	13 Prior	 	 	14 Prior	 	 	15 Prior	 	 	 	 	 	 	 	 	 
	 	 	 	 	Month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	month	 	 	 	 	 	 	 	 
	39
	 	Subcapitation payments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	40
	 	Pharmacy Rebates	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	41
	 	Settlements	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	42
	 	Sum of claims, Subcapitation
payments, and settlements	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	43
	 	Current estimate of remaining liability	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	44
	 	Total Incurred Claims	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

Table #19
— Part A                           
            Income Statement by Rate Cell Grouping

AFDC/NJCPW/NJ
KidCare A (Excluding AIDS) — NORTHERN REGION4

FOR THE THREE MONTHS ENDING                                          FOR                     

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	 	Three-	 	 	Three	 	 	YTD $	 	 	YTD	 	 	SFY End	 	 	SFY End $	 
	 	 	 	 	month	 	 	month	 	 	 	 	 	 	PMPM	 	 	$@9/305	 	 	@9/30	 
	 	 	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	 	 	 	 	 	 	 	PMPM	 
	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1	 	Capitated Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2	 	Supplemental Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2a	 	Maternity
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2b	 	Reimbursable HIV/AIDS Drugs and Blood
Product
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2c	 	EPSDT Incentive Payment
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2d	 	Reimbursable Medical and Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2e	 	Managed Care Service Administrator Premium
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2f	 	Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4	 	Interest
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5	 	COB
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6	 	Reinsurance Recoveries
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7	 	Other Revenue
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8	 	TOTAL REVENUE (3+4+5+6+7)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9	 	Inpatient Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10	 	Primary Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11	 	Physician Specialty Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12	 	Outpatient Hospital (excludes ER)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13	 	Other Professional Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14	 	Emergency Room
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15	 	DME/Medical Supplies
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16	 	Prosthetics & Orthotics
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17	 	Covered Dental
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18	 	Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	19	 	Reimbursable HIV/AIDS Drugs and Blood
Product
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	20	 	Home Health, Hospice and PDN
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	21	 	Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	22	 	Lab & X-ray
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	23	 	Vision Care, including eyeglasses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	24	 	Mental Health/Substance Abuse
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	25	 	Reinsurance Expenses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26A	 	EPSDT Medical & PDN
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26B	 	EPSDT Dental
— EPD
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	27	 	Family Planning
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	28	 	Other Medical
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	29	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	30	 	Compensation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	31	 	Occupancy/Depreciation/Amortization
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	32	 	Interest Expense
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	4	 	Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.
	 
	5	 	For the twelve months incurred claims expenses
ending State Fiscal Year June 30, total should be reported with an additional
three months of paid claims at quarter ending Sept 30.

	 	 	 	 	 
	HMO Financial Reporting Specifications

	 	 	 	State of New Jersey     
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	 	Three-	 	 	Three	 	 	YTD $	 	 	YTD	 	 	SFY End	 	 	SFY End $	 
	 	 	 	 	month	 	 	month	 	 	 	 	 	 	PMPM	 	 	$@9/305	 	 	@9/30	 
	 	 	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	 	 	 	 	 	 	 	PMPM	 
	 
	33	 	Education/Outreach
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	34	 	Sanctions
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	35	 	Corporate Overhead Allocations
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	36	 	Subcontract/Delegated Administrative services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	37	 	Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	38	 	TOTAL ADMINISTRATION
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	39	 	TOTAL EXPENSES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	40	 	OPERATION INCOME (LOSS) (8-39)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	41	 	Extraordinary Item
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	42	 	Provision
for State, Federal and Other Governmental Taxes
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	43	 	Other than Income taxes6
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	44	 	Adjustment for prior period IBNR Estimates
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	45	 	Non-claim adjustments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	46	 	NET INCOME (LOSS) (40-41-42-43-44-45)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	6	 	Reported items other than State or Federal
income taxes

	 	 	 	 	 
	HMO Financial Reporting Specifications

	 	 	 	State of New Jersey     
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

Table #19
— Part
B                          
             Income Statement by Rate Cell Grouping

AFDC/NJCPW/NJ
KidCare A (Excluding AIDS) — CENTRAL REGION7

FOR THE THREE MONTHS ENDING                                          FOR                     

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	 	Three-	 	 	Three	 	 	YTD $	 	 	YTD	 	 	SFY End	 	 	SFY End $	 
	 	 	 	 	month	 	 	month	 	 	 	 	 	 	PMPM	 	 	$@9/308	 	 	@9/30	 
	 	 	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	 	 	 	 	 	 	 	PMPM	 
	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1	 	Capitated Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2	 	Supplemental Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2a	 	Maternity
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2b	 	Reimbursable
HIV/AIDS Drugs and Blood Product
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2c	 	EPSDT Incentive Payment
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2d	 	Reimbursable Medical and Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2e	 	Managed Care Service Administrator Premium
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2f	 	Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4	 	Interest
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5	 	COB
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6	 	Reinsurance Recoveries
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7	 	Other Revenue
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8	 	TOTAL REVENUE (3+4+5+6+7)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9	 	Inpatient Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10	 	Primary Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11	 	Physician Specialty Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12	 	Outpatient Hospital (excludes ER)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13	 	Other Professional Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14	 	Emergency Room
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15	 	DME/Medical Supplies
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16	 	Prosthetics & Orthotics
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17	 	Covered Dental
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18	 	Pharmacy (not to include Reimbursable
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	HIV/AIDS Drugs and Blood Products)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	19	 	Reimbursable
HIV/AIDS Drugs and Blood Product
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	20	 	Home Health, Hospice and PDN
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	21	 	Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	22	 	Lab & X-ray
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	23	 	Vision Care, including eyeglasses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	24	 	Mental Health/Substance Abuse
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	25	 	Reinsurance Expenses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26A	 	EPSDT Medical & PDN
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26B	 	EPSDT Dental
— EPD
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	27	 	Family Planning
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	28	 	Other Medical
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	29	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	30	 	Compensation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	31	 	Occupancy/Depreciation/Amortization
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	32	 	Interest Expense
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	7	 	Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.
	 
	8	 	For the twelve months incurred claims expenses
ending State Fiscal Year June 30, total should be reported with an additional
three months of paid claims at quarter ending Sept 30.

	 	 	 	 	 
	HMO Financial Reporting Specifications

	 	 	 	State of New Jersey     
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	 	Three-	 	 	Three	 	 	YTD $	 	 	YTD	 	 	SFY End	 	 	SFY End $	 
	 	 	 	 	month	 	 	month	 	 	 	 	 	 	PMPM	 	 	$@9/308	 	 	@9/30	 
	 	 	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	 	 	 	 	 	 	 	PMPM	 
	 
	33	 	Education/Outreach
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	34	 	Sanctions
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	35	 	Corporate Overhead Allocations
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	36	 	Subcontract/Delegated Administrative services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	37	 	Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	38	 	TOTAL ADMINISTRATION
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	39	 	TOTAL EXPENSES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	40	 	OPERATION INCOME (LOSS) (8-39)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	41	 	Extraordinary Item
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	42	 	Provision
for State, Federal and Other Governmental Taxes
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	43	 	Other than Income taxes9
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	44	 	Adjustment for prior period IBNR Estimates
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	45	 	Non-claim adjustments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	46	 	NET INCOME (LOSS) (40-41-42-43-44-45)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	9	 	Reported items other than State or Federal
income taxes

	 	 	 	 	 
	HMO Financial Reporting Specifications

	 	 	 	State of New Jersey     
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

Table #19
— Part C
                       
                 Income Statement by Rate Cell Grouping

AFDC/NJCPW/NJ
KidCare A (Excluding AIDS) — SOUTHERN REGION10

FOR THE THREE MONTHS ENDING                                          FOR                     

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	 	Three-	 	 	Three	 	 	YTD $	 	 	YTD	 	 	SFY End	 	 	SFY End $	 
	 	 	 	 	month	 	 	month	 	 	 	 	 	 	PMPM	 	 	$@9/3011	 	 	@9/30	 
	 	 	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	 	 	 	 	 	 	 	PMPM	 
	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1	 	Capitated Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2	 	Supplemental Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2a	 	Maternity
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2b	 	Reimbursable
HIV/AIDS Drugs and Blood Product
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2c	 	EPSDT Incentive Payment
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2d	 	Reimbursable Medical and Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2e	 	Managed Care Service Administrator Premium
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2f	 	Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4	 	Interest
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5	 	COB
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6	 	Reinsurance Recoveries
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7	 	Other Revenue
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8	 	TOTAL REVENUE (3+4+5+6+7)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9	 	Inpatient Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10	 	Primary Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11	 	Physician Specialty Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12	 	Outpatient Hospital (excludes ER)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13	 	Other Professional Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14	 	Emergency Room
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15	 	DME/Medical Supplies
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16	 	Prosthetics & Orthotics
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17	 	Covered Dental
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18	 	Pharmacy (not to include Reimbursable
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	HIV/AIDS Drugs and Blood Products)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	19	 	Reimbursable
HIV/AIDS Drugs and Blood Product
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	20	 	Home Health, Hospice and PDN
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	21	 	Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	22	 	Lab & X-ray
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	23	 	Vision Care, including eyeglasses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	24	 	Mental Health/Substance Abuse
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	25	 	Reinsurance Expenses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26A	 	EPSDT Medical & PDN
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26B	 	EPSDT Dental
— EPD
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	27	 	Family Planning
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	28	 	Other Medical
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	29	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	30	 	Compensation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	31	 	Occupancy/Depreciation/Amortization
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	32	 	Interest Expense
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	10	 	 Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.
	 
	11	 	For the twelve months incurred claims expenses
ending State Fiscal Year June 30, total should be reported with an additional
three months of paid claims at quarter ending Sept 30.

	 	 	 	 	 
	HMO Financial Reporting Specifications

	 	 	 	State of New Jersey     
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	 	Three-	 	 	Three	 	 	YTD $	 	 	YTD	 	 	SFY End	 	 	SFY End $	 
	 	 	 	 	month	 	 	month	 	 	 	 	 	 	PMPM	 	 	$@9/3011	 	 	@9/30	 
	 	 	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	 	 	 	 	 	 	 	PMPM	 
	 
	33	 	Education/Outreach
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	34	 	Sanctions
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	35	 	Corporate Overhead Allocations
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	36	 	Subcontract/Delegated Administrative services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	37	 	Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	38	 	TOTAL ADMINISTRATION
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	39	 	TOTAL EXPENSES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	40	 	OPERATION INCOME (LOSS) (8-39)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	41	 	Extraordinary Item
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	42	 	Provision
for State, Federal and Other Governmental Taxes
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	43	 	Other than Income taxes12
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	44	 	Adjustment for prior period IBNR Estimates
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	45	 	Non-claim adjustments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	46	 	NET INCOME (LOSS) (40-41-42-43-44-45)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	12	 	Reported items other than State or Federal
income taxes

	 	 	 	 	 
	HMO Financial Reporting Specifications

	 	 	 	State of New Jersey     
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

Table #19
— Part D
                             
                 Income Statement by Rate Cell Grouping

DFYS
(EXCLUDING AIDS) — STATEWIDE13

FOR THE THREE MONTHS ENDING                                          FOR                     

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	 	Three-	 	 	Three	 	 	YTD $	 	 	YTD	 	 	SFY End	 	 	SFY End $	 
	 	 	 	 	month	 	 	month	 	 	 	 	 	 	PMPM	 	 	$@9/3014	 	 	@9/30	 
	 	 	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	 	 	 	 	 	 	 	PMPM	 
	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1	 	Capitated Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2	 	Supplemental Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2a	 	Maternity
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2b	 	Reimbursable
HIV/AIDS Drugs and Blood Product
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2c	 	EPSDT Incentive Payment
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2d	 	Reimbursable Medical and Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2e	 	Managed Care Service Administrator Premium
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2f	 	Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4	 	Interest
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5	 	COB
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6	 	Reinsurance Recoveries
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7	 	Other Revenue
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8	 	TOTAL REVENUE (3+4+5+6+7)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9	 	Inpatient Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10	 	Primary Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11	 	Physician Specialty Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12	 	Outpatient Hospital (excludes ER)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13	 	Other Professional Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14	 	Emergency Room
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15	 	DME/Medical Supplies
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16	 	Prosthetics & Orthotics
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17	 	Covered Dental
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18	 	Pharmacy
(not to include Reimbursable HIV/AIDS Drugs and Blood Products)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	19	 	Reimbursable
HIV/AIDS Drugs and Blood Product
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	20	 	Home Health, Hospice and PDN
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	21	 	Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	22	 	Lab & X-ray
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	23	 	Vision Care, including eyeglasses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	24	 	Mental Health/Substance Abuse
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	25	 	Reinsurance Expenses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26A	 	EPSDT Medical & PDN
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26B	 	EPSDT Dental
— EPD
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	27	 	Family Planning
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	28	 	Other Medical
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	29	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	30	 	Compensation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	31	 	Occupancy/Depreciation/Amortization
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	32	 	Interest Expense
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	13	 	Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.
	 
	14	 	For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.

	 	 	 	 	 
	HMO Financial Reporting Specifications

	 	 	 	State of New Jersey     
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	 	Three-	 	 	Three	 	 	YTD $	 	 	YTD	 	 	SFY End	 	 	SFY End $	 
	 	 	 	 	month	 	 	month	 	 	 	 	 	 	PMPM	 	 	$@9/3014	 	 	@9/30	 
	 	 	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	 	 	 	 	 	 	 	PMPM	 
	 
	33	 	Education/Outreach
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	34	 	Sanctions
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	35	 	Corporate Overhead Allocations
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	36	 	Subcontract/Delegated Administrative services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	37	 	Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	38	 	TOTAL ADMINISTRATION
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	39	 	TOTAL EXPENSES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	40	 	OPERATION INCOME (LOSS) (8-39)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	41	 	Extraordinary Item
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	42	 	Provision
for State, Federal and Other Governmental Taxes
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	43	 	Other than Income taxes15
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	44	 	Adjustment for prior period IBNR Estimates
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	45	 	Non-claim adjustments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	46	 	NET INCOME (LOSS) (40-41-42-43-44-45)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	15	 	Reported items other than State or Federal
income taxes

	 	 	 	 	 
	HMO Financial Reporting Specifications

	 	 	 	State of New Jersey     
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

Table #19
— Part E
                      
                Income Statement by Rate Cell Grouping

ABD WITH
MEDICARE- DDD (Excluding AIDS) — STATEWIDE16

FOR THE THREE MONTHS ENDING                                          FOR                     

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	 	Three-	 	 	Three	 	 	YTD $	 	 	YTD	 	 	SFY End	 	 	SFY End $	 
	 	 	 	 	month	 	 	month	 	 	 	 	 	 	PMPM	 	 	$@9/3016	 	 	@9/30	 
	 	 	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	 	 	 	 	 	 	 	PMPM	 
	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1	 	Capitated Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2	 	Supplemental Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2a	 	Maternity
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2b	 	Reimbursable
HIV/AIDS Drugs and Blood Product
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2c	 	EPSDT Incentive Payment
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2d	 	Reimbursable Medical and Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2e	 	Managed Care Service Administrator Premium
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2f	 	Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4	 	Interest
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5	 	COB
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6	 	Reinsurance Recoveries
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7	 	Other Revenue
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8	 	TOTAL REVENUE (3+4+5+6+7)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9	 	Inpatient Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10	 	Primary Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11	 	Physician Specialty Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12	 	Outpatient Hospital (excludes ER)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13	 	Other Professional Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14	 	Emergency Room
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15	 	DME/Medical Supplies
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16	 	Prosthetics & Orthotics
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17	 	Covered Dental
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18	 	Pharmacy
(not to include Reimbursable HIV/AIDS Drugs and Blood Products)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	19	 	Reimbursable
HIV/AIDS Drugs and Blood Product
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	20	 	Home Health, Hospice and PDN
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	21	 	Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	22	 	Lab & X-ray
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	23	 	Vision Care, including eyeglasses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	24	 	Mental Health/Substance Abuse
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	25	 	Reinsurance Expenses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26A	 	EPSDT Medical & PDN
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26B	 	EPSDT Dental
— EPD
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	27	 	Family Planning
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	28	 	Other Medical
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	29	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	30	 	Compensation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	31	 	Occupancy/Depreciation/Amortization
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	32	 	Interest Expense
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	16	 	Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.
	 
	17	 	For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.

	 	 	 	 	 
	HMO Financial Reporting Specifications

	 	 	 	State of New Jersey     
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	 	Three-	 	 	Three	 	 	YTD $	 	 	YTD	 	 	SFY End	 	 	SFY End $	 
	 	 	 	 	month	 	 	month	 	 	 	 	 	 	PMPM	 	 	$@9/3016	 	 	@9/30	 
	 	 	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	 	 	 	 	 	 	 	PMPM	 
	 
	33	 	Education/Outreach
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	34	 	Sanctions
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	35	 	Corporate Overhead Allocations
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	36	 	Subcontract/Delegated Administrative services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	37	 	Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	38	 	TOTAL ADMINISTRATION
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	39	 	TOTAL EXPENSES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	40	 	OPERATION INCOME (LOSS) (8-39)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	41	 	Extraordinary Item
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	42	 	Provision
for State, Federal and Other Governmental Taxes
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	43	 	Other than Income taxes18
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	44	 	Adjustment for prior period IBNR Estimates
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	45	 	Non-claim adjustments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	46	 	NET INCOME (LOSS) (40-41-42-43-44-45)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	18	 	Reported items other than State or Federal
income taxes

	 	 	 	 	 
	HMO Financial Reporting Specifications

	 	 	 	State of New Jersey     
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 	 	 

 

 

Table # 19 — Part F                Income Statement by Rate Cell Grouping

ABD WITH MEDICARE — NON-DDD (Excluding AIDS) — STATEWIDE19

FOR THE THREE MONTHS ENDING ______           FOR ______

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3020	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 
	1

	 	Capitated Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	Supplemental Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2a

	 	Maternity	 	 	 	 	 	 	 	 	 	 	 	 
	2b

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	2c

	 	EPSDT Incentive Payment	 	 	 	 	 	 	 	 	 	 	 	 
	2d

	 	Reimbursable Medical and Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	2e

	 	Managed Care Service Administrator Premium	 	 	 	 	 	 	 	 	 	 	 	 
	2f

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	3

	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	Interest	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	COB	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	Reinsurance Recoveries	 	 	 	 	 	 	 	 	 	 	 	 
	7

	 	Other Revenue	 	 	 	 	 	 	 	 	 	 	 	 
	8

	 	TOTAL REVENUE (3+4+5+6+7)	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 
	9

	 	Inpatient Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	10

	 	Primary Care	 	 	 	 	 	 	 	 	 	 	 	 
	11

	 	Physician Specialty Services	 	 	 	 	 	 	 	 	 	 	 	 
	12

	 	Outpatient Hospital (excludes ER)	 	 	 	 	 	 	 	 	 	 	 	 
	13

	 	Other Professional Services	 	 	 	 	 	 	 	 	 	 	 	 
	14

	 	Emergency Room	 	 	 	 	 	 	 	 	 	 	 	 
	15

	 	DME/Medical Supplies	 	 	 	 	 	 	 	 	 	 	 	 
	16

	 	Prosthetics & Orthotics	 	 	 	 	 	 	 	 	 	 	 	 
	17

	 	Covered Dental	 	 	 	 	 	 	 	 	 	 	 	 
	18

	 	Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)	 	 	 	 	 	 	 	 	 	 	 	 
	19

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	20

	 	Home Health, Hospice and PDN	 	 	 	 	 	 	 	 	 	 	 	 
	21

	 	Transportation	 	 	 	 	 	 	 	 	 	 	 	 
	22

	 	Lab & X-ray	 	 	 	 	 	 	 	 	 	 	 	 
	23

	 	Vision Care, including eyeglasses	 	 	 	 	 	 	 	 	 	 	 	 
	24

	 	Mental Health/Substance Abuse	 	 	 	 	 	 	 	 	 	 	 	 
	25

	 	Reinsurance Expenses	 	 	 	 	 	 	 	 	 	 	 	 
	26A

	 	EPSDT Medical & PDN	 	 	 	 	 	 	 	 	 	 	 	 
	26B

	 	EPSDT Dental — EPD	 	 	 	 	 	 	 	 	 	 	 	 
	27

	 	Family Planning	 	 	 	 	 	 	 	 	 	 	 	 
	28

	 	Other Medical	 	 	 	 	 	 	 	 	 	 	 	 
	29

	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 
	30

	 	Compensation	 	 	 	 	 	 	 	 	 	 	 	 
	31

	 	Occupancy/Depreciation/Amortization	 	 	 	 	 	 	 	 	 	 	 	 
	32

	 	Interest Expense	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	19	 	Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.
	 
	20	 	For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3020	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	33

	 	Education/Outreach	 	 	 	 	 	 	 	 	 	 	 	 
	34

	 	Sanctions	 	 	 	 	 	 	 	 	 	 	 	 
	35

	 	Corporate Overhead Allocations	 	 	 	 	 	 	 	 	 	 	 	 
	36

	 	Subcontract/Delegated Administrative

services	 	 	 	 	 	 	 	 	 	 	 	 
	37

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	38

	 	TOTAL ADMINISTRATION	 	 	 	 	 	 	 	 	 	 	 	 
	39

	 	TOTAL EXPENSES	 	 	 	 	 	 	 	 	 	 	 	 
	40

	 	OPERATION INCOME (LOSS) (8-39)	 	 	 	 	 	 	 	 	 	 	 	 
	41

	 	Extraordinary Item	 	 	 	 	 	 	 	 	 	 	 	 
	42

	 	Provision for State, Federal and Other
Governmental Taxes	 	 	 	 	 	 	 	 	 	 	 	 
	43

	 	Other than Income taxes21	 	 	 	 	 	 	 	 	 	 	 	 
	44

	 	Adjustment for prior period IBNR Estimates	 	 	 	 	 	 	 	 	 	 	 	 
	45

	 	Non-claim adjustments	 	 	 	 	 	 	 	 	 	 	 	 
	46

	 	NET INCOME (LOSS) (40-41-42-43-44-45)	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	21	 	Reported items other than State or Federal
income taxes

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Table # 19 — Part G                Income Statement by Rate Cell Grouping

NON- ABD — DDD (Excluding AIDS) — STATEWIDE22

FOR THE THREE MONTHS ENDING ______           FOR ______

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3023	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 
	1

	 	Capitated Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	Supplemental Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2a

	 	Maternity	 	 	 	 	 	 	 	 	 	 	 	 
	2b

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	2c

	 	EPSDT Incentive Payment	 	 	 	 	 	 	 	 	 	 	 	 
	2d

	 	Reimbursable Medical and Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	2e

	 	Managed Care Service Administrator Premium	 	 	 	 	 	 	 	 	 	 	 	 
	2f

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	3

	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	Interest	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	COB	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	Reinsurance Recoveries	 	 	 	 	 	 	 	 	 	 	 	 
	7

	 	Other Revenue	 	 	 	 	 	 	 	 	 	 	 	 
	8

	 	TOTAL REVENUE (3+4+5+6+7)	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 
	9

	 	Inpatient Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	10

	 	Primary Care	 	 	 	 	 	 	 	 	 	 	 	 
	11

	 	Physician Specialty Services	 	 	 	 	 	 	 	 	 	 	 	 
	12

	 	Outpatient Hospital (excludes ER)	 	 	 	 	 	 	 	 	 	 	 	 
	13

	 	Other Professional Services	 	 	 	 	 	 	 	 	 	 	 	 
	14

	 	Emergency Room	 	 	 	 	 	 	 	 	 	 	 	 
	15

	 	DME/Medical Supplies	 	 	 	 	 	 	 	 	 	 	 	 
	16

	 	Prosthetics & Orthotics	 	 	 	 	 	 	 	 	 	 	 	 
	17

	 	Covered Dental	 	 	 	 	 	 	 	 	 	 	 	 
	18

	 	Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)	 	 	 	 	 	 	 	 	 	 	 	 
	19

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	20

	 	Home Health, Hospice and PDN	 	 	 	 	 	 	 	 	 	 	 	 
	21

	 	Transportation	 	 	 	 	 	 	 	 	 	 	 	 
	22

	 	Lab & X-ray	 	 	 	 	 	 	 	 	 	 	 	 
	23

	 	Vision Care, including eyeglasses	 	 	 	 	 	 	 	 	 	 	 	 
	24

	 	Mental Health/Substance Abuse	 	 	 	 	 	 	 	 	 	 	 	 
	25

	 	Reinsurance Expenses	 	 	 	 	 	 	 	 	 	 	 	 
	26A

	 	EPSDT Medical & PDN	 	 	 	 	 	 	 	 	 	 	 	 
	26B

	 	EPSDT Dental — EPD	 	 	 	 	 	 	 	 	 	 	 	 
	27

	 	Family Planning	 	 	 	 	 	 	 	 	 	 	 	 
	28

	 	Other Medical	 	 	 	 	 	 	 	 	 	 	 	 
	29

	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 
	30

	 	Compensation	 	 	 	 	 	 	 	 	 	 	 	 
	31

	 	Occupancy/Depreciation/Amortization	 	 	 	 	 	 	 	 	 	 	 	 
	32

	 	Interest Expense	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	22	 	Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.
	 
	23	 	For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3023	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	33

	 	Education/Outreach	 	 	 	 	 	 	 	 	 	 	 	 
	34

	 	Sanctions	 	 	 	 	 	 	 	 	 	 	 	 
	35

	 	Corporate Overhead Allocations	 	 	 	 	 	 	 	 	 	 	 	 
	36

	 	Subcontract/Delegated Administrative

services	 	 	 	 	 	 	 	 	 	 	 	 
	37

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	38

	 	TOTAL ADMINISTRATION	 	 	 	 	 	 	 	 	 	 	 	 
	39

	 	TOTAL EXPENSES	 	 	 	 	 	 	 	 	 	 	 	 
	40

	 	OPERATION INCOME (LOSS) (8-39)	 	 	 	 	 	 	 	 	 	 	 	 
	41

	 	Extraordinary Item	 	 	 	 	 	 	 	 	 	 	 	 
	42

	 	Provision for State, Federal and Other
Governmental Taxes	 	 	 	 	 	 	 	 	 	 	 	 
	43

	 	Other than Income taxes24	 	 	 	 	 	 	 	 	 	 	 	 
	44

	 	Adjustment for prior period IBNR Estimates	 	 	 	 	 	 	 	 	 	 	 	 
	45

	 	Non-claim adjustments	 	 	 	 	 	 	 	 	 	 	 	 
	46

	 	NET INCOME (LOSS) (40-41-42-43-44-45)	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	24	 	Reported items other than State or Federal
income taxes

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Table # 19 — Part H                Income Statement by Rate Cell Grouping

ABD WITHOUT MEDICARE —DDD (Including AIDS) — STATEWIDE25

FOR THE THREE MONTHS ENDING ______           FOR ______

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3026	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 
	1

	 	Capitated Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	Supplemental Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2a

	 	Maternity	 	 	 	 	 	 	 	 	 	 	 	 
	2b

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	2c

	 	EPSDT Incentive Payment	 	 	 	 	 	 	 	 	 	 	 	 
	2d

	 	Reimbursable Medical and Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	2e

	 	Managed Care Service Administrator Premium	 	 	 	 	 	 	 	 	 	 	 	 
	2f

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	3

	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	Interest	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	COB	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	Reinsurance Recoveries	 	 	 	 	 	 	 	 	 	 	 	 
	7

	 	Other Revenue	 	 	 	 	 	 	 	 	 	 	 	 
	8

	 	TOTAL REVENUE (3+4+5+6+7)	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 
	9

	 	Inpatient Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	10

	 	Primary Care	 	 	 	 	 	 	 	 	 	 	 	 
	11

	 	Physician Specialty Services	 	 	 	 	 	 	 	 	 	 	 	 
	12

	 	Outpatient Hospital (excludes ER)	 	 	 	 	 	 	 	 	 	 	 	 
	13

	 	Other Professional Services	 	 	 	 	 	 	 	 	 	 	 	 
	14

	 	Emergency Room	 	 	 	 	 	 	 	 	 	 	 	 
	15

	 	DME/Medical Supplies	 	 	 	 	 	 	 	 	 	 	 	 
	16

	 	Prosthetics & Orthotics	 	 	 	 	 	 	 	 	 	 	 	 
	17

	 	Covered Dental	 	 	 	 	 	 	 	 	 	 	 	 
	18

	 	Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)	 	 	 	 	 	 	 	 	 	 	 	 
	19

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	20

	 	Home Health, Hospice and PDN	 	 	 	 	 	 	 	 	 	 	 	 
	21

	 	Transportation	 	 	 	 	 	 	 	 	 	 	 	 
	22

	 	Lab & X-ray	 	 	 	 	 	 	 	 	 	 	 	 
	23

	 	Vision Care, including eyeglasses	 	 	 	 	 	 	 	 	 	 	 	 
	24

	 	Mental Health/Substance Abuse	 	 	 	 	 	 	 	 	 	 	 	 
	25

	 	Reinsurance Expenses	 	 	 	 	 	 	 	 	 	 	 	 
	26A

	 	EPSDT Medical & PDN	 	 	 	 	 	 	 	 	 	 	 	 
	26B

	 	EPSDT Dental — EPD	 	 	 	 	 	 	 	 	 	 	 	 
	27

	 	Family Planning	 	 	 	 	 	 	 	 	 	 	 	 
	28

	 	Other Medical	 	 	 	 	 	 	 	 	 	 	 	 
	29

	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 
	30

	 	Compensation	 	 	 	 	 	 	 	 	 	 	 	 
	31

	 	Occupancy/Depreciation/Amortization	 	 	 	 	 	 	 	 	 	 	 	 
	32

	 	Interest Expense	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	25	 	Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.
	 
	26	 	For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3026	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	33

	 	Education/Outreach	 	 	 	 	 	 	 	 	 	 	 	 
	34

	 	Sanctions	 	 	 	 	 	 	 	 	 	 	 	 
	35

	 	Corporate Overhead Allocations	 	 	 	 	 	 	 	 	 	 	 	 
	36

	 	Subcontract/Delegated Administrative

services	 	 	 	 	 	 	 	 	 	 	 	 
	37

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	38

	 	TOTAL ADMINISTRATION	 	 	 	 	 	 	 	 	 	 	 	 
	39

	 	TOTAL EXPENSES	 	 	 	 	 	 	 	 	 	 	 	 
	40

	 	OPERATION INCOME (LOSS) (8-39)	 	 	 	 	 	 	 	 	 	 	 	 
	41

	 	Extraordinary Item	 	 	 	 	 	 	 	 	 	 	 	 
	42

	 	Provision for State, Federal and Other
Governmental Taxes	 	 	 	 	 	 	 	 	 	 	 	 
	43

	 	Other than Income taxes27	 	 	 	 	 	 	 	 	 	 	 	 
	44

	 	Adjustment for prior period IBNR Estimates	 	 	 	 	 	 	 	 	 	 	 	 
	45

	 	Non-claim adjustments	 	 	 	 	 	 	 	 	 	 	 	 
	46

	 	NET INCOME (LOSS) (40-41-42-43-44-45)	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	27	 	Reported items other than State or Federal
income taxes

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Table # 19 — Part I                Income Statement by Rate Cell Grouping

ABD WITHOUT MEDICARE — NON —DDD (including AIDS) — STATEWIDE28

FOR THE THREE MONTHS ENDING ______           FOR ______

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3029	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 
	1

	 	Capitated Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	Supplemental Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2a

	 	Maternity	 	 	 	 	 	 	 	 	 	 	 	 
	2b

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	2c

	 	EPSDT Incentive Payment	 	 	 	 	 	 	 	 	 	 	 	 
	2d

	 	Reimbursable Medical and Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	2e

	 	Managed Care Service Administrator Premium	 	 	 	 	 	 	 	 	 	 	 	 
	2f

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	3

	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	Interest	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	COB	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	Reinsurance Recoveries	 	 	 	 	 	 	 	 	 	 	 	 
	7

	 	Other Revenue	 	 	 	 	 	 	 	 	 	 	 	 
	8

	 	TOTAL REVENUE (3+4+5+6+7)	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 
	9

	 	Inpatient Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	10

	 	Primary Care	 	 	 	 	 	 	 	 	 	 	 	 
	11

	 	Physician Specialty Services	 	 	 	 	 	 	 	 	 	 	 	 
	12

	 	Outpatient Hospital (excludes ER)	 	 	 	 	 	 	 	 	 	 	 	 
	13

	 	Other Professional Services	 	 	 	 	 	 	 	 	 	 	 	 
	14

	 	Emergency Room	 	 	 	 	 	 	 	 	 	 	 	 
	15

	 	DME/Medical Supplies	 	 	 	 	 	 	 	 	 	 	 	 
	16

	 	Prosthetics & Orthotics	 	 	 	 	 	 	 	 	 	 	 	 
	17

	 	Covered Dental	 	 	 	 	 	 	 	 	 	 	 	 
	18

	 	Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)	 	 	 	 	 	 	 	 	 	 	 	 
	19

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	20

	 	Home Health, Hospice and PDN	 	 	 	 	 	 	 	 	 	 	 	 
	21

	 	Transportation	 	 	 	 	 	 	 	 	 	 	 	 
	22

	 	Lab & X-ray	 	 	 	 	 	 	 	 	 	 	 	 
	23

	 	Vision Care, including eyeglasses	 	 	 	 	 	 	 	 	 	 	 	 
	24

	 	Mental Health/Substance Abuse	 	 	 	 	 	 	 	 	 	 	 	 
	25

	 	Reinsurance Expenses	 	 	 	 	 	 	 	 	 	 	 	 
	26A

	 	EPSDT Medical & PDN	 	 	 	 	 	 	 	 	 	 	 	 
	26B

	 	EPSDT Dental — EPD	 	 	 	 	 	 	 	 	 	 	 	 
	27

	 	Family Planning	 	 	 	 	 	 	 	 	 	 	 	 
	28

	 	Other Medical	 	 	 	 	 	 	 	 	 	 	 	 
	29

	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 
	30

	 	Compensation	 	 	 	 	 	 	 	 	 	 	 	 
	31

	 	Occupancy/Depreciation/Amortization	 	 	 	 	 	 	 	 	 	 	 	 
	32

	 	Interest Expense	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	28	 	Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.
	 
	29	 	For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3029	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	33

	 	Education/Outreach	 	 	 	 	 	 	 	 	 	 	 	 
	34

	 	Sanctions	 	 	 	 	 	 	 	 	 	 	 	 
	35

	 	Corporate Overhead Allocations	 	 	 	 	 	 	 	 	 	 	 	 
	36

	 	Subcontract/Delegated Administrative

services	 	 	 	 	 	 	 	 	 	 	 	 
	37

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	38

	 	TOTAL ADMINISTRATION	 	 	 	 	 	 	 	 	 	 	 	 
	39

	 	TOTAL EXPENSES	 	 	 	 	 	 	 	 	 	 	 	 
	40

	 	OPERATION INCOME (LOSS) (8-39)	 	 	 	 	 	 	 	 	 	 	 	 
	41

	 	Extraordinary Item	 	 	 	 	 	 	 	 	 	 	 	 
	42

	 	Provision for State, Federal and Other
Governmental Taxes	 	 	 	 	 	 	 	 	 	 	 	 
	43

	 	Other than Income taxes30	 	 	 	 	 	 	 	 	 	 	 	 
	44

	 	Adjustment for prior period IBNR Estimates	 	 	 	 	 	 	 	 	 	 	 	 
	45

	 	Non-claim adjustments	 	 	 	 	 	 	 	 	 	 	 	 
	46

	 	NET INCOME (LOSS) (40-41-42-43-44-45)	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	30	 	Reported items other than State or Federal
income taxes

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Table # 19 — Part J                Income Statement by Rate Cell Grouping

NJ KIDCARE B&C (Excluding AIDS) — STATEWIDE31

FOR THE THREE MONTHS ENDING ______           FOR ______

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3032	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 
	1

	 	Capitated Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	Supplemental Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2a

	 	Maternity	 	 	 	 	 	 	 	 	 	 	 	 
	2b

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	2c

	 	EPSDT Incentive Payment	 	 	 	 	 	 	 	 	 	 	 	 
	2d

	 	Reimbursable Medical and Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	2e

	 	Managed Care Service Administrator Premium	 	 	 	 	 	 	 	 	 	 	 	 
	2f

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	3

	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	Interest	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	COB	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	Reinsurance Recoveries	 	 	 	 	 	 	 	 	 	 	 	 
	7

	 	Other Revenue	 	 	 	 	 	 	 	 	 	 	 	 
	8

	 	TOTAL REVENUE (3+4+5+6+7)	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 
	9

	 	Inpatient Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	10

	 	Primary Care	 	 	 	 	 	 	 	 	 	 	 	 
	11

	 	Physician Specialty Services	 	 	 	 	 	 	 	 	 	 	 	 
	12

	 	Outpatient Hospital (excludes ER)	 	 	 	 	 	 	 	 	 	 	 	 
	13

	 	Other Professional Services	 	 	 	 	 	 	 	 	 	 	 	 
	14

	 	Emergency Room	 	 	 	 	 	 	 	 	 	 	 	 
	15

	 	DME/Medical Supplies	 	 	 	 	 	 	 	 	 	 	 	 
	16

	 	Prosthetics & Orthotics	 	 	 	 	 	 	 	 	 	 	 	 
	17

	 	Covered Dental	 	 	 	 	 	 	 	 	 	 	 	 
	18

	 	Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)	 	 	 	 	 	 	 	 	 	 	 	 
	19

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	20

	 	Home Health, Hospice and PDN	 	 	 	 	 	 	 	 	 	 	 	 
	21

	 	Transportation	 	 	 	 	 	 	 	 	 	 	 	 
	22

	 	Lab & X-ray	 	 	 	 	 	 	 	 	 	 	 	 
	23

	 	Vision Care, including eyeglasses	 	 	 	 	 	 	 	 	 	 	 	 
	24

	 	Mental Health/Substance Abuse	 	 	 	 	 	 	 	 	 	 	 	 
	25

	 	Reinsurance Expenses	 	 	 	 	 	 	 	 	 	 	 	 
	26A

	 	EPSDT Medical & PDN	 	 	 	 	 	 	 	 	 	 	 	 
	26B

	 	EPSDT Dental — EPD	 	 	 	 	 	 	 	 	 	 	 	 
	27

	 	Family Planning	 	 	 	 	 	 	 	 	 	 	 	 
	28

	 	Other Medical	 	 	 	 	 	 	 	 	 	 	 	 
	29

	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 
	30

	 	Compensation	 	 	 	 	 	 	 	 	 	 	 	 
	31

	 	Occupancy/Depreciation/Amortization	 	 	 	 	 	 	 	 	 	 	 	 
	32

	 	Interest Expense	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	31	 	Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.
	 
	32	 	For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3032	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	33

	 	Education/Outreach	 	 	 	 	 	 	 	 	 	 	 	 
	34

	 	Sanctions	 	 	 	 	 	 	 	 	 	 	 	 
	35

	 	Corporate Overhead Allocations	 	 	 	 	 	 	 	 	 	 	 	 
	36

	 	Subcontract/Delegated Administrative

services	 	 	 	 	 	 	 	 	 	 	 	 
	37

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	38

	 	TOTAL ADMINISTRATION	 	 	 	 	 	 	 	 	 	 	 	 
	39

	 	TOTAL EXPENSES	 	 	 	 	 	 	 	 	 	 	 	 
	40

	 	OPERATION INCOME (LOSS) (8-39)	 	 	 	 	 	 	 	 	 	 	 	 
	41

	 	Extraordinary Item	 	 	 	 	 	 	 	 	 	 	 	 
	42

	 	Provision for State, Federal and Other
Governmental Taxes	 	 	 	 	 	 	 	 	 	 	 	 
	43

	 	Other than Income taxes33	 	 	 	 	 	 	 	 	 	 	 	 
	44

	 	Adjustment for prior period IBNR Estimates	 	 	 	 	 	 	 	 	 	 	 	 
	45

	 	Non-claim adjustments	 	 	 	 	 	 	 	 	 	 	 	 
	46

	 	NET INCOME (LOSS) (40-41-42-43-44-45)	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	33	 	Reported items other than State or Federal
income taxes

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Table # 19 — Part K                Income Statement by Rate Cell Grouping

NJ KIDCARE D (Excluding AIDS) — STATEWIDE34

FOR THE THREE MONTHS ENDING ______           FOR ______

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3035	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 
	1

	 	Capitated Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	Supplemental Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2a

	 	Maternity	 	 	 	 	 	 	 	 	 	 	 	 
	2b

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	2c

	 	EPSDT Incentive Payment	 	 	 	 	 	 	 	 	 	 	 	 
	2d

	 	Reimbursable Medical and Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	2e

	 	Managed Care Service Administrator Premium	 	 	 	 	 	 	 	 	 	 	 	 
	2f

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	3

	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	Interest	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	COB	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	Reinsurance Recoveries	 	 	 	 	 	 	 	 	 	 	 	 
	7

	 	Other Revenue	 	 	 	 	 	 	 	 	 	 	 	 
	8

	 	TOTAL REVENUE (3+4+5+6+7)	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 
	9

	 	Inpatient Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	10

	 	Primary Care	 	 	 	 	 	 	 	 	 	 	 	 
	11

	 	Physician Specialty Services	 	 	 	 	 	 	 	 	 	 	 	 
	12

	 	Outpatient Hospital (excludes ER)	 	 	 	 	 	 	 	 	 	 	 	 
	13

	 	Other Professional Services	 	 	 	 	 	 	 	 	 	 	 	 
	14

	 	Emergency Room	 	 	 	 	 	 	 	 	 	 	 	 
	15

	 	DME/Medical Supplies	 	 	 	 	 	 	 	 	 	 	 	 
	16

	 	Prosthetics & Orthotics	 	 	 	 	 	 	 	 	 	 	 	 
	17

	 	Covered Dental	 	 	 	 	 	 	 	 	 	 	 	 
	18

	 	Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)	 	 	 	 	 	 	 	 	 	 	 	 
	19

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	20

	 	Home Health, Hospice and PDN	 	 	 	 	 	 	 	 	 	 	 	 
	21

	 	Transportation	 	 	 	 	 	 	 	 	 	 	 	 
	22

	 	Lab & X-ray	 	 	 	 	 	 	 	 	 	 	 	 
	23

	 	Vision Care, including eyeglasses	 	 	 	 	 	 	 	 	 	 	 	 
	24

	 	Mental Health/Substance Abuse	 	 	 	 	 	 	 	 	 	 	 	 
	25

	 	Reinsurance Expenses	 	 	 	 	 	 	 	 	 	 	 	 
	26A

	 	EPSDT Medical & PDN	 	 	 	 	 	 	 	 	 	 	 	 
	26B

	 	EPSDT Dental — EPD	 	 	 	 	 	 	 	 	 	 	 	 
	27

	 	Family Planning	 	 	 	 	 	 	 	 	 	 	 	 
	28

	 	Other Medical	 	 	 	 	 	 	 	 	 	 	 	 
	29

	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 
	30

	 	Compensation	 	 	 	 	 	 	 	 	 	 	 	 
	31

	 	Occupancy/Depreciation/Amortization	 	 	 	 	 	 	 	 	 	 	 	 
	32

	 	Interest Expense	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	34	 	Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.
	 
	35	 	For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3035	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	33

	 	Education/Outreach	 	 	 	 	 	 	 	 	 	 	 	 
	34

	 	Sanctions	 	 	 	 	 	 	 	 	 	 	 	 
	35

	 	Corporate Overhead Allocations	 	 	 	 	 	 	 	 	 	 	 	 
	36

	 	Subcontract/Delegated Administrative

services	 	 	 	 	 	 	 	 	 	 	 	 
	37

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	38

	 	TOTAL ADMINISTRATION	 	 	 	 	 	 	 	 	 	 	 	 
	39

	 	TOTAL EXPENSES	 	 	 	 	 	 	 	 	 	 	 	 
	40

	 	OPERATION INCOME (LOSS) (8-39)	 	 	 	 	 	 	 	 	 	 	 	 
	41

	 	Extraordinary Item	 	 	 	 	 	 	 	 	 	 	 	 
	42

	 	Provision for State, Federal and Other
Governmental Taxes	 	 	 	 	 	 	 	 	 	 	 	 
	43

	 	Other than Income taxes36	 	 	 	 	 	 	 	 	 	 	 	 
	44

	 	Adjustment for prior period IBNR Estimates	 	 	 	 	 	 	 	 	 	 	 	 
	45

	 	Non-claim adjustments	 	 	 	 	 	 	 	 	 	 	 	 
	46

	 	NET INCOME (LOSS) (40-41-42-43-44-45)	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	36	 	Reported items other than State or Federal
income taxes

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Table #19 — Part L                Statement Income Statement by Rate Cell Grouping

Reserved

FOR THE THREE MONTHS ENDING ___           FOR ___

 (HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	 	 	month	 	month	 	 	 	PMPM 	 	@9/3037	 	@9/30
	 	 	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 
	1

	 	 	 	Capitated Premiums

	 	 
	 	 
	 	 
	 	 
	 	 
	 	 
	2

	 	 	 	Supplemental Premiums
	 	 	 	 	 	 	 	 	 	 	 	 
	2a

	 	 	 	Maternity
	 	 	 	 	 	 	 	 	 	 	 	 
	2b

	 	 	 	Reimbursable HIV/AIDS Drugs and Blood Product
	 	 	 	 	 	 	 	 	 	 	 	 
	2c

	 	 	 	EPSDT Incentive Payment
	 	 	 	 	 	 	 	 	 	 	 	 
	2d

	 	 	 	Reimbursable Medical and Hospital 
	 	 	 	 	 	 	 	 	 	 	 	 
	2e

	 	 	 	Managed Care Service Administrator Premium
	 	 	 	 	 	 	 	 	 	 	 	 
	2f

	 	 	 	Other
	 	 	 	 	 	 	 	 	 	 	 	 
	3

	 	 	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	 	 	Interest
	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	 	 	COB
	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	 	 	Reinsurance Recoveries
	 	 	 	 	 	 	 	 	 	 	 	 
	7

	 	 	 	Other Revenue
	 	 	 	 	 	 	 	 	 	 	 	 
	8

	 	 	 	TOTAL REVENUE (3+4+5+6+7)
	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 
	9

	 	 	 	Inpatient Hospital 
	 	 	 	 	 	 	 	 	 	 	 	 
	10

	 	 	 	Primary Care
	 	 	 	 	 	 	 	 	 	 	 	 
	11

	 	 	 	Physician Specialty Services
	 	 	 	 	 	 	 	 	 	 	 	 
	12

	 	 	 	Outpatient Hospital (excludes ER)
	 	 	 	 	 	 	 	 	 	 	 	 
	13

	 	 	 	Other Professional Services 
	 	 	 	 	 	 	 	 	 	 	 	 
	14

	 	 	 	Emergency Room
	 	 	 	 	 	 	 	 	 	 	 	 
	15

	 	 	 	DME/Medical Supplies
	 	 	 	 	 	 	 	 	 	 	 	 
	16

	 	 	 	Prosthetics & Orthotics 
	 	 	 	 	 	 	 	 	 	 	 	 
	17

	 	 	 	Covered Dental
	 	 	 	 	 	 	 	 	 	 	 	 
	18

	 	 	 	Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)
	 	 	 	 	 	 	 	 	 	 	 	 
	19

	 	 	 	Reimbursable HIV/AIDS Drugs and Blood Product
	 	 	 	 	 	 	 	 	 	 	 	 
	20

	 	 	 	Home Health, Hospice and PDN
	 	 	 	 	 	 	 	 	 	 	 	 
	21

	 	 	 	Transportation
	 	 	 	 	 	 	 	 	 	 	 	 
	22

	 	 	 	Lab & X-ray
	 	 	 	 	 	 	 	 	 	 	 	 
	23

	 	 	 	Vision Care, including eyeglasses
	 	 	 	 	 	 	 	 	 	 	 	 
	24

	 	 	 	Mental Health/Substance Abuse
	 	 	 	 	 	 	 	 	 	 	 	 
	25

	 	 	 	Reinsurance Expenses
	 	 	 	 	 	 	 	 	 	 	 	 
	26A

	 	 	 	EPSDT Medical & PDN
	 	 	 	 	 	 	 	 	 	 	 	 
	26B

	 	 	 	EPSDT Dental — EPD
	 	 	 	 	 	 	 	 	 	 	 	 
	27

	 	 	 	Family Planning
	 	 	 	 	 	 	 	 	 	 	 	 
	28

	 	 	 	Other Medical 
	 	 	 	 	 	 	 	 	 	 	 	 
	29

	 	 	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)
	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 
	30

	 	 	 	Compensation
	 	 	 	 	 	 	 	 	 	 	 	 
	31

	 	 	 	Occupancy/Depreciation/Amortization
	 	 	 	 	 	 	 	 	 	 	 	 
	32

	 	 	 	Interest Expense
	 	 	 	 	 	 	 	 	 	 	 	 
	33

	 	 	 	Education/Outreach
	 	 	 	 	 	 	 	 	 	 	 	 
	34

	 	 	 	Sanctions
	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	37	 	For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	 	 	month	 	month	 	 	 	PMPM 	 	@9/3037	 	@9/30
	 	 	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	35

	 	 	 	Corporate Overhead Allocations

	 	 
	 	 
	 	 
	 	 
	 	 
	 	 
	36

	 	 	 	Subcontract/Delegated Administrative

services

	 	 
	 	 
	 	 
	 	 
	 	 
	 	 
	37

	 	 	 	Other

	 	 
	 	 
	 	 
	 	 
	 	 
	 	 
	38

	 	 	 	TOTAL ADMINISTRATION
	 	 	 	 	 	 	 	 	 	 	 	 
	39

	 	 	 	TOTAL EXPENSES
	 	 	 	 	 	 	 	 	 	 	 	 
	40

	 	 	 	OPERATION INCOME (LOSS) (8-39)
	 	 	 	 	 	 	 	 	 	 	 	 
	41

	 	 	 	Extraordinary Item
	 	 	 	 	 	 	 	 	 	 	 	 
	42

	 	 	 	Provision for State, Federal and Other
Governmental Taxes
	 	 	 	 	 	 	 	 	 	 	 	 
	43

	 	 	 	Other than Income taxes35
	 	 	 	 	 	 	 	 	 	 	 	 
	44

	 	 	 	Adjustment for prior period IBNR Estimates

	 	 	 	 	 	 	 	 	 	 	 	 
	45

	 	 	 	Non-claim adjustments
	 	 	 	 	 	 	 	 	 	 	 	 
	46

	 	 	 	NET INCOME (LOSS)

(40-41-42-43-44-45)
	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	38	 	Reported items other than State or Federal
income taxes

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Table # 19 — Part M                Income Statement by Rate Cell Grouping

NJ FAMILYCARE PARENTS 0-133% FPL (Excluding AIDS) — STATEWIDE39

FOR THE THREE MONTHS ENDING ______           FOR ______

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3040	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 
	1

	 	Capitated Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	Supplemental Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2a

	 	Maternity	 	 	 	 	 	 	 	 	 	 	 	 
	2b

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	2c

	 	EPSDT Incentive Payment	 	 	 	 	 	 	 	 	 	 	 	 
	2d

	 	Reimbursable Medical and Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	2e

	 	Managed Care Service Administrator Premium	 	 	 	 	 	 	 	 	 	 	 	 
	2f

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	3

	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	Interest	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	COB	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	Reinsurance Recoveries	 	 	 	 	 	 	 	 	 	 	 	 
	7

	 	Other Revenue	 	 	 	 	 	 	 	 	 	 	 	 
	8

	 	TOTAL REVENUE (3+4+5+6+7)	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 
	9

	 	Inpatient Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	10

	 	Primary Care	 	 	 	 	 	 	 	 	 	 	 	 
	11

	 	Physician Specialty Services	 	 	 	 	 	 	 	 	 	 	 	 
	12

	 	Outpatient Hospital (excludes ER)	 	 	 	 	 	 	 	 	 	 	 	 
	13

	 	Other Professional Services	 	 	 	 	 	 	 	 	 	 	 	 
	14

	 	Emergency Room	 	 	 	 	 	 	 	 	 	 	 	 
	15

	 	DME/Medical Supplies	 	 	 	 	 	 	 	 	 	 	 	 
	16

	 	Prosthetics & Orthotics	 	 	 	 	 	 	 	 	 	 	 	 
	17

	 	Covered Dental	 	 	 	 	 	 	 	 	 	 	 	 
	18

	 	Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)	 	 	 	 	 	 	 	 	 	 	 	 
	19

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	20

	 	Home Health, Hospice and PDN	 	 	 	 	 	 	 	 	 	 	 	 
	21

	 	Transportation	 	 	 	 	 	 	 	 	 	 	 	 
	22

	 	Lab & X-ray	 	 	 	 	 	 	 	 	 	 	 	 
	23

	 	Vision Care, including eyeglasses	 	 	 	 	 	 	 	 	 	 	 	 
	24

	 	Mental Health/Substance Abuse	 	 	 	 	 	 	 	 	 	 	 	 
	25

	 	Reinsurance Expenses	 	 	 	 	 	 	 	 	 	 	 	 
	26A

	 	EPSDT Medical & PDN	 	 	 	 	 	 	 	 	 	 	 	 
	26B

	 	EPSDT Dental — EPD	 	 	 	 	 	 	 	 	 	 	 	 
	27

	 	Family Planning	 	 	 	 	 	 	 	 	 	 	 	 
	28

	 	Other Medical	 	 	 	 	 	 	 	 	 	 	 	 
	29

	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 
	30

	 	Compensation	 	 	 	 	 	 	 	 	 	 	 	 
	31

	 	Occupancy/Depreciation/Amortization	 	 	 	 	 	 	 	 	 	 	 	 
	32

	 	Interest Expense	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	39	 	Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.
	 
	40	 	For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3040	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	33

	 	Education/Outreach	 	 	 	 	 	 	 	 	 	 	 	 
	34

	 	Sanctions	 	 	 	 	 	 	 	 	 	 	 	 
	35

	 	Corporate Overhead Allocations	 	 	 	 	 	 	 	 	 	 	 	 
	36

	 	Subcontract/Delegated Administrative

services	 	 	 	 	 	 	 	 	 	 	 	 
	37

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	38

	 	TOTAL ADMINISTRATION	 	 	 	 	 	 	 	 	 	 	 	 
	39

	 	TOTAL EXPENSES	 	 	 	 	 	 	 	 	 	 	 	 
	40

	 	OPERATION INCOME (LOSS) (8-39)	 	 	 	 	 	 	 	 	 	 	 	 
	41

	 	Extraordinary Item	 	 	 	 	 	 	 	 	 	 	 	 
	42

	 	Provision for State, Federal and Other
Governmental Taxes	 	 	 	 	 	 	 	 	 	 	 	 
	43

	 	Other than Income taxes41	 	 	 	 	 	 	 	 	 	 	 	 
	44

	 	Adjustment for prior period IBNR Estimates	 	 	 	 	 	 	 	 	 	 	 	 
	45

	 	Non-claim adjustments	 	 	 	 	 	 	 	 	 	 	 	 
	46

	 	NET INCOME (LOSS) (40-41-42-43-44-45)	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	41	 	Reported items other than State or Federal
income taxes

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Table #19 — Part N                Income Statement by Rate Cell Grouping 

RESERVED

FOR
THE THREE MONTHS ENDING ___     FOR ___

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3042	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	Member Months	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 
	1

	 	 	 	Capitated Premiums
	 	 	 	 	 	 	 	 	 	 
	2

	 	 	 	Supplemental Premiums
	 	 	 	 	 	 	 	 	 	 
	2a

	 	 	 	 Maternity
	 	 	 	 	 	 	 	 	 	 
	2b

	 	 	 	 Reimbursable HIV/AIDS Drugs and Blood
Product
	 	 	 	 	 	 	 	 	 	 
	2c

	 	 	 	 EPSDT Incentive Payment
	 	 	 	 	 	 	 	 	 	 
	2d

	 	 	 	 Reimbursable Medical and Hospital

	 	 	 	 	 	 	 	 	 	 
	2e

	 	 	 	 Managed Care Service Administrator

Premium
	 	 	 	 	 	 	 	 	 	 
	2f

	 	 	 	 Other
	 	 	 	 	 	 	 	 	 	 
	3

	 	 	 	Total Premiums (Lines

1+2a+2b+2c+2d+2e+2f)
	 	 	 	 	 	 	 	 	 	 
	4

	 	 	 	Interest
	 	 	 	 	 	 	 	 	 	 
	5

	 	 	 	COB
	 	 	 	 	 	 	 	 	 	 
	6

	 	 	 	Reinsurance Recoveries
	 	 	 	 	 	 	 	 	 	 
	7

	 	 	 	Other Revenue
	 	 	 	 	 	 	 	 	 	 
	8

	 	 	 	TOTAL REVENUE (3+4+5+6+7)
	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 
	9

	 	 	 	Inpatient Hospital 
	 	 	 	 	 	 	 	 	 	 
	10

	 	 	 	Primary Care
	 	 	 	 	 	 	 	 	 	 
	11

	 	 	 	Physician Specialty Services
	 	 	 	 	 	 	 	 	 	 
	12

	 	 	 	Outpatient Hospital (excludes ER)
	 	 	 	 	 	 	 	 	 	 
	13

	 	 	 	Other Professional Services 
	 	 	 	 	 	 	 	 	 	 
	14

	 	 	 	Emergency Room
	 	 	 	 	 	 	 	 	 	 
	15

	 	 	 	DME/Medical Supplies
	 	 	 	 	 	 	 	 	 	 
	16

	 	 	 	Prosthetics & Orthotics 
	 	 	 	 	 	 	 	 	 	 
	17

	 	 	 	Covered Dental
	 	 	 	 	 	 	 	 	 	 
	18

	 	 	 	Pharmacy (not to include Reimbursable HIV/AIDS
Drugs and Blood Products)
	 	 	 	 	 	 	 	 	 	 
	19

	 	 	 	Reimbursable HIV/AIDS Drugs and Blood
Product
	 	 	 	 	 	 	 	 	 	 
	20

	 	 	 	Home Health, Hospice and PDN
	 	 	 	 	 	 	 	 	 	 
	21

	 	 	 	Transportation
	 	 	 	 	 	 	 	 	 	 
	22

	 	 	 	Lab & X-ray
	 	 	 	 	 	 	 	 	 	 
	23

	 	 	 	Vision Care, including eyeglasses
	 	 	 	 	 	 	 	 	 	 
	24

	 	 	 	Mental Health/Substance Abuse
	 	 	 	 	 	 	 	 	 	 
	25

	 	 	 	Reinsurance Expenses
	 	 	 	 	 	 	 	 	 	 
	26A

	 	 	 	EPSDT Medical & PDN
	 	 	 	 	 	 	 	 	 	 
	26B

	 	 	 	EPSDT Dental — EPD
	 	 	 	 	 	 	 	 	 	 
	27

	 	 	 	Family Planning
	 	 	 	 	 	 	 	 	 	 
	28

	 	 	 	Other Medical 
	 	 	 	 	 	 	 	 	 	 
	29

	 	 	 	TOTAL MEDICAL & HOSPITAL (9 THRU

28)
	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 
	30

	 	 	 	Compensation
	 	 	 	 	 	 	 	 	 	 
	31

	 	 	 	Occupancy/Depreciation/Amortization
	 	 	 	 	 	 	 	 	 	 
	32

	 	 	 	Interest Expense
	 	 	 	 	 	 	 	 	 	 
	33

	 	 	 	Education/Outreach
	 	 	 	 	 	 	 	 	 	 
	34

	 	 	 	Sanctions
	 	 	 	 	 	 	 	 	 	 
	35

	 	 	 	Corporate Overhead Allocations
	 	 	 	 	 	 	 	 	 	 

 

			
	42	 	For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3042	 	@9/30
	 	 	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	36

	 	 	 	Subcontract/Delegated Administrative

services

	 	  
	 	 
	 	 	 	 
	 	 
	 	 
	37

	 	 	 	Other
	 	 	 	 	 	 	 	 	 	 	 	 
	38

	 	 	 	TOTAL ADMINISTRATION

	 	 
	 	 
	 	 	 	 
	 	 
	 	 
	39

	 	 	 	TOTAL EXPENSES
	 	 	 	 	 	 	 	 	 	 	 	 
	40

	 	 	 	OPERATION INCOME (LOSS) (8-39)
	 	 	 	 	 	 	 	 	 	 	 	 
	41

	 	 	 	Extraordinary Item
	 	 	 	 	 	 	 	 	 	 	 	 
	42

	 	 	 	Provision for State, Federal and Other
Governmental Taxes
	 	 	 	 	 	 	 	 	 	 	 	 
	43

	 	 	 	Other than Income taxes40
	 	 	 	 	 	 	 	 	 	 	 	 
	44

	 	 	 	Adjustment for prior period IBNR Estimates

	 	 	 	 	 	 	 	 	 	 	 	 
	45

	 	 	 	Non-claim adjustments
	 	 	 	 	 	 	 	 	 	 	 	 
	46

	 	 	 	NET INCOME (LOSS)

(40-41-42-43-44-45)
	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	43	 	Reported items other than State or Federal
income taxes

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Table # 19 — Part O                Income Statement by Rate Cell Grouping

NJ FAMILYCARE PARENTS 133-250 % FPL (Excluding AIDS) — STATEWIDE44

FOR THE THREE MONTHS ENDING ______           FOR ______

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3045	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 
	1

	 	Capitated Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	Supplemental Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2a

	 	Maternity	 	 	 	 	 	 	 	 	 	 	 	 
	2b

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	2c

	 	EPSDT Incentive Payment	 	 	 	 	 	 	 	 	 	 	 	 
	2d

	 	Reimbursable Medical and Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	2e

	 	Managed Care Service Administrator Premium	 	 	 	 	 	 	 	 	 	 	 	 
	2f

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	3

	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	Interest	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	COB	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	Reinsurance Recoveries	 	 	 	 	 	 	 	 	 	 	 	 
	7

	 	Other Revenue	 	 	 	 	 	 	 	 	 	 	 	 
	8

	 	TOTAL REVENUE (3+4+5+6+7)	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 
	9

	 	Inpatient Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	10

	 	Primary Care	 	 	 	 	 	 	 	 	 	 	 	 
	11

	 	Physician Specialty Services	 	 	 	 	 	 	 	 	 	 	 	 
	12

	 	Outpatient Hospital (excludes ER)	 	 	 	 	 	 	 	 	 	 	 	 
	13

	 	Other Professional Services	 	 	 	 	 	 	 	 	 	 	 	 
	14

	 	Emergency Room	 	 	 	 	 	 	 	 	 	 	 	 
	15

	 	DME/Medical Supplies	 	 	 	 	 	 	 	 	 	 	 	 
	16

	 	Prosthetics & Orthotics	 	 	 	 	 	 	 	 	 	 	 	 
	17

	 	Covered Dental	 	 	 	 	 	 	 	 	 	 	 	 
	18

	 	Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)	 	 	 	 	 	 	 	 	 	 	 	 
	19

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	20

	 	Home Health, Hospice and PDN	 	 	 	 	 	 	 	 	 	 	 	 
	21

	 	Transportation	 	 	 	 	 	 	 	 	 	 	 	 
	22

	 	Lab & X-ray	 	 	 	 	 	 	 	 	 	 	 	 
	23

	 	Vision Care, including eyeglasses	 	 	 	 	 	 	 	 	 	 	 	 
	24

	 	Mental Health/Substance Abuse	 	 	 	 	 	 	 	 	 	 	 	 
	25

	 	Reinsurance Expenses	 	 	 	 	 	 	 	 	 	 	 	 
	26A

	 	EPSDT Medical & PDN	 	 	 	 	 	 	 	 	 	 	 	 
	26B

	 	EPSDT Dental — EPD	 	 	 	 	 	 	 	 	 	 	 	 
	27

	 	Family Planning	 	 	 	 	 	 	 	 	 	 	 	 
	28

	 	Other Medical	 	 	 	 	 	 	 	 	 	 	 	 
	29

	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 
	30

	 	Compensation	 	 	 	 	 	 	 	 	 	 	 	 
	31

	 	Occupancy/Depreciation/Amortization	 	 	 	 	 	 	 	 	 	 	 	 
	32

	 	Interest Expense	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	44	 	Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.
	 
	45	 	For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3045	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	33

	 	Education/Outreach	 	 	 	 	 	 	 	 	 	 	 	 
	34

	 	Sanctions	 	 	 	 	 	 	 	 	 	 	 	 
	35

	 	Corporate Overhead Allocations	 	 	 	 	 	 	 	 	 	 	 	 
	36

	 	Subcontract/Delegated Administrative

services	 	 	 	 	 	 	 	 	 	 	 	 
	37

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	38

	 	TOTAL ADMINISTRATION	 	 	 	 	 	 	 	 	 	 	 	 
	39

	 	TOTAL EXPENSES	 	 	 	 	 	 	 	 	 	 	 	 
	40

	 	OPERATION INCOME (LOSS) (8-39)	 	 	 	 	 	 	 	 	 	 	 	 
	41

	 	Extraordinary Item	 	 	 	 	 	 	 	 	 	 	 	 
	42

	 	Provision for State, Federal and Other
Governmental Taxes	 	 	 	 	 	 	 	 	 	 	 	 
	43

	 	Other than Income taxes46	 	 	 	 	 	 	 	 	 	 	 	 
	44

	 	Adjustment for prior period IBNR Estimates	 	 	 	 	 	 	 	 	 	 	 	 
	45

	 	Non-claim adjustments	 	 	 	 	 	 	 	 	 	 	 	 
	46

	 	NET INCOME (LOSS) (40-41-42-43-44-45)	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	46	 	Reported items other than State or Federal
income taxes

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Table # 19 — Part P                Income Statement by Rate Cell Grouping

ABD WITH MEDICARE — AIDS — STATEWIDE47

FOR THE THREE MONTHS ENDING ______           FOR ______

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3048	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 
	1

	 	Capitated Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	Supplemental Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2a

	 	Maternity	 	 	 	 	 	 	 	 	 	 	 	 
	2b

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	2c

	 	EPSDT Incentive Payment	 	 	 	 	 	 	 	 	 	 	 	 
	2d

	 	Reimbursable Medical and Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	2e

	 	Managed Care Service Administrator Premium	 	 	 	 	 	 	 	 	 	 	 	 
	2f

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	3

	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	Interest	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	COB	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	Reinsurance Recoveries	 	 	 	 	 	 	 	 	 	 	 	 
	7

	 	Other Revenue	 	 	 	 	 	 	 	 	 	 	 	 
	8

	 	TOTAL REVENUE (3+4+5+6+7)	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 
	9

	 	Inpatient Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	10

	 	Primary Care	 	 	 	 	 	 	 	 	 	 	 	 
	11

	 	Physician Specialty Services	 	 	 	 	 	 	 	 	 	 	 	 
	12

	 	Outpatient Hospital (excludes ER)	 	 	 	 	 	 	 	 	 	 	 	 
	13

	 	Other Professional Services	 	 	 	 	 	 	 	 	 	 	 	 
	14

	 	Emergency Room	 	 	 	 	 	 	 	 	 	 	 	 
	15

	 	DME/Medical Supplies	 	 	 	 	 	 	 	 	 	 	 	 
	16

	 	Prosthetics & Orthotics	 	 	 	 	 	 	 	 	 	 	 	 
	17

	 	Covered Dental	 	 	 	 	 	 	 	 	 	 	 	 
	18

	 	Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)	 	 	 	 	 	 	 	 	 	 	 	 
	19

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	20

	 	Home Health, Hospice and PDN	 	 	 	 	 	 	 	 	 	 	 	 
	21

	 	Transportation	 	 	 	 	 	 	 	 	 	 	 	 
	22

	 	Lab & X-ray	 	 	 	 	 	 	 	 	 	 	 	 
	23

	 	Vision Care, including eyeglasses	 	 	 	 	 	 	 	 	 	 	 	 
	24

	 	Mental Health/Substance Abuse	 	 	 	 	 	 	 	 	 	 	 	 
	25

	 	Reinsurance Expenses	 	 	 	 	 	 	 	 	 	 	 	 
	26A

	 	EPSDT Medical & PDN	 	 	 	 	 	 	 	 	 	 	 	 
	26B

	 	EPSDT Dental — EPD	 	 	 	 	 	 	 	 	 	 	 	 
	27

	 	Family Planning	 	 	 	 	 	 	 	 	 	 	 	 
	28

	 	Other Medical	 	 	 	 	 	 	 	 	 	 	 	 
	29

	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 
	30

	 	Compensation	 	 	 	 	 	 	 	 	 	 	 	 
	31

	 	Occupancy/Depreciation/Amortization	 	 	 	 	 	 	 	 	 	 	 	 
	32

	 	Interest Expense	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	47	 	Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.
	 
	48	 	For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3048	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	33

	 	Education/Outreach	 	 	 	 	 	 	 	 	 	 	 	 
	34

	 	Sanctions	 	 	 	 	 	 	 	 	 	 	 	 
	35

	 	Corporate Overhead Allocations	 	 	 	 	 	 	 	 	 	 	 	 
	36

	 	Subcontract/Delegated Administrative

services	 	 	 	 	 	 	 	 	 	 	 	 
	37

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	38

	 	TOTAL ADMINISTRATION	 	 	 	 	 	 	 	 	 	 	 	 
	39

	 	TOTAL EXPENSES	 	 	 	 	 	 	 	 	 	 	 	 
	40

	 	OPERATION INCOME (LOSS) (8-39)	 	 	 	 	 	 	 	 	 	 	 	 
	41

	 	Extraordinary Item	 	 	 	 	 	 	 	 	 	 	 	 
	42

	 	Provision for State, Federal and Other
Governmental Taxes	 	 	 	 	 	 	 	 	 	 	 	 
	43

	 	Other than Income taxes49	 	 	 	 	 	 	 	 	 	 	 	 
	44

	 	Adjustment for prior period IBNR Estimates	 	 	 	 	 	 	 	 	 	 	 	 
	45

	 	Non-claim adjustments	 	 	 	 	 	 	 	 	 	 	 	 
	46

	 	NET INCOME (LOSS) (40-41-42-43-44-45)	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	49	 	Reported items other than State or Federal
income taxes

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Table # 19 — Part Q                Income Statement by Rate Cell Grouping

NON-ABD -AIDS — STATEWIDE50

FOR THE THREE MONTHS ENDING ______           FOR ______

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3051	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 
	1

	 	Capitated Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	Supplemental Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2a

	 	Maternity	 	 	 	 	 	 	 	 	 	 	 	 
	2b

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	2c

	 	EPSDT Incentive Payment	 	 	 	 	 	 	 	 	 	 	 	 
	2d

	 	Reimbursable Medical and Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	2e

	 	Managed Care Service Administrator Premium	 	 	 	 	 	 	 	 	 	 	 	 
	2f

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	3

	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	Interest	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	COB	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	Reinsurance Recoveries	 	 	 	 	 	 	 	 	 	 	 	 
	7

	 	Other Revenue	 	 	 	 	 	 	 	 	 	 	 	 
	8

	 	TOTAL REVENUE (3+4+5+6+7)	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 
	9

	 	Inpatient Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	10

	 	Primary Care	 	 	 	 	 	 	 	 	 	 	 	 
	11

	 	Physician Specialty Services	 	 	 	 	 	 	 	 	 	 	 	 
	12

	 	Outpatient Hospital (excludes ER)	 	 	 	 	 	 	 	 	 	 	 	 
	13

	 	Other Professional Services	 	 	 	 	 	 	 	 	 	 	 	 
	14

	 	Emergency Room	 	 	 	 	 	 	 	 	 	 	 	 
	15

	 	DME/Medical Supplies	 	 	 	 	 	 	 	 	 	 	 	 
	16

	 	Prosthetics & Orthotics	 	 	 	 	 	 	 	 	 	 	 	 
	17

	 	Covered Dental	 	 	 	 	 	 	 	 	 	 	 	 
	18

	 	Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)	 	 	 	 	 	 	 	 	 	 	 	 
	19

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	20

	 	Home Health, Hospice and PDN	 	 	 	 	 	 	 	 	 	 	 	 
	21

	 	Transportation	 	 	 	 	 	 	 	 	 	 	 	 
	22

	 	Lab & X-ray	 	 	 	 	 	 	 	 	 	 	 	 
	23

	 	Vision Care, including eyeglasses	 	 	 	 	 	 	 	 	 	 	 	 
	24

	 	Mental Health/Substance Abuse	 	 	 	 	 	 	 	 	 	 	 	 
	25

	 	Reinsurance Expenses	 	 	 	 	 	 	 	 	 	 	 	 
	26A

	 	EPSDT Medical & PDN	 	 	 	 	 	 	 	 	 	 	 	 
	26B

	 	EPSDT Dental — EPD	 	 	 	 	 	 	 	 	 	 	 	 
	27

	 	Family Planning	 	 	 	 	 	 	 	 	 	 	 	 
	28

	 	Other Medical	 	 	 	 	 	 	 	 	 	 	 	 
	29

	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 
	30

	 	Compensation	 	 	 	 	 	 	 	 	 	 	 	 
	31

	 	Occupancy/Depreciation/Amortization	 	 	 	 	 	 	 	 	 	 	 	 
	32

	 	Interest Expense	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	50	 	Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.
	 
	51	 	For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3051	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	33

	 	Education/Outreach	 	 	 	 	 	 	 	 	 	 	 	 
	34

	 	Sanctions	 	 	 	 	 	 	 	 	 	 	 	 
	35

	 	Corporate Overhead Allocations	 	 	 	 	 	 	 	 	 	 	 	 
	36

	 	Subcontract/Delegated Administrative

services	 	 	 	 	 	 	 	 	 	 	 	 
	37

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	38

	 	TOTAL ADMINISTRATION	 	 	 	 	 	 	 	 	 	 	 	 
	39

	 	TOTAL EXPENSES	 	 	 	 	 	 	 	 	 	 	 	 
	40

	 	OPERATION

 INCOME (LOSS) (8-39)	 	 	 	 	 	 	 	 	 	 	 	 
	41

	 	Extraordinary Item	 	 	 	 	 	 	 	 	 	 	 	 
	42

	 	Provision for State, Federal and Other
Governmental Taxes	 	 	 	 	 	 	 	 	 	 	 	 
	43

	 	Other than Income taxes52	 	 	 	 	 	 	 	 	 	 	 	 
	44

	 	Adjustment for prior period IBNR Estimates	 	 	 	 	 	 	 	 	 	 	 	 
	45

	 	Non-claim adjustments	 	 	 	 	 	 	 	 	 	 	 	 
	46

	 	NET INCOME (LOSS) (40-41-42-43-44-45)	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	52	 	Reported items other than State or Federal
income taxes

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Table # 19 — Part R1                Income Statement by Rate Cell Grouping

MATERNITY — STATEWIDE53

FOR THE THREE MONTHS ENDING ______           FOR ______

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD per	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	delivery	 	$@9/3054	 	@9/30
	 	 	 	 	 	 	per delivery	 	 	 	 	 	 	 	PMPM
	 
	Deliveries	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 
	1

	 	Capitated Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	Supplemental Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2a

	 	Maternity	 	 	 	 	 	 	 	 	 	 	 	 
	2b

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	2c

	 	EPSDT Incentive Payment	 	 	 	 	 	 	 	 	 	 	 	 
	2d

	 	Reimbursable Medical and Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	2e

	 	Managed Care Service Administrator Premium	 	 	 	 	 	 	 	 	 	 	 	 
	2f

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	3

	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	Interest	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	COB	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	Reinsurance Recoveries	 	 	 	 	 	 	 	 	 	 	 	 
	7

	 	Other Revenue	 	 	 	 	 	 	 	 	 	 	 	 
	8

	 	TOTAL REVENUE (3+4+5+6+7)	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 
	9

	 	Inpatient Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	10

	 	Primary Care	 	 	 	 	 	 	 	 	 	 	 	 
	11

	 	Physician Specialty Services	 	 	 	 	 	 	 	 	 	 	 	 
	12

	 	Outpatient Hospital (excludes ER)	 	 	 	 	 	 	 	 	 	 	 	 
	13

	 	Other Professional Services	 	 	 	 	 	 	 	 	 	 	 	 
	14

	 	Emergency Room	 	 	 	 	 	 	 	 	 	 	 	 
	15

	 	DME/Medical Supplies	 	 	 	 	 	 	 	 	 	 	 	 
	16

	 	Prosthetics & Orthotics	 	 	 	 	 	 	 	 	 	 	 	 
	17

	 	Covered Dental	 	 	 	 	 	 	 	 	 	 	 	 
	18

	 	Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)	 	 	 	 	 	 	 	 	 	 	 	 
	19

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	20

	 	Home Health, Hospice and PDN	 	 	 	 	 	 	 	 	 	 	 	 
	21

	 	Transportation	 	 	 	 	 	 	 	 	 	 	 	 
	22

	 	Lab & X-ray	 	 	 	 	 	 	 	 	 	 	 	 
	23

	 	Vision Care, including eyeglasses	 	 	 	 	 	 	 	 	 	 	 	 
	24

	 	Mental Health/Substance Abuse	 	 	 	 	 	 	 	 	 	 	 	 
	25

	 	Reinsurance Expenses	 	 	 	 	 	 	 	 	 	 	 	 
	26A

	 	EPSDT Medical & PDN	 	 	 	 	 	 	 	 	 	 	 	 
	26B

	 	EPSDT Dental — EPD	 	 	 	 	 	 	 	 	 	 	 	 
	27

	 	Family Planning	 	 	 	 	 	 	 	 	 	 	 	 
	28

	 	Other Medical	 	 	 	 	 	 	 	 	 	 	 	 
	29

	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 
	30

	 	Compensation	 	 	 	 	 	 	 	 	 	 	 	 
	31

	 	Occupancy/Depreciation/Amortization	 	 	 	 	 	 	 	 	 	 	 	 
	32

	 	Interest Expense	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	53	 	Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.
	 
	54	 	For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD per	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	delivery	 	$@9/3054	 	@9/30
	 	 	 	 	 	 	per delivery	 	 	 	 	 	 	 	PMPM
	 
	33

	 	Education/Outreach	 	 	 	 	 	 	 	 	 	 	 	 
	34

	 	Sanctions	 	 	 	 	 	 	 	 	 	 	 	 
	35

	 	Corporate Overhead Allocations	 	 	 	 	 	 	 	 	 	 	 	 
	36

	 	Subcontract/Delegated Administrative

services	 	 	 	 	 	 	 	 	 	 	 	 
	37

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	38

	 	TOTAL ADMINISTRATION	 	 	 	 	 	 	 	 	 	 	 	 
	39

	 	TOTAL EXPENSES	 	 	 	 	 	 	 	 	 	 	 	 
	40

	 	OPERATION INCOME (LOSS) (8-39)	 	 	 	 	 	 	 	 	 	 	 	 
	41

	 	Extraordinary Item	 	 	 	 	 	 	 	 	 	 	 	 
	42

	 	Provision for State, Federal and Other
Governmental Taxes	 	 	 	 	 	 	 	 	 	 	 	 
	43

	 	Other than Income taxes55	 	 	 	 	 	 	 	 	 	 	 	 
	44

	 	Adjustment for prior period IBNR Estimates	 	 	 	 	 	 	 	 	 	 	 	 
	45

	 	Non-claim adjustments	 	 	 	 	 	 	 	 	 	 	 	 
	46

	 	NET INCOME

 (LOSS) (40-41-42-43-44-45)	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	55	 	Reported items other than State or Federal
income taxes

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Table # 19 — Part R2                Income Statement by Rate Cell Grouping

Newborn STATEWIDE56

FOR THE THREE MONTHS ENDING ______           FOR ______

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3057	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 
	1

	 	Capitated Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	Supplemental Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2a

	 	Maternity	 	 	 	 	 	 	 	 	 	 	 	 
	2b

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	2c

	 	EPSDT Incentive Payment	 	 	 	 	 	 	 	 	 	 	 	 
	2d

	 	Reimbursable Medical and Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	2e

	 	Managed Care Service Administrator Premium	 	 	 	 	 	 	 	 	 	 	 	 
	2f

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	3

	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	Interest	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	COB	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	Reinsurance Recoveries	 	 	 	 	 	 	 	 	 	 	 	 
	7

	 	Other Revenue	 	 	 	 	 	 	 	 	 	 	 	 
	8

	 	TOTAL REVENUE (3+4+5+6+7)	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 
	9

	 	Inpatient Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	10

	 	Primary Care	 	 	 	 	 	 	 	 	 	 	 	 
	11

	 	Physician Specialty Services	 	 	 	 	 	 	 	 	 	 	 	 
	12

	 	Outpatient Hospital (excludes ER)	 	 	 	 	 	 	 	 	 	 	 	 
	13

	 	Other Professional Services	 	 	 	 	 	 	 	 	 	 	 	 
	14

	 	Emergency Room	 	 	 	 	 	 	 	 	 	 	 	 
	15

	 	DME/Medical Supplies	 	 	 	 	 	 	 	 	 	 	 	 
	16

	 	Prosthetics & Orthotics	 	 	 	 	 	 	 	 	 	 	 	 
	17

	 	Covered Dental	 	 	 	 	 	 	 	 	 	 	 	 
	18

	 	Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)	 	 	 	 	 	 	 	 	 	 	 	 
	19

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	20

	 	Home Health, Hospice and PDN	 	 	 	 	 	 	 	 	 	 	 	 
	21

	 	Transportation	 	 	 	 	 	 	 	 	 	 	 	 
	22

	 	Lab & X-ray	 	 	 	 	 	 	 	 	 	 	 	 
	23

	 	Vision Care, including eyeglasses	 	 	 	 	 	 	 	 	 	 	 	 
	24

	 	Mental Health/Substance Abuse	 	 	 	 	 	 	 	 	 	 	 	 
	25

	 	Reinsurance Expenses	 	 	 	 	 	 	 	 	 	 	 	 
	26A

	 	EPSDT Medical & PDN	 	 	 	 	 	 	 	 	 	 	 	 
	26B

	 	EPSDT Dental — EPD	 	 	 	 	 	 	 	 	 	 	 	 
	27

	 	Family Planning	 	 	 	 	 	 	 	 	 	 	 	 
	28

	 	Other Medical	 	 	 	 	 	 	 	 	 	 	 	 
	29

	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 
	30

	 	Compensation	 	 	 	 	 	 	 	 	 	 	 	 
	31

	 	Occupancy/Depreciation/Amortization	 	 	 	 	 	 	 	 	 	 	 	 
	32

	 	Interest Expense	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	56	 	Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.
	 
	57	 	For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-	 	Three	 	YTD $	 	YTD	 	SFY End	 	SFY End $
	 	 	 	 	month	 	month	 	 	 	PMPM	 	$@9/3057	 	@9/30
	 	 	 	 	 	 	PMPM	 	 	 	 	 	 	 	PMPM
	 
	33

	 	Education/Outreach	 	 	 	 	 	 	 	 	 	 	 	 
	34

	 	Sanctions	 	 	 	 	 	 	 	 	 	 	 	 
	35

	 	Corporate Overhead Allocations	 	 	 	 	 	 	 	 	 	 	 	 
	36

	 	Subcontract/Delegated Administrative

services	 	 	 	 	 	 	 	 	 	 	 	 
	37

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	38

	 	TOTAL ADMINISTRATION	 	 	 	 	 	 	 	 	 	 	 	 
	39

	 	TOTAL EXPENSES	 	 	 	 	 	 	 	 	 	 	 	 
	40

	 	OPERATION

 INCOME (LOSS) (8-39)	 	 	 	 	 	 	 	 	 	 	 	 
	41

	 	Extraordinary Item	 	 	 	 	 	 	 	 	 	 	 	 
	42

	 	Provision for State, Federal and Other
Governmental Taxes	 	 	 	 	 	 	 	 	 	 	 	 
	43

	 	Other than Income taxes58	 	 	 	 	 	 	 	 	 	 	 	 
	44

	 	Adjustment for prior period IBNR Estimates	 	 	 	 	 	 	 	 	 	 	 	 
	45

	 	Non-claim adjustments	 	 	 	 	 	 	 	 	 	 	 	 
	46

	 	NET INCOME (LOSS) (40-41-42-43-44-45)	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	58	 	Reported items other than State or Federal
income taxes

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

Table # 19 — Part S1                Income Statement by Rate Cell Grouping

All At-Risk rate cell groupings On Claims Incurred DURING THE CURRENT QUARTER —STATEWIDE59

FOR THE THREE MONTHS ENDING ______           FOR ______

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	(A)	 	(B) Three	 	O=(a)+(b)	 	Three	 	SFY End	 	SFY End $
	 	 	 	 	Three-	 	month	 	Three-	 	month	 	$@9/3060	 	@9/30
	 	 	 	 	month Paid Claims	 	IBNR & RBUC	 	month Total $	 	PMPM	 	 	 	PMPM
	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 
	1

	 	Capitated Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	Supplemental Premiums	 	 	 	 	 	 	 	 	 	 	 	 
	2a

	 	Maternity	 	 	 	 	 	 	 	 	 	 	 	 
	2b

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	2c

	 	EPSDT Incentive Payment	 	 	 	 	 	 	 	 	 	 	 	 
	2d

	 	Reimbursable Medical and Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	2e

	 	Managed Care Service Administrator Premium	 	 	 	 	 	 	 	 	 	 	 	 
	2f

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	3

	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	Interest	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	COB	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	Reinsurance Recoveries	 	 	 	 	 	 	 	 	 	 	 	 
	7

	 	Other Revenue	 	 	 	 	 	 	 	 	 	 	 	 
	8

	 	TOTAL REVENUE (3+4+5+6+7)	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 
	9

	 	Inpatient Hospital	 	 	 	 	 	 	 	 	 	 	 	 
	10

	 	Primary Care	 	 	 	 	 	 	 	 	 	 	 	 
	11

	 	Physician Specialty Services	 	 	 	 	 	 	 	 	 	 	 	 
	12

	 	Outpatient Hospital (excludes ER)	 	 	 	 	 	 	 	 	 	 	 	 
	13

	 	Other Professional Services	 	 	 	 	 	 	 	 	 	 	 	 
	14

	 	Emergency Room	 	 	 	 	 	 	 	 	 	 	 	 
	15

	 	DME/Medical Supplies	 	 	 	 	 	 	 	 	 	 	 	 
	16

	 	Prosthetics & Orthotics	 	 	 	 	 	 	 	 	 	 	 	 
	17

	 	Covered Dental	 	 	 	 	 	 	 	 	 	 	 	 
	18

	 	Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)	 	 	 	 	 	 	 	 	 	 	 	 
	19

	 	Reimbursable HIV/AIDS Drugs and Blood
Product	 	 	 	 	 	 	 	 	 	 	 	 
	20

	 	Home Health, Hospice and PDN	 	 	 	 	 	 	 	 	 	 	 	 
	21

	 	Transportation	 	 	 	 	 	 	 	 	 	 	 	 
	22

	 	Lab & X-ray	 	 	 	 	 	 	 	 	 	 	 	 
	23

	 	Vision Care, including eyeglasses	 	 	 	 	 	 	 	 	 	 	 	 
	24

	 	Mental Health/Substance Abuse	 	 	 	 	 	 	 	 	 	 	 	 
	25

	 	Reinsurance Expenses	 	 	 	 	 	 	 	 	 	 	 	 
	26A

	 	EPSDT Medical & PDN	 	 	 	 	 	 	 	 	 	 	 	 
	26B

	 	EPSDT Dental — EPD	 	 	 	 	 	 	 	 	 	 	 	 
	27

	 	Family Planning	 	 	 	 	 	 	 	 	 	 	 	 
	28

	 	Other Medical	 	 	 	 	 	 	 	 	 	 	 	 
	29

	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	59	 	Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Service Administrator
program.
	 
	60	 	For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	(A)	 	(B) Three	 	O=(a)+(b)	 	Three	 	SFY End	 	SFY End $
	 	 	 	 	Three-	 	month	 	Three-	 	month	 	$@9/3060	 	@9/30
	 	 	 	 	month Paid Claims	 	IBNR & RBUC	 	month Total $	 	PMPM	 	 	 	PMPM
	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 
	30

	 	Compensation	 	 	 	 	 	 	 	 	 	 	 	 
	31

	 	Occupancy/Depreciation/Amortization	 	 	 	 	 	 	 	 	 	 	 	 
	32

	 	Interest Expense	 	 	 	 	 	 	 	 	 	 	 	 
	33

	 	Education/Outreach	 	 	 	 	 	 	 	 	 	 	 	 
	34

	 	Sanctions	 	 	 	 	 	 	 	 	 	 	 	 
	35

	 	Corporate Overhead Allocations	 	 	 	 	 	 	 	 	 	 	 	 
	36

	 	Subcontract/Delegated Administrative

services	 	 	 	 	 	 	 	 	 	 	 	 
	37

	 	Other	 	 	 	 	 	 	 	 	 	 	 	 
	38

	 	TOTAL ADMINISTRATION	 	 	 	 	 	 	 	 	 	 	 	 
	39

	 	TOTAL EXPENSES	 	 	 	 	 	 	 	 	 	 	 	 
	40

	 	OPERATION INCOME (LOSS) (8-39)	 	 	 	 	 	 	 	 	 	 	 	 
	41

	 	Extraordinary Item	 	 	 	 	 	 	 	 	 	 	 	 
	42

	 	Provision for State, Federal and Other
Governmental Taxes	 	 	 	 	 	 	 	 	 	 	 	 
	43

	 	Other than Income taxes61	 	 	 	 	 	 	 	 	 	 	 	 
	44

	 	Adjustment for prior period IBNR Estimates	 	 	 	 	 	 	 	 	 	 	 	 
	45

	 	Non-claim adjustments	 	 	 	 	 	 	 	 	 	 	 	 
	46

	 	NET INCOME (LOSS) (40-41-42-43-44-45)	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	61	 	Reported items other than State or Federal
income taxes

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

 

	 	 	 
	Table #19 – Part s2

	 	Income Statement by Rate Cell Grouping

All At-Risk Rate Cell Groupings On Claims Incurred YEAR TO DATE – STATEWIDE62

	 	 	 
	FOR THE THREE MONTHS ENDING                     

	 	FOR                     

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	(A)	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	YTD	 	 	(B) YTD	 	 	O=(a)+(b)	 	 	 	 	 	 	 	 	 	 	SFY End $	 
	 	 	 	 	 	 	Paid	 	 	IBNR &	 	 	YTD Total	 	 	YTD	 	 	SFY End	 	 	@9/30	 
	Revenues/Expenses/Administration	 	Claims	 	 	RBUC	 	 	$	 	 	PMPM	 	 	$@9/3063	 	 	PMPM	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	1	 	 	Capitated Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	2	 	 	Supplemental Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	2a	 	 	Maternity
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	2b	 	 	Reimbursable HIV/AIDS Drugs and Blood Product
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	2c	 	 	EPSDT Incentive Payment
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	2d	 	 	Reimbursable Medical and Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	2e	 	 	Managed Care Service Administrator Premium
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	2f	 	 	Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	3	 	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	4	 	 	Interest
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	5	 	 	COB
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	6	 	 	Reinsurance Recoveries
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	7	 	 	Other Revenue
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	8	 	 	TOTAL REVENUE (3+4+5+6+7)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	9	 	 	Inpatient Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	10	 	 	Primary Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	11	 	 	Physician Specialty Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	12	 	 	Outpatient Hospital (excludes ER)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	13	 	 	Other Professional Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	14	 	 	Emergency Room
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	15	 	 	DME/Medical Supplies
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	16	 	 	Prosthetics & Orthotics
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	17	 	 	Covered Dental
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	18	 	 	Pharmacy (not to include Reimbursable HIV/AIDS Drugs and Blood Products)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	19	 	 	Reimbursable HIV/AIDS Drugs and Blood Product
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	20	 	 	Home Health, Hospice and PDN
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	21	 	 	Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	22	 	 	Lab & Xray
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	23	 	 	Vision Care, including eyeglasses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	24	 	 	Mental Health/Substance Abuse
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	25	 	 	Reinsurance Expenses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	26A	 	 	EPSDT Medical & PDN
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	26B	 	 	EPSDT Dental – EPD
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	27	 	 	Family Planning
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	28	 	 	Other Medical
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	29	 	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	30	 	 	Compensation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	31	 	 	Occupancy/Depreciation/Amortization
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	62	 	Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Service Administrator
program.
	 
	63	 	For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	(A)	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	YTD	 	 	(B) YTD	 	 	O=(a)+(b)	 	 	 	 	 	 	 	 	 	 	SFY End $	 
	 	 	 	 	 	 	Paid	 	 	IBNR &	 	 	YTD Total	 	 	YTD	 	 	SFY End	 	 	@9/30	 
	Revenues/Expenses/Administration	 	Claims	 	 	RBUC	 	 	$	 	 	PMPM	 	 	$@9/3063	 	 	PMPM	 
	 	32	 	 	Interest Expense
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	33	 	 	Education/Outreach
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	34	 	 	Sanctions
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	35	 	 	Corporate Overhead Allocations
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	36	 	 	Subcontract/Delegated Administrative services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	37	 	 	Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	38	 	 	TOTAL ADMINISTRATION
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	39	 	 	TOTAL EXPENSES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	40	 	 	OPERATION INCOME (LOSS) (8-39)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	41	 	 	Extraordinary Item
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	42	 	 	Provision for State, Federal and Other Governmental Taxes
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	43	 	 	Other than Income taxes64
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	44	 	 	Adjustment for prior period IBNR Estimates
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	45	 	 	Non-claim adjustments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	46	 	 	NET INCOME (LOSS) (40-41-42-43-44-45)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	64	 	Reported items other than State or Federal
income taxes

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

	 	 	 
	Table #19 – Part S3

	 	Income Statement by Rate Cell Grouping

Reconciliations

	 	 	 
	FOR THE THREE MONTHS ENDING                     

	 	FOR                                         

Revenue Reconciliation

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	Total Premiums
	 	 	 	 	 	 	 	 	 	 	Received for At-
	Only 5 rows provided	 	 	 	 	 	 	 	 	 	Risk Rate Cell
	(Insert additional rows if needed)	 	Date	 	Check #	 	Groupings
	1
	 	 	01/00/00	 	 	 	0000	 	 	$	 	 
	2
	 	 	01/00/00	 	 	 	0000	 	 	$	 	 
	3
	 	 	01/00/00	 	 	 	0000	 	 	$	 	 
	4
	 	 	01/00/00	 	 	 	0000	 	 	$	 	 
	5
	 	 	01/00/00	 	 	 	0000	 	 	$	 	 
	6 Subtotal Premiums Received (lines 1 – 5)
	 	 	 	 	 	 	 	 	 	$	 	 
	7 Premiums Reported Quarter in #19S1
	 	 	 	 	 	 	 	 	 	$	 	 
	8 Difference (Lines 6-7)
	 	 	 	 	 	 	 	 	 	$	 	 

 

Notes:

Cells with
this shading are calculated fields and are not to be filled out

1 – Detail any differences in the “notes” section

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

	 	 	 
	Table # 19 — Part S3

	 	Income Statement by Rate Cell Grouping

Reconciliations

	 	 	 
	FOR THE THREE MONTHS ENDING                     

	 	FOR                                         

Lag Triangle and Income Statement Reconciliation for Quarter

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Three month Paid	 	 	 	 	 	 	 
	Lag Report	 	 	Table #19 – Parts S1 &S2	 	 	Claims	 	 	Three-month IBNR & RBUC	 	 	Three Month Total $	 
	Lag Report #	 	Medical	 	 	Line	 	 	Consolidated Category of Service	 	 	Lag Report Table #19	 	 	Lag Report Table #19 Difference	 	 	Lag Report Table #19 Difference	 
	 	 	Cost	 	 	#	 	 	 	 	 	 	Difference Part S1	 	 	Part S1	 	 	Part S1	 
	 	 	Grouping	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Table #20
-Part A
	 	Inpatient Hospital	 	 	9	 	 	Inpatient Hospital	 	$	 	 	 	$	 	 	 	$	 	 
	Table #20
	 	Physician	 	 	10	 	 	Primary care	 	 	 	 	 	 	 	 	 	 	 	 
	-Part B
	 	 	 	 	11	 	 	Physician Specialty Services	 	$	 	 	 	$	 	 	 	$	 	 
	Table 20
	 	Pharmacy	 	 	18	 	 	Pharmacy (not to include	 	$	 	 	 	$	 	 	 	$	 	 
	-Part C
	 	 	 	 	 	 	19	 	 	Reimbursable HIV/AIDS	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	Reimbursable HIV/AIDS	 	 	 	 	 	 	 	 	 	 	 	 
	Table #20
	 	Other	 	 	12	 	 	Other Professional Services	 	$	 	 	 	$	 	 	 	$	 	 
	-Part D
	 	 	 	 	 	 	13	 	 	Emergency Room	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	14	 	 	DME/Medical Supplies	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	15	 	 	Prosthetics & Orthotics	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	16	 	 	Covered Dental	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	17	 	 	Home Health, Hospice and PDN	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	20	 	 	Transportation	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	21	 	 	Lab & X-ray	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	22	 	 	Vision Care, including eyeglasses	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	23	 	 	Mental Health/Substance Abuse	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	24	 	 	Reinsurance Expenses	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	26a	 	 	EPSDT Medical & PDN	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	26b	 	 	EPSDT Dental – EPD	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	27	 	 	Family Planning	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	28	 	 	Other Medical	 	 	 	 	 	 	 	 	 	 	 	 

Lag Triangle and Income Statement Reconciliation for YTD

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	YTD	 	 	YTD	 	 	YTD	 
	Lag Report	 	Table #19 – Parts S1 &S2	 	Paid Claims	 	 	IBNR & RBUC	 	 	Total $	 
	Lag Report #	 	Medical	 	Line	 	 	Consolidated Category of Service	 	 	Lag Report Table #19	 	 	Lag Report Table #19 Difference	 	 	Lag Report Table #19 Difference	 
	 	 	Cost	 	#	 	 	 	 	 	 	Difference Part S1	 	 	Part S1	 	 	Part S1	 
	 	 	Grouping	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Table #20
-Part A
	 	Inpatient Hospital	 	 	9	 	 	Inpatient Hospital	 	$	 	 	 	$	 	 	 	 	 	 	 	$	 	$	 	 	 	 	 	$	 	 	 	 	 	 	 	$	 	 	 	 	 	 
	Table #20
	 	Physician	 	 	10	 	 	Primary care	 	$	 	 	 	$	 	 	 	 	 	 	 	$	 	$	 	 	 	 	 	$	 	 	 	 	 	 	 	$	 	 	 	 	 	 
	-Part B
	 	 	 	 	11	 	 	Physician Specialty Services	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Table 20
	 	Pharmacy	 	 	18	 	 	Pharmacy (not to include	 	$	 	 	 	$	 	 	 	 	 	 	 	$	 	$	 	 	 	 	 	$	 	 	 	 	 	 	 	$	 	 	 	 	 	 
	-Part C
	 	 	 	 	19	 	 	Reimbursable HIV/AIDS	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	19	 	 	Reimbursable HIV/AIDS	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Table #20
	 	Other	 	 	12	 	 	Other Professional Services	 	$	 	 	 	$	 	 	 	 	 	 	 	$	 	$	 	 	 	 	 	$	 	 	 	 	 	 	 	$	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	YTD	 	 	YTD	 	YTD	 
	Lag Report	 	Table #19 – Parts S1 &S2	 	Paid Claims	 	 	IBNR & RBUC	 	Total $	 
	Lag Report #	 	Medical	 	Line	 	 	Consolidated Category of Service	 	 	Lag Report Table #19	 	 	Lag Report Table #19 Difference	 	Lag Report Table #19 Difference
	 	 	Cost	 	#	 	 	 	 	 	 	Difference Part S1	 	 	Part S1	 	Part S1	 
	 	 	Grouping	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	-Part D
	 	 	 	 	 	 	13	 	 	Emergency Room	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	14	 	 	DME/Medical Supplies	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	15	 	 	Prosthetics & Orthotics	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	16	 	 	Covered Dental	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	17	 	 	Home Health, Hospice and PDN	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	20	 	 	Transportation	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	21	 	 	Lab & X-ray	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	22	 	 	Vision Care, including eyeglasses	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	23	 	 	Mental Health/Substance Abuse	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	24	 	 	Reinsurance Expenses	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	26	a	 	EPSDT Medical & PDN	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	26	b	 	EPSDT Dental – EPD	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	27	 	 	Family Planning	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	28	 	 	Other Medical	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

	 	 	 
	Table #19 – Part S3

	 	Income Statement by Rate Cell Grouping

Reconciliations

	 	 	 
	FOR THE THREE MONTHS ENDING                     

	 	FOR                                         

Prior Period IBNR Reconciliation for Quarter End

	 	 	 	 	 
	 	 	Incurred in	 
	 	 	Quarters Prior to	 
	1 Claims Paid in Most Recent Order
	 	$	 	 
	2 + IBNR as of Most Recent Quarter (line
43 of #2-A-D lag Triangles)
	 	$	 	 
	3 – IBNR as of prior Quarter
	 	$	 	 
	4 + Subcapitation Payments, Pharmacy
Rebates, Settlements as of Most Recent
Quarter
	 	$	 	 
	5 - Subcapitation Payments, Pharmacy
Rebates, Settlements as of Prior Quarter
	 	$	 	 
	6 Prior Period IBNR Adjustment for QTR end
(lines 1+2+3+4-5)
	 	$	 	 
	7 Table #19 – Parts S1 Adjustment for
prior period IBNR estimates
(Line 44 of Table #19S1)
	 	$	 	 
	8 Difference (Lines 6-7)
	 	$	 	 

Prior Period IBNR Reconciliation for Calendar Year End

	 	 	 	 	 
	 	 	Incurred in Calendar Years	 
	 	 	Prior to	 
	1 Claims Paid in Most Recent Calendar YTD
	 	$	 	 
	2 + IBNR as of Most Recent Quarter (line 43 of #2-A-D lag Triangles)
	 	$	 	 
	3 – IBNR as of prior calendar Year End
	 	$	 	 
	4 + Subcapitation Payments, Pharmacy Rebates, Settlements as of Most
Recent Quarter
	 	$	 	 
	5 - Subcapitation Payments, Pharmacy Rebates, Settlements as of Prior
Calendar Year End
	 	$	 	 
	6 Prior Period IBNR Adjustment for Calendar Year end
(lines 1+2+3+4-5)
	 	$	 	 
	7 Table #19 – Parts S1 Adjustment for prior period IBNR estimates
(Line 44 of Table #19S1)
	 	$	 	 
	8 Difference (Lines 6-7)
	 	$	 	 

Cells with
this shading are calculated fields and should not be filled
out

1 – Detail any difference in Notes Section

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

	 	 	 
	Table #19 – Part S3

	 	Income Statement by Rate Cell Grouping

Reconciliations

	 	 	 
	FOR THE THREE MONTHS ENDING                     

	 	FOR                                         

“Other” Administrative Expenses – Detail for an Expense Category over $250,000

	 	 	 	 	 	 	 
	Other Charged Detailed	 	 	 
	Breakdown Description	 	Total Incurred $ for the	 
	(insert additional rows if needed)	 	Quarter	 
	1
	 	 	 	 	 	 
	2
	 	 	 	 	 	 
	3
	 	 	 	 	 	 
	4
	 	 	 	 	 	 
	5
	 	 	 	 	 	 
	6
	 	 	 	 	 	 
	7
	 	 	 	 	 	 
	8
	 	 	 	 	 	 
	9
	 	 	 	 	 	 
	10
	 	 	 	 	 	 
	11
	 	Total Other Administration Expense (lines 1 through 10)	 	 	 	 
	12
	 	Table #19 – parts S2 Other Administration Expenses (line 37 of Table #19S1)	 	 	 	 
	13
	 	Difference	 	 	 	 

“Other” Administrative Expenses – Detail for an Expense Category over $250,000

	 	 	 	 	 	 	 
	Other Charged Detailed	 	Total Incurred $ YTD	 
	1
	 	 	 	 	 	 
	2
	 	 	 	 	 	 
	3
	 	 	 	 	 	 
	4
	 	 	 	 	 	 
	5
	 	 	 	 	 	 
	6
	 	 	 	 	 	 
	7
	 	 	 	 	 	 
	8
	 	 	 	 	 	 
	9
	 	 	 	 	 	 
	10
	 	 	 	 	 	 
	11
	 	Total Other Administration Expense (lines 1 through 10)	 	 	 	 
	12
	 	Table #19 – parts S2 Other Administration Expenses (line 37 of Table #19S1)	 	 	 	 
	13
	 	Difference	 	 	 	 

Cells with
this shading are calculated fields and should not be filled out

1 – Detail any difference in Notes Section

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part T – Non-state Plan Service Expenses by Rate Cell Grouping

Non-State Plan Services

	 	 	 
	FOR THE THREE MONTHS ENDING                     

	 	FOR                                         
	 

	 	               (HMO Name)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	AFDC/NJCPW/NJ KidCare A – North	 	 	AFDC/NJCPW/NJ KidCare A – Central	 
	 	 	 	 	Three-month	 	 	Three-month	 	 	 	 	 	 	 	 	 	 	Three-month	 	 	Three-month	 	 	 	 	 	 	 
	Expenses	 	$	 	 	units	 	 	YTD $	 	 	YTD Units	 	 	$	 	 	units	 	 	YTD $	 	 	YTD Units	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL NON-STATE SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	2
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	3
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	4
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	5
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	6
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	7
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	8
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	9
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	10
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	11
	 	Total MEDICAL AND HOSPITAL NON-STATE SERVICES (1 through 10)	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	ADMINISTRATION FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12
	 	TOTAL ADMINISTRATION	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	TOTAL EXPENSE FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13
	 	TOTAL EXPENSES (11+12)	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 

 

			
	1	 	Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health
Access individuals without dependent children, and Adult Restricted Aliens (excluding pregnant
women) populations were transferred into two groups under a managed care Service Administrator
program.
	 
	1	 	All medical and administrative expenses must be reported using actual incurred
and paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description
	 
	1	 	 
	 
	2	 	 
	 
	3	 	 
	 
	4	 	 
	 
	5	 	 
	 
	6	 	 
	 
	7	 	 
	 
	8	 	 
	 
	9	 	 
	 
	10	 	 
	 
	*	 	If medial and hospital claims exist for non-state plan services, then must have some amount of
administration for non-State Plan services.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 — Part T — Non-state Plan Service Expenses by Rate Cell Grouping

Non-State Plan Services

	 	 	 
	FOR THE THREE MONTHS ENDING                     

	 	FOR                                         
	 

	 	               (HMO Name)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	AFDC/NJCPW/NJ KidCare A – South	 	 	DYFS	 
	 	 	 	 	Three-month	 	 	Three-month	 	 	 	 	 	 	 	 	 	 	Three-month	 	 	Three-month	 	 	 	 	 	 	 
	Expenses	 	$	 	 	units	 	 	YTD $	 	 	YTD Units	 	 	$	 	 	units	 	 	YTD $	 	 	YTD Units	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL NON-STATE SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	2
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	3
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	4
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	5
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	6
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	7
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	8
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	9
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	10
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	11
	 	Total MEDICAL AND HOSPITAL NON-STATE SERVICES (1 through 10)	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	ADMINISTRATION FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12
	 	TOTAL ADMINISTRATION	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	TOTAL EXPENSE FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13
	 	TOTAL EXPENSES (11+12)	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 

 

			
	1	 	Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health
Access individuals without dependent children, and Adult Restricted Aliens (excluding pregnant
women) populations were transferred into two groups under a managed care Service Administrator
program.
	 
	1	 	All medical and administrative expenses must be reported using actual incurred
and paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description
	 
	1	 	 
	 
	2	 	 
	 
	3	 	 
	 
	4	 	 
	 
	5	 	 
	 
	6	 	 
	 
	7	 	 
	 
	8	 	 
	 
	9	 	 
	 
	10	 	 
	 
	*	 	If medial and hospital claims exist for non-state plan services, then must have some amount of
administration for non-State Plan services.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part T – Non-state Plan Service Expenses by Rate Cell Grouping

Non-State Plan Services

	 	 	 
	FOR THE THREE MONTHS ENDING                     

	 	FOR                                         
	 

	 	               (HMO Name)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	ABD with Medicare – DDD	 	 	ABD With Medicare – Non - DDD	 
	 	 	 	 	Three-month	 	 	Three-month	 	 	 	 	 	 	 	 	 	 	Three-month	 	 	Three-month	 	 	 	 	 	 	 
	Expenses	 	$	 	 	units	 	 	YTD $	 	 	YTD Units	 	 	$	 	 	units	 	 	YTD $	 	 	YTD Units	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL NON-STATE SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	2
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	3
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	4
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	5
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	6
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	7
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	8
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	9
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	10
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	11
	 	Total MEDICAL AND HOSPITAL NON-STATE SERVICES (1 through 10)	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	ADMINISTRATION FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12
	 	TOTAL ADMINISTRATION	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	TOTAL EXPENSE FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13
	 	TOTAL EXPENSES (11+12)	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 

 

			
	1	 	Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health
Access individuals without dependent children, and Adult Restricted Aliens (excluding pregnant
women) populations were transferred into two groups under a managed care Service Administrator
program.
	 
	1	 	All medical and administrative expenses must be reported using actual incurred
and paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description
	 
	1	 	 
	 
	2	 	 
	 
	3	 	 
	 
	4	 	 
	 
	5	 	 
	 
	6	 	 
	 
	7	 	 
	 
	8	 	 
	 
	9	 	 
	 
	10	 	 
	 
	*	 	If medial and hospital claims exist for non-state plan services, then must have some amount of
administration for non-State Plan services.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part T – Non-state Plan Service Expenses by Rate Cell Grouping

Non-State Plan Services

	 	 	 
	FOR THE THREE MONTHS ENDING                     

	 	FOR                                         
	 

	 	               (HMO Name)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Non-ABD – DDD	 	 	AVD Without Medicare - DDD	 
	 	 	 	 	Three-month	 	 	Three-month	 	 	 	 	 	 	 	 	 	 	Three-month	 	 	Three-month	 	 	 	 	 	 	 
	Expenses	 	$	 	 	units	 	 	YTD $	 	 	YTD Units	 	 	$	 	 	units	 	 	YTD $	 	 	YTD Units	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL NON-STATE SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	2
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	3
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	4
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	5
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	6
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	7
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	8
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	9
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	10
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	11
	 	Total MEDICAL AND HOSPITAL NON-STATE SERVICES (1 through 10)	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	ADMINISTRATION FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12
	 	TOTAL ADMINISTRATION	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	TOTAL EXPENSE FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13
	 	TOTAL EXPENSES (11+12)	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 

 

			
	1	 	Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.
	 
	1	 	All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description
	 
	1	 	 
	 
	2	 	 
	 
	3	 	 
	 
	4	 	 
	 
	5	 	 
	 
	6	 	 
	 
	7	 	 
	 
	8	 	 
	 
	9	 	 
	 
	10	 	 
	 
	*	 	If medial and hospital claims exist for non-state plan services, then must have some amount of
administration for non-State Plan services.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part T – Non-state Plan Service Expenses by Rate Cell Grouping

Non-State Plan Services

	 	 	 
	FOR THE THREE MONTHS ENDING                     

	 	FOR                                         
	 

	 	               (HMO Name)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	ABD Without Medicare – Non DDD	 	 	NJ KidCare B&C	 
	 	 	 	 	Three-month	 	 	Three-month	 	 	 	 	 	 	 	 	 	 	Three-month	 	 	Three-month	 	 	 	 	 	 	 
	Expenses	 	$	 	 	units	 	 	YTD $	 	 	YTD Units	 	 	$	 	 	units	 	 	YTD $	 	 	YTD Units	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL NON-STATE SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	2
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	3
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	4
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	5
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	6
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	7
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	8
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	9
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	10
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	11
	 	Total MEDICAL AND HOSPITAL NON-STATE SERVICES (1 through 10)	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	ADMINISTRATION FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12
	 	TOTAL ADMINISTRATION	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	TOTAL EXPENSE FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13
	 	TOTAL EXPENSES (11+12)	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 

 

			
	1	 	Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.
	 
	1	 	All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description
	 
	1	 	 
	 
	2	 	 
	 
	3	 	 
	 
	4	 	 
	 
	5	 	 
	 
	6	 	 
	 
	7	 	 
	 
	8	 	 
	 
	9	 	 
	 
	10	 	 
	 
	*	 	If medial and hospital claims exist for non-state plan services, then must have some amount of
administration for non-State Plan services.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part T – Non-state Plan Service Expenses by Rate Cell Grouping

Non-State Plan Services

	 	 	 
	FOR THE THREE MONTHS ENDING                     

	 	FOR                                         
	 

	 	               (HMO Name)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	NJ KidCare D	 	 	NJ FamilyCare Adults 0-100% FPL	 
	 	 	 	 	Three-month	 	 	Three-month	 	 	 	 	 	 	 	 	 	 	Three-month	 	 	Three-month	 	 	 	 	 	 	 
	Expenses	 	$	 	 	units	 	 	YTD $	 	 	YTD Units	 	 	$	 	 	units	 	 	YTD $	 	 	YTD Units	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL NON-STATE SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	2
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	3
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	4
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	5
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	6
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	7
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	8
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	9
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	10
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	11
	 	Total MEDICAL AND HOSPITAL NON-STATE SERVICES (1 through 10)	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	ADMINISTRATION FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12
	 	TOTAL ADMINISTRATION	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	TOTAL EXPENSE FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13
	 	TOTAL EXPENSES (11+12)	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 

 

			
	1	 	Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.
	 
	1	 	All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description
	 
	1	 	 
	 
	2	 	 
	 
	3	 	 
	 
	4	 	 
	 
	5	 	 
	 
	6	 	 
	 
	7	 	 
	 
	8	 	 
	 
	9	 	 
	 
	10	 	 
	 
	*	 	If medial and hospital claims exist for non-state plan services, then must have some amount of
administration for non-State Plan services.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part T – Non-state Plan Service Expenses by Rate Cell Grouping

Non-State Plan Services

	 	 	 
	FOR THE THREE MONTHS ENDING                     

	 	FOR                                         
	 

	 	               (HMO Name)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	NJ FamilyCare Parents 0-133% FPL	 	 	NJ FamilyCare Parents 134-250% FPL	 
	 	 	 	 	Three-month	 	 	Three-month	 	 	 	 	 	 	 	 	 	 	Three-month	 	 	Three-month	 	 	 	 	 	 	 
	Expenses	 	$	 	 	units	 	 	YTD $	 	 	YTD Units	 	 	$	 	 	units	 	 	YTD $	 	 	YTD Units	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL NON-STATE SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	2
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	3
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	4
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	5
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	6
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	7
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	8
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	9
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	10
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	11
	 	Total MEDICAL AND HOSPITAL NON-STATE SERVICES (1 through 10)	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	ADMINISTRATION FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12
	 	TOTAL ADMINISTRATION	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	TOTAL EXPENSE FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13
	 	TOTAL EXPENSES (11+12)	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 

 

			
	1	 	Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.
	 
	1	 	All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description
	 
	1	 	 
	 
	2	 	 
	 
	3	 	 
	 
	4	 	 
	 
	5	 	 
	 
	6	 	 
	 
	7	 	 
	 
	8	 	 
	 
	9	 	 
	 
	10	 	 
	 
	*	 	If medial and hospital claims exist for non-state plan services, then must have some amount of
administration for non-State Plan services.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part T – Non-state Plan Service Expenses by Rate Cell Grouping

Non-State Plan Services

	 	 	 
	FOR THE THREE MONTHS ENDING                     

	 	FOR                                         
	 

	 	               (HMO Name)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	ABD with Medicare AIDS	 	 	NON-ABD - AIDS	 
	 	 	 	 	Three-month	 	 	Three-month	 	 	 	 	 	 	 	 	 	 	Three-month	 	 	Three-month	 	 	 	 	 	 	 
	Expenses	 	$	 	 	units	 	 	YTD $	 	 	YTD Units	 	 	$	 	 	units	 	 	YTD $	 	 	YTD Units	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL NON-STATE SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	2
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	3
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	4
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	5
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	6
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	7
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	8
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	9
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	10
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	11
	 	Total MEDICAL AND HOSPITAL NON-STATE SERVICES (1 through 10)	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	ADMINISTRATION FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12
	 	TOTAL ADMINISTRATION	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	TOTAL EXPENSE FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13
	 	TOTAL EXPENSES (11+12)	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 

 

			
	1	 	Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.
	 
	1	 	All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description
	 
	1	 	 
	 
	2	 	 
	 
	3	 	 
	 
	4	 	 
	 
	5	 	 
	 
	6	 	 
	 
	7	 	 
	 
	8	 	 
	 
	9	 	 
	 
	10	 	 
	 
	*	 	If medial and hospital claims exist for non-state plan services, then must have some amount of
administration for non-State Plan services.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part T – Non-state Plan Service Expenses by Rate Cell Grouping

Non-State Plan Services

	 	 	 
	FOR THE THREE MONTHS ENDING                     

	 	FOR                                         
	 

	 	               (HMO Name)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Maternity	 	 	Newborns	 
	 	 	 	 	Three-month	 	 	Three-month	 	 	 	 	 	 	 	 	 	 	Three-month	 	 	Three-month	 	 	 	 	 	 	 
	Expenses	 	$	 	 	units	 	 	YTD $	 	 	YTD Units	 	 	$	 	 	units	 	 	YTD $	 	 	YTD Units	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL NON-STATE SERVICES	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	2
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	3
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	4
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	5
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	6
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	7
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	8
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	9
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	10
	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	11
	 	Total MEDICAL AND HOSPITAL NON-STATE SERVICES (1 through 10)	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	ADMINISTRATION FOR NON-STATE PLAN SERVICES	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12
	 	TOTAL ADMINISTRATION	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	TOTAL EXPENSE FOR NON-STATE PLAN SERVICES	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13
	 	TOTAL EXPENSES (11+12)	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 

 

			
	1	 	Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.
	 
	1	 	All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description
	 
	1	 	 
	 
	2	 	 
	 
	3	 	 
	 
	4	 	 
	 
	5	 	 
	 
	6	 	 
	 
	7	 	 
	 
	8	 	 
	 
	9	 	 
	 
	10	 	 
	 
	*	 	If medial and hospital claims exist for non-state plan services, then must have some amount of
administration for non-State Plan services.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

					
	Table #19 — Part U
	 	Income Statement by Rate Cell Grouping
	 	 

NJ FamilyCare Adults 0-100% FPL (Excluding AIDS) STATEWIDE65

	 	 	 
	FOR THE THREE MONTHS ENDING                     

	 	FOR                                         
	 
	 

	 	               (HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	Three	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SFY End $	 
	 	 	 	 	 	 	Three-	 	 	month	 	 	 	 	 	 	YTD	 	 	SFY End	 	 	@9/30	 
	Revenues/Expenses/Administration	 	month	 	 	PMPM	 	 	YTD $	 	 	PMPM	 	 	$@9/3066	 	 	PMPM	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1	 	 	 	Capitated Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2	 	 	 	Supplemental Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2a	 	 	 	Maternity
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2b	 	 	 	Reimbursable HIV/AIDS Drugs and Blood Product
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2c	 	 	 	EPSDT Incentive Payment
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2d	 	 	 	Reimbursable Medical and Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2e	 	 	 	Managed Care Service Administrator Premium
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2f	 	 	 	Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3	 	 	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4	 	 	 	Interest
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5	 	 	 	COB
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6	 	 	 	Reinsurance Recoveries
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7	 	 	 	Other Revenue
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8	 	 	 	TOTAL REVENUE (3+4+5+6+7)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9	 	 	 	Inpatient Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10	 	 	 	Primary Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11	 	 	 	Physician Specialty Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12	 	 	 	Outpatient Hospital (excludes ER)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13	 	 	 	Other Professional Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14	 	 	 	Emergency Room
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15	 	 	 	DME/Medical Supplies
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16	 	 	 	Prosthetics & Orthotics
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17	 	 	 	Covered Dental
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18	 	 	 	Pharmacy (not to include Reimbursable HIV/AIDS Drugs and Blood Products)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	19	 	 	 	Reimbursable HIV/AIDS Drugs and Blood Product
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	20	 	 	 	Home Health, Hospice and PDN
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	21	 	 	 	Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	22	 	 	 	Lab & X-ray
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	23	 	 	 	Vision Care, including eyeglasses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	24	 	 	 	Mental Health/Substance Abuse
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	25	 	 	 	Reinsurance Expenses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26A	 	 	 	EPSDT Medical & PDN
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26B	 	 	 	EPSDT Dental — EPD
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	27	 	 	 	Family Planning
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	28	 	 	 	Other Medical
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	29	 	 	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	30	 	 	 	Compensation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	31	 	 	 	Occupancy/Depreciation/Amortization
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	32	 	 	 	Interest Expense
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	33	 	 	 	Education/Outreach
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	34	 	 	 	Sanctions
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	35	 	 	 	Corporate Overhead Allocations
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	36	 	 	 	Subcontract/Delegated Administrative services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	37	 	 	 	Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	38	 	 	 	TOTAL ADMINISTRATION
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	65	 	Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Service Administrator
program.
	 
	66	 	For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	Three	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SFY End $	 
	 	 	 	 	 	 	Three-	 	 	month	 	 	 	 	 	 	YTD	 	 	SFY End	 	 	@9/30	 
	Revenues/Expenses/Administration	 	month	 	 	PMPM	 	 	YTD $	 	 	PMPM	 	 	$@9/3066	 	 	PMPM	 
	39
	 	TOTAL EXPENSES	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	40
	 	OPERATION INCOME (LOSS) (8-39)	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	41
	 	Extraordinary Item	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	42
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	43
	 	Other than Income taxes67	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	44
	 	Adjustment for prior period IBNR Estimates	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	45
	 	Non-claim adjustments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	46
	 	NET INCOME (LOSS) (40-41-42-43-44-45)	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	67	 	Reported items other than State or Federal
income taxes

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

					
	Table #19 — Part V
	 	Income Statement by Rate Cell Grouping
	 	 

Adults Restricted Aliens — STATEWIDE68

	 	 	 
	FOR THE THREE MONTHS ENDING                     

	 	FOR                                         
	 

	 	               (HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	Three	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SFY End $	 
	 	 	 	 	 	 	Three-	 	 	month	 	 	 	 	 	 	YTD	 	 	SFY End	 	 	@9/30	 
	Revenues/Expenses/Administration	 	month	 	 	PMPM	 	 	YTD $	 	 	PMPM	 	 	$@9/3069	 	 	PMPM	 
	Member Months	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1	 	 	 	Capitated Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2	 	 	 	Supplemental Premiums
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2a	 	 	 	Maternity
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2b	 	 	 	Reimbursable HIV/AIDS Drugs and Blood Product
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	EPSDT Incentive Payment
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2d	 	 	 	Reimbursable Medical and Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2e	 	 	 	Managed Care Service Administrator Premium
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2f	 	 	 	Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3	 	 	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4	 	 	 	Interest
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5	 	 	 	COB
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6	 	 	 	Reinsurance Recoveries
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7	 	 	 	Other Revenue
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8	 	 	 	TOTAL REVENUE (3+4+5+6+7)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9	 	 	 	Inpatient Hospital
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10	 	 	 	Primary Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11	 	 	 	Physician Specialty Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12	 	 	 	Outpatient Hospital (excludes ER)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13	 	 	 	Other Professional Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14	 	 	 	Emergency Room
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15	 	 	 	DME/Medical Supplies
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16	 	 	 	Prosthetics & Orthotics
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17	 	 	 	Covered Dental
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18	 	 	 	Pharmacy (not to include Reimbursable HIV/AIDS Drugs and Blood Products)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	19	 	 	 	Reimbursable HIV/AIDS Drugs and Blood Product
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	20	 	 	 	Home Health, Hospice and PDN
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	21	 	 	 	Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	22	 	 	 	Lab & X-ray
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	23	 	 	 	Vision Care, including eyeglasses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	24	 	 	 	Mental Health/Substance Abuse
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	25	 	 	 	Reinsurance Expenses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26A	 	 	 	EPSDT Medical & PDN
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	26B	 	 	 	EPSDT Dental — EPD
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	27	 	 	 	Family Planning
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	28	 	 	 	Other Medical
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	29	 	 	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	30	 	 	 	Compensation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	31	 	 	 	Occupancy/Depreciation/Amortization
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	32	 	 	 	Interest Expense
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	33	 	 	 	Education/Outreach
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	34	 	 	 	Sanctions
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	35	 	 	 	Corporate Overhead Allocations
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	36	 	 	 	Subcontract/Delegated Administrative services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	37	 	 	 	Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	38	 	 	 	TOTAL ADMINISTRATION
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	68	 	Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Service Administrator
program.
	 
	69	 	For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	Three	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SFY End $	 
	 	 	 	 	 	 	Three-	 	 	month	 	 	 	 	 	 	YTD	 	 	SFY End	 	 	@9/30	 
	Revenues/Expenses/Administration	 	month	 	 	PMPM	 	 	YTD $	 	 	PMPM	 	 	$@9/3069	 	 	PMPM	 
	39
	 	TOTAL EXPENSES	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	40
	 	OPERATION INCOME (LOSS) (8-39)	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	41
	 	Extraordinary Item	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	42
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	43
	 	Other than Income taxes70	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	44
	 	Adjustment for prior period IBNR Estimates	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	45
	 	Non-claim adjustments	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	46
	 	NET INCOME (LOSS) (40-41-42-43-44-45)	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 

			
	70	 	Reported items other than State or Federal
income taxes

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

NOTES TO FINANCIAL REPORTS

	 		
	FOR THE THREE MONTHS ENDING
                                        
             FOR                     

	 	 	 	 	 	 
	 	 	 	 	 	 
	 	Any notes or further explanations of any items contained in any of the reports or in the reporting of financial disclosures are to be noted here.
Appropriate references and attachments are to be used as necessary. Space is provided below or you may use a separate page as necessary.	 
	 	 	 	 	 	 
	 	Table # 4
	 	 	 	 
	 	• Part A — Claims Lag report for manually submitted
	 	 	 	 
	 	 
	 	 	 	 
	 	• Part B — Claims Lag report for electronically submitted
	 	 	 	 
	 	 	 	 	 	 
	 	Table # 7
	 	 	 	 
	 	Parts A-C — Stop Loss
	 	 	 	 
	 	 
	 	 	 	 
	 	 	 	 	 	 
	 	Table # 10 — Third Party Liability
	 	 	 	 
	 	 
	 	 	 	 
	 	 	 	 	 	 
	 	Table # 19
	 	 	 	 
	 	Parts A-V — Income Statement by RATE CELL GROUPINGS
	 	 	 	 
	 	 
	 	 	 	 
	 	 	 	 	 	 
	 	Table # 20
	 	 	 	 
	 	Part A — Lag Report for Inpatient hospital Payments
	 	 	 	 
	 	Part B — Lag Report for physician Payments
	 	 	 	 
	 	Part C — Lag Report for pharmacy Payments
	 	 	 	 
	 	Part
D — Lag Report for Other Medical Payments
	 	 	 	 
	 	Part E — Lag Report for MCSA Payments
	 	 	 	 
	 	 
	 	 	 	 
	 	 	 	 	 	 
	 	Table # 21
	 	 	 	 
	 	Maternity Outcome Counts
	 	 	 	 
	 	 
	 	 	 	 
	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 — Part A Income Statement by Rate Cell Grouping

AFDC/NJCPW/NJ KidCare A (Excluding AIDS) — NORTHERN REGION71

FOR THE THREE MONTHS ENDING                                      FOR                     

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	     Maternity	 	 	 	 	 	 	 	 
	2b
	 	     Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	2c
	 	     EPSDT Incentive Payment	 	$	 	$	 	$	 	$
	2d
	 	     Reimbursable Medical and Hospital 	 	$	 	$	 	$	 	$
	2e
	 	     Managed Care Service Administrator Premium	 	$	 	$	 	$	 	$
	2f
	 	     Other	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:
	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

 

			
	71	 	Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women) populations were transferred into two groups
under a managed care Sevcie Administrator program.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 — Part B Income Statement by Rate Cell Grouping

AFDC/NJCPW/NJ KidCare A (Excluding AIDS) — CENTRAL REGION72

FOR THE THREE MONTHS ENDING                                      FOR                     

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	     Maternity	 	 	 	 	 	 	 	 
	2b
	 	     Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	2c
	 	     EPSDT Incentive Payment	 	$	 	$	 	$	 	$
	2d
	 	     Reimbursable Medical and Hospital 	 	$	 	$	 	$	 	$
	2e
	 	     Managed Care Service Administrator Premium	 	$	 	$	 	$	 	$
	2f
	 	     Other	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

 

			
	72	 	Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women) populations were transferred into two groups
under a managed care Sevcie Administrator program.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 — Part C Income Statement by Rate Cell Grouping

AFDC/NJCPW/NJ KidCare A (Excluding AIDS) — SOUTHERN REGION73

FOR THE THREE MONTHS ENDING                                      FOR                     

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	     Maternity	 	 	 	 	 	 	 	 
	2b
	 	     Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	2c
	 	     EPSDT Incentive Payment	 	$	 	$	 	$	 	$
	2d
	 	     Reimbursable Medical and Hospital 	 	$	 	$	 	$	 	$
	2e
	 	     Managed Care Service Administrator Premium	 	$	 	$	 	$	 	$
	2f
	 	     Other	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

 

			
	73	 	Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women) populations were transferred into two groups
under a managed care Sevcie Administrator program.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 — Part D Income Statement by Rate Cell Grouping

DYFS (Excluding AIDS) STATEWIDE

FOR THE THREE MONTHS ENDING                                      FOR                     

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	     Maternity	 	 	 	 	 	 	 	 
	2b
	 	     Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	2c
	 	     EPSDT Incentive Payment	 	$	 	$	 	$	 	$
	2d
	 	     Reimbursable Medical and Hospital 	 	$	 	$	 	$	 	$
	2e
	 	     Managed Care Service Administrator Premium	 	$	 	$	 	$	 	$
	2f
	 	     Other	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 — Part E Income Statement by Rate Cell Grouping

ABD with Medicare — DDD (Excluding AIDS) — STATEWIDE

FOR THE THREE MONTHS ENDING                                      FOR                     

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	     Maternity	 	 	 	 	 	 	 	 
	2b
	 	     Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	2c
	 	     EPSDT Incentive Payment	 	$	 	$	 	$	 	$
	2d
	 	     Reimbursable Medical and Hospital 	 	$	 	$	 	$	 	$
	2e
	 	     Managed Care Service Administrator Premium	 	$	 	$	 	$	 	$
	2f
	 	     Other	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 — Part F Income Statement by Rate Cell Grouping

ABD with Medicare -NON- DDD (Excluding AIDS) — STATEWIDE

FOR THE THREE MONTHS ENDING                                      FOR                     

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	     Maternity	 	 	 	 	 	 	 	 
	2b
	 	     Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	2c
	 	     EPSDT Incentive Payment	 	$	 	$	 	$	 	$
	2d
	 	     Reimbursable Medical and Hospital 	 	$	 	$	 	$	 	$
	2e
	 	     Managed Care Service Administrator Premium	 	$	 	$	 	$	 	$
	2f
	 	     Other	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 — Part G Income Statement by Rate Cell Grouping

N0N-ABD DDD (Excluding AIDS) — STATEWIDE

FOR THE THREE MONTHS ENDING                                      FOR                     

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	     Maternity	 	 	 	 	 	 	 	 
	2b
	 	     Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	2c
	 	     EPSDT Incentive Payment	 	$	 	$	 	$	 	$
	2d
	 	     Reimbursable Medical and Hospital 	 	$	 	$	 	$	 	$
	2e
	 	     Managed Care Service Administrator Premium	 	$	 	$	 	$	 	$
	2f
	 	     Other	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 — Part H Income Statement by Rate Cell Grouping

ABD without Medicare — DDD (Including AIDS) — STATEWIDE

FOR THE THREE MONTHS ENDING                                      FOR                     

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	     Maternity	 	 	 	 	 	 	 	 
	2b
	 	     Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	2c
	 	     EPSDT Incentive Payment	 	$	 	$	 	$	 	$
	2d
	 	     Reimbursable Medical and Hospital 	 	$	 	$	 	$	 	$
	2e
	 	     Managed Care Service Administrator Premium	 	$	 	$	 	$	 	$
	2f
	 	     Other	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 — Part E Income Statement by Rate Cell Grouping

ABD with Medicare — DDD (Excluding AIDS) — STATEWIDE

FOR THE THREE MONTHS ENDING                                      FOR                     

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	     Maternity	 	 	 	 	 	 	 	 
	2b
	 	     Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	2c
	 	     EPSDT Incentive Payment	 	$	 	$	 	$	 	$
	2d
	 	     Reimbursable Medical and Hospital 	 	$	 	$	 	$	 	$
	2e
	 	     Managed Care Service Administrator Premium	 	$	 	$	 	$	 	$
	2f
	 	     Other	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 — Part I Income Statement by Rate Cell Grouping

ABD without Medicare — Non-DDD (Including AIDS) — STATEWIDE

FOR THE THREE MONTHS ENDING                                      FOR                     

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	     Maternity	 	 	 	 	 	 	 	 
	2b
	 	     Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	2c
	 	     EPSDT Incentive Payment	 	$	 	$	 	$	 	$
	2d
	 	     Reimbursable Medical and Hospital 	 	$	 	$	 	$	 	$
	2e
	 	     Managed Care Service Administrator Premium	 	$	 	$	 	$	 	$
	2f
	 	     Other	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part J Income Statement by Rate Cell Grouping 

NJKidCare B&C

(Excluding AIDS) – STATEWIDE

 FOR THE THREE MONTHS

ENDING ________ FOR _____________ 

	 	 	 	 		 	 	 	 	 	 
	 	 	 	 	(HMO NAME)	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums
	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	  Maternity
	 	 	 	 	 	 	 	 
	2b
	 	
Reimbursable HIV/AIDS Drugs and Blood Product
	 	$	 	$	 	$	 	$
	2c
	 	
EPSDT Incentive Payment
	 	$	 	$	 	$	 	$
	2d
	 	  Reimbursable Medical and
Hospital 
	 	$	 	$	 	$	 	$
	2e
	 	
Managed Care Service Administrator Premium
	 	$	 	$	 	$	 	$
	2f
	 	  Other
	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs
and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part E Income Statement by Rate Cell Grouping 

 ABD with Medicare DDD

(Excluding AIDS) – STATEWIDE

FOR THE THREE MONTHS

ENDING ________ FOR _____________

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	(HMO NAME)	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums
	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	  Maternity
	 	 	 	 	 	 	 	 
	2b
	 	  Reimbursable HIV/AIDS Drugs and Blood Product
	 	$	 	$	 	$	 	$
	2c
	 	  EPSDT Incentive Payment
	 	$	 	$	 	$	 	$
	2d
	 	  Reimbursable Medical and Hospital 
	 	$	 	$	 	$	 	$
	2e
	 	  Managed Care Service Administrator Premium
	 	$	 	$	 	$	 	$
	2f
	 	  Other
	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part K

Income Statement by Rate Cell Grouping

NJ KidCare D (Excluding

AIDS) – STATEWIDE

FOR THE THREE MONTHS

ENDING ________ FOR _____________

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	(HMO NAME)	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums
	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	  Maternity
	 	 	 	 	 	 	 	 
	2b
	 	  Reimbursable HIV/AIDS Drugs and Blood Product
	 	$	 	$	 	$	 	$
	2c
	 	  EPSDT Incentive Payment
	 	$	 	$	 	$	 	$
	2d
	 	  Reimbursable Medical and Hospital 
	 	$	 	$	 	$	 	$
	2e
	 	  Managed Care Service Administrator Premium
	 	$	 	$	 	$	 	$
	2f
	 	  Other
	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part L

Income Statement by Rate Cell Grouping RESERVED 

RESERVED

FOR THE THREE MONTHS ENDING ________ FOR _____________

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	(HMO NAME)	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums
	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	  Maternity
	 	 	 	 	 	 	 	 
	2b
	 	  Reimbursable HIV/AIDS Drugs and Blood Product
	 	$	 	$	 	$	 	$
	2c
	 	  EPSDT Incentive Payment
	 	$	 	$	 	$	 	$
	2d
	 	  Reimbursable Medical and Hospital 
	 	$	 	$	 	$	 	$
	2e
	 	  Managed Care Service Administrator Premium
	 	$	 	$	 	$	 	$
	2f
	 	  Other
	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part M

Income Statement by Rate Cell Grouping

NJ FamilyCare Parents

0133% FPL (Excluding AIDS) – STATEWIDE

FOR THE THREE MONTHS

ENDING ________ FOR _____________

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	(HMO NAME)	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums
	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	  Maternity
	 	 	 	 	 	 	 	 
	2b
	 	  Reimbursable HIV/AIDS Drugs and Blood Product
	 	$	 	$	 	$	 	$
	2c
	 	  EPSDT Incentive Payment
	 	$	 	$	 	$	 	$
	2d
	 	  Reimbursable Medical and Hospital 
	 	$	 	$	 	$	 	$
	2e
	 	  Managed Care Service Administrator Premium
	 	$	 	$	 	$	 	$
	2f
	 	  Other
	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

 Table #19 – Part N

Income Statement by Rate Cell Grouping ) 

Reserved

FOR THE THREE MONTHS

ENDING ________ FOR _____________ 

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	(HMO NAME)	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums
	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	  Maternity
	 	 	 	 	 	 	 	 
	2b
	 	  Reimbursable HIV/AIDS Drugs and Blood Product
	 	$	 	$	 	$	 	$
	2c
	 	  EPSDT Incentive Payment
	 	$	 	$	 	$	 	$
	2d
	 	  Reimbursable Medical and Hospital 
	 	$	 	$	 	$	 	$
	2e
	 	  Managed Care Service Administrator Premium
	 	$	 	$	 	$	 	$
	2f
	 	  Other
	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part O

Income Statement by Rate Cell Grouping 

FOR THE THREE MONTHS

ENDING ________ FOR _____________ 

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	(HMO NAME)	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums
	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	  Maternity
	 	 	 	 	 	 	 	 
	2b
	 	  Reimbursable HIV/AIDS Drugs and Blood Product
	 	$	 	$	 	$	 	$
	2c
	 	  EPSDT Incentive Payment
	 	$	 	$	 	$	 	$
	2d
	 	  Reimbursable Medical and Hospital 
	 	$	 	$	 	$	 	$
	2e
	 	  Managed Care Service Administrator Premium
	 	$	 	$	 	$	 	$
	2f
	 	  Other
	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part P

Income Statement by Rate Cell Grouping 

 ABD with Medicare

AIDS – STATEWIDE

 FOR THE THREE MONTHS

ENDING ________ FOR _____________ 

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	(HMO NAME)	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums
	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	  Maternity
	 	 	 	 	 	 	 	 
	2b
	 	  Reimbursable HIV/AIDS Drugs and Blood Product
	 	$	 	$	 	$	 	$
	2c
	 	  EPSDT Incentive Payment
	 	$	 	$	 	$	 	$
	2d
	 	  Reimbursable Medical and Hospital 
	 	$	 	$	 	$	 	$
	2e
	 	  Managed Care Service Administrator Premium
	 	$	 	$	 	$	 	$
	2f
	 	  Other
	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part Q

Income Statement by Rate Cell Grouping 

 Non=ABD –

AIDS– STATEWIDE

FOR THE THREE MONTHS

ENDING ________ FOR _____________ 

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	(HMO NAME)	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums
	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	  Maternity
	 	 	 	 	 	 	 	 
	2b
	 	  Reimbursable HIV/AIDS Drugs and Blood Product
	 	$	 	$	 	$	 	$
	2c
	 	  EPSDT Incentive Payment
	 	$	 	$	 	$	 	$
	2d
	 	  Reimbursable Medical and Hospital 
	 	$	 	$	 	$	 	$
	2e
	 	  Managed Care Service Administrator Premium
	 	$	 	$	 	$	 	$
	2f
	 	  Other
	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part R1

Income Statement by Rate Cell Grouping 

 MATERNITY –

STATEWIDE

FOR THE THREE MONTHS

ENDING ________ FOR _____________ 

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	(HMO NAME)	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums
	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	  Maternity
	 	 	 	 	 	 	 	 
	2b
	 	  Reimbursable HIV/AIDS Drugs and Blood Product
	 	$	 	$	 	$	 	$
	2c
	 	  EPSDT Incentive Payment
	 	$	 	$	 	$	 	$
	2d
	 	  Reimbursable Medical and Hospital 
	 	$	 	$	 	$	 	$
	2e
	 	  Managed Care Service Administrator Premium
	 	$	 	$	 	$	 	$
	2f
	 	  Other
	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part R2

Income Statement by Rate Cell Grouping 

 NEWBORN –

STATEWIDE

FOR THE THREE MONTHS

ENDING ________ FOR _____________ 

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	(HMO NAME)	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums
	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	  Maternity
	 	 	 	 	 	 	 	 
	2b
	 	  Reimbursable HIV/AIDS Drugs and Blood Product
	 	$	 	$	 	$	 	$
	2c
	 	  EPSDT Incentive Payment
	 	$	 	$	 	$	 	$
	2d
	 	  Reimbursable Medical and Hospital 
	 	$	 	$	 	$	 	$
	2e
	 	  Managed Care Service Administrator Premium
	 	$	 	$	 	$	 	$
	2f
	 	  Other
	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

 Table #19 – Part S

Income Statement by Rate Cell Grouping 

ALL Rate cell groupings STATEWIDE

FOR THE THREE MONTHS

ENDING ________ FOR _____________ 

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	(HMO NAME)	 	 	 	 	 	 
	Revenues/Expenses/Administration	 	Three-month	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 $	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums
	 	$	 	$	 	$	 	$
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	  Maternity

	 	 	 	 	 	 	 	 
	2b
	 	  Reimbursable HIV/AIDS Drugs and Blood Product
	 	$	 	$	 	$	 	$
	2c
	 	  EPSDT Incentive Payment
	 	$	 	$	 	$	 	$
	2d
	 	  Reimbursable Medical and Hospital 
	 	$	 	$	 	$	 	$
	2e
	 	  Managed Care Service Administrator Premium
	 	$	 	$	 	$	 	$
	2f
	 	  Other
	 	$	 	$	 	$	 	$
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL 	 	 	 	 	 	 	 	 
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital (excludes ER)	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	 	 	 	 	 	 	 
	19
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	$	 	$	 	$	 	$
	20
	 	Home Health, Hospice and PDN	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment 	 	$	 	$	 	$	 	$
	27
	 	Family Planning	 	$	 	$	 	$	 	$
	28
	 	Other Medical 	 	$	 	$	 	$	 	$
	29
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	 	 	 	 	 	 	 
	ADMINISTRATION:	 	 	 	 	 	 	 	 
	30
	 	Compensation	 	$	 	$	 	$	 	$
	31
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	32
	 	Interest Expense	 	$	 	$	 	$	 	$
	33
	 	Education/Outreach	 	$	 	$	 	$	 	$
	34
	 	Sanctions	 	$	 	$	 	$	 	$
	37
	 	Other	 	$	 	$	 	$	 	$
	38
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	39
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	 	 	 	 	 	 	 
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	 	 	 	 	 	 	 
	40
	 	Adjustment for prior period IBNR Estimates 	 	 	 	 	 	 	 	 
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	 	 	 	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part T – Non-state Plan Service Expenses by Rate Cell Grouping

Non-State Plan Services

	 	 	 	 	 	 	 
	FOR THE THREE MONTHS ENDING

	 	 	 	FOR	 	 
	 
	 	 
	 	 	 
	 
	 	 	 	 	 	(HMO Name)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	AFDC/NJCPW/NJ KidCare A – North	 	 	AFDC/NJCPW/NJ KidCare A – Central	 
	Expenses	 	Three-month $	 	 	Three-month units	 	 	YTD $	 	 	YTD Units	 	 	Three-month $	 	 	Three-month units	 	 	YTD $	 	 	YTD Units	 
	EXPENSES:
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL NON-STATE SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	2
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	3
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	4
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	5
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	6
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	7
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	8
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	9
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	10
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	11 Total MEDICAL AND
HOSPITAL NON-STATE
SERVICES (1 through
10)
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	ADMINISTRATION FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12
TOTAL ADMINISTRATION        
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	TOTAL EXPENSE FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13 TOTAL EXPENSES (11+12)
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 

 

			
	1   Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care
Service Administrator program.

	 
	1   All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves
non-State Plan Services Description)

1

2

3

4

5

6

7

8

9

10

* If medial and hospital claims exist for non-state plan services, then must have some amount of administration for non-State Plan services.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part T – Non-state Plan Service Expenses by Rate Cell Grouping

Non-State Plan Services

	 	 	 	 	 	 	 
	FOR THE THREE MONTHS ENDING

	 	 	 	FOR	 	 
	 
	 	 
	 	 	 
	 
	 	 	 	 	 	(HMO Name)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	AFDC/NJCPW/NJ KidCare A – South	 	 	DYFS	 
	Expenses	 	Three-month $	 	 	Three-month units	 	 	YTD $	 	 	YTD Units	 	 	Three-month $	 	 	Three-month units	 	 	YTD $	 	 	YTD Units	 
	EXPENSES:
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL NON-STATE SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	2
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	3
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	4
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	5
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	6
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	7
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	8
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	9
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	10
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	11 Total MEDICAL AND
HOSPITAL NON-STATE
SERVICES (1 through
10)
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	ADMINISTRATION FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12 TOTAL ADMINISTRATION        
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	TOTAL EXPENSE FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13 TOTAL EXPENSES (11+12)
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 

 

			
	1   Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care
Service Administrator program.

	 
	1   All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves)
non-State Plan Services DescriptioN

1

2

3

4

5

6

7

8

9

10

* If medial and hospital claims exist for non-state plan services, then must have some amount of administration for non-State Plan services.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part T – Non-state Plan Service Expenses by Rate Cell Grouping

Non-State Plan Services

	 	 	 	 	 	 	 
	FOR THE THREE MONTHS ENDING

	 	 	 	FOR	 	 
	 
	 	 
	 	 	 
	 
	 	 	 	 	 	(HMO Name)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	ABD with Medicare – DDD	 	 	ABD With Medicare – Non - DDD	 
	Expenses	 	Three-month $	 	 	Three-month units	 	 	YTD $	 	 	YTD Units	 	 	Three-month $	 	 	Three-month units	 	 	YTD $	 	 	YTD Units	 
	EXPENSES:
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL NON-STATE SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	2
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	3
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	4
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	5
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	6
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	7
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	8
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	9
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	10
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	11 Total MEDICAL AND
HOSPITAL NON-STATE
SERVICES (1 through
10)
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	ADMINISTRATION FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12 TOTAL ADMINISTRATION        
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	TOTAL EXPENSE FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13 TOTAL EXPENSES (11+12)
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 

 

			
	1   Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.

	 
	1   All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves) non-State Plan Services Description

1

2

3

4

5

6

7

8

9

10

* If medial and hospital claims exist for non-state plan services, then must have some amount of administration for non-State Plan services.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

	 	 

 

 

Table #19 – Part T – Non-state Plan Service Expenses by Rate Cell Grouping

Non-State Plan Services

	 	 	 	 	 	 	 
	FOR THE THREE MONTHS ENDING

	 	 	 	FOR	 	 
	 
	 	 
	 	 	 
	 
	 	 	 	 	 	(HMO Name)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Non-ABD – DDD	 	 	AVD Without Medicare - DDD	 
	Expenses	 	Three-month $	 	 	Three-month units	 	 	YTD $	 	 	YTD Units	 	 	Three-month $	 	 	Three-month units	 	 	YTD $	 	 	YTD Units	 
	EXPENSES:
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL NON-STATE SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	2
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	3
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	4
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	5
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	6
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	7
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	8
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	9
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	10
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	11 Total MEDICAL AND
HOSPITAL NON-STATE
SERVICES (1 through
10)
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	ADMINISTRATION FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12 TOTAL ADMINISTRATION         
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 
	TOTAL EXPENSE FOR NON-STATE PLAN SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13 TOTAL EXPENSES (11+12)
	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 	 	$	 	 

 

			
	1   Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care
Service Administrator program.

	 
	1   All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description

1

2

3

4

5

6

7

8

9

10

* If medial and hospital claims exist for non-state plan services, then must have some amount of administration for non-State Plan services.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 — Part T — Non-state Plan Service Expenses by Rate Cell Grouping 

Non-State Plan Services

FOR THE THREE MONTHS ENDING                                          FOR                                                             

                                                                                                                                   (HMO Name)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	ABD Without Medicare - Non DDD	 	 NJ KidCare B&C
	 	 	 	 	Three-month	 	Three-month	 	 	 	 	 	 Three-month 	 	Three-month	 	 	 	 
	Expenses	 	 $	 	 units	 	 YTD $ 	 	YTD Units	 	 $	 	units	 	YTD $	 	YTD Units  
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL NON-STATE SERVICES	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	2	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	3	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	4	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	5	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	6	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	7	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	8	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	9	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	10	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	11	 	Total MEDICAL AND
HOSPITAL NON-STATE
SERVICES (1 through
10)
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	ADMINISTRATION FOR NON-STATE PLAN SERVICES	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12	 	TOTAL ADMINISTRATION    
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	TOTAL EXPENSE FOR NON-STATE PLAN SERVICES	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13	 	TOTAL EXPENSES (11+12)
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$

 

			
	1	 	Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.
	 
	1	 	All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves) non-State Plan Services Description

1

2

3

4

5

6

7

8

9

10

*If medial and hospital claims exist for non-state plan
services, then must have some amount of administration for non-State Plan services.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey   
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 — Part T — Non-state Plan Service Expenses by Rate Cell Grouping 

Non-State Plan Services

FOR THE THREE MONTHS ENDING                                          FOR                                                             

                                                                                                                                   (HMO Name)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	NJ KidCare D	 	 NJ FamilyCare parents 0133% FPL 
	 	 	 	 	Three-month	 	Three-month	 	 	 	 	 	 Three-month 	 	Three-month	 	 	 	 
	Expenses	 	 $	 	 units   	 	 YTD $ 	 	YTD Units	 	 $	 	units	 	YTD $	 	YTD Units
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL NON-STATE SERVICES	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	2	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	3	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	4	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	5	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	6	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	7	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	8	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	9	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	10	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	11	 	Total MEDICAL AND
HOSPITAL NON-STATE
SERVICES (1 through
10)
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	ADMINISTRATION FOR NON-STATE PLAN SERVICES	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12	 	TOTAL ADMINISTRATION    
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	TOTAL EXPENSE FOR NON-STATE PLAN SERVICES	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13	 	TOTAL EXPENSES (11+12)
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$

 

			
	1	 	Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.
	 
	1	 	All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves) non-State Plan Services Description

1

2

3

4

5

6

7

8

9

10

*If medial and hospital claims exist for non-state plan
services, then must have some amount of administration for non-State Plan services.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey   
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 — Part T — Non-state Plan Service Expenses by Rate Cell Grouping 

Non-State Plan Services

FOR THE THREE MONTHS ENDING                                          FOR                                                             

                                                                                                                                   (HMO Name)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	NJ KidCare D	 	 NJ FamilyCare parents 0133% FPL 
	 	 	 	 	Three-month	 	Three-month	 	 	 	 	 	 Three-month 	 	Three-month	 	 	 	 
	Expenses	 	 $	 	 units   	 	 YTD $ 	 	YTD Units	 	 $	 	units	 	YTD $	 	YTD Units
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL NON-STATE SERVICES	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	2	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	3	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	4	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	5	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	6	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	7	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	8	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	9	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	10	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	11	 	Total MEDICAL AND
HOSPITAL NON-STATE
SERVICES (1 through
10)
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	ADMINISTRATION FOR NON-STATE PLAN SERVICES	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12	 	TOTAL ADMINISTRATION   
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	TOTAL EXPENSE FOR NON-STATE PLAN SERVICES	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13	 	TOTAL EXPENSES (11+12)
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$

 

			
	1	 	Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.
	 
	1	 	All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves) non-State Plan Services Description

1

2

3

4

5

6

7

8

9

10

*If medial and hospital claims exist for non-state plan
services, then must have some amount of administration for non-State Plan services.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey   
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 — Part T — Non-state Plan Service Expenses by Rate Cell Grouping 

Non-State Plan Services

FOR THE THREE MONTHS ENDING                                          FOR                                                             

                                                                                                                                   (HMO Name)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	ABD With Medicare AIDS 	 	 NON ABD AIDS
	 	 	 	 	Three-month	 	Three-month	 	 	 	 	 	 Three-month 	 	Three-month	 	 	 	 
	Expenses	 	 $	 	 units   	 	 YTD $ 	 	YTD Units	 	 $	 	units	 	YTD $	 	YTD Units
	EXPENSES:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL NON-STATE SERVICES	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	2	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	3	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	4	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	5	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	6	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	7	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	8	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	9	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	10	 	 
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	11	 	Total MEDICAL AND
HOSPITAL NON-STATE
SERVICES (1 through
10)
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	ADMINISTRATION FOR NON-STATE PLAN SERVICES	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12	 	TOTAL ADMINISTRATION      
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$
	TOTAL EXPENSE FOR NON-STATE PLAN SERVICES	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13	 	TOTAL EXPENSES (11+12)
	 	$	 	$	 	$	 	$	 	$	 	$	 	$	 	$

 

			
	1	 	Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.
	 
	1	 	All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves) non-State Plan Services Description

1

2

3

4

5

6

7

8

9

10

*If medial and hospital claims exist for non-state plan
services, then must have some amount of administration for non-State Plan services.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey   
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part T – Non-state Plan Service Expenses by Rate Cell Grouping

 Non-State Plan Services

	 	 	 
	FOR THE THREE MONTHS ENDING                                         

	 	FOR                                                            
	 

	 	(HMO Name)

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Maternity
	Expenses	 	Three-month	 	Three-month	 	YTD	 	YTD Units
	 	 	$	 	units	 	$	 	 
	EXPENSES:	 	 	 	 	 	 	 	 
	MEDICAL AND HOSPITAL NON-STATE SERVICES	 	 	 	 	 	 	 	 
	1
	 	 	 	$	 	$	 	$	 	$
	2
	 	 	 	$	 	$	 	$	 	$
	3
	 	 	 	$	 	$	 	$	 	$
	4
	 	 	 	$	 	$	 	$	 	$
	5
	 	 	 	$	 	$	 	$	 	$
	6
	 	 	 	$	 	$	 	$	 	$
	7
	 	 	 	$	 	$	 	$	 	$
	8
	 	 	 	$	 	$	 	$	 	$
	9
	 	 	 	$	 	$	 	$	 	$
	10
	 	 	 	$	 	$	 	$	 	$
	11
	 	Total MEDICAL AND HOSPITAL NON-STATE SERVICES (1 through 10)	 	$	 	$	 	$	 	$
	ADMINISTRATION FOR NON-STATE PLAN SERVICES	 	 	 	 	 	 	 	 
	12
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	TOTAL EXPENSE FOR NON-STATE PLAN SERVICES	 	 	 	 	 	 	 	 
	13
	 	TOTAL EXPENSES (11+12)	 	$	 	$	 	$	 	$

 

			
	1	 	Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL,
Health Access individuals without dependent children, and Adult Restricted Aliens (excluding
pregnant women) populations were transferred into two groups under a managed care Service
Administrator program.
	 
	1	 	All medical and administrative expenses must be reported
using actual incurred and paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description
	 
	1	 	 
	 
	2	 	 
	 
	3	 	 
	 
	4	 	 
	 
	5	 	 
	 
	6	 	 
	 
	7	 	 
	 
	8	 	 
	 
	9	 	 
	 
	10	 	 
	 
	*	 	If medial and hospital claims exist for non-state plan services, then must have some amount of administration for non-State Plan services.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part U Income Statement by Rate Cell Grouping

NJ FamilyCare Adults 0-100% FPL (Excluding AIDS) STATEWIDE74

	 	 	 
	FOR THE THREE MONTHS ENDING                                                             

	 	FOR                                                             
	 

	 	(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses	 	Three-month $	 	Three month	 	YTD	 	YTD PMPM
	 	 	 	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums	 	 	 	 	 	 	 	 
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	Maternity	 	 	 	 	 	 	 	 
	2b
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	 	 	 	 	 	 	 
	2c
	 	EPSDT Incentive Payment	 	 	 	 	 	 	 	 
	2d
	 	Other 	 	 	 	 	 	 	 	 
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	$	 	$	 	$
	MEDICAL AND HOSPITAL 	 	 	 	$	 	$	 	$
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	$	 	$	 	$	 	$
	19
	 	Reimbursable HIV/AIDS Drugs	 	 	 	 	 	 	 	 
	20
	 	Home Health Care	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment	 	$	 	$	 	$	 	$
	27
	 	Other Medical	 	$	 	$	 	$	 	$
	28
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	$	 	$	 	$	 	$
	ADMINISTRATION:	 	 	 	$	 	$	 	$
	29
	 	Compensation	 	$	 	$	 	$	 	$
	30
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	31
	 	Interest Expense	 	$	 	$	 	$	 	$
	32
	 	Education/Outreach	 	$	 	$	 	$	 	$
	33
	 	Marketing	 	$	 	$	 	$	 	$
	34
	 	Other	 	$	 	$	 	$	 	$
	35
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	36
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS)(8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	$	 	$	 	$	 	$
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	$	 	$	 	$	 	$
	40
	 	Adjustment for prior period IBNR Estimates	 	$	 	$	 	$	 	$
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	$	 	$	 	$	 	$

 

			
	74	 	Notes: Administrative expenses are to
be allocated to the NJ FamilyCare 0-100% FPL, rate cell groupings

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #19 – Part v Income Statement by Rate Cell Grouping 

Adult Restricted Aliens STATEWIDE 

	 	 	 
	FOR THE THREE MONTHS ENDING                                                             

	 	FOR                                                             
	 

	 	(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 
	Revenues/Expenses	 	Three-month $	 	Three month	 	YTD $	 	YTD PMPM
	 	 	 	 	PMPM	 	 	 	 
	Member Months	 	 	 	 	 	 	 	 
	REVENUES:	 	 	 	 	 	 	 	 
	1
	 	Capitated Premiums	 	 	 	 	 	 	 	 
	2
	 	Supplemental Premiums	 	 	 	 	 	 	 	 
	2a
	 	Maternity	 	 	 	 	 	 	 	 
	2b
	 	Reimbursable HIV/AIDS Drugs and Blood Product	 	 	 	 	 	 	 	 
	2c
	 	EPSDT Incentive Payment	 	 	 	 	 	 	 	 
	2d
	 	 Other 	 	 	 	 	 	 	 	 
	3
	 	Total Premiums (Lines 1+2a+2b+2c+2d)	 	$	 	$	 	$	 	$
	4
	 	Interest	 	$	 	$	 	$	 	$
	5
	 	COB	 	$	 	$	 	$	 	$
	6
	 	Reinsurance Recoveries	 	$	 	$	 	$	 	$
	7
	 	Other Revenue	 	$	 	$	 	$	 	$
	8
	 	TOTAL REVENUE (3+4+5+6+7)	 	$	 	$	 	$	 	$
	EXPENSES:	 	 	 	$	 	$	 	$
	MEDICAL AND HOSPITAL 	 	 	 	$	 	$	 	$
	9
	 	Inpatient Hospital 	 	$	 	$	 	$	 	$
	10
	 	Primary Care	 	$	 	$	 	$	 	$
	11
	 	Physician Specialty Services	 	$	 	$	 	$	 	$
	12
	 	Outpatient Hospital	 	$	 	$	 	$	 	$
	13
	 	Other Professional Services 	 	$	 	$	 	$	 	$
	14
	 	Emergency Room	 	$	 	$	 	$	 	$
	15
	 	DME/Medical Supplies	 	$	 	$	 	$	 	$
	16
	 	Prosthetics & Orthotics 	 	$	 	$	 	$	 	$
	17
	 	Covered Dental	 	$	 	$	 	$	 	$
	18
	 	Pharmacy	 	$	 	$	 	$	 	$
	19
	 	Reimbursable HIV/AIDS Drugs	 	 	 	 	 	 	 	 
	20
	 	Home Health Care	 	$	 	$	 	$	 	$
	21
	 	Transportation	 	$	 	$	 	$	 	$
	22
	 	Lab & X-ray	 	$	 	$	 	$	 	$
	23
	 	Vision Care, including eyeglasses	 	$	 	$	 	$	 	$
	24
	 	Mental Health/Substance Abuse	 	$	 	$	 	$	 	$
	25
	 	Reinsurance Expenses	 	$	 	$	 	$	 	$
	26
	 	Incentive Pool Adjustment	 	$	 	$	 	$	 	$
	27
	 	Other Medical 	 	$	 	$	 	$	 	$
	28
	 	TOTAL MEDICAL & HOSPITAL (9 THRU 28)	 	$	 	$	 	$	 	$
	ADMINISTRATION:	 	 	 	$	 	$	 	$
	29
	 	Compensation	 	$	 	$	 	$	 	$
	30
	 	Occupancy/Depreciation/Amortization	 	$	 	$	 	$	 	$
	31
	 	Interest Expense	 	$	 	$	 	$	 	$
	32
	 	Education/Outreach	 	$	 	$	 	$	 	$
	33
	 	Marketing	 	$	 	$	 	$	 	$
	34
	 	Other	 	$	 	$	 	$	 	$
	35
	 	TOTAL ADMINISTRATION	 	$	 	$	 	$	 	$
	36
	 	TOTAL EXPENSES	 	$	 	$	 	$	 	$
	37
	 	OPERATION INCOME (LOSS) (8-39)	 	$	 	$	 	$	 	$
	38
	 	Extraordinary Item	 	$	 	$	 	$	 	$
	39
	 	Provision for State, Federal and Other Governmental Taxes	 	$	 	$	 	$	 	$
	40
	 	Adjustment for prior period IBNR Estimates 	 	$	 	$	 	$	 	$
	41
	 	NET INCOME (LOSS) (37-38-39-40)	 	$	 	$	 	$	 	$

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

A.7.22 Table 20, Parts A through E Reserved

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A.7.23 Table 21 Reserved

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Table #21 – Maternity Outcome Counts

FOR THE THREE MONTHS ENDING _______________________ FOR __________________

(HMO NAME)

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Current Period	 	Year to Date
	 	 	Live Births	 	Non-live	 	Live Births	Non-live      
	 	 	C-Section	 	Vaginal	 	births	 	C-Section	 	Vaginal	 	births
	NORTHERN REGION

AFDC/NJCPW/NJ

KIDCARE A

	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	CENTRAL REGION

AFDC/NJCPW/NJ 

KIDCARE A

	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	SOUTHERN REGION

AFDC/NJCPW/NJ

KIDCARE A

	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	STATEWIDE

NJ FamilyCare Parents 134-250%

FPL
	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	STATEWIDE

ALL OTHER 
	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	TOTAL
	 	 	 	 	 	 	 	 	 	 	 	 

Note: Only outcomes on or after the thirteenth week of gestation should be
included in this report, excluding elective abortions.

 
	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

A.8.3 Estate Referral Form

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

STATE OF NEW JERSEY

DEPARTMENT OF HUMAN SERVICES

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES

ESTATE REFERRAL FORM

	 	 	 	 	 
	HMO Notification of Deceased Members Age 55 and Older

	Quarter Ending	 	 
	 

	 	 	 	 
	HMO

	 	HMO ID
#        	 	 
	 	 

	 	 	 

This will serve as notification that the following members of our health care plan age 55 or older
have died.

	 	 	 	 	 	 	 	 	 
	Member Name
	 	DOB
	 	SSN
	 	Date of Death
	 	Medicaid ID #
	 
	 	 
	 	 
	 	 
	 	 
	 
	 	 
	 	 
	 	 
	 	 
	 	 	 	 	 	 	 	 	 
	 
	 	 
	 	 
	 	 
	 	 
	 
	 	 
	 	 
	 	 
	 	 
	 	 	 	 	 	 	 	 	 
	 
	 	 
	 	 
	 	 
	 	 
	 
	 	 
	 	 
	 	 
	 	 
	 	 	 	 	 	 	 	 	 
	 
	 	 
	 	 
	 	 
	 	 
	 
	 	 
	 	 
	 	 
	 	 
	 	 	 	 	 	 	 	 	 
	 
	 	 
	 	 
	 	 
	 	 
	 
	 	 
	 	 
	 	 
	 	 
	 
	 	 
	 	 
	 	 
	 	 
	 
	 
	 	 
	 	 
	 	 
	 	 
	 
	 	 
	 	 
	 	 
	 	 
	 
	 
	 	 
	 	 
	 	 
	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

B.3.1 Monthly Roster Extract File Reserved

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

STATE OF NEW JERSEY

DEPARTMENT OF THE TREASURY

OFFICE OF INFORMATION TECHNOLOGY

FILE LAYOUT

FILE NAME: MONTHLY ROSTER FILE

EFFECTIVE DATE

	 	 	 
	DATA SET NAME

	 	RECORD SIZE

BLOCK SIZE

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Elem	 	FIELDNAME	 	CHARS	 	BYTES	 	REL TO 1	 	FMT	 	COBOL PICTURE	 	DESCRIPTIONS AND REMARKS
	1

	 	NX55 CASE NUMBER
	 	10
	 	10
	 	1-10
	 	NU
	 	9(10)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	NX55 RECIPIENT
	 	2
	 	2
	 	11-12
	 	NU
	 	X(02)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3

	 	NX55 LAST NAME
	 	12
	 	12
	 	13-24
	 	AN
	 	X(12)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	NX55 FIRST NAME
	 	7
	 	7
	 	25-31
	 	AN
	 	X(07)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	NX55 COUNTY OF RESID
	 	2
	 	2
	 	32-33
	 	AN
	 	X(02)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	NX55 MC CODE
	 	3
	 	3
	 	34-36
	 	AN
	 	X(03)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7

	 	NX55 MC EFF DATE
	 	8
	 	8
	 	37-44
	 	NU
	 	9(08)
	 	CCYYMMDD
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8

	 	NX55 MC TERM DTE
	 	8
	 	8
	 	45-52
	 	NU
	 	9(08)
	 	CCYYMMDD
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9

	 	NX55 MC PAYMENT CODE
	 	1
	 	1
	 	53-
	 	AN
	 	X(01)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10

	 	NX55 MC CAP CODE
	 	5
	 	5
	 	54-58
	 	AN
	 	X(05)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11

	 	NX55 PSC
	 	3
	 	3
	 	59-61
	 	AN
	 	X(03)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12

	 	NX55 RACE
	 	1
	 	1
	 	62
	 	AN
	 	X(01)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13

	 	FILLER
	 	7
	 	7
	 	63-69
	 	AN
	 	X(07)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14

	 	NX55 RECORD TYPE
	 	1
	 	1
	 	70
	 	AN
	 	X(01)	 	 

	 	 	 	 	 
	FORMAT B1=BINARY PD=PACKED DECIMAL

	 	ED = EXTENDED DECIMAL
	 	AN
	ALPHANUMERIC NU = NUMBERIC

	 	 	 	 
	LAST UPDATED 3/11/2005 51/30/2002
	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

B.32.2 Managed Care Register File Data Files
Resource Guide

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

DATA FILES RESOURCE GUIDE

	 	 	 	 	 	 	 	 	 
	 	 	FROM	 	TO	 	FREQUENCY	 	DEFINITION
	HIPAA 835 Encounters

	 	UNISYS
	 	HMO
	 	Monthly
	 	This file
represents the
remittance advice
for encounters
received and
processed Unisys.
The HIPAA 835 is a
nationally defined
format and is the
required format for
New Jersey as of
01/01/2005.
Detailed
information
regarding this file
is available in the
HIPPA
Implementation and
New Jersey Medicaid
Companion Guides.
This file is
available via the
NJMMIS website.
	 
	 	 	 	 	 	 	 	 
	HIPAA 835 —
Capitation and FFS
Claims

	 	UNISYS
	 	HMO
	 	Monthly
	 	This file
represents the
remittance advice
for capitation and
fee-for-service
(FFS) claims
created by Unisys.
The 835 is a
nationally defined
format and is the
required format for
New Jersey.
Detailed
information
regarding this file
is available in the
HIPPA
Implementation and
New Jersey Medicaid
Companion Guides.
This file is
available via the
NJMMIS website.
	 
	 	 	 	 	 	 	 	 
	RHMF Extracts

	 	UNISYS
	 	HMO
	 	Monthly
	 	These files
represent
demographic,
eligibility, and
enrollment data for
all HMO enrollees
from the Unisys
Recipient History
Master File (RHMF),
and is produced as
part of the monthly
capitation run by
Unisys. Each of
these file extracts
is detailed below.
These files are
available via the
NJMMIS website.
	 
	 	 	 	 	 	 	 	 
	RHMF
Extract — Base

Records

	 	UNISYS
	 	HMO
	 	Monthly
	 	This file extract
will contain
demographic data
for each enrollee.
The data elements
include: Original
ID, Last Name,
First Name, Middle
initial, Date of
Birth, Address Line
1, Address Line 2,
Address Line 3,
Address Line 4,
Address Line 5,
Address Line 6, Zip
Code, Social
Security Number,
Gender code, and
Race Code. This
file is in
comma-delimited
format.
	 
	 	 	 	 	 	 	 	 
	RMHF
Extract —

	 	UNISYS
	 	HMO
	 	Monthly
	 	This file extract will contain a

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

	 	 	 	 	 	 	 	 	 
	 	 	FROM	 	TO	 	FREQUENCY	 	DEFINITION
	Eligibility Records

	 	 	 	 	 	 	 	complete
eligibility history
for each enrollee.
The data elements
include: Original
ID, Current ID,
Program Status
Code, Eligibility
Extension code,
Effective Date,
Termination, County
of Residence, and
County of
Supervision. This
file is in
comma-delimited
format.

	 	 	 
	Page
1 of 3
	 	 
	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

DATA FILES RESOURCE GUIDE

	 	 	 	 	 	 	 	 	 
	 	 	FROM	 	TO	 	FREQUENCY	 	DEFINITION
	RHMF Extract –

Enrollment Records

	 	UNISYS
	 	HMO
	 	Monthly
	 	This file extract will contain a
complete managed care enrollment
history for each enrollee. The
data elements include: Original
ID, Current ID, HMO Code,
Payment Code, Effective Date,
Termination Date, Capitation
Code, and Health Benefit
Indicator. This file is in
comma-delimited format.
	 
	 	 	 	 	 	 	 	 
	Denied Encounters

Edit File

	 	UNISYS
	 	HMO
	 	Monthly
	 	This data file contains the NJ
Medicaid edit codes posted to
denied encounters. This file
will contain the Internal
Control Number (ICN) assigned to
each encounter, along with a
maximum of ten (10) edit codes.
It serves to alert the HMO
regarding local edit codes,
which are no longer permitted on
the national remittance format
(835) under HIPAA. It is a
comma-delimited file.
	 
	 	 	 	 	 	 	 	 
	TPL Extracts

	 	UNISYS
	 	HMO
	 	Monthly
	 	This file represents third party
liability (TPL) data for all HMO
beneficiaries as contained on
the Unisys TPL Resources File.
This file is available via the
NJMMIS website.
	 
	 	 	 	 	 	 	 	 
	Pharmacy Claims –
Aged, Blind and
Disabled (ABD)
Enrollees

	 	UNISYS
	 	HMO
	 	Monthly
	 	This file represents pharmacy
claims data for aged, blind or
disabled (ABD) individuals. This
file is available via the NJMMIS
website.
	 
	 	 	 	 	 	 	 	 
	Diagnosis Data –
ABDs and DDD

	 	UNISYS
	 	HMO
	 	Monthly
	 	file is in comma-delimited format
	 
	 	 	 	 	 	 	 	 
	HIPAA 837 Encounters

	 	HMO
	 	UNISYS
	 	As Needed
	 	This file represents the
nationally defined format for
submission of non-pharmacy
encounters (institutional,
professional, and dental). It is
the required format for New
Jersey Medicaid. Detailed
information regarding this file
is available in the HIPPA
Implementation and New Jersey
Medicaid Companion Guides.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

	 	 	 	 	 	 	 	 	 
	 	 	FROM	 	TO	 	FREQUENCY	 	DEFINITION
	HIPAA NCPDP

Encounters

	 	HMO
	 	UNISYS
	 	As Needed
	 	This file represents the nationally defined format for
submission of pharmacy encounters. It is the required
format for New Jersey Medicaid. Detailed information
regarding this file is available in the HIPPA
Implementation and New Jersey Medicaid Companion
Guides.
	 
	 	 	 	 	 	 	 	 
	 

	 	OIT
	 	HMO
	 	Daily
	 	This file represents the nationally defined format for
the communication of enrollment data to the HMOs. It
has not proprietary equivalent, but is made available
to provide more timely information. Detailed
information regarding this file is available in the
HIPPA Implementation and New Jersey Medicaid Companion
Guides. This file is made available via the OIT
“Portal” website.
	 
	 	 	 	 	 	 	 	 
	 

	 	OIT
	 	HMO
	 	Weekly
	 	This file represents the nationally defined format for
the communication of enrollment data to the HMOs.
Detailed information regarding this file is available
in the HIPPA Implementation and New Jersey Medicaid
Companion Guides. This file is made available via the
OIT “Portal” website.
	 
	 	 	 	 	 	 	 	 
	 

	 	OIT
	 	HMO
	 	Monthly
	 	This file represents the nationally defined format for
the communication of enrollment data to the HMOs.
Detailed information regarding this file is available
in the HIPPA Implementation and New Jersey Medicaid
Companion Guides. This file is made available via the
OIT “Portal” website
	 
	 	 	 	 	 	 	 	 
	 

	 	HMO
	 	OIT
	 	As Needed
	 	This file represents certification data and identifies
HMO enrollees as HIV, AIDS, or blood factor 8/9
dependent.
	 
	 	 	 	 	 	 	 	 
	 

	 	HMO
	 	STATE
	 	Monthly
	 	This data represents data for the HMOs provider network.
	 
	 	 	 	 	 	 	 	 
	 

	 	HMO
	 	STATE
	 	Monthly
	 	This data represents data supporting an invoice of
maternity deliveries, for which the State generates a
monthly financial transaction (payment).
	 
	 	 	 	 	 	 	 	 
	 

	 	HMO
	 	STATE
	 	Monthly
	 	This data represents encounter data, which support an
invoice of services provided to ASO beneficiaries, for
which the State generates a monthly financial
transaction (payment).

Page 3 of 3

STATE OF NEW JERSEY

DEPARTMENT OF THE TREASURY

OFFICE OF INFORMATION TECHNOLOGY

FILE LAYOUT

FILE NAME: MANAGED CARE REGISTER FILE

EFFECTIVE DATE 4/2002

	 	 	 
	DATA SET NAME: NX20AMCR

	 	RECORD SIZE 297

BLOCK SIZE

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Elem	 	FIELD NAME	 	CHARS	 	BYTES	 	REL TO 1	 	FMT	 	COBOL PICTURE	 	DESCRIPTIONS AND REMARKS
	31

	 	NX-TR-MC-RECORD
	 	297
	 	297
	 	1-297
	 	GROUP
	 	X(297)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	NX-TR-MEDICAID ID
	 	12
	 	12
	 	1-12
	 	GROUP
	 	X(12)	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Elem	 	FIELD NAME	 	CHARS	 	BYTES	 	REL TO 1	 	FMT	 	COBOL PICTURE	 	DESCRIPTIONS AND REMARKS
	1

	 	NX TR CASE NUMBER
	 	10
	 	10
	 	1-10
	 	AN
	 	X(10)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	NXTR RECIPIENT NUMBER
	 	2
	 	2
	 	11-12
	 	AN
	 	X(2)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3

	 	NX-TRCHANGE TYPE
	 	1
	 	1
	 	13-13
	 	AN
	 	X(1)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	NX TR CHANGE DATE
	 	8
	 	8
	 	14-21
	 	NU
	 	X(03)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	NX TR SOURCE
	 	4
	 	4
	 	22-25
	 	AN
	 	X(4)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	NX TR CM HMO
	 	8
	 	8
	 	26-28
	 	AN
	 	X(3)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7

	 	NX TR LST NAME
	 	1
	 	1
	 	29-40
	 	AN
	 	X(12)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8

	 	NX TR FST NAME
	 	5
	 	5
	 	41-47
	 	AN
	 	X(7)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9

	 	NX TR DOB
	 	3
	 	3
	 	48-55
	 	NU
	 	9(8)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10

	 	NX TR SEX
	 	1
	 	1
	 	56-56
	 	AN
	 	X(1)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11

	 	NX TR SSN
	 	7
	 	7
	 	57-65
	 	AN
	 	X(9)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12

19

	 	NX TR ADDRESS
	 	141
	 	141
	 	66-206
	 	GROUP
	 	X(141)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12

	 	NX TR ADDRESS LINE 1
	 	 	22	 	 	 	22	 	 	66-87
	 	AN
	 	X(22)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13

	 	NX TR ADDRESS LINE 2
	 	 	22	 	 	 	22	 	 	88-109
	 	AN
	 	X(22)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14

	 	NX TR ADDRESS LINE 3
	 	 	22	 	 	 	22	 	 	110-131
	 	AN
	 	X(22)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	15

	 	NX TR ADDRESS LINE 4
	 	 	22	 	 	 	22	 	 	132-153
	 	AN
	 	X(22)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	16

	 	NX TR ADDRESS LINE 5
	 	 	22	 	 	 	22	 	 	154-175
	 	AN
	 	X(22)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	17

	 	NX TR ADDRESS LINE 6
	 	 	22	 	 	 	22	 	 	176-197
	 	AN
	 	X(22)	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	18

	 	NX TR ZIP CODE
	 	 	5	 	 	 	5	 	 	198-202
	 	An
	 	X(5)	 	 

	 	 	 	 	 
	FORMAT B1=BINARY PD=PACKED DECIMAL

	 	ED = EXTENDED DECIMAL
	 	AN
	ALPHANUMERIC NU = NUMBERIC

	 	 	 	 
	LDATE UPDATED 3/11/2005 51/30/2002
	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

STATE OF NEW JERSEY

DEPARTMENT OF THE TREASURY

OFFICE OF INFORMATION TECHNOLOGY

FILE LAYOUT

	 	 	 	 	 
	FILE NAME: MANAGED CARE REGISTER FILE	 	 
	 

	 	EFFECTIVE DATE 4/2002	 	 
	DATA SET NAME: NX20AMCR	 	RECORD SIZE 297
	 

	 	BLOCK SIZE	 	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Elem	 	FIELD NAME	 	CHARS	 	BYTES	 	REL TO 1	 	FMT	 	COBOL PICTURE	 	DESCRIPTIONS AND REMARKS
	19

	 	nx-tr-zip
suffix
	 	 	4	 	 	 	4	 	 	203-206
	 	AN
	 	 	X	(4)	 	 
	20

	 	NX-TR-PR

ENROLL DTE
	 	 	12	 	 	 	12	 	 	1-12
	 	GROUP
	 	 	X	(12)	 	FORMAT YYYYMMDD OR

SPACES
	21

	 	NX TR PR

DISENROL DTE
	 	 	10	 	 	 	10	 	 	1-10
	 	AN
	 	 	X	(10)	 	FORMAT YYYYMMDD OR

SPACES
	22

	 	nxtr PR HMO

CAP CDE
	 	 	2	 	 	 	2	 	 	11-12
	 	AN
	 	 	X	(2)	 	 
	23

	 	NX-TR PR

BENEFIT IND
	 	 	1	 	 	 	1	 	 	13-13
	 	AN
	 	 	X	(1)	 	 
	24

	 	NX TR CURR

ENROLL DTE
	 	 	8	 	 	 	8	 	 	14-21
	 	NU
	 	 	X	(03)	 	FORMAT YYYYMMDD OR

SPACES
	25

	 	NXTR CUR

DISENRL DTE
	 	 	4	 	 	 	4	 	 	22-25
	 	AN
	 	 	X	(4)	 	FORMAT YYYYMMDD OR

SPACES
	26

	 	NX TR CUR HMO

CAP CDE
	 	 	8	 	 	 	8	 	 	26-28
	 	AN
	 	 	X	(3)	 	 
	27

	 	NX TR BENEFIT

IND
	 	 	1	 	 	 	1	 	 	29-40
	 	AN
	 	 	X	(12)	 	 
	28

	 	NX TR BATCH

NUM
	 	 	5	 	 	 	5	 	 	41-47
	 	AN
	 	 	X	(7)	 	 
	29

	 	NX TR PCM STA

CDE
	 	 	3	 	 	 	3	 	 	48-55
	 	NU
	 	 	9	(8)	 	 
	30

	 	NX TR PR

DISENROL RSN
	 	 	1	 	 	 	1	 	 	56-56
	 	AN
	 	 	X	(1)	 	 
	31

	 	NX TR CURR

DISENROLL RSN
	 	 	7	 	 	 	7	 	 	57-65
	 	AN
	 	 	X	(9)	 	 
	32

	 	NX TR EXT

TYPE CDE
	 	 	141	 	 	 	141	 	 	66-206
	 	AN
	 	 	X	(141)	 	 
	33

	 	NX TR PR

SOURCE CHG
	 	 	22	 	 	 	22	 	 	66-87
	 	AN
	 	 	X	(22)	 	 
	34

	 	NX TR PR PAY

CODE
	 	 	22	 	 	 	22	 	 	88-109
	 	AN
	 	 	X	(22)	 	 
	35

	 	NX TR CURR

PAY CODE
	 	 	22	 	 	 	22	 	 	110-131
	 	AN
	 	 	X	(22)	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medical/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Elem	 	FIELD NAME	 	CHARS	 	BYTES	 	REL TO 1	 	FMT	 	COBOL PICTURE	 	DESCRIPTIONS AND REMARKS
	36

	 	NX TR TR RACE
	 	 	22	 	 	 	22	 	 	132-153
	 	AN
	 	 	X	(22)	 	 
	37

	 	NX TR FILLER
	 	 	22	 	 	 	22	 	 	154-175
	 	AN
	 	 	X	(22)	 	 
	38

	 	NX TR PHONE
	 	 	22	 	 	 	22	 	 	176-197
	 	AN
	 	 	X	(22)	 	 
	40

	 	nx tr lanc code
	 	 	5	 	 	 	5	 	 	198-202
	 	AN
	 	 	X	(5)	 	 

	 	 	 
	FORMAT B1=BINARY PD=PACKED DECIMAL

	 	ED = EXTENDED DECIMAL      AN
	ALPHANUMERIC NU = NUMBERIC
	 	 
	LDATE UPDATED 3/11/2005 51/30/2002

STATE OF NEW JERSEY

DEPARTMENT OF THE TREASURY

OFFICE OF INFORMATION TECHNOLOGY

FILE LAYOUT

	 	 	 	 	 
	FILE NAME: MANAGED CARE REGISTER FILE	 	 
	 

	 	EFFECTIVE DATE 4/2002	 	 
	DATA SET NAME: NX20AMCR	 	RECORD SIZE 297
	 

	 	BLOCK SIZE	 	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	DESCRIPTIONS AND
	Elem	 	FIELD NAME	 	CHARS	 	BYTES	 	REL TO 1	 	FMT	 	COBOL PICTURE	 	REMARKS
	1	 	nx-tr trailer
	 	297	 	297	 	GROUP	 	 	 	 	 	REDEFINES NXOTR MCRECORD
	2	 	nx-tr trailer – num
	 	12	 	12	 	1-12	 	GROUP	 	X(12)	 	VALUE ‘9999999999999’
	3	 	nx-tr trailer – ind
	 	1	 	1	 	13	 	AN	 	X(1)	 	VALUE ‘Z’
	4	 	nx-tr tape date
	 	8	 	8	 	14-21	 	AN	 	X(8)	 	YYYYMMDD FORMAT
	5	 	nx-tr frequency ind
	 	1	 	1	 	22	 	AN	 	X(1)	 	VALUE ‘W’ OR ‘M’
	6	 	FILLER
	 	3	 	3	 	23-25	 	NU	 	X(3)	 	 
	7	 	nx-tr mc hmo
	 	3	 	3	 	26-28	 	AN	 	X(3)	 	 
	8	 	nx-tr hmo name
	 	19	 	19	 	29-47	 	AN	 	X(19)	 	 
	9	 	FILLER
	 	9	 	9	 	48-56	 	AN	 	X(9)	 	 
	10	 	nx-tr total count
	 	9	 	9	 	57-65	 	AN	 	X(9)	 	 
	11	 	FILLER
	 	232	 	232	 	66-297	 	NU	 	X(232)	 	 

 
	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medical/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

	 	 	 
	FORMAT B1=BINARY PD=PACKED DECIMAL

	 	ED = EXTENDED DECIMAL      AN
	ALPHANUMERIC NU = NUMBERIC
	 	 
	LAST DATE UPDATED 3/11/2005 51/30/2002

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medical/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

B.4.6 School-Based Youth Services Program

The contractor shall utilize the following DHS website to access an updated list of School Based
Youth Service Programs and program director:

http://www.state.nj.us/humanservices/sp&i/sbys-list.html

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medical/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

PROGRAM DIRECTORS

School-Based Youth Services Program

	 	 	 
	ATLANTIC
	 	 
	Dan Carter

	 	Atlantic City Teen Service Center
	 

	 	Altantic City high School
	(609) 345-8336

	 	1400 Albany Ave
	FAX (609) 345-8373

	 	Altantic City, New Jersey 08401
	 
	 	 
	Trish Helms

	 	Pleasantville School Based Program
	(609) 383-6900x240

	 	701 Mill Road
	FAX (609) 383-6952

	 	Pleasantville, NJ 07601
	 
	 	 
	BERGEN
	 	 
	 
	 	 
	Dominic Polifrone

	 	Hackensack High School
	(201)646-0722

	 	First and Beech Streets
	FAX (201)646-1558

	 	Hackensack, NJ 07601
	 
	 	 
	BURLINGTON
	 	 
	 
	 	 
	Shaun Stern

	 	Pemberton School Based Program
	 

	 	PO Box 256
	(609)894-0170

	 	Pemberton High School
	FAX (609) 894-0153

	 	Pemberton, NJ 08068
	 
	 	 
	CAMDEN
	 	 
	Sharon Shields

	 	Camden High Vocational Annex
	Office (856)541-0253

	 	Park and Baird boulevards
	FAX (856)541-1989

	 	Camden, NJ 08103
	Camden HS Site (856)614-7680
	 	 
	FAX (856)966-5282
	 	 
	Woodrow Wilson Site (856)966-4282
	 	 
	East Camden Middle
	 	 
	 
	 	 
	CAPE MAY
	 	 
	Caren Maene

	 	Cape Counseling Service, Inc.
	 

	 	ATTN: SBYSP
	609-884-8641

	 	128 Crest Haven Road
	FAX 609-884-4840

	 	Cape May Court House, NJ 08219

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

	 	 

 

 

	 	 	 
	CUMBERLAND
	 	 
	Robert Gondolf

	 	CHCI SBYSP Teen Center
	856-451-4440

	 	Bridgeton High School
	 

	 	Bridgeton, NJ 08302
	Fax 856-451-5815
	 	 
	 
	 	 
	ESSEX
	 	 
	Mary Ellen Mess

	 	Teen Powerhouse
	MEM’s Office 973-972-635391 	 	west Market Street
	Site 973-622-1100 x4080

	 	Newark, NJ 07103
	Fax 973-372-6545
	 	 
	 
	 	 
	Beverly Canady, site Manager

	 	Irvington School Based Program
	973-228-3000

	 	Caldwell, NJ 07006
	 
	 	 
	GLOUCESTER
	 	 
	 
	 	 
	Frankie Lamborne

	 	Gloucester Co. Institute of Technology
	856-468-1445

	 	PO Box 800
	ext. 2151

	 	1360 Tanyard Road
	 

	 	Sewell, NJ 08080
	 
	 	 
	Wayne Copeland

	 	Clayton Place
	 

	 	457 North Delsea Drive
	 

	 	PO Box 85
	Fax 856-863-8329

	 	Clayton, NJ 08312

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

	 	 

 

 

	 	 	 
	Hudson
	 	 
	Richard Quagliariello

	 	Union City Board of Education
	Program Director

	 	3912 Bergen Turnpike
	 

	 	Union City, NJ 08087
	 
	 	 
	(201)392-3646
	 	 
	FAX 201-348-1810
	 	 
	 
	 	 
	Nivia Rojas

	 	Emerson High School
	Human Services Coordinator

	 	318 18th street
	201-392-3265

	 	Union City, NJ 07087
	 
	 	 
	Agnes Gillespie

	 	Bayonne School Based Program
	 

	 	Bayonne Board of Education
	201-858-7885

	 	Student Center, Room 124
	 

	 	Avenue A and 29th St
	 

	 	Bayonne, NJ 07002
	 
	 	 
	HUNTERDON
	 	 
	Gary Piscitelli

	 	Hunterdon Medical Center HBH
	908-788-6401

	 	2100 Wescott Drive
	fax 908-788-6584

	 	Flemington, NJ 08822
	David Eichlin, coordinator
	 	 
	 
	 	 
	MERCER
	 	 
	Pam Lackey

	 	Trenton School Based Program
	 

	 	Trenton Central High School
	609-989-2965

	 	400 Chambers ST. Portable Unit
	 

	 	Trenton, NJ 08609
	 
	 	 
	MIDDLESEX
	 	 
	Gail Reynolds

	 	New Brunswick High School
	732-235-53206

	 	School Based Program
	 

	 	1125 Livingston Avenue
	 

	 	New Brunswick, NJ 08901
	 
	 	 
	Marylyn Green

	 	Roosevelt School
	 

	 	83 Livingston Ave
	732-235-8438

	 	New Brunswick, NJ 08901

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

	 	 

 

 

	 	 	 
	Leslie Hodes

	 	South Brunswick School Based Program
	 

	 	South Brunswick High SBYSP
	732-329-4044 x3224

	 	750 Ridge Road, PO Box 183
	FAX 732-274-1237

	 	Monmouth Junction, NJ 08852
	 
	 	 
	MONMOUTH
	 	 
	 
	 	 
	Pamela Zern Coviello

	 	Long Branch High School
	732-728-9533

	 	391 Westwood Ave
	FAX 732-728-9670

	 	Long Branch, NJ 07740
	 
	 	 
	MORRIS
	 	 
	 
	 	 
	Linda Seeley

	 	Dover High School
	973-989-0540 (Site)

	 	!00 Grace Street
	973-989-0045

	 	Dover, NJ 07801
	 
	 	 
	OCEAN 
	 	 
	 
	 	 
	Dominick Riggi

	 	Preferred Children’s Services
	732-363-7272

	 	CN 2036
	FAX 732-915-5644

	 	Lakewood, NJ 08701
	 
	 	 
	Ginny Galaro

	 	Pinelands Regional High School
	 

	 	Nugentown Road
	609-296-3106 Ext. 283

	 	PO Box 248
	FAX 609-294-9519

	 	Tuckerton, NJ 08087-0248
	 
	 	 
	PASSAIC
	 	 
	 
	 	 
	Paula Howe

	 	School Based Youth Services Program
	973-881-3333

	 	Kennedy High School
	973-881-3350/52

	 	62 127 Preakness Ave.
	FAX 973-881-9532

	 	Paterson, NJ 07522
	 
	 	 
	Susan Proietti

	 	Passaic School based Program
	973-470-5590

	 	185 Paulison Ave
	973-473-2408

	 	Passaic, NJ 07055
	FAX 973-473-6883
	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

	 	 

 

 

	 	 	 
	SALEM
	 	 
	Joan Hoolahan

	 	Salem County School Based Youth Services Program
	 

	 	Salem County Vocational Technical Schools
	856-935-7365

	 	166 Salem-Woodstown Road
	 

	 	Salem, NJ 08079
	 
	 	 
	SOMERSET
	 	 
	 
	 	 
	Pam Brink

	 	Somerset County Vocational Technical High School
	 

	 	PO Box 6350
	908-526-8900 Ext 7286

	 	North Bridge St & Vogt Drive
	FAX 908-526-9212

	 	Bridgewater, NJ 08807
	 
	 	 
	SUSSEX
	 	 
	 
	 	 
	Sharon Hosking

	 	Sussex County Vocational Technical School
	973-383-6700 x329

	 	105 North Church Road
	973-579-7725

	 	Sparta, NJ 07871
	 
	 	 
	UNION
	 	 
	 
	 	 
	Stacy Greene

	 	Elizabeth SBYSP YES Program
	 

	 	Social Service Department
	908-527-5287

	 	St. Elizabeth Hospital
	FAX 908-226-2551

	 	225 Williams St
	 

	 	Elizabeth, NJ 07207
	 
	 	 
	Loise Yohalem

	 	Plainfield School Based Youth Services Program
	908-753-3192

	 	925 Arlington Ave.
	Fax 908-226-2551

	 	Plainfield, NJ 07060
	 
	 	 
	WARREN
	 	 
	 
	 	 
	Sue Pappas

	 	Philipsburg SBUSP
	908-213-2596

	 	Board of Education
	908-859-2127

	 	575 Elder Ave.
	FAX 908-213-2062

	 	Philipsburg, NJ 08865

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

	 	 

 

 

Sallie Gorohoff

Coordinator of the Children and Family Initiative in Atlantic City

Shore View Building

101 S Shore Road

Northfield, NJ 08225

609-645 7700x4332

FAX 609-645-5809

Essex

Rose Smith

SBYSP

Children’s Hospital of NJ

201 Lyons Ave, H1

Newark, NJ 07112

Monmouth

Therese T. Henderickson

School Based Health & Social Servcie clinic

Keansburg School District

140 Port Monmouth Rd

Keansburg, NJ 07734

Hudson

Marilyn Cintron

Horizon Health Center

Program Administrator for School Based Clinics

714 Bergen Ave

Jersey City, NJ 07360

Kelly Gleason

District Service Broker

Division of community & Support Services

Jersey City Public Schools

346 Clarement Ave, 6th floor

Jersey City, NJ 07305

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

	 	 

 

 

	 	 	 	 	 
	 	 	 	 	STAFFING
	SITE	 	SERVICES RENDERED	 	(with degrees noted)
	Bridgeton SBYSP

MAJOR HEALTH
PROVIDER

Community Health
Center, INC (FQHC)

	 	Comprehensive adolescent
health care, including

Physicals

HIV/STD, pregnancy screenings
and treatment

Emergency care and referrals
Well and Sick care for infants
and toddlers in child care
centers

Chronic Illness oversight
Immunizations

EPSDTs

Connect children and families
to NJ FamilyCare
	 	2 Registerd Nurses
(full time) who are
shared by high
school, middle
school and
elementary school

2 Nurse
Practitioners, one
full tiem at
Bridgeton High, one
at the middle
school

One MD part time (4
hours/week, plus
phone supervision
and referrals as
needed)
	 
	 	 	 	 
	Atlantic City High
SPYSP

MAJOR HEALTH
PROVIDER

AtlantiCare

	 	Comprehensive Adolescent Health

Physical Exams

Immunizations

Primary and preventative
Health services
Emergency care and referrals

Health Education

Substance Abuse

Connect children and families
to NJ FamilyCare
	 	1 Registered Nurse
(full time)

1 MD (Pediatrician)
part time for 6
hours/week
	 
	 	 	 	 
	Elizabeth High SPYSP

MAJOR HEALTH
PROVIDER

St. Elizabeth
Hospital through
SBYSP funding

	 	Comprehensive Adolescent Health

Services focused on
maturational issues;
Pregnancy screens, counseling,
prenatal care, nutrition
education, pregnancy
prevention education with
special attention to immigrant
youth;
Emergency care and referrals
	 	1 Doctor (MD) (at
hospital clinic)
part time for 4
hours/week on site
and referrals as
needed

1 BSN Registered
Nurse full time

1 BSN Registered
Nurse part time

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

	 	 	 	 	 
	 	 	 	 	STAFFING
	SITE	 	SERVICES RENDERED	 	(with degrees noted)
	 

	 	Referrals & Follow up
for chronic illness, using hospital
services & previous prescriptions
by doctors in other countries;	 	 
	 

	 	Some sports and school re-admission
physicals
Teen Only clinic at hospital (one
day/week)	 	 
	 

	 	Note: Hospital is across the street
from the high school

Connect children and families to NJ	 	 
	 

	 	FamilyCare	 	 
	 
	 	 	 	 
	Long Branch High
School

MAJOR HEALTH PROVIDER
SBYSP

Lead Agency (board of Ed) and
SBYSP Director higher
personnel

	 	Primary Health care
(12-13 protocols) asthma, support
group, diabetes support group,
health education, pregnancy testing
and family planning information,
community health referrals,
nutrition counseling, teen
parenting support, and pregnant
teen counseling.

Connect children and families to NJ
FamilyCare
	 	1 NP
MSN (nurse
practitioner with
Masters Degree) full
time

1 Registered Nurse
(full time) part time
16 hours/week

1 MD (Pediatrician)
part time for 6
hours/week
	 
	 	 	 	 
	Camden SPYSP

	 	Comprehensive
Adolescent Health Care including:	 	1 NP
Full time at Camden
High School
	
MAJOR HEALTH PROVIDER

CamCare through $60,000

subcontract SBYSP funds

	 	Physicals (job, sports)

Test (eg. Anemia, sickle cell, HBP,
STD, pregnancy)

Follow up on chronic problems
(e.g., diabetes, anemia, asthma,
allergies, eating disorders)

Substance abuse counseling, family,
therapy referrals

Psychotic symptoms referred to
mental health clinicians

Sexuality: counsel, education, some
treatment (eg., STDs), prenatal
care
Services focused on maturational
issues;
Emergency care and
referrals
	 	

1 RN full time

1 Doctor (MD)) part
time for 4 hours/week
at Camden HS and
referrals as needed

1NP part time (20
hours/week) at
Woodrow Wilson High
School

1NP Part time (10
hours/week at east
Camden Middle School
	 
	 	 	 	 
	 

	 	Immunization referrals
Well and sick care for infants in
child care centers	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

	 	 

 

 

	 	 	 	 	 
	 	 	 	 	STAFFING
	SITE	 	SERVICES RENDERED	 	(with degrees noted)
	Plainfield SBYSP

	 	Comprehensive
Adolescent Health Care including: 	 	1 Pediatrician (MD)
full time
	 
	MAJOR HEALTH PROVIDER

	 	
Physicals (job, sports)
HIV, STC, pregnancy screenings and
treatment	 	
1 RNNP (Registered
Nurse Practitioner)
full
time
	 
	
The Cardinal Health Center, a
Satellite of Plainfield Health
Center (FQHC)

	 	
Emergency care and referrals
Well and sick care for infants and
toddlers in child care centers
Chronic Illness oversight
Immunizations
EPSDTs
Connect children and families to NJ
FamilyCare
	 	 
	 
	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

	 	 

 

 

B.4.7 Local Health Departments

The contractor shall utilize the following DHSS website to access an updated list of Local Health
Departments in New Jersey

http://www.state.nj.us/health/lh/lhdeirectory.pdf

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

	 	 

 

 

LOCAL HEALTH DEPARTMENTS IN NEW JERSEY

JANUARY 1999

ATLANTIC COUNTY

Atlantic City Health Dept

Ronald L. Cash, M.P.P., M.P.A.

Dir, Div of Hlth

City Hall

1301 Bacharach Blvd. — 4th Floor

Atlantic City, NJ 08401-4603

609-347-5663

Atlantic County Division of Public Health

Tracye M. Ardle, M.P.H.

Health Officer

201 South Shore Road

Northfield, NJ 08225-2370

609-645 5935

ABSECON BRIGANTINE BUENA

BUENA VISTA CORBIN EGG HARBOR CITY

EGG HARBOR TWP ESTELLE MANOR FOLSOM

GALLOWAY HAMILTON TWP (ATLANTIC CO.) HAMMONTON

LINWOOD LONGPORT MARGATE

MULLICA NORTHFIELD PLEASANTVILLE

PORT REPUBLIC SOMERS POINT VENTNOR

WEYMOUTH

BERGEN COUNTY

Bergen County Dept of Health Services

Mark Guarino, MPH

Director

327 E Ridgewood Avenue

Paramus, NJ 07652-4895

201-634-2600

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

ALLENDALE ALPINE CLIFFSIDE PARK

DUMONT EAST RUTHERFORD EDGEWATER

FAIRVIEW FRANKLIN LAKES GLEN ROCK

HASBROUGH HEGHTS HAWORTH HO-HO-KUS

LITTLE FERRY LODI LYNDHURST

MAYWOOD MOONACHIE NORTH ARLINGTON

NORWOOD OAKLAND ORADELL

PARK RIDGE ROCHELLE PARK RUTHERFORD

SADDLE BROOK TETERBORO WOODCLIFF LAKE

WOODRIDGE WYCKOFF TWP

Bergenfield Health Dept

David Volpe, M.A., B.S.

Health Officer

Borough Hall

198 N. Washington Avenue

Bergenfield, NJ 07621-1395

201-387-4055 5

E-mail address: health@bergenfieldboro.com

BERGENFIELD

Closter Health Dept

Louis S. Apa

Health Officer

Municipal Building

295 Closter Dock Road Closter, NJ 07624-2697

201-784-0752

E-mail address: closter.health@verizon.net

http://www.bergenhealth.org

CLOSTER

ROCKLEIGH

DuRidge Regoinal Health Commission

Guy Stark, BS, MA, PhD

Health Officer

50 Washington Ave

Dumont, NJ 07628-3694

201-387-5028 Fax 201-387-6065

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

DUMONT RIDGEFIELD

GARFIELD RIDGEFIELD PARK TWP

MOONACHIE SADDLE RIVER

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Elmwood Park Dept of Health

Deborah Ricci, M.P.A. Health Officer

Municipal Building 182 Market Street

Elmwood Park, NJ 07407-1497

201-796-1072

E-mail address: elmwoodhealth@aol.com

http://www.bergenhealth.org

ELMWOOD PARK

HASBROUCK HEIGHTS

Englewood Health Dept

Violet P. Cherry, A.C.S.W. ,M.P.H., C.H.E.S.

Health Officer

73 South Van Brunt Street

Englewood, NJ 07631-3485

201-568-3450

E-mail address: violetpcherry@cityofenglewood.org

ENGLEWOOD

Fair Lawn Health Dept

Denise A. DePalma Farr, MA, CHES

Health Officer

Borough of Fair Lawn 8-01 Fair Lawn Avenue

Fair Lawn, NJ 07410

201-794-5327

E-mail address: health@fairlawn.org

http://www.bergenhealth.org

FAIR LAWN

Fort Lee Health Dept

Stephen S. Wielkocz, M.A

Health Officer

Memorial Health Building 309 Main Street Fort Lee, NJ 07024-4799

201-592-3590

E-mail address: s-wielkocz@fortleenj.org

http://www.bergenhealth.org

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

FORT LEE

Hackensack Health Dept

John G. Christ, M.P.A.

Health Officer

215 State Street

Hackensack, NJ 07601-5582

201-646-3965

FAX # 201-646-3989

HACKENSACK

Mid-Bergen Regional Health Commission

Carol Wagner, MS

Director

705 Kinderkamack Road

River Edge, NJ 07661

201-599-6290

BOGOTA

CARLSTADT

ENGLEWOOD CLIFFS

NEW MILFORD

RAMSEY

RIVER EDGE

SOUTH HACKENSACK TWP

TENAFLY

WALLINGTON

N.W. Bergen Regional Health Commission

Rod W. Preiss

Health Officer

22 West Prospect Street

Waldwick, NJ 07463

201-445-7217 Fax # 201-445-7219

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

HILLSDALE

MIDLAND PARK

MONTVALE

NORTHVALE OLD

TAPPAN

UPPER SADDLE RIVER

WALDWICK

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Palisades Park Health Dept

Jad Mihalinec, M.A.

Health Officer

Municipal Building

275 Broad Avenue

Palisades Park, NJ 07650-1578

201-585-4106

E-mail address: ppbdhealth@aol.com

http://www.bergenhealth.org

PALISADES PARK

Paramus Board of Health

John Hopper Health Officer

Borough Hall, Jockish Square Paramus, NJ 07652-2771

201-265-2100

E-mail address: jhopper@paramusborough.org

http://www.bergenhealth.org

MAHWAH

PARAMUS

Teaneck Dept of Health & Human Services

Wayne A. Fisher, M.A. Health Officer

Municipal Building

818 Teaneck Road

Teaneck, NJ 07666-9998

201-837-4824

E-mail address: wfisher537@aol.com

http://www.bergenhealth.org

TEANECK

Township of Washington Local Health Agency

Daniel G. Levy, M.P.A. Health Officer

350 Hudson Avenue

Twp. of Washington, NJ 07675-4798

201-666-8512

E-mail address: dglevy@bellatlantic.net

http://www.bergenhealth.org

CRESSKILL

DEMAREST

EMERSON

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

HARRINGTON PARK

RIVER VALE

WASHINGTON TWP

BURLINGTON COUNTY

Burlington County Health Dept

Robert Gogats

Health Officer, Pub Hlth Coord

Raphael Meadow Health Center 15 Pioneer Blvd., PO Box 6000 Westampton, NJ 08060-1384

609-265-5548

E-mail address: rgogats@co.burlington.nj.us

 

BASS RIVER TWP BEVERLY BORDENTOWN CITY

BORDENTOWN TWPBURLINGTON CITYBURLINGTON TWP

CHESTERFIELD TWP CINNAMINSON TWPDELANCO TWP

DELRAN TWPEASTAMPTON EDGEWATER PK

EVESHAM TWP FIELDSBORO FLORENCE

HAINESPORT LUMBERTON MANSFIELD (BURLINGTON CO.)

MAPLE SHADE MEDFORD LAKES MEDFORD TWP

MOORESTOWN MT HOLLY MT LAUREL

NEW HANOVER NORTH HANOVER PALMYRA

PEMBERTON PEMBERTON TWP RIVERSIDE

RIVERTON SHAMONG SOUTHAMPTON

SPRINGFIELD TWP (BURLINGTON CO.) TABERNACLE WASHINGTON TWP

(BURLINGTON CO.)

WESTAMPTON WILLINGBORO WOODLAND

WRIGHTSTOWN

CAMDEN COUNTY

Camden County Dept of Health

Jung H. Cho, V.M.D., Dr. P.H. County Health Officer

DiPiero Center, Lakeland Road PO Box 9

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Blackwood, NJ 08012-0009

856-374-6037

E-mail address: ccho@camdencounty.com

http://www.co.camden.nj.us/

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

 

AUDUBON AUDUBON PARK BARRINGTON

BELLMAWR BERLIN BORO BERLIN TWP

BROOKLAWNCAMDEN CHERRY HILL

CHESILHURST CLEMENTON COLLINGSWOOD

GIBBSBORO GLOUCESTER CITY GLOUCESTER TWP

HADDON HEIGHTS HADDON TWP HADDONFIELD

HI-NELLA LAUREL SPRINGS LAWNSIDE

LINDENWOLD MAGNOLIA MERCHANTVILLE

MT EPHRAIM OAKLYN PENNSAUKEN

PINE HILL PINE VALLEYRUNNEMEDE

SOMERDALE STRATFORD TAVISTOCK

VOORHEES TWP WATERFORD TWP WINSLOW TWP

WOODLYNNE

LHD Code D0400

Fax # 856-374-6034

CAPE MAY COUNTY

Cape May County Health Dept

Louis Lamanna, M.A., H.O. Pub Hlth Coord

4 Moore Road, DN 601 LHD Code D0500

Cape May Court House, NJ 08210-1601

609-465-1187 Fax #609-465-3933

E-mail address: lamann@co.cape-may.nj.us

http://www.capemaycountygov.net/

AVALON CAPE MAYCAPE MAY POINT

DENNIS TWP LOWER TWP MIDDLE TWP

NORTH WILDWOOD OCEAN CITY SEA ISLE

STONE HARBOR UPPER TWP WEST CAPE MAY

WEST WILDWOOD WILDWOOD WILDWOOD CREST

WOODBINE

CUMBERLAND COUNTY

City of Vineland Dept of Health

Louis F. Cresci, Jr., B.A. Health Officer

City Hall

640 E. Wood Street, PO Box 1508

Vineland, NJ 08360-0978

856-794-4131

E-mail address: gsartorio@vinelandcity.org http://www.salem-cumberlandhealth.org/

VINELAND

Cumberland/Salem Dept. of Health

Herbert W. Roeschke, Sr. M.S. Health Officer

790 East Commerce Street Bridgeton, NJ 08302

856-453-2150

E-mail address: hroeschke@salemco.org

http://www.salem-cumberlandhealth.org/

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

 

BRIDGETON COMMERCIAL TWP DEERFIELD

DOWNE TWP FAIRFIELD TWP (CUMBERLAND CO.) GREENWICH TWP (CUMBERLAND CO.)

HOPEWELL TWP (CUMBERLAND CO.) LAWRENCE TWP (CUMBERLAND CO.)

MAURICE RIVER

MILLVILLE SHILOH STOW CREEK

UPPER DEERFIELD

LHD Code D0680

Fax # 856-794-1159

LHD Code D0600

Fax # 856-453-0338

ESSEX COUNTY

Bloomfield Dept of Health

Trevor J. Weigle

Health Officer

1 Municipal Plaza

Room 111

Bloomfield, NJ 07003-3487 LHD Code D0708

973-680-4024 Fax # 973-680-4825 E-mail address: health@mail.bloomfieldtwpnj.com

http://www.co.essex.nj.us/

BLOOMFIELD CALDWELL

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

East Orange Health Dept

Attn: Rochelle Evans, Director Health Department -143 New Street

East Orange, NJ 07017-4918LHD Code D0724

973-266-5465 Fax # 973-266-5402 E-mail address:

http://www.co.essex.nj.us/

EAST ORANGE

Essex County Dept of Health

Michael Festa, Ph.D. Health Officer

120 Fairview Avenue

Cedar Grove, NJ 07009 LHD Code D0725

973-228-8152 Fax # 973-403-1754 E-mail address: ecdoh@viconet.com

http://www.co.essex.nj.us/

Essex Regional Health Commission

Robert Ferraiuolo, MPA Health Officer

2 Babcock Place

West Orange, NJ 07052

973-325-3212

E-mail address: essexrhc@aol.com

Irvington Dept of Health & Welfare

Sandra M. Harris, M.S.

Health Officer

Civic Square, Municipal Building

Irvington, NJ 07111-2497 LHD Code D0736

973-399-6647 Fax # 973-371-1489 E-mail address: Plasmodium99@yahoo.com

IRVINGTON

Livingston Health Dept

Louis E. Anello, M.E.S.

Director of Health

204 Hillside Avenue

Livingston, NJ 07039-3994

973-535-7961 Fax # 973-535-3234 E-mail address: livingstonhd@aol.com

LIVINGSTON

Maplewood Health Dept

Robert D. Roe, M.P.A.

Health Officer

574 Valley Street

Maplewood, NJ 07040-2691

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

973-762-8120 Fax # 973-762-1934

MAPLEWOOD

Montclair Health Dept

Thomas A. Restaino Dir, Hlth & Hum Srvcs

205 Claremont Avenue

Montclair, NJ 07042-3401 LHD Code D0752

973-509-4967 Fax # 973-509-1479 E-mail address: tarestaino@aol.com

http://www.co.essex.nj.us/

BELLEVILLE CEDAR GROVEGLEN RIDGE

MONTCLAIR NUTLEY VERONA WAYNE (PASSAIC CO.)

Newark Dept of Health

Marsha McGowan, M.P.H., M.A.

Health Officer

110 William Street

Newark, NJ 07102-1316 LHD Code D0756

973-733-7592 Fax # 973-733-5614 E-mail address: mcgowanm@ci.newark.nj.us

NEWARK

West Caldwell Health Dept

Peter N. Tabbot, M.P.H.

Health Officer

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Boro Hall

30 Clinton Road

West Caldwell, NJ 07006-6774

973-226-2303

E-mail address: PTabbot@aol.com

http://www.co.essex.nj.us/

FAIRFIELDWEST

CLADWELL

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

West Orange Health Dept

Joseph A. Fonzino, M.S.

Health Officer

Municipal Building

66 Main Street

West Orange, NJ 07052-5404

973-325-4124 Fax # 973-325-4005 E

ESSEX FELLS

ORANGE

WEST ORANGE

GLOUCESTER COUNTY

Gloucester County Dept of Health

Donald Benedik

Health Officer

160 Fries Mill Road

Turnersville, NJ 08012

856-262-4101 Fax #856-262-4109

 

CLAYTON LOGAN SWEDESBORO

DEPTFORD MANTUA EAST GREENWICH

ELK TWP FRANKLIN TWP (GLOUCESTER CO.) GLASSBORO

GREENWICH TWP (GLOUCESTER CO.) HARRISON TWP (GLOUCESTER CO.)

MONROE TWP (GLOUCESTER CO.) NATIONAL PARK

NEWFIELD PAULSBORO PITMAN

SOUTH HARRISON WASHINGTON TWP (GLOUCESTER CO.)

WENONAH WEST DEPTFORD WESTVILLE

WOODBURY WOODBURY HEIGHTS WOOLWICH

HUDSON COUNTY

Bayonne Dept of Health

Brigid Breivogel, R.N., M.S.

Health Officer

Municipal Building

630 Avenue C

Bayonne, NJ 07002-3878

201-858-6112 Fax # 201-858-6111

BAYONNE

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Harrison Board of Health

Karen Comer, M.S., C.H.E.S.

Health Officer

318 Harrison Avenue

Harrison, NJ 07029-1752

973-268-2441 Fax # 973-482-2924

HARRISON

Hoboken Health Dept

Frank S. Sasso, M.S., M.S.W.

Health Officer

124 Grand Street Hoboken, NJ 07030-4297

201-420-2365 Fax # 201-420-7862

HOBOKEN

Jersey City Division of Health

Joseph Castagna, M.S.

Health Officer

586 Newark Avenue

Jersey City, NJ 07306-2302

201-547-5545 Fax # 201-547-4848

JERSEY CITY

Kearny Dept of Health

John P. Sarnas, M.A.

Health Officer

645 Kearny Avenue Kearny, NJ 07032-2998

201-997-0600

Fax #201-997-9703

EAST NEWARK KEARNY

HUDSON CO. DIV. OF ENVIRONMENTAL HEALTH

North Bergen Health Dept

Richard J. Censullo, M.P.H.

Health Officer

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

1116 43rd Street

North Bergen, NJ 07047

201-392-2084

NORTH BERGEN

UNION CITY

Secaucus Health Department

VACANT

Health Officer

20 Centre Avenue

Secaucus, NJ 07094

201-330-2030 FAX 201-330-8352

SECAUCUS

West New York Health Dept

Vincent A. Rivelli, M.S.

Health Officer

428 — 60th Street, Room 31 West New York, NJ 07093

201-295-5070

Fax # 201-869-1715

GUTTENBERG

WEEHAWKEN

WEST NEW YORK

HUNTERDON COUNTY

Hunterdon County Dept of Health

John Beckley, M.P.H.

Health Officer

County Complex, Building #7 Route 12 — PO Box 2900

Flemington, NJ 08822-1396

908-788-1351

Fax # 908-782-7510

ALEXANDRIA TWP BETHLEHAM TWP BLOOMSBURY

CALIFON CLINTON TOWN CLINTON TWP

DELAWARE TWP EAST AMWELL TWP FLEMINGTON

FRANKLIN TWP (HUNTERDON CO.) FRENCHTOWN GLEN GARDNER

HAMPTON BORO (HUNTERDON CO.) HIGH BRIDGE HOLLAND

KINGWOOD LAMBERTVILLE LEBANON

LEBANON TWP MILFORD RARITAN TWP

READINGTON TWP STOCKTON TEWKSBURY

UNION TWP WEST AMWELL TWP

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

MERCER COUNTY

East Windsor Township Health Department

Patricia A. Hart, RS MPH

Health Officer

Municipal Building

16 Lanning Boulevard

East Windsor, NJ 08520-1999

609-443-4000 Fax # 609-443-8030

EAST WINDSOR TWP

HIGHTSTOWN BORO

EWING TWP

Hamilton Township Division of Health

Jeffrey J. Plunkett, B.A., M.Ed. Health Officer

2100 Greenwood Avenue

PO Box 00150

Hamilton, NJ 08650-1050

609-890-3820

E-mail address: jplunkett@hamiltonnj.com

http://www.hamiltonnj.com/index.htm

HAMILTON TWP

Hopewell Township Health Dept

Gary A. Guarino

Health Officer

201 Washington Crossing-Pennington Rd Titusville, NJ 08560-1410

609-737-0120

FAX # 609-737-1022

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

HOPEWELL BORO

HOPEWELL TWP

PENNINGTON BORO

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Princeton Regional Health Commission

William J Hinshillwood, MA

Health Officer

Borough Hall

1 Monument Drive, PO Box 390 Princeton, NJ 08542

609-497-7610

E-mail address: dhenry@princetonboro.org

PRINCETON BORO

PRINCETON TWP

Lawrence Township Health Department

Carol Chamberlain

Health Officer

PO Box 6006

2207 Lawrenceville Road

Lawrenceville, New Jersey 08648-3198

609-844-7089 Fax # 609-884-5324

LAWRENCE TWP

City of Trenton — Dept of Health & Human Services, DOH

Richard D. Salter, M.A.

Health Officer

222 East State Street

Trenton, NJ 08608-1866

609-989-3636

TRENTON

West Windsor Township Health Dept

Robert Hary, M.A., M.B.A. Health Officer

PO Box 38

271 Clarksville Road

Princeton Junction, NJ 08550-0038

609-799-2400 FAX # 609-799-2044

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

WASHINGTON TWP

WEST WINDSOR TWP

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

MIDDLESEX COUNTY

Edison Dept of Health & Human Resources

John O. Grun, M.S.

Health Officer

Municipal Complex

100 Municipal Boulevard Edison, NJ 08817-3353

732-248-7290

E-mail address: health@edisonnj.org

www.edisonnj.org

EDISON

Middle-Brook Regional Health Commission

Kevin G. Sumner, M.P.H. Health Officer

Boro Hall

1200 Mountain Avenue Middlesex, NJ 08846-1200

732-356-8090 FAX # 732-356-7954

BOUND BROOK (SOMERSET CO.)

GREEN BROOK TWP (SOMERSET CO.)

MIDDLESEX BORO

SOUTH BOUND BROOK (SOMERSET CO.)

WARREN TWP (SOMERSET CO.)

WATCHUNG (SOMERSET CO.)

Middlesex County Public Health Dept

Bernard G Mihalko

Director

35 Oakwood Avenue

Edison, NJ 08837

732-745-3100

 

CARTERET CRANBURY DUNELLEN

EAST BRUNSWICK HELMETTA HIGHLAND PARK

JAMESBURG METUCHEN MILLTOWN

MONROE TWP (MIDDLESEX CO.) NEW BRUNSWICK NORTH BRUNSWICK

OLD BRIDGE PERTH AMBOY PLAINSBORO

 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

SAYREVILLE SOUTH AMBOY SOUTH PLAINFIELD

SOUTH RIVER SPOTSWOOD

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Piscataway Township Health Dept

Andrew C. Simpf, Jr., M.A.

Health Officer

455 Hoes Lane

Piscataway, NJ 08854-5097

732-562-2323 Fax # 732-743-2500

PISCATAWAY

South Brunswick Health Dept

Stephen J. Papenberg Health Officer

Ridge Road/Route 522 PO Box 190

Monmouth Junction, NJ 08852-0190

732-329-4000 x 237

ROCKY HILL (SOMERSET CO.)

SOUTH BRUNSWICK

Woodbridge Twp Dept of Hlth & Hum Srvs

Patrick O Hanson

Health Officer

2 George Frederick Plaza

Woodbridge, NJ 07095 LHD Code D1278

732-855-0600 x 5025 Fax # 732-855-0944

WOODBRIDGE

MONMOUTH COUNTY

Colts Neck Township Health Dept

William McBride

Health Officer

124 Cedar Drive

Colts Neck, NJ 07722-0249

732-462-5470

COLTS NECK

Freehold Area Health Department

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

R. Chadwick Taylor, MBA

Health Officer

1 Municipal Plaza

Freehold, NJ 07728-3099

732-294-2060 FAX # 732-462-2340

FREEHOLD BORO

FREEHOLD TWP

MILLSTONE

UPPER FREEHOLD

Hazlet-Aberdeen Health Dept

Robert N. Scapicio, M.A.

Health Officer

3400 State Highway 35

Suite 9

Hazlet, NJ 07730-0371

732-264-5541 Fax # 732-264-0659

ABERDEEN

HAZLET

Long Branch Dept of Health

David Roach, M.P.H. Health Officer

344 Broadway

Long Branch, NJ 07740-6938

732-571-5665

LONG BRANCH

Manalapan Township Dept of Health

W. David Richardson, M.P.H. Health Officer

120 Route 522

Manalapan, NJ 07726-3497

732-446-8345

E-mail address: health@twp.manalapan.nj.us

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

MANALAPAN

Matawan Regional Department of Health

Alan C. Hopper

Health Officer

145 Borad Street

Matawan, New Jersey 07748

732-566-0740 Fax # 732-566-7283

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

 HOLMDEL

KEANSBURG

KEYPORT

MATAWAN

 Middletown Township Health Dept

Stephen L. McKee

Health Officer

Johnson Gill Annex Building 1 Kings Highway

Middletown, NJ 07748-2594

732-615-2095

E-mail address: smckee@middletownnj.org

 MIDDLETOWN

 Monmouth County Health Dept

Lester W. Jargowsky, M.P.H. Pub Hlth Coord

3435 Highway 9 Freehold, NJ 07728-2850

732-431-7456

E-mail address: ljargows@co.monmouth.nj.us

ALLENTOWN BORO ASBURY PARK CITY ATL HIGHLANDS BORO

AVON-BY-THE-SEA BORO BELMAR BORO BOROUGH OF LAKE COMO

BRADLEY BEACH BORO ENGLISHTOWN BORO FARMINGDALE BORO

HOWELL TWP MANASQUAN MARLBORO TWP

MATAWAN MILLSTONE TWP NEPTUNE CITY

NEPTUNE TWP OCEANPORT ROOSEVELT BORO

SEA GIRT BORO SPRING LAKE BORO UNION BEACH

WALL TWP

 

Monmouth Cty Reg Health Commission # 1

Sidney B. Johnson, Jr., M.S., MBA Health Officer

1540 West Park Avenue

Suite 1

Ocean Twp, NJ 07712

732-493-9520

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

E-mail address: IPPY2@IX.NETCOM.COM

 

ALLENHURST BRIELLE DEAL

EATONTOWN FAIR HAVEN HIGHLANDS

HOLMDEL INTERLAKEN KEANSBURG

KEYPORT LITTLE SILVER LOCH ARBOR VILLAGE

MONMOUTH BEACH OCEAN TWP (MONMOUTH CO.) RED BANK

RUMSON SEA BRIGHT SHREWSBURY

SPRING LAKE HEIGHTS SREWSBURY TWP TINTON FALLS

WEST LONG BRANCH

Red Bank Health Department

Frederick A Riehart

Health officer

90 Monmouth Street, Box 868

Red Bank, New Jersey 07701

732-530-2754

FAIRHAVEN RED BANK

LITTLE SILVERRUMSON

 MORRIS COUNTY

 Denville Division of Health

Herbert J Yardley, MA

Health Officer

1 Saint Mary’s Place Denville, NJ 07834-2199

973-625-8305 FAX 973-627-8371

 DENVILLE

 Dover Health Dept

Donald N. Costanzo, M.A., M.P.A.

Health Officer

37 North Sussex Street, Box 798

Dover, NJ 07802-0798

973-366-2200 ext. 120 Fax. 973-328-6604

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 DOVER

 East Hanover Health Dept

Peter Summers, MA

Health Officer

411 Ridgedale Avenue

East Hanover, NJ 07936-1487

973-428-3035 E-mail address:chanover@interactive.net

Fax # 973-428-2986

Website: http://www.easthanovertownship.com

 EAST HANOVER TWP

ROSELAND BORO (ESSEX CO.)

 Township of Hanover Health Dept

George Van Orden, PhD

Health Officer

1000 Route 10, PO Box 250

Whippany,, NJ 07981-0250

973-428-2484 E-mail address:van122w@wonder.em.ede.gov

 HARDING TWP MORRIS TWP

HANOVER TWP

 Jefferson Township Health Dept

Cindee DeGennaro, M.A. Health Officer

1033 Weldon Road

Lake Hopatcong, NJ 07849-0367

973-697-1500 FAX: 973-697-8090

 JEFFERSON TWP

 Borough of Kinnelon Health Department

Calliope C. Alexander, MA, BS

Health Officer

Municipal Building, 130 Kinnelon Road

Kinnelon, New Jersey 07405

973-838-5403 fax 973-838-1862

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 KINNELON

 Lincoln Park Health Dept

Pasquale A. Pignatelli, Jr., M.P.A.

Health Officer

34 Chapel Hill Road

Lincoln Park, NJ 07035-1998

973-694-6306 Fax # 973-628-9512

 BOONTON TWP

LINCOLN PARK

RIVERDALE

 Madison Boro Board of Health

John Theese, M.S.

Health Officer

28 Walnut Street

Madison, NJ 07940-2592

973-593-3079

 CHATHAM BORO CHATHAM TWP FLORHAM PARK BORO

LONG HILL TWP MADISON BORO MINE HILL TWP

MORRIS PLAINS BORO MOUNT ARLINGTON BORO VICTORY GARDEN BORO

 Montville Township Health Dept

John A. Wozniak, Jr., M.E.H. Health Officer

195 Changebridge Road

Montville, NJ 07045-9498

973-331-3316 FAX 973-402-0787

 MONTVILLE

MOUNTAIN LAKES

 Morris County Office of Health Management

Howard Steinberg

Health Officer

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 200 South Street PO Box 914

Morristown, NJ 07963-0914

973-292-6707 FAX# 973-292-6730

 MORRISTOWN

 Mt. Olive Township Health Dept

Frank P. Wilpert

Dir, Hlth, Welf & San

Route 46, PO Box 450 Budd Lake, NJ 07828-3200

973-691-0900 FAX # 973-691-7681

 MT OLIVE

 Parsippany Health Dept

P. Wayne Croughn

Health Officer

Municipal Building

1001 Parsippany Blvd

Parsippany, NJ 07054-1222

973-263-7160 Fax # 973-299-1349

 PARSIPPANY-TROY HILLS

 Pequannock Township Board of Health

Peter Correale

Health Officer

530 Newark-Pompton Turnpike

Pompton Plains, NJ 07444-1799

973-835-5700 x 128 Fax # 973-835-4328

 BLOOMINGDALE (PASSAIC CO.)

BUTLER BORO

PEQUANNOCK

 Randolph Township Board of Health

Clement R. Ferdinando, M.P.H.

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 Health Officer

502 Millbrook Avenue

Randolph, NJ 07869-3799

973-989-7050 Fax # 973-989-7076

http://www.gti.net/randolph/

 RANDOLPH ROCKAWAY BORO

 Rockaway Township Health Dept

Steven C. Levinson, M.S.

Health Officer

65 Mt. Hope Road

Rockaway, NJ 07866-1699

973-983-2848 Fax # 973-983-2497

 BOONTON BORO CHESTER TWP

ROCKAWAY TWP

 Roxbury Township Health Department

Frank A. Grisi

Health Officer

72 Eyland Avenue

Succasunna, NJ 07876-1622

973-448-2028 Fax # 973-252-6079

E-mail address: grisif@roxburynj.us

 ROXBURY WHARTON BORO

 Washington Township Health Dept

Cristianna Cooke-Gibbs, M.P.H. Health Officer

43 Schooley’s Mountain Road

Long Valley, NJ 07853

908-876-3650 Fax # 908-876-5138

 WASHINGTON TWP

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 OCEAN COUNTY

Long Beach Island Health Dept

Timothy J. Hilferty

Health Officer

11601 Long Beach Boulevard

Haven Beach, NJ 08008-3661

609-492-1212 Fax # 609-492-9215

 BARNEGAT LIGHT LONG BEACH

BEACH HAVEN SHIP BOTTOM

HARVEY CEDARS SURF CITY

 Ocean County Health Dept

Joseph Przywara, B.A.

Pub Health Coordinator

175 Sunset Avenue PO Box 2191

Toms River, NJ 08754-2191

732-341-9700 FAX 732-341-4467

 E-mail address: OCHD@americom.net

Website: http://www.ochd.org

 BARNEGAT TWP BAY HEAD BEACHWOOD

BERKELEY TWP BRICK TWP DOVER TWP

EAGLESWOOD TWP ISLAND HEIGHTS JACKSON TWP

LAKEHURST LAKEWOOD

LAVALLETTE LITTLE EGG HARBOR TWP MANCHESTER

MANTOLOKING OCEAN GATE OCEAN TWP

PINE BEACH POINT PLEASANT

POINT PLEASANT BEACH S. TOMS RIVER SEASIDE HEIGHTS

SEASIDE PARK STAFFORD TUCKERTON

LACEY TWP PLUMSTEAD

 PASSAIC COUNTY

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 Bloomingdale – See Pequannock (MORRIS CO)

Wanaque – See Pequannock (MORRIS CO)

Wayne – See Montclair (ESSEX CO)

 Clifton Board of Health

Albert Greco, MA

Health Officer

900 Clifton Avenue

Clifton, NJ 07013-2705

973-470-5763 FAX 973-470-5768

E-mail address: agrecol@worldnet.att.net

 CLIFTON

 Township of Little Falls Health Department

John M. Festa, MA

Health Officer

Municipal Annex

35 Stevens Avenue

Little Falls, New Jersey 07424

973-256-0170 FAX 973-890-4501

 LITTLE FALLS

SOUTH ORANGE (ESSEX CO.)

PASSAIC

 Passaic City Health Dept

Henry C McCafferty

Health Officer

City Hall

330 Passaic Street

Passaic, NJ 07055-5814

973-365-5603 FAX 973-365-5582

 PASSAIC

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 Passaic County Dept of Health

John J. Ferraioli

Health Officer

Administrative Bldg, Annex Rm 201

317 Pennsylvania Avenue

Paterson, NJ 07503-1788

973-881-4396 fax 973-225-0222

Email address: jfpedh@intercall.com

 Paterson Division of Health

Joseph J. Surowiec

Health Officer

176 Broadway

Paterson, NJ 07505-1198

973-881-6922 FAX # 973-279-7511

E-mail address: mosses@interactive.net

 HALEDON PROSPECT PARK

HAWTHORNE TOTOWA

NORTH HALEDON WEST PATERSON

PATERSON

 Ringwood Health Dept

Christopher Chapman, M.P.H.

Health Officer

60 Margaret King Avenue

Ringwood, NJ 07456-1703

973-962-7079 Fax # 973-962-6028

 RINGWOOD

WANAQUE

 West Milford Township Health Dept

Kenneth R. Hawkswell, M.P.H.

Health Officer

1480 Union Valley Road

West Milford, NJ 07480-1303

973-728-2720

POMPTON LAKES

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 WEST MILFORD

SALEM COUNTY

Salem Co. Dept of Health

Lawrence P. Devlin, Jr., M.P.A., R.S., CSW

Health Officer

98 Market Street

Salem, NJ 08079-1995

609-935-7510 Fax # 609-935-8483

 

ALLOWAY CARNEYS POINT ELMER

ELSINBORO TWP LOWER ALLOWAYS MANNINGTON

OLDMANS PENNS GROVE PENNSVILLE

PILESGROVE PITTSGROVE QUINTON

SALEM UPPER PITTSGROVE WOODSTOWN

 SOMERSET COUNTY

Bround Brook – See Middle Brook (MIDDLESEX CO.)

Green Brook – See Middle Brook (MIDDLESEX CO.)

Rocky Hill – See S. Brunswick (MIDDLESEX CO.)

South Bround Brook – See Middle Brook (MIDDLESEX CO.)

Warren Twp – See Middle Brook (MIDDLESEX CO.)

Watchung – See Middle Brook (MIDDLESEX CO.)

 Bernards Township Health Dept

Lucy A. Forgione, M.S.

Health Officer

262 South Finley Avenue

Basking Ridge, NJ 07920-1418

908-204-3070 FAX 908-204-3075

 CHESTER BORO (MORRIS CO.) FAR HILLS

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 BEDMINSTER BERNARDS BERNARDSVILLE

MENDHAM BORO (MORRIS CO.)

MENDHAM TWP (MORRIS CO.) PEAPACK-GLADSTONE

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 Branchburg Township Health Dept

Leonard H. Williams, MPA, REHS/RS

Health Officer

Branchburg Township Department of Health

34 Kenbury Road

Somersville, NJ 08876

908-526-1300 x 215, FAX # 908-704-1214

E-mail address: bburg@superlink.com

 BRANCHBURG

 Bridgewater Township Health Dept

Richard N Martini, MPH.

Health Officer

700 Garretson Road

PO Box 6300

Bridgewater, NJ 08807-0300

908-725-5750

website: http://www.bcbex.net/bridgewater

 BRIDGEWATER

 Franklin Township Health Dept

Walter P. Galanowsky, M.P.H.

Health Officer

935 Hamilton Street Somerset, NJ 08873-3697

732-873-2500 x 377 FAX # 732-214-0969

 FRANKLIN TWP

 Hillsborough Township Health Dept

Glen Belnay, Ph.D.

Health Officer

379 South Branch Road Hillsborough, NJ 08844

908-369-5652 fax 908-369-8565

 HILLSBOROUGH MILLSTONE BORO

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 Montgomery Township Health Dept

David A. Henry, M.P.H.

Health Officer

Municipal Building

2261 Van Horne Road — Route 206

Belle Mead, NJ 08502-4012

908-359-8211 x245 Fax # 908-359-4308

E-mail address: monthealth@aol.com

 MONTGOMERY

 North Plainfield Health Department

Herbert W. Roesehke, Sr., M.S.

Health Officer

263 Somerset Street

North Plainfield, New Jersey 07060

908-769-2907, Fax # 908-769-6499

 NORTH PLAINFIELD

 Somerset County Health Dept

John A. Horensky, M.S.

Health Officer

County Admin. Bldg.,

20 Grove Street PO Box 3000

Somerville, NJ 08876-1262

908-231-7155 Fax 908-704-8042

 Somerville Health Dept

Steve Krajewski, M.P.H.

Health Officer

25 West End Avenue Municipal Building

Someville, NJ 08876-0399

908-704-6980 Fax # 908-704-8042

E-mail address: skraj@njpha.org

Website: http://www.njpha.org

 MANVILLE RARITAN SOMERVILLE

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 SUSSEX COUNTY

Borough of Hopatcong

Carl Sever, B.A.,

Health Officer

Municipal Building

111 River Styx Road

Hopatcong, NJ 07843-1535

973-770-1200 143 Fax # 973-398-3650

 HOPATCONG

 Sparta Health Dept

Ralph J. D’Aries, R.S., M.A.

Health Officer

65 Main Street

Sparta, NJ 07871-1986

973-729-6174

 FRANKLIN BORO

HARDYSTOWN

OGDNESBURG

SPARTA

STANHOPE

 Sussex Cty Dept of Health, Public Safety & Senior Srvs

Philip Morlock

Administrator

127 Morris Turnpike

Newton, NJ 07860-7860

973-579-0370 Fax #973-948-2593

 ANDOVER BORO LAFAYETTE

ANDOVER TWP MONTAGUE

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 BRANCHVILLE

BYRAM FRANKFORD FREDON

GREEN TWP HAMBURG

NEWTON

SANDYSTON STILLWATER SUSSEX

WALPACK WANTAGE HAMPTON

 Vernon Township Board of Health

Gene S. Osias, M.S.W.

Health Officer

Municipal Center, 21 Church Street

PO Box 340

Vernon, NJ 07462-0340

973-764-4055 Fax 973-764-4055

 VERNON

 UNION COUNTY

 Clark Health Dept

Nancy A. Ogonowski, M.P.H.

Health Officer

430 Westfield Avenue

Clark, NJ 07066

732-388-3600 x 3045 Fax # 732-388-1268

 CLARK

 Township of Cranford Department of Health

Warren J Hehl, MPA

Health Officer

8 Springfield Avenue

Cranford, NJ 07016-2199

908-709-7238 Fax# 908-276-7664

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 CRANFORD

 Elizabeth Dept. of Health & Human Services

John N. Surmay

Health Officer

City Hall of Elizabeth G-12

50 Winfield Scott Plaza

Elizabeth, NJ 07201-2462

908-820-4060 Fax # 908-820-4290

 ELIZABETH

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 Linden Board of Health

Nancy Koblis

Health Officer

City Hall

301 North Wood Avenue

Linden, NJ 07036-4296 LHD Code D2032

908-474-8409 Fax # 908-474-8418

 LINDEN ROSELLE

 City of Plainfield Health Department

Ruby Hodge, MS, MA

Health Officer

510 Watchung Avenue, PO Box 431

Plainfield, New Jersey 07061- 0431

E-mail Address: jdipane@plainfield.com

Website: http://www.plainfield.com

 PLAINFIELD

 Rahway Health Department

Anthony D. Deige

Health Officer

1 City Hall Avenue

Rahway, NJ 07065-3930

732-827-2081 Fax # 732-381-7668

 HILLSIDE

RAHWAY

WINFIELD TWP

SCOTCH PLAINS

 Summit Health Department

Stuart B. Palfreyman, B.S.E.H., M.S.E.H., R.S.

Health Officer

512 Springfield Avenue

Summit, NJ 07901-3682

908-522-3614 Fax # 908-277-0185

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 BERKELEY HEIGHTS

NEW PROVIDENCE

SUMMIT

 Township of Union Department of Health

Dennis V. SanFilippo, MPA

Health Officer

Municipal Building

1976 Morris Avenue

Union, NJ 07083-1894

908-851-8507 Fax # 908-851-4673

 UNION

KENILWORTH

 Westfield Regional Health Dept

Robert M. Sherr, M.A. Health Officer

Municipal Building

425 East Broad Street

Westfield, NJ 07090-2197

908-789-4070

E-mail address: health@westfieldnj.net

http://www.westfieldnj.net/health

 FANWOOD

GARWOOD

MOUNTAINSIDE

ROSELLE PARK

SPRINGFIELD

WESTFIELD

 WARREN COUNTY

Warren County Health Dept

John Hawk, MPA

Health Officer

315 W. Washington Avenue

Washington, NJ 07882-2153

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

 

 908-689-6693 Fax # 908-689-3832

E-mail address: hawkjohn@njlincs.net

 ALLAMUCHY ALPHA BELVIDERE

BLAIRSTOWN FRANKLIN TWP (WARREN CO.) FREINGHUYSEN

GREENWICH TWP (WARREN CO.) HACKETTSTOWN HARDWICK

HARMONY HOPE INDEPENDENCE

KNOWLTON LIBERTY LOPATCONG

MANSFIELD (WARREN CO.) OXFORD PHILLPSBURG

POHATCONG WASHINGTON BORO (WARREN CO.) WASHINGTON TWP (WARREN CO.)

WHITE TWP

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

B.4.9 Mental Health/Substance Abuse Screening Tools

			
	HMO Financial Reporting Specifications
	 	State of New Jersey

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

 

															
	o
	Americhoice	 	o	Amerigroup	 	 	o	Horizon MercyNJ Health	 	o	Health Net	 	o	University Health
Plans

Well-Being Screening Tool

For Adolescents & Adults

Patient Problem Questionnaire

	 	 	 	 	 	 	 
	Patient Name:

	 	 	 	Date Completed:	 	 
	 

	 	 
	 	 	 	 
	Member ID#:

	 	 	 	PCP Name:	 	 
	 

	 	 
	 	 	 	 

The purpose of this questionnaire is to identify problems your doctor may be able to help you
with.

Please answer all questions by checking one box per question.

	 	 	 	 	 
	During the past month generally (questions 1-11):	 	YES	 	NO
	 
	1. Have you been feeling tired or have low energy?
	 	 	 	 
	 
	 	 	 	 
	2. Have you been having trouble sleeping (Too much or too little)?
	 	 	 	 
	 
	 	 	 	 
	3. Have you been feeling sad, hopeless, or unusually happy?
	 	 	 	 
	 
	 	 	 	 
	4. Have you been feeling bad about yourself that you are a failure or have let yourself or
your family down?
	 	 	 	 
	 
	 	 	 	 
	5. Have you been having trouble concentrating on things, such as watching TV, reading the
newspaper, or reading a book?
	 	 	 	 
	 
	 	 	 	 
	6. Have you been feeling on edge, nervous?
	 	 	 	 
	 
	 	 	 	 
	7. Have your eating patterns or appetite changed?
	 	 	 	 
	 
	 	 	 	 
	8. Have you been trying not to gain weight (making yourself vomit, taking excessive
laxatives, or exercising more than an hour per day)?
	 	 	 	 
	 
	 	 	 	 
	9. Have you felt sudden fear or panic for no obvious reason?
	 	 	 	 
	 
	 	 	 	 
	10. Have you been having thoughts that you would be better off dead, or of hurting yourself?
	 	 	 	 
	 
	 	 	 	 
	11. Are you troubled by being unable to control your anger or by having thoughts about
hurting others?
	 	 	 	 
	 
	 	 	 	 
	12. Have you
	 	 	 	 
	 
	 	 	 	 
	a. Ever felt you ought to cut down on your drinking or drug use?
	 	 	 	 
	 
	 	 	 	 
	b. Ever felt annoyed by people who comment on your drinking or drug use?
	 	 	 	 
	 
	 	 	 	 
	c. Ever felt bad or guilty about your drinking or drug use?
	 	 	 	 
	 
	 	 	 	 
	d. Ever had a drink or used drugs first thing in the morning to steady your nerves or get
rid of a hangover (eye opener)?
	 	 	 	 
	 
	 	 	 	 
	13. Do you have any other concerns about your well-being? Please Explain
	 	 	 	 
	 
	 	 	 	 
	14. Have you ever sought treatment for any of the above problems for which you checked yes?
	 	 	 	 
	 
	 	 	 	 
	15. If you checked yes to any of the above questions, how difficult have these problems
made it for you to do your work, go to school, take care of things at home or get along
with other people?
	 	 	 	 
	Not Difficult At All Somewhat Difficult Very Difficult Extremely Difficult
	 	 	 	 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For
Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

B.4.11 Special Child Health Services Network 

The contractor shall utilize the following DHSS website to access an updated list of special Child
Health Services County Case Management Units:

http://www.state.nj.us/health/fhs/sccasemg.htm

The following pages list special child health services network agencies by provider type.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For
Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

NEW JERSEY DEPARTMENT OF HEALTH AND SENIOR SERVICES

SPECIAL CHILD, ADULT AND EARLY INTERVENTION SERVICES

County Case Management Units

Atlantic County SCHS Case Management Unit

Department. Of Intergenerational Services

101 South Shore Road

Northfield, NJ 08225-2320

609-645-77010 Ext. 4358

Fax # 609-645-5907

Bergen County SCHS-Case Management Unit

Bergen County Dept. of Health Services

327 Ridgewood Avenue, Second Floor

Paramus, NJ 07652-4895

(201) 634-2620

Fax # (201) 599-8947

Burlington County SCHS-Case Management Unit

Community Nursing Services

Raphael Meadow Health Center

P.O. Box 287 Woodlane Road

Mount Holly, NJ 08060-0287

(609) 267-1950 Ext. 42882

Fax # (609) 702-0541

Camden County SCHS-Case Management Unit

Camden County Division of Health

Jefferson House — Lakeland Road, PO Box 9

Blackwood, NJ 08012-0009

(856) 374-6021 or (800) 999-9045

Fax # (856) 374-9734

Cape May County SCHS-Case Management Unit

Cape May Dept. of Health

6 Moore Rd. Crest Haven Complex

Cape May Court House, NJ 08210-3067

(609) 465-1203

Fax # (609) 463-3527

Cumberland County SCHS-Case Management Unit

Cumberland County Dept. of Health

790 East Commerce Street

Bridgeton, NJ 08302-2293

(856) 453-2154

Fax # (856) 453-0338

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For
Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

Essex County SCHS-Case Management Unit

County of Essex Department of Health and Rehabilitation

Division of Community Health Services

Unit of Special Child, Adult and Early Intervention Services

160 Fairview Ave. Rawson Hall, Bldg. #37

Cedar Grove, NJ 07009

(973) 857-4663 or 857-4745

Fax # (973) 857-5163

Gloucester County SCHS-Case Management Unit

Gloucester County Health Department

160 Fries-Mill Road

Turnersville, NJ 08012-2496

(856) 262-4100 (Ext. 4157)

Fax # (856) 629-0469

Hudson County SCHS-Case Management Unit

Jersey City Medical Center

50 Baldwin Avenue, Dept. 2124

12 th  Floor Clinic Bldg.

Jersey City, NJ 07304-3199

(201) 915-2514

Fax # (201) 915-2565

Hunterdon County SCHS-Case Management Unit

Hunterdon Medical Center

2100 Wescott Drive

Flemington, NJ 08822-9238

(908) 788-6399

Fax # (908) 788-6581

Mercer County SCHS-Case Management Unit

Sypek Center

129 Bull Run Road

Pennington, NJ 08534

(609) 730-4152 or (609) 730-4151

Fax # (609) 730-4154

Middlesex County SCHS-Case Management Unit

Middlesex County Department of Health

75 Bayard Street — 5 th  Floor

New Brunswick, NJ 08901

(732) 745-3100

Fax # (732) 296-7990

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For
Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

Monmouth County SCHS-Case Management Unit

Monmouth County — Special Child Health/Early Intervention

141 Bodman Place

Red Bank, NJ 07701

(732) 224-6950

Fax # (732) 747-4404

Morris County SCHS-Case Management Unit

Morristown Memorial Hospital

100 Madison Avenue, Box 99

Morristown, NJ 07960-6095

(973) 971-4155

Fax # (973) 290-7358

Ocean County SCHS-Case Management Unit

Ocean County Department of Health

PO Box 2191

Sunset Avenue

Toms River, NJ 08754-2191

(732) 341-9700 Ext. 7602

Fax # (732) 341-5461

Passaic County SCHS-Case Management Unit

Catholic Family and Community Services

279 Carroll Street

Paterson, NJ 07505

(973) 523-6778

Fax # (973) 523-7715

E-mail address: schspassaic@aol.com

Salem County SCHS-Case Management Unit

Salem County Department of Health

98 Market Street

Salem, NJ 08079-1911

(856) 935-7510 Ext. 8479

Fax # (856) 935-8483

Somerset County SCHS-Case Management Unit

Somerset Handicapped Children’s Treatment Center

377 Union Avenue

P.O. Box 6824

Bridgewater, NJ 08807-0824

(908) 725-2366

Fax # (908) 725-3945

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For
Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Sussex County SCHS-Case Management Unit

Sussex County Health Department

Division of Public Health Nursing

129 Morris Turnpike

Newton, NJ 07860

(973) 948-5400 Ext. 49

Fax # (973) 948-2270

Union County SCHS-Case Management Unit

328 South Avenue

Fanwood, NJ 07023

(908) 889-0950

Fax # (908) 889-7535

Warren County SCHS-Case Management Unit

Warren County Health Department

Special Child, Adult and Early Intervention Services

162 East Washington Avenue

Washington, NJ 07882-2196

(908) 689-6000 Ext. 258

Fax # (908) 835-1172

E-mail address: wcschs@netscape.net

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For
Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

B.4.13 Ryan White CARE Act Grantees Statewide Family Centered HIV
Care Network (Ryan White Title IV)

The contractor shall utilize the following DHSS website to access an updated list of the Statewide
Family Centered HIV Network — (Ryan White Title V) centers.

http://www.state.nj.us/health/fhs/sregional.htm

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For
Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

 RYAN WHITE HIV CARE

CONSORTIA/RESOURCE CENTERS

The Consortia/Resource Centers provide regional planning and coordination of comprehensive
HIVrelated services: information and referral, prevention education, and a network of care and
treatment based on community-based case management.

AIDS Coalition of Southern New Jersey

Resource Center

100 Essex Road, Suite 300

Bellmawr, NJ 08031

609-933-9500 FAX (609)933-9515

Good Shepherd Community Services, Inc.

1576 Palisade Avenue

Ft. Lee, NJ 07024

201-461-7241 Fax: 201-461-2307

Mercer County HIV Consortium

447 Bellevue Avenue

Trenton, NJ 08618

609-278-9555 or 1-800-550-6755 Fax: 609-278-0553

Middlesex County HIV Resource Center

Visiting Nurse Association of Central Jersey

275 Hobart Street

Perth Amboy, NJ 08861

732-442-6225 Fax: 732-442-4285

Monmouth-Ocean HIV Care Consortium

VNA of Central Jersey Foundation, Inc.

625 Bangs Avenue

Asbury Park, NJ 07712

732-502-5122 or 1-800-947-0020 Fax: 732-774-6006

Resource Center: 732-502-5128

Passaic County AIDS Resource Center

Coalition on AIDS in Passaic County, Inc.

100 Hamilton Plaza, Room 707

Paterson, NJ 07505

973-742-6742 Fax: 973-742-6750

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For
Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Somerset-Hunterdon HIV Care Consortium

Women’s Health and Counseling Center

95 Veteran’s Memorial Drive

Somerville, NJ 08876

1-800-313-2335 Fax: 908-526-7023

Resource Center 908-704-9641

South Jersey AIDS Alliance

Resource Center Atlantic/Cape May HIV Case Consortium

19 Gordon’s Alley

Atlantic City, NJ 08101

609-347-1085 FAX 609-348-8775

South Jersey Council on AIDS

(serving Burlington, Camden, Salem and Gloucester)

120 White Horse Pike, Suite 110

Haddon Heights, NJ 08035

609-547-6600 Fax: 609-547-6656

The HIV Care Consortium/Resource Center

Atlantic City Medical Center

16 South Ohio Avenue

Atlantic City, NJ 08401

609-441-8181 or 1-800-281-2437 Fax: 609-441-8938

Union County HIV Consortium

Union County HIV Resource Center

80 West Grand Street — Lower Level

Elizabeth, NJ 07202

908-352-7700 or 1-800-279-2437 Fax: 908-352-7727

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For
Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

B.5.2 Cost-Sharing Requirements for NJ FamilyCare Plan C, Plan D and Plan H
Beneficiaries

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For
Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

COST-SHARING REQUIREMENTS FOR

NJ FAMILYCARE PLAN H

Copayments will be required of individuals eligible through NJ FamilyCare Plan H whose family
income is between 151% and up to and including 250% of the federal poverty level. The total family
limit (regardless of family size) on all cost-sharing may not exceed 5% of the annual family
income.

Below is listed the services requiring copayments and the amount of each copayment.

	 	 	 
	SERVICE	 	AMOUNT OF COPAYMENT
	1. Outpatient Hospital Clinic Visits, including
Diagnostic Testing

	 	$5 copayment for each outpatient clinic visit
that is not for preventive services
	 
	 	 
	2. Independent Clinic Visits

	 	$5 copayment for each visit except
for preventive services
	 
	 	 
	3. Hospital Outpatient Mental Health Visits

	 	$25 copayment for each visit
	 
	 	 
	4. Outpatient Substance Abuse Services
for Detoxification

	 	$5 copayment for each
visit
	 
	 	 
	5. 4. Hospital
Outpatient Emergency Services
Covered for Emergency Services only, including
services provided in an outpatient hospital
department or an urgent care facility. [Note:
Triage and medical screenings must be covered
in all situations.]

	 	$35 copayment; no copayment is required if the
member was referred to the Emergency Room by
his/her primary care provider for services
that should have been rendered in the primary
care provider’s office or if the member is
admitted into the hospital.
	 
	 	 
	6. 5. Primary Care
Provider Services provided during normal office
hours

	 	$5 copayment for each visit (except for
preventive services.)
	 
	 	 
	7. 6. Primary Care
Provider Services during nonoffice hours and for
home visits

	 	$10 copayment for each visit
	 
	 	 
	8. 7. Prescription Drugs

	 	$5 copayment. If greater than a 34-day supply
of a prescription drug is dispensed, a $10
copayment applies.
	 
	 	 
	9. 8. Nurse Midwives,
non-maternity services; certified nurse
practitioner, clinical nurse specialist

	 	$5 copayment except for preventive services;
$10 for services rendered during non-office
hours and for home visits
	 
	 	 
	10. 9. Physician
specialist office visits during normal office hours

	 	$5 copayment per visit
	 
	 	 
	11. 10. Physician
specialist office visits during nonoffice hours or
home visits

	 	$10 copayment per visit
	 
	 	 
	12. 11. Psychologist
Services

	 	$5 copayment for each visit
	 
	 	 
	13. 12. Laboratory and
X-ray Services

	 	$5 copayment for each visit that is not part
of an office visit

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For
Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

B.7.3 Financial Guide for Reporting Medicaid/NJ FamilyCare Rate Cell Grouping
CostsReserved

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For
Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

HMO Financial

Reporting Manual

For Medicaid/NJ FamilyCare

Rate Cell Grouping Costs

State of New Jersey 

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For
Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Contents

	 	 	 	 	 
	1. Introduction
	 	 	2	 
	 
	 	 	 	 
	2. General Instructions
	 	 	7	 
	 
	 	 	 	 
	3. Report Specifications
	 	 	9	 
	 
	 	 	 	 
	• Report #1: Lag Report (Table 20, Parts A-E)
	 	 	9	 
	 
	 	 	 	 
	• Report #2: Income Statements by Rate Cell Grouping (Table 19, Parts A-V)
	 	 	13	 
	 
	 	 	 	 
	Table 19, Parts A – S3: Medicaid/NJ FamilyCare Managed Care at Risk Groupings
	 	 	 	 
	 
	 	 	 	 
	Table 19, Part T: Non State Plan Services
	 	 	 	 
	 
	 	 	 	 
	Table 19, Parts U and V: Managed Care Service Administrator Groupings
	 	 	 	 
	 
	 	 	 	 
	• Report #3: Maternity Outcome Counts (Table 21)
	 	 	24	 
	 
	 	 	 	 
	• Report #4: Claims Processing Lag Report (Parts A – B)
	 	 	25	 
	 
	 	 	 	 
	• Report #7: Stop Loss Summary (Parts A- C)
	 	 	29	 
	 
	 	 	 	 
	• Report #10: Third Party Liability Collections
	 	 	30	 
	 
	 	 	 	 
	4. Incurred But Not Reported (IBNR) Methodology
	 	Appendix A
	 
	 	 	 	 
	5. Report Forms
	 	Appendix B

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For
Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Introduction

 

Purpose

The objective of this Financial Reporting Specifications is to ensure uniformity, accuracy and
completeness in reporting Medicaid/NJ FamilyCare rate cell groupings. In addition, the provision
of this Financial Reporting Specifications to the HMOs will help to eliminate inconsistencies, as
reports can vary in the presentation of items such as allocation of expenses, accrual of incurred
but not reported (IBNR) claims, handling of maternity claims, and other items. All reports shall
be submitted as outlined in the general instructions. The financial reports submitted from this
Financial Reporting Specifications will be used in future rate setting and to better assess the
financial performance of HMOs.

The reports in this Financial Reporting Specifications are to supplement, not replace, the
reporting requirements currently required in the Division of Medical Assistance and Health Services
(DMAHS) Managed Care Contract (please refer to Section A of the contract). Key differences between
this Financial Reporting Specifications and the reports currently submitted to the State are as
follows:

*Rate cell grouping detail;

*Regional detail;

*IBNR calculation detail; and

*Timing of submissions.

Rate Cell Groupings

     This Financial Reporting Specifications requires key cost reporting by rate cell grouping.
Rate cells have been combined into nineteen rate cell groupings for these reporting purposes
(seventeen rate call groupings for Medicaid/NJ FamilyCare Managed care at risk populations and two
rate cell groupings for Managed Care Service Administrator (MCSA) populations). Please note where
Acquired Immunodeficiency Syndrome (AIDS) individuals are included or excluded in the rate cell
groupings. Also note that maternity and newborn costs are reported as separate rate cell groupings
and shall be excluded from other rate cell groupings. The rate cell groupings are as follows:

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Introduction

 

	 	 	 	 	 	 	 	 	 
	Rate Cell	 	 	 	 	 	 
	Reference	 	Rate Cell Grouping	 	Capitation Code	 	Description
	AFDC/SSI/DDD

	 
	 	 	 	 	 	 	 	 
	Table
#19 –
Parts
A, B, C

	 	AFDC/NJCPW/ NJ
KidCare A
(Excluding AIDS)
	 	125R1 – 125R3

143R1 – 143R3

171R1 – 171R3

172R1 – 172R3

183R1 – 183R3
	 	Individuals eligible
for Aid to Families
with Dependent
Children (AFDC), New
Jersey Care Pregnant
Women (NJCPW), or NJ
KidCare A (children
below the age of 19
with family incomes up
to and includingi 133%
of the federal poverty
level (FPL)),
excluding individuals
with AIDS.
	 
	 	 	 	 	 	 	 	 
	Table
#19 –
Part D

	 	DYFS Clients
(Excluding AIDS)
	 	 	32599, 34399	 	 	Individuals eligible
through the Division
of Youth and Family
Services (DYFA),
including Foster Care
children and children
with Adoption
Assistance, excluding
individuals with AIDS.
	 
	 	 	 	 	 	 	 	 
	Table
#19 –
Part E

	 	ABD with Medicare –
DDD
(Excluding AIDS)
	 	 	48399	 	 	ABD (Aged, Blind,
and/or Disabled)
individuals who
receive Medicare and
are eligible for
services through the
Division of
Developmental
Disabilities (DDD),
excluding individuals
with AIDS.
	 
	 	 	 	 	 	 	 	 
	Table
#19 –
Part F

	 	ABD with Medicare –
DDD
(Excluding AIDS)
	 	 	711R1 – 711R3

813R1 – 813R3

823R1 – 823R3	 	 	ABD individuals who
receive Medicare and
are not eligible for
services through the
DDD, excluding
individuals with AIDS.
	 
	 	 	 	 	 	 	 	 
	Table
#19 –
Part G

	 	Non ABD – DDD
(Excluding AIDS)
	 	 	47399	 	 	Non ABD individuals
eligible for services
through the DDD,
excluding individuals
with AIDS.
	 
	 	 	 	 	 	 	 	 
	Table
#19 –
Part H

	 	ABD without
Medicare – DDD
(Including AIDS)
	 	 	49339	 	 	ABD individuals not
receiving Medicare and
eligible for services
through the DDD,
including individuals
with AIDS.

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Introduction

 

	 	 	 	 	 	 	 	 	 
	Rate Cell	 	 	 	 	 	 
	Reference	 	Rate Cell Grouping	 	Capitation Code	 	Description
	AFDC/SSI/DDD

	 
	 	 	 	 	 	 	 	 
	Table
#19 –
Part I

	 	ABD without
Medicare – DDD
(Including AIDS)
	 	 	71099,	 	 	ABD individuals not
receiving Medicare and
eligible for services
through the DDD,
including individuals
with AIDS.
	 
	 	 	 	 	 	 	 	 
	NJ FamilyCare/NJ KidCare

	 
	 	 	 	 	 	 	 	 
	Table
#19 –
Part J

	 	NJ KidCare B&C
(Excluding AIDS)
	 	 	62599, 63399	 	 	Eligible children
under age 19 with
family income above
133% and up to and
including 200% FPL,
excluding individuals
with AIDS.
	 
	 	 	 	 	 	 	 	 
	Table
#19 –
Part K

	 	NJ KidCare D
(Excluding AIDS)
	 	 	92599. 93399	 	 	Eligible children
under age 19 with
family income between
201% and up to and
including 350% FPL,
excluding individuals
with AIDS.
	 
	 	 	 	 	 	 	 	 
	Table
#19 –
Part M

	 	NJ FamilyCare
Parents 0-133% FPL
(Excluding AIDS)
	 	 	57199, 57899, 58499	 	 	Parents with dependent
children with family
income between 0% and
133% FPL, excluding
individuals with AIDS.
	 
	 	 	 	 	 	 	 	 
	Table
#19 –
Part O

	 	NJ FamilyCare
Parents 134-250% FPL
(Excluding AIDS)
	 	 	95499, 97499, 98499	 	 	Parents with dependent
children with family
income between 134%
and 200% FPL,
Parents/caretakers
with children below
the age of 23, and
children from the age
of 19 through 22
years, who are full
time students who do
not qualify for AFDC
Medicaid with family
incomes up to and
including 250% of FPL,
excluding individuals
with AIDS.
	 
	 	 	 	 	 	 	 	 
	Special Populations/Data

	 
	 	 	 	 	 	 	 	 
	Table
#19 –
Part

	 	ABD with Medicare
P- AIDS
	 	 	28499, 45499	 	 	ABD individuals with
AIDS who receive
Medicare, including
those eligible for
DDD, excluding the
risk adjusted
populations.

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Introduction

 

	 	 	 	 	 	 	 
	Rate Cell	 	 	 	 	 	 
	Reference	 	Rate Cell Grouping	 	Capitation Code	 	Description
	AFDC/SSI/DDD

	 
	 	 	 	 	 	 
	Table
#19 –
Part Q

	 	Non ABD — AIDS
	 	27499, 47499, 27699
	 	Non ABD individuals
with AIDS including
AFDC, NJCPW, NJ
KidCare DYFS, and NJ
FamilyCare Parents,
excluding the risk
adjusted populations.
	 
	 	 	 	 	 	 
	Table
#19 –
Part R1

	 	Maternity
	 	N/A
	 	Please refer to
criteria outlined in
the instructions for
Report #2R1 in the
Report Specifications
section.
	 
	 	 	 	 	 	 
	Table
#19 –
PartR2

	 	Newborn
	 	Include 6 newborn
claims costs
associated within:
103R1, 103R3.
30399, 60399,
80399, 90399
	 	Pleae refer to
criteria outlined in
the instructions for
Report #2R2, in the
Report Specifications
section.
	 
	 	 	 	 	 	 
	MCSA

	 
	 	 	 	 	 	 
	Table
#19 –
Part U

	 	NJ FamilyCare
Adults 0-100% FPL
(Excluding AIDS)
	 	65499, 97499, 68499
	 	Single adults and
couples without
dependent children
with family income
between 0% and 100%
FPL, adults and
couples without
dependent children
under the age of 23,
with family incomes up
to and including 250%
of FPL, excluding
individuals with AIDS.
Includes health
Access Individuals
without dependent
children.
	 
	 	 	 	 	 	 
	Table
#19 –
Part V

	 	Adult Restricted
Aliens
	 	40199, 40299, 40399
	 	Classification based
on restricted alien
status in PSCs 310-
330, 410- 430, 470 and
380 over the age of
20, or FamilyCare PSCs
763, and 497 & 498,
and corresponding cap
codes.

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Introduction

 

Geographic Regions

     Some of the reports in this HMO Reporting Specifications request information from the three
geographic regions corresponding to those used in rate setting. Listed below are the counties
included in each geographic region:

	 	 	 	 	 
	Northern (Region 1)	 	Central (Region 2)	 	Southern (Region 3)
	Bergen

	 	Essex
	 	Atlantic
	Hudson

	 	Mercer
	 	Burlington
	Hunterdon

	 	Middlesex
	 	Camden
	Morris

	 	Union
	 	Cape May
	Passaic

	 	 	 	Cumberland
	Somset

	 	 	 	Gloucester
	Sussex

	 	 	 	Monmouth
	Warren

	 	 	 	Ocean
	 

	 	 	 	Salem

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

General Instructions

 

The following are general instructions for completing the various reports required to be submitted
by the HMOs to the State. These instructions are designed to promote uniformity in reporting.

Due Dates

All Medicaid/NJ FamilyCare revenues and expenses must be reported using the accrual basis of
accounting except for Report #2 Parts T-V (Non-State Plan Services by rate cell grouping and MCSA
groupings). Report #2 Parts T-V shall be reported on a paid basis. Reports shall be submitted
quarterly and are due 45 days following each quarter end:

Quarterly Reports

	 	 	 
	Quarter Ending:	 	Due Date:
	March 31

	 	May 15
	June 30

	 	August 15
	September 30

	 	November 15
	December 31

	 	February 15

If a due date falls on a weekend or state holiday, reports will be due the next business day.
Please submit the completed reports to:

State of New Jersey

Director, HMO Financial Reporting

David.Moran@dhs.state.nj.us

and

Mercer Government Human Services Consulting

Actuarial Services

Mike.Nordstrom@mercer.com

Format

The HMO will submit these reports electronically, including notes to the financial statements, in
the formats specified, to the e-mail addresses listed above. Copies of the reports are included in
Appendix B of this manual.

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

General Instructions

 

Annual Audit Requirement

Please refer to Section 7.27 for the audit requirements in the managed care contract.

Other Instructions

Line titles and columnar headings of the various reports are, in general, self explanatory.
Specific instructions are provided for items that may have some question as to content. Any entry
for which no specific instructions are included shall be made in accordance with sound accounting
principles and in a manner consistent with related items covered by specific instructions.

Incorporate adjustments to prior data in current reporting period. Adjustments for prior period
IBNR estimates shall be included on Report #2, Table 19, Parts S1 and S2, in Line 42, and a
detailed reconciliation shall be included on Report #2, Table 19, Part S3. Information about any
adjustments that pertain to prior periods shall be explained in a note to the reports. However, if
there was material error in preparation of the prior period report, a revised report shall be
submitted.

Unanswered questions or blank lines on any report or schedule will render the report or schedule
incomplete and may result in a resubmission request. Any resubmission must be clearly identified
as such. If no answers or entries are to be made, write “None”, “Not Applicable (N/A)”, or “0” in
the space provided. Always use predefined categories or classifications before reporting an amount
as “Other”.

Dollar amounts shall be reported to the nearest dollar. Per member month (PMPM) amounts, however,
shall be shown with two digits to the right of the decimal point.

Additional sheets referencing the applicable reports must be attached for further explanation. The
contractor shall use “Notes to Financial Reports” in Appendix B for write ins and explanations.

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Report Specifications

 

Report #1: Lag Reports (Table 20, Parts A-E)

Analyzing the accuracy of historical medical claims liability estimates is necessary in assessing
the adequacy of current liabilities. In addition, valid IBNR liability estimates are crucial when
utilizing financial statements in the managed care rate setting process. This schedule provides
the necessary information to make this analysis.

Information is provided on Inpatient Hospital, Physician, Pharmacy, and Other Medical Payments on
Parts A through D, respectively, with all rate cell groupings combined, excluding the managed Care
Service Administrator (MCSA) rate cell groupings. Lag report information shall be provided for
each Medical Cost Grouping as defined below and map to the corresponding consolidated category of
service for the corresponding incurral period within Report #2, Table 19, Parts S1 and S2. A
detailed reconciliation of the lag report information and Income Statements by Rate Cell Group
shall be included on Report #2, Table 19, Part S3. Information about any adjustments that pertain
shall be explained in a note to the reports.

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Managed Care	 	 	 	 
	Consolidated	 	Income Statement	 	Category of	 	Medical Cost	 	Lag Report
	Category of Service	 	Reference	 	Service Codes	 	Grouping	 	Reference
	Inpatient Hospital

	 	Table #19 – Parts

S1 & S2, Line 9
	 	 	01	 	 	Inpatient Hospital
	 	Table #20 – Part A
	Primary Care

	 	Table #19 – Parts

S1 & S2, Line 10
	 	 	10P	 	 	Physician
	 	Table #20 – Part B
	Physician

Specialty Services

	 	Table #19 – Parts

S1 & S2, Line 11
	 	 	10S	 	 	Physician
	 	Table #20 – Part B
	Pharmacy (not to
include
Reimbursable
HIV/AIDS Drugs and
Blood Products)

	 	Table #19 – Parts

S1 & S2, Line 18
	 	 	20N	 	 	Pharmacy
	 	Table #20 – Part C
	Reimbursable
HIV/AIDS Drugs and
Blood Products

	 	Table #19 – Parts

S1 & S2, Line 19
	 	 	20H	 	 	Pharmacy
	 	Table #20 – Part C
	Outpatient

Hospital (excludes

ER)

	 	Table #19 – Parts

S1 & S2, Line 12
	 	 	04N	 	 	Other
	 	Table #20 – Part D
	Other Professional

Services

	 	Table #19 – Parts

S1 & S2, Line 13
	 	14, 15S, 17, PAS
	 	Other
	 	Table #20 – Part D
	Emergency Room

	 	Table #19 – Parts

S1 & S2, Line 14
	 	 	04e	 	 	Other
	 	Table #20 – Part D

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Report Specifications

 

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Managed Care	 	 	 	 
	Consolidated	 	Income Statement	 	Category of	 	Medical Cost	 	Lag Report
	Category of Service	 	Reference	 	Service Codes	 	Grouping	 	Reference
	DME/Medical

Supplies

	 	Table #19 – Parts

S1 & S2, Line 15
	 	 	30, 31, 32	 	 	Other
	 	Table #20 – Part D
	Prosthetics and
Orthotics

	 	Table #19 – Parts

S1 & S2, Line 16
	 	 	18	 	 	Other
	 	Table #20 – Part D
	Dental

	 	Table #19 – Parts

S1 & S2, Line 17
	 	 	11	 	 	Other
	 	Table #20 – Part D
	Home health,

Hospice, & PDN

	 	Table #19 – Parts

S1 & S2, Line 20
	 	40, 50, PDN
	 	Other
	 	Table #20 – Part D
	Transportation

	 	Table #19 – Parts

S1 & S2, Line 21
	 	 	70	 	 	Other
	 	Table #20 – Part D
	Lab & X-ray

	 	Table #19 – Parts

S1 & S2, Line 22
	 	 	60, 65	 	 	Other
	 	Table #20 – Part D
	Vision Care

including

Eyeglasses

	 	Table #19 – Parts

S1 & S2, Line 23
	 	 	09, 13	 	 	Other
	 	Table #20 – Part D
	Mental Health/Substance

Abuse

	 	Table #19 – Parts

S1 & S2, Line 24
	 	MH, SA
	 	Other
	 	Table #20 – Part D
	EPSDT Medical & PDN

	 	Table #19 – Parts

S1 & S2, Line 26a
	 	08D, EPM
	 	Other
	 	Table #20 – Part D
	EPSDT Dental

	 	Table #19 – Parts

S1 & S2, Line 26b
	 	EPD
	 	Other
	 	Table #20 – Part D
	Family Planning

	 	Table #19 – Parts

S1 & S2, Line 27
	 	FP
	 	Other
	 	Table #20 – Part D
	Other Medical

	 	Table #19 – Parts

S1 & S2, Line 28
	 	XM
	 	Other
	 	Table #20 – Part D

The schedules are arranged with the month of service horizontally and the month of payment
vertically. Therefore, payments made during the current month for services rendered during the
current month would be reported in Line 1, Column 3, while payments made during the current month
for services rendered in prior months would be reported on Line 1, Columns 4 through 39. Please
note that columns 13 through 38 and rows 11 through 36 are hidden in the sample worksheet. Lines 1
though 3 contain data for payments made in the current period. Earlier data on Lines 4 through 37
shall match data on appropriate lines on the prior period’s submission. If Lines 4 through 37
change from the prior period’s submission, include an explanation. The current month is the last
month of the period that is being reported. For example, in the report for the

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Report Specifications

 

period ended June 30, 2003, the current month would be June 2003, and the first prior month would
be May 2003. Do not include risk pool distributions as payments in this schedule.

Report #1 must provide data for the period beginning with the first month the HMO is responsible
for providing medical benefits to Medicaid/NJ FamilyCare recipients, and ending with the current
month.

Line 39 – Subcapitation payments shall be reported here, by month of payment. They are not to be
included above Line 39. For the current period, Line 39 shall contain new data in Columns 3
through 5. Data in columns 6 through 38 shall match data in appropriate columns on the prior
period’s submission. If columns 6 through 38 change from the prior period’s submission, include an
explanation.

Line 40 – Report pharmacy rebates anticipated for drugs dispensed this period. Adjust as
appropriate any adjustment applicable to a prior period. Only complete for the Pharmacy Payment
report, Part C.

Line 41 – The HMO shall report payments on Lines 1-36. If the HMO makes a settlement or other
payment that cannot be reported on Lines 1-36 due to lack of data, the amount shall be reported on
Line 41. If the service month(s) can be determined, the settlement dollars can be allocated to the
service month. Otherwise, the payment month can be used as a substitute for the service month. If
an amount is shown on Line 41 in columns 3 through 5, include an explanation. If columns 6 and
greater change from the prior submission, also include an explanation.

Line 42 – This line is the total amount paid to date for services rendered. Line 42 shall equal
the sum of Lines 38, 39 and 41. For the Pharmacy Payment report, Part C, also include Line 40.

Line 43 – This line provides the current estimate of remaining liability for unpaid claims for each
month of service. The amount in each column on this line must be updated each period.
The amount in Column 40 is the sum of amounts in Columns 3 through 39. The sum of the amounts in
Column 40, in parts A through D, is the unpaid claim liability (IBNR and reported but unpaid claims
(RBUC)). Please refer to attachment A for a methodology for calculating IBNR.

Line 44 – The total incurred claims is the sum of Lines 42 (the amounts paid to date) and Line 43
(estimate of unpaid claims liability). Amounts on Line 44 are shown for each month.

The State recognizes that claims liabilities may include the administrative portion of claim
settlement expenses. Any liability for future claim settlement expense must be disclosed in the
notes in the reports.

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

The Family Care Adults 0 – 100 percent of FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations are classified into
two groups under the MCSA program. As the State has assumed the responsibility for financial risk
for medical costs of these populations, the medical expenses for these populations shall be
excluded from Parts A – D of the Lag Report. All medical expenses for these populations must be
reported within Part E of the Lag Report.

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Report Specifications

 

Report #2: Income Statement by Rate Cell Grouping (Table 19, Parts A – V)

This report is meant to provide detailed summary information on revenues and expenses. A separate
report is to be completed for each of the fifteen rate cell groupings and for Maternity and
Newborn, with Report #2 Part S1 and S2 being the summations fo Parts A-R2 respectively for quarter
end and calendar year to date end. For reporting purposes, AIDS revenues and expenses are
included or excluded from the rate cell groupings as indicated on the report forms and in the
chart defining the rate cell groupings provided on page 2.

Additionally, State fiscal year end information will be provided on the first fiscal quarter
ending reports (September 30). This information shall include all data with incurred dates
through the most recent completed state fiscal year, with paid data through September 30 (incurred
in 12 months, paid in 15 months). Reports are to be completed for each of the fifteen rate cell
groupings and for Maternity and Newborn categories. Besides quarter ending September 30, this
information is not required for any other quarter ending time periods.

The Family Care Adults 0 – 100 percent of FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations are classified into
two groups under the MCSA program. As the State has assumed the responsibility for financial risk
for medical costs of these populations, the medical expenses for these populations shall be
excluded from Parts A –T and reported separately in Parts U and V. Part V has been created to
provide information on services for the non-risk Adult Restricted Aliens (excluding pregnant
women). The Adult Restricted Aliens (excluding pregnant women) expenses and revenues, which have
been scattered across several COAs, shall now only be included in Part V. Revenue and expenses
for non-risk FamilyCare Adults 0 – 100 percent of FPL will be reported within Part U.

Do not include maternity or newborn revenues or expenses in Parts A – Q. Only include Maternity
and newborn revenues and maternity expenses on the Income Statement for Maternity, part R1,and for
All Rate Cell Groupings, parts S1 and S2. Include newborn expenses on the Income Statement for
Newborn, part R2, and for All Rate Cell Groupings, Parts S1 and S2. Include Maternity costs
associated with the following codes for still births or live births after the twelfth week of
gestation, excluding elective abortions:

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Report Specifications

 

ICD 9 Diagnosis Codes:

	 
	*640.01, 640.81, 640.91

	*641.01, 641.11, 641.21, 641.31, 641.81, 641.91,

	*642.01, 642.11, 642.21, 642.31, 642.41, 642.51, 642.61, 642.71, 642.91, 642.02, 642.12, 642.22,
642.32, 642.42, 642.52, 642.62, 642.72, 642.92

	*643.01, 643.11, 643.21, 643.81, 643.81

	*645.01

	*646.01, 646.11, 646.12, 646.21, 646.22, 646.31, 646.41, 646.42, 646.51, 646.52, 646.61, 646.62,
646.71, 646.81, 646.82, 646.91

	*647.01,647.11, 647.21, 647.31, 647.41, 647.51, 647.61, 647.81, 647.91, 647.02, 647.12, 647.22,
647.32, 647.42, 647.52, 647.62, 647.82, 647.92

	*648.01,648.11, 648.21, 648.31, 648.41, 648.51, 648.61, 648.71, 648.81, 648.91, 648.02, 648.12,
648.22, 648.32, 647.42, 648.52, 648.62, 648.72, 648.82, 648.92

	*650 (and any or no trailing characters)

	*651.01,651.11, 651.21, 651.31, 651.41, 651.51, 651.61, 651.81, 651.91

	*652.01,652.11, 652.21, 652.31, 652.41, 652.51, 652.61, 652.71, 652.81, 652.91

	*653.01,653.11, 653.21, 653.31, 653.41, 653.51, 653.61, 653.71, 653.81, 653.91

	*654.01,654.11, 654.21, 654.31, 654.41, 654.51, 654.61, 654.71, 654.81, 654.91, 654.02, 654.12,
654.22, 654.32, 647.42, 654.52, 654.62, 654.72, 654.82, 654.92

	*655.01,655.11, 655.21, 655.31, 655.41, 655.51, 655.61, 655.71, 655.81, 655.91

	*656.01,656.11, 656.21, 656.31, 656.41, 656.51, 656.61, 656.71, 656.81, 656.91

	*657.01

	*658.01,658.11, 658.21, 658.31, 658.41, 658.81, 658.91

	*659.01,659.11, 659.21, 659.31, 659.41, 659.51, 659.61, 659.71, 659.81, 659.91

	*660.01,660.11, 660.21, 660.31, 660.41, 660.51, 660.61, 660.71, 660.81, 660.91

	*661.01,661.11, 661.21, 661.31, 661.41, 661.91

	*662.01,662.11, 662.21, 662.31

	*663.01,663.11, 663.21, 663.31, 663.41, 663.51, 663.61, 663.81, 663.91

	*664 (and any or no trailing characters)

	*665.01,665.11, 665.31, 665.41, 665.51, 665.61, 665.71, 665.81, 665.91, 665.22, 665.72, 665.82,
665.92

	*666.02, 666.12, 666.22, 666.32

	*667.02, 667.12

	*668.01, 668.11, 668.21, 668.81, 668.02, 668.12, 668.22, 668.82

	*669.01, 669.11, 669.21, 669.31, 669.41, 669.51, 669.61, 669.71, 669.81, 669.91, 669.02, 669.12,
669.22, 669.32, 669.42, 669.82, 669.92

	*670.02

	*671.01, 671.11, 671.21, 671.31, 671.42, 671.51, 671.81, 671.91, 671.02, 671.12, 671.22, 671.52,
671.82, 671.92

	*672.02

	*673.01, 673.11, 673.21, 673.31, 673.81, 673.02, 673.12, 673.22, 673.32, 673.82

	*674.01, 674.02, 674.12, 674.22, 674.32, 674.42, 674.82, 674.92

	*675.01, 675.11, 675.21, 675.81, 675.91, 675302, 675.12, 675.22, 675.22, 675.82, 675.92

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Report Specifications

 

	 
	*676.01, 676.11, 676.21, 676.31, 676.41, 676.51, 676.61, 676.81, 676.91, 676.02, 676.12,
676.22, 676.32, 676.42, 676.52, 676.62, 676.82, 676.92, 677 (no other characters)

	*V27, V27.0, V27.1, V27.2, V27.3, V27.4, V27.5, V27.6, V27.7, V27.9

	 

	CPT-4 Codes

	*59400, 59409, 59410, 54912, 59414, 59430, 59510, 59514, 59515, 59525, 59610, 59612, 59614, 59618,
596250, 59622, 59821

	 

	Revenue Codes

	*720, 722, 724, 729

Additionally, Report R2 (Income Statement for Newborn) includes newborn claims for the partial
month of birth and the first two (2) months thereafter, previously reported in the
AFDC/NJCPW/KidCare B, C, and D, DYFS, and Blind/Disabled rate cell groupings. Age shall be
determined by counting the child’s age as of their last birthday, on the first of the month in
which the claim is incurred.

Except for non-State Plan Services (Part T) and MCSA reports (Parts U – V), all revenues and
expenses must be reported on Report #2 using the accrual basis of accounting for the requested
period of the calendar year. Cumulative YTD revenues and expenses are also required in this
report. Each report is based on statewide reporting except for the rate cell grouping
AFDC/NJCPW/NJ KidCare A, which is to be reported for each of the Norther, Central and southern
regions (Report #2 Parts A-C). Each report must provide total dollar amounts and PMPM amounts.
Cells shaded are not to be filled out.

The non-State Plan services (see: Supplemental Benefits, Article 4.1.8 of the contract) report
(Part T) has been created to provide information on benefits/services reported within Report #2,
Parts A-S2 in excess of the State Plan. All medical and administrative expenses must be reported
using actual incurred and paid data for the current period of the calendar year. Unit cost
expenses for the non-State Plan services must also be provided. An example of non-State Plan
approved medical expenses would be enhanced eyeglass allowance and over the counter drugs for
adults.

All medical and administrative expenses within the MCSA reports (Parts U – V) must be reported
using paid data for he current period of the calendar year.

Member Months

A member month is equivalent to the one member for whom th HMO has recognized capitation based
revenue for the entire month. Where the revenue is recognized for only part of a month for a given
individual, a partial, pro-rated member month shall be counted. A partial member month is
pro-rated based on the actual number of days in a particular month. The member
months shall be reported on a cumulative basis by the rate cell grouping as shown on the report.
Enter the number of member months for the

 

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Report Specifications

 

current period in the second column of the Member Months line and the member months for the year to
date in the fourth column.

The Maternity Income Statement, Part R1, shall list number of deliveries, rather than member
months. Newborn member months, as defined in the previous section, will be reported within Part R2
and are not to be included with Parts S1 – S2.

Revenue

Line 1 – Capitated Premiums – Revenue recognized on a prepaid basis for enrollees for provision of
a specified range of health services over a defined period of time, generally one month. If
advance payments are made to the HMO, for more than one reporting period, the portion of he payment
that has not been earned must be treated as a liability (Unearned Premiums). Refer to Part S3 for
reconciliations.

Line 2 – Supplemental Premiums – Revenue paid to the HMO in addition to capitated premiums for
certain services provided. See Lines 2a through 2f below.

Line
2a —
Maternity75 — Supplemental payment per pregnancy outcome. This line item shall
only be included in Part R1 (Maternity) and Parts S1 and S2 (All Rate Cell Groupings).

Line 2b – Reimbursable HIV/AIDS Drugs and Blood Products – Supplemental payment for HIV/AIDS Drugs
(protease inhibitors and, effective 7/1/01 other anti-retrovirals) and clotting factor VIII and IX
blood products.

Line 2c – Early and periodic Screening, Diagnosis and Treatment (EPSDT) Incentive Payment –
Supplemental payment for EPSDT services.

Line 2d – Reimbursible Medical and Hospital – Supplemental payment for medical and hospital
expenses for FamilyCare Adults 0 – 100 percent of FPL, health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations who are under a MCSA
program. This revenue shall only be included in Part U (FamilyCare Adults 0 – 100 percent of FPL)
and Part V (Adult Restricted Aliens), and is not be included in Parts S1 and S2 (All Rate Cell
Groupings).

 

	 	 	 
	75	 	Because costs for pregnancy outcomes were not
included in the capitation rates, a separate maternity payment is paid for
pregnancy outcomes (each live birth, still birth, or miscarriage occurring at
or after the thirteenth (13th) wee of gestation). This supplemental
payment reimburses HMOs for its inpatient hospital, antepartum, and postpartum
costs incurred in connection with delivery. Costs for care of the baby are
included only for the first two months of newborn claims in the AFDC/NJCPW/NJ
KidCare A, NJ KidCare B, C, and D, DYFS, and Blind/Disabled rate cell
groupings.

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Line 2e – Managed Care Service Administrator Premium – Supplemental payment for administrative
expenses for FamilyCare Adults 0 – 100 percent of FPL, Health Access

Report Specifications

individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations who are under a MCSA program. This revenue shall only be included in Part U
(FamilyCare Adults 0 – 100 percent of FPL), and Part V (Adult Restricted Aliens), and is not be
included in Parts S1 and S2 (All Rate Cell Groupings).

Line 2f – Other – Any other revenue paid by DMAHS to the HMO in addition to capitation for covered
services that is not included in Lines 2a, 2b, 2c, 2d or 2e above.

Line 3 – Total Premiums – All Medicaid/NJ FamilyCare premiums pad to the HMO reported on lines 1,
2a, 2b, 2c, 2 d, 2e and 2f. A detailed reconciliation of total premiums received and reported on
the Income Statement in Part S1 shall be included on Report #2, Table 19, Part S3. Information
about any differences shall be explained in a note to the reports.

Line 4 – Interest  — Interest earned from all sources including escrow and reserve accounts.

Line 5 – C.O.B. – Income from Coordination of Benefits (COB) and Subrogration. Alternatively, COB
for a particular claim may be recognized as a negative claim expense.

Line 6 – Reinsurance Recoveries – Income from the settlement of claims resulting from a plicy with
a private reinsurance carrier.

Line 7 – Other Revenue – Revenue from sources not covered in the previous revenue accounts.

Line 8 – Total Revenue – Total revenue (the sume of lines 3 through 7).

Expenses

Medical and Hospital

Line 9 – Inpatient Hospital – Code 01 – For description, see the Medicare/NJ FamilyCare Managed
Care Contract.

Line 10 – Primary Care – Code 10P – For description, see the Medicare/NJ FamilyCare Managed Care
Contract.

Line 11 – Physician Specialty Services – Code 10S — For description, see the Medicare/NJ FamilyCare
Managed Care Contract.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Line 12 – Outpatient Hospital (excludes ER) – Code 04N — For description, see the Medicare/NJ FamilyCare Managed Care Contract.

Report Specifications

Line 13 – Other Professional Services – Codes 14, 15S, 17, PAS — For descriptions see the Medicare/NJ FamilyCare Managed Care Contract.

Line 14 – Emergency Room – Code 04E — For description, see the Medicare/NJ FamilyCare Managed Care Contract.

Line 15 – DME/Medical Supplies – Codes 30, 31, 32 — For descriptions see the Medicare/NJ FamilyCare
Managed Care Contract.

Line 16 – Prosthetics and Orthotics – Code 18 — For description, see the Medicare/NJ FamilyCare
Managed Care Contract.

Line 17 – Covered Dental – Code 11 — For description, see the Medicare/NJ FamilyCare Managed Care
Contract.

Line 18 – Pharmacy (not to include Reimbursable HIV/AIDS Drugs and Blood Products) – Code 20N — For
description, see the Medicare/NJ FamilyCare Managed Care Contract.

Line 19 – Reimbursable HIV/AIDS Drugs and Blood Products – Code 20H — For description, see the
Medicare/NJ FamilyCare Managed Care Contract.

Line 20 – Home Health, Hospice, PDN – Codes 40, 50, PDN — For descriptions, see the Medicare/NJ
FamilyCare Managed Care Contract.

Line 21 – Transportation – Code 70 –For description, see the Medicare/NJ FamilyCare Managed Care
Contract.

Line 22 – Lab & X-ray – Codes 60, 65 — For descriptions, see the Medicare/NJ FamilyCare Managed
Care Contract.

Line 23 – vision Care including Eyeglasses – Codes 09, 13 — For descriptions, see the Medicare/NJ
FamilyCare Managed Care Contract.

Line 24 – Mental health/Substance Abuse – Codes MH, SA — For descriptions, see the Medicare/NJ
FamilyCare Managed Care Contract.

Line 25 – Reinsurance Expenses – Expenses for reinsurance or “stop loss” insurance made to a
contracted reinsurer.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Line 26a – EPSDT Medical & PDN – Codes 08D, EPM — For descriptions, see the Medicare/NJ FamilyCare
Managed Care Contract.

Line 26b – EPSDT Dental – Code EPD — For description, see the Medicare/NJ FamilyCare Managed Care
Contract.

Report Specifications

 
Line 27 – Family Planning – Code FP – For description, see the Medicare/NJ FamilyCare Managed Care
Contract.

Line 28 – Other Medical – Code XM — For description, see the Medicare/NJ FamilyCare Managed Care
Contract

Line 29 – Total Medical and Hospital – The total of all medical and hospital expenses. (sum of
lines 9 through 28)

Administration

Administrative expenses shall be reported on designated forms for the MCSA populations (Parts U and
V) and the forms for all rate cell groupings (Parts S1 – s2). Except for the MCSA rate cell
groupings, this eliminates the need to allocate these costs across the remaining rate cell
groupings. As the State has the responsibility for financial risk for medical costs of the NJ
FamilyCare Adults 0 – 100 percent of FPL, Health Access individuals without dependent children, and
Adult Restricted Aliens (excluding pregnant women) populations, the administrative expenses for
these populations shall be excluded from Parts S1 – S2. The administration expenses for these
populations shall be reported separately in Parts U – V. Administration must also be reported on
Part T if the HMO provides any non-State Plan services. Costs associated with the overall
management and operation of the HMO including the following components:

Line 30 – Compensation – All expenses for administrative services including compensation and fringe
benefits for personnel time devoted to or in direct support of administration. Include expenses
for management contracts. Do not include marketing expenses her.

Line 31 – Occupancy, Depreciation, and Amortization.

Line 32 – Interest expense – Interest paid during the period on loans.

Line 33 – Education/Outreach and Marketing – Expenses incurred for education and outreach
activities for enrollees. Expenses directly related to marketing activities including advertising,
printing, marketing salaries and fringe benefits, commissions, broker fees, travel, occupancy, and
other expenses allocated to the marketing activity.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Line 34 – Sanctions – Expenses related to events where DMAHS finds the contractor to be out of
compliance with the program standards, performance standards, or the terms and conditions of the
Medicaid managed care contract.

Line 35 – Corporate Overhead Allocations – All expenses for management fees, and other allocations
of corporate expenses. Methodologies for allocated expenses may include PMPM, percent of revenue,
percent of head counts and/or full time equivalents

Report Specifications

(FTE), etc. Include an explanation of the expenses included and the basis of methodology in
the notes to the financial reports.

Line 36 – Subcontracted/Delegated Administrative Services – Administrative portion of delegated
administrative expenses such as Pharmacy Benefits Manager (PBM) or Third Party Administrators (TPA)
payments that cover costs such as claims processing and medical management of the PBM/TPA. An
example of TPA expenses includes dental subcontractors and delegated case management administrative
expenses.

Line 37 – Other C – Costs which are not appropriately assigned to the health plan administration
categories defined in lines 30 to 36 above. An explanation for this expense must be detailed on
Table 19, Part S3 for categories where the expense is greater than $250,000.

Line 38 – Total Administration – the total of costs of administration (the sum of lines 30 through
37).

Line 39 – Total Expenses – The sum of Total Medical and Hospital Expenses (line 29) and Total
Administration (line 38).

Line 40 – Operation Income (Loss) – Excess or deficiency of Total Revenue (line 8) minus Total
Expenses (line 39).

Line 41 – Extraordinary Item – A non-recurring gain or loss.

Line 42 – Provision for State, and Federal, and other governmental Income Taxes – All income taxes
for the period.

Line 43 – Other than Income Taxes – Expenses other than state or federal income taxes (i.e. State
assessments irrespective of profit position).

Line 44 – Adjustment for prior period IBNR estimates – Shall include a reconciliation within Part
S3, an explanation of prior period IBNR estimates, and a detailed calculation within Report

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

#2,
Table 20, Parts A through D. A contra expense would be reported if IBNR estimates exceeded actual
expenses.

	 	 	 
	HMO Financial Reporting Specifications

	 	State of New Jersey
	For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	 

 

 

Report Specifications

 

In the explanation below, the term “IBNR” (Incurred But Not Reported) is used to represent all
claims incurred but unpaid. In statutory accounting for HMOs the incurred claims for a period are
calculated as follows:

	 	 	 	 	 	 	 	 	 
	 	 	Example for	 	 	 	 
	 	 	Quarter Ending 06/30/20xx	 	Example using
	 	 	Reporting Period	 	Dollars
	- Claims paid in the period
	 	- Claims paid in quarter ending 06/30/20xx	 	 	$48,000,000	 
	 
	 	 	 	 	 	 	 	 
	+ IBNR at the end of the period
	 	+ IBNR as of 06/30/20xx	 	 	+$11,000,000	 
	 
	 	 	 	 	 	 	 	 
	- IBNR at the end of the prior period
	 	- IBNR as of 03/31/20xx	 	 	-$9,000,000	 
	 
	 	 	 	 	 	 	 	 
	+ Subcapitation Payments, Pharmacy Rebates, Settlements at the end of theperiod
	 	+ Subcapitaiton
Payments, Pharmacy Rebates, Settlements as of 06/30/20xx	 	 	+$500,000	 
	 
	 	 	 	 	 	 	 	 
	- Subcapitation Payments, Pharmacy Rebates, Settlements at the end of theperiod
	 	- Subcapitation Payments, Pharmacy Rebates, Settlements as of 03/31/20xx	 	 	-$450,000	 
	 
	 	 	 	 	 	 	 	 
	- Claims incurred in the period
	 	- Claims incurred in quarter ending 06/30/20xx	 	 	$50,050,000	 

 

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Report Specifications

 

The above calculation can be split into two components — the first for services rendered in the
period and the second for services rendered prior to the period, as follows:

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Incurred in	 	 	Incurred in	 	 	 	 
	 	 	Quarter Ending	 	 	03/31/20xx &	 	 	 	 
	 	 	06/30/20xx	 	 	Prior	 	 	Total	 
	Claims Paid in Qtr Ending 06/30/20xx
	 	 	$35,500,000	 	 	 	$8,500,000	 	 	 	$48,000,000	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	+ IBNR as of 06/30/20xx
	 	 	$10,900,000	 	 	 	$100,000	 	 	 	$11,000,000	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	- IBNR as of 3/31/20xx
	 	None	 	 	 	$9,000,000	 	 	 	$9,000,000	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	+ Subcapitaiton Payments, Pharmacy Rebates, Settlements as of 06/30/20xx
	 	 	$50,000	 	 	 	$450,000	 	 	 	$500,000	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	+ Subcapitaiton Payments, Pharmacy Rebates, Settlements as of 03/31/20xx
	 	None	 	 	 	$450,000	 	 	 	$450,000	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	Recognized in Qtr Ending 06/30/20xx
	 	 	$50,450,000	 	 	 	-$400,000	 	 	 	$50,050,-000	 

In the example, claims incurred in the quarter ending 06/30/20xx are $50.45 million. This is the
amount that would be shown on Report #2S line 29; the Statewide Total Hospital and Medical Expense
for the 3 months ended 06/30/20xx. The negative $0.4 million would be reported on line 44
Adjustment for prior period IBNR estimates. This is the effect of the estimation error for the
prior year end IBNR. Such estimation errors are to be expected, since the actual amount of unpaid
claims will never exactly match the estimate made earlier.

The sum of the amounts on lines 29 and 44 shall be consistent with the statutory accounting amount
of claims recognized as incurred in the period, $50 million in the

 

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Report Specifications

 

example above. Any non-claim adjustments for prior periods which are not to be grouped into Line
44, but in line 45, and shall be explained in a note to the reports. A detailed reconciliation of
prior period IBNR shall be included on Report #2, Table 19, Part S3.

Line 45 — Non claim adjustments for prior periods.

Line 46 — Net Income (Loss) — Operation Income (Loss) (line 40) minus Lines 41, 42, 43, 44, and 45.

 

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Report Specifications

 

Report #3 (Table 21): Maternity Outcome Counts

This
report provides counts of second and third trimester maternity
outcomes76 for the
current period and year to date.

The HMO will provide counts for the following:

*Live births

Cesarean Section deliveries

Vaginal deliveries

*Non live births

These counts will be reported for the following rate cell groupings and geographic areas:

	 	 	 
	Rate Cell Grouping	 	Geographic Area
	AFDC/NJCPW/NJ KidCare A

	 	Northern
	AFDC/NJCPW/NJ KidCare A

	 	Central
	AFDC/NJCPW/NJ KidCare A

	 	Southern
	All Other

	 	Statewide

Multiple births should be counted as one maternity outcome.

 

			
	76	 	Still or live births at or after the thirteenth week of gestation, excluding elective abortions.

 

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Report Specifications

 

Report #4: Claims Processing Lag Report (Tables 4A & 4B)

This report is meant to provide a detailed summary of manual and electronic submitted claims that
were processed during the quarter.

Table 4A

Use Table 4A, to report manually submitted claims that were processed during the quarterly period.
Claims submitted and processed electronically must be reported separately on Table 4B. Manual
claims submission shall be processed within 40 days of receipt. Report amounts for each
consolidated category of service and total listed in Column 1 in the following columns:

Column 2 Non-Processed Claims from Prior Quarters — Enter the number of manually submitted claims
on hand that were unprocessed as of the closing date of the last quarterly period. The number shall
be the same that was reported in Column 16 of the last prior quarterly report.

Column 3 — Claims Received During Quarter — Enter the amount of all manually submitted claims that
were received curing the quarterly period being reported.

Column 4 — Total Claims — Enter the sum of Columns 2 and 3.

Column 5- Claims Processed This Quarter —Enter the amount of all manually submitted claims
processed (both paid and denied) during the quarterly period being reported. Do not count pended
claims.

Column 6 — 01-40 Days —  Enter the number of manually submitted claims that were processed (either
paid or denied) within 40 days of their receipt. Note: The number of days required to process a
claim is calculated by comparing the date the claim was received by the contractor to the date the
claim was paid or denied by the contractor (See Article 7.16.5 of this contract for further
details.).

Column 7 — Percent of Total- Enter the percentage of manually submitted claims processed within 40
days (Compared to the total claims processed. Divide Column 6 by Column 5 to arrive at percent).

Column 8 — 41-60 Days — Enter the number of manually submitted claims that were processed (either
paid or denied) between 41-60 days of their receipt.

Column 9 Percent of Total — Enter the percentage of manually submitted claims processed within
between 41-60 days (Compared to the total claims processed. Divide Column 8 by Column 5 to arrive
at percent).

Column 10 — 61-90 Days- Enter the number of manually submitted claims that were processed (either
paid or denied) between 61-90 days of their receipt

 

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Column 11 — Percent of Total — Enter the percentage of manually submitted claims processed within
between 61-90 days (Compared to the total claims processed. Divide Column 12 by Column 5 to arrive
at percent).

Column 12 — 91-120 Days -Enter the number of manually submitted claims that were processed (either
paid or denied) between 90-120 days of their receipt

Column 13 — Percent of Total — Enter the percentage of manually submitted claims processed within
between 90-120 days (Compared to the total claims processed. Divide Column 12 by Column 5 to arrive
at percent).

Column
14 —  >120 Days Enter the number of manually submitted claims that were processed (either
paid or denied) after 120 days of their receipt.

Column 15 — Percent of Total — Enter the percentage of manually submitted claims processed after
120 days (Compared to the total claims processed. Divide Column 14 by Column 5 to arrive at
percent).

Column 16 — Non Processed Claims on Hand at End of Quarter -Enter the number of manually submitted
claims on hand that were not processed as of closing date of the last report period. (Should be the
difference of Column 4 minus Column 5). Same number should match number of claims entered in column
2 of next quarter reports.

Column 17 — Percent of Claims Not Processed at End of Quarter (Column 17). Divide Column 16 by
Column 4 to arrive at percent.

Table 4B

Use Table 4B, to report electronically submitted claims that were processed during the quarterly
period. Claims submitted and processed manually must be reported separately on Table 4A. Electronic
claims submission shall be processed within 30 days of receipt. Report amounts for each
consolidated category of service and total listed in Column 1 in the following columns:

Column 2 Non-Processed Claims from Prior Quarters — Enter the number of electronically submitted
claims on hand that were unprocessed as of the closing date of the last quarterly period. The
number shall be the same that was reported in Column 16 of the last prior quarterly report.

Column 3 — Claims Received During Quarter — Enter the amount of all electronically submitted claims
that were received curing the quarterly period being reported.

Column 4 — Total Claims — Enter the sum of Columns 2 and 3.

 

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Column 5- Claims Processed This Quarter —Enter the amount of all electronically submitted claims
processed (both paid and denied) during the quarterly period being reported. Do not count pended
claims.

Column 6 — 01-30 Days —  Enter the number of electronically submitted claims that were processed
(either paid or denied) within 30 days of their receipt. Note: The number of days required to
process a claim is calculated by comparing the date the claim was received by the contractor to the
date the claim was paid or denied by the contractor (See Article 7.16.5 of this contract for
further details.).

Column 7 — Percent of Total- Enter the percentage of electronically submitted claims processed
within 40 days (Compared to the total claims processed. Divide Column 6 by Column 5 to arrive at
percent).

Column 8 — 31-60 Days — Enter the number of electronically submitted claims that were processed
(either paid or denied) between 31-60 days of their receipt.

Column 9 Percent of Total — Enter the percentage of electronically submitted claims processed
within between 31-60 days (Compared to the total claims processed. Divide Column 8 by Column 5 to
arrive at percent).

Column 10 — 61-90 Days- Enter the number of electronically submitted claims that were processed
(either paid or denied) between 61-90 days of their receipt

Column 11 — Percent of Total — Enter the percentage of electronically submitted claims processed
within between 61-90 days (Compared to the total claims processed. Divide Column 12 by Column 5 to
arrive at percent).

Column 12 — 91-120 Days -Enter the number of electronically submitted claims that were processed
(either paid or denied) between 90-120 days of their receipt

Column 13 — Percent of Total — Enter the percentage of electronically submitted claims processed
within between 90-120 days (Compared to the total claims processed. Divide Column 12 by Column 5 to
arrive at percent).

Column 14 —  >120 Days Enter the number of electronically submitted claims that were processed
(either paid or denied) after 120 days of their receipt.

Column 15 — Percent of Total — Enter the percentage of electronically submitted claims processed
after 120 days (Compared to the total claims processed. Divide Column 14 by Column 5 to arrive at
percent).

Column 16 — Non Processed Claims on Hand at End of Quarter -Enter the number of electronically
submitted claims on hand that were not processed as of closing date of the last report period.
(Should be the difference of Column 4 minus Column 5). Same number should match number of claims
entered in column 2 of next quarter reports.

 

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Column 17 — Percent of Claims Not Processed at End of Quarter (Column 17). Divide Column 16 by
Column 4 to arrive at percent.

	 		
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Report
# 7:   Stop Loss Summary (Table 7, Parts A-C)

The contractor shall identify reinsurance coverage in effect during the calendar year for the
reporting period ending Dec 31 of each year. For each of the designated eligibility categories, the
contractor shall report the total number of enrollees that exceeded the stop loss threshold and the
total net expenditures exceeding the stop loss threshold during the period.

 

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Report
# 10: Third Party Liability Collections (Table 10)

 The contractor shall report quarterly the categories of all third party
liability collections and shall include the amounts and nature of all third party payments
recovered for Medicaid/NJ FamilyCare enrollees including but not limited to payments for services
ad condition which are:

	 	•      Covered through coordination of benefits;
	 
	 	•      Employment related injuries or illnesses;
	 
	 	•      Related to motor vehicle accidents, whether injured as pedestrians, drivers, passengers or bicyclists; and
	 
	 	•      Contained in diagnosis Codes 800 through 999 (ICD9CM) with the exception of Code 994.6.

 

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Appendix A — IBNR Methodology

IBNR Methodology

IBNRs are difficult to estimate because of the quantity of service and exact service cost are not
always known until claims are actually received. Since medical claims are the major expenses
incurred by the HMOs, it is extremely important to accurately identify costs for outstanding
unbilled services. To accomplish this, a reliable claims system and a logical IBNR methodology are
required.

Selection of the most appropriate system for estimating IBNR claims expense requires judgment based
on an HMO’s own circumstances, characteristics, and the availability and reliability of various
data sources. A primary estimation methodology along with supplementary analysis usually produces
the most accurate IBNR estimates. Other common elements needed for successful IBNR systems are:

	 	•	 	An IBNR system must function as part of the overall financial management and claims
system. These systems combine to collect, analyze, and share claims data. They require
effective referral, prior authorization, utilization review, and discharge planning
functions. Also, the HMO must have a full accrual accounting system. Full accrual
accounting systems help properly identify and record the expense, together with the related
liability, for all unpaid and unbilled medical services provided to HMO members.
	 
	 	•	 	An effective IBNR system requires the development of reliable lag tables that identify
the length of time between provision of service, receipt of claims, and processing and
payment of claims by major provider type (inpatient hospital, physician, pharmacy, and
other medical). Reliable claims/cash disbursement systems generally produce most of the
necessary data. Lag tables, and the projections developed from them, are most useful when
there is sufficient, accurate claims history, which show stable claims lag patterns.
Otherwise, the tables will need modification, on a pro forma basis, to reflect corrections
for known errors or skewed payment patterns. The data included in the lag schedules shall
include all information received to date in order to take advantage of all known amounts
(i.e., RBUCs and paid claims).
	 
	 	•	 	Accurate, complete, and timely claims data should shall be monitored, collected,
compiled, and evaluated as early as possible. Whenever practical, claims data collection
and analysis shall begin before the service is provided (i.e. prior authorization records).
This prospective claims data, together with claims data collected as the services are
provided, shall be used to identify claims liabilities. Claims data shall also be
segregated to permit analysis by major rate code, region/county, and consolidated category
of service.

Subcontractor agreements shall clearly state each party’s responsibility for
claims/encounter submission, prior notification, authorization, and reimbursement rates. These
agreements shall be in writing, clearly understood and followed consistently by each party.

 

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

The individual IBNR amounts, once established, shall be monitored for adequacy and
adjusted as needed. If IBNR estimates are subsequently found to be significantly inaccurate,
analysis shall be performed to determine the reasons for the inaccuracy. Such an analysis shall be
used to refine an HMO’s IBNR methodology if applicable.

There are several different methods that can be used to determine the amount of IBNRs. The HMO
shall employ the one that best meets its needs and accurately estimates its IBNRs. If an HMO is
utilizing a method different from the methods included herein, a detailed description of the
process must be submitted to the State for approval. This process may be described in the “notes to
Financial Reports” section. The IBNR methodology used by the HMO must be evaluated by the HMO’s
independent accountant or actuary for reasonableness.

Case Basis Method

Accruals are based on estimates of individual claims and/or episodes. This method is generally used
for those types of claims where the amount of the cost will be large, requiring prior
authorization. The final estimated cost could be made after the services have been authorized by
the HMO. For example, if an HMO knows how many hospitals days were authorized for a certain time
period, and can incorporate the contracted reimbursement arrangement(s) with the hospital (s), a
reasonable estimate should be attainable. This is also the most common and can be the most accurate
method for small and medium sized organizations.

Average Cost Method

As the name suggests, average costs of services are used to estimate total expense. The expenses
estimated using average costs. Two primary average costs methods are discussed below. It is
important to note that each method may be used by and HMO to estimate different categories of IBNRs
(i.e. hospitalization vs. other medical). Also, either method may be utilized in conjunction with
other IBNR methodologies discussed in this document.

PMPM Averages

Under this method the average costs are based on the population of each rate code (or group of
homogenous rate codes) over a given time period, in this case one month. The average cost may cover
one or more service categories and it multiplied by the number of members in the specific
population to estimate the total expense of the service category. Any claims paid are subtracted
from the expense estimate that results in the IBNR liability estimate for that service category.

 

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Per Diem or Per Service Averages

Averages for this method are of specific occurrences known by the HMO at the time of the
estimation. Therefore, it is first necessary to know how many hospital days, procedure or visits
were authorized as of the date for which the IBNR is being estimated. Again, once the total expense
has been estimated, the amount of related paid claims shall be subtracted to get the IBNR
liability. This method is primarily used for hospitalization IBNRs as HMOs know the amount of
hospital days authorized at any given time.

Lag Tables

Lag tables are used to track historical payment patterns. When a sufficient history exists and a
regular claims submission pattern has been established, this methodology can be employed. All HMOs
shall use lag information as a validation test for accruals calculated using other methods, if it
is not the primary methodology employed. Typically, the information on the schedules I organized
according to the month claims are incurred on the horizontal axis and the month claims are paid by
the HMO on the vertical axis.

Once a number of months becomes “fully developed” (i.e. claims submissions are thought to be
complete for the month of service), the information can be utilized to effectively estimate IBNRs.
Computing the average period over which claims are submitted historically and applying this
information to months that are not yet fully developed does this.

	 		
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Appendix B — Report Forms

Quarterly Report Forms

This section includes copies of the forms to be completed electronically by the HMO for each quarter.

	 	 • 	 	Quarterly Certification Statement
	 
	 	 • 	 	Report #1: Lag Report

	 	 • 	 	Part A: Lag Report for Inpatient Hospital Payments Excluding MCSA Populations.
	 
	 	 • 	 	Part B: Lag Report for Physician Payments Excluding MCSA Populations
	 
	 	 • 	 	Part C: Lag Report for Pharmacy Payments Excluding MCSA Populations
	 
	 	 • 	 	Part D: Lag Report for Other Medical Payments Excluding MCSA Populations
	 
	 	 • 	 	Part E: Lag Report for MCSA Populations

	 	 • 	 	Report #2: Income Statement by RATE CELL GROUPING

	 	 • 	 	Part A: AFDC/NJCPW/NJ KidCare A — Northern Region
	 
	 	 • 	 	Part B: AFDC/NJCPW/NJ KidCare A — Central Region
	 
	 	 • 	 	Part C: AFDC/NJCPW/NJ KidCare A — Southern Region
	 
	 	 • 	 	Part D: DYFS — Statewide
	 
	 	 • 	 	Part E: ABD with Medicare — DDD — Statewide
	 
	 	 • 	 	Part F: ABD with Medicare — non-DDD — Statewide
	 
	 	 • 	 	Part G: Non-ABD — DDD — Statewide
	 
	 	 • 	 	Part H: ABD without Medicare — DDD — Statewide
	 
	 	 • 	 	Part I: ABD without Medicare — Non DDD — Statewide
	 
	 	 • 	 	Part J: NJ KidCare B&C Statewide
	 
	 	 • 	 	Park K: NJ KidCare D Statewide
	 
	 	 • 	 	Part L: Reserved
	 
	 	 • 	 	Part M: NJ FamilyCare Parents 0-133% FPL — Statewide

 

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

	 	•	 	Part N: (Reserved)
	 
	 	•	 	Part O: NJ FamilyCare Parents 134-200 250% FPL — Statewide
	 
	 	•	 	Part P: ABD with Medicare — AIDS- Statewide
	 
	 	•	 	Part Q: Non- ABD —  AIDS- Statewide
	 
	 	•	 	Part R1: Maternity- Statewide
	 
	 	•	 	Part R2: Newborn — Statewide
	 
	 	•	 	Part S1: All Rate Cell Groupings Current Quarter — Statewide
	 
	 	•	 	Part S2: All Rate Cell Groupings Year  — To -Date — Statewide
	 
	 	•	 	Part S3: Reconciliations
	 
	 	•	 	Part T: Non-State Plan Services
	 
	 	•	 	Part U: NJ FamilyCare Adults 0-100% FPL — Statewide
	 
	 	•	 	Part V: Adult Restricted Aliens — Statewide

	 	•	 	Report #3: table 21: Maternity Outcome Counts
	 
	 	•	 	Report #4: Claims Processing Lag Report

	 	•	 	Part A: Claims Processing Lag Report for Manually Submitted Claims
	 
	 	•	 	Part B: Claims Processing Lag Report for Electronically Submitted Claims

	 	•	 	Report #7: Stop Loss Summary
	 
	 	•	 	Report #10 : Third Party Liability Collections
	 
	 	•	 	Notes to Financial Reports

 

			
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
	 	State of New Jersey 

 

 

Appendix B — Report Forms

QUARTERLY CERTIFICATION STATEMENT

OF

 

HMO NAME

TO THE

NEW JERSEY DEPARTMENT OF HUMAN SERVICES

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES

FOR THE PERIOD ENDED

 

(Month/day/year)

Name of Preparer ___

Title ___

Phone Number ___

Please check which reports are included with this packet:

O
Report
#1                O Report #2                O Report #3

O Report #4                O Report #7                O Report #10

I hereby attest that the information submitted in the reports herein is current, complete
and accurate to the best of my knowledge. I understand that whoever knowingly and willfully
makes or causes to be made a false statement or representation on the reports may be
prosecuted under applicable state laws. In addition, knowingly and willfully failing to
fully and accurately disclose the information requested may result in denial of a request to
participate, or where the entity already participates, a termination of an HMO’s agreement
or contract with the State.

Date                Chief Financial Officer               
                Signature

	 	 	 
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

	 	State of New Jersey

 

 

Appendix B — Report Forms

NOTE TO
FINANCIAL REPORTS

Any notes or further explanation of any items contained in any of the reports or in the
reporting of financial disclosures are to be noted here. Appropriate references and
attachments are to be used as necessary. Space is provided below or you may use a separate
page as necessary.

	 	 	 
	HMO Financial Reporting Specifications

For Medicaid/NJ FamilyCare Rate Cell Grouping Costs

	 	State of New Jersey

 

 

B.7.4 Agreed Upon Procedures — For Rate Cell Cost Report Reserved

 

 

AGREED UPON PROCEDURES

For Rate Cell Cost Reports

The following agreed upon procedures between the plan and its independent public accountant
are required to meet audit requirements of Rate Cell Grouping Cost Reports as further explained in
Article 7.27.1B of the contract.

Procedures contained herein are established as minimum requirements. Additional procedures may be
added and performed as agreed to by the contractor and the accountant performing them without DMAHS
approval. However, changes, deletions or variations to the procedures specified herein will
require prior approval of DMAHS.

 

 

Report
#1 Claim Lag Triangles

Step
1: Validate the mathematical accuracy of Report #1.

Step 2: Validate the accuracy of the amounts paid for each month.

	 	a.	 	Trace and agree monthly amount to the supporting documentation used by the
contractor to complete the report.
	 
	 	b.	 	Trace and agree each monthly amount to the monthly check register or claims
system monthly summary.

Step 3: Validate the accuracy of the amounts paid in the individual cells.

	 	a.	 	For the claims paid and incurred on Report #1, trace and agree 4 cells to the
supporting documentation used by the contractor to complete the report.

Step 4: Validate the accuracy of the amounts that comprise the individual cells.

	 	b.	 	Select 8 claims from each lag triangle.
	 
	 	c.	 	Verify the claim is reported in the correct month of service by tracing and
agreeing to the date of service on the claim.
	 
	 	d.	 	Verify the claim is reported in the correct month of payment by tracing and
agreeing to bank statements.
	 
	 	e.	 	Verify the claim is reported in the correct month of payment by tracing and
agreeing type of service to the hard/electronic copy of the claim.
	 
	 	f.	 	Verify the claim is related to a New Jersey Medicaid or NJ Family Care
beneficiary by tracing and agreeing to the member eligibility system.

Step 5: Validate the accuracy of the subcapitation payments reported

	 	a.	 	Select 2 cells from each of applicable lag triangles
	 
	 	b.	 	Trace and agree selected cells to the supporting documentation used by the
contractor to complete the report.

Step 6: Validate the accuracy of the amounts that comprise subcapitation payments

	 	a.	 	Verify that the transaction is recorded in the correct month of service by
tracing and agreeing to the invoice or check request that substantiates the check.

	 	b.	 	Verify that the check has cleared the bank by tracing and agreeing to the bank
statement.

	 	c.	 	Verify the transaction is accurately reported in Report #1 by tracing and
agreeing to the contract provider type and covered services.

Step 7: Validate the accuracy of amounts reported as Pharmacy Rebates.

	 	a.	 	Select 2 cells from each of the applicable lag triangles.

 

 

	 	b.	 	Trace and agree selected cells the supporting documentation used by the
contractor to complete the report.
	 
	 	c.	 	Trace and agree each monthly amount to the monthly check register or claims
system monthly summary.

Report
#2 Income Statement by Rate Cell Groupings

Step 1: Verify that amounts reported as Medicaid/NJ Family Care expense are consistent with
amounts reported in statutory filings.

	 	a.	 	Trace and agree total amounts reported as Medicaid/NJ Family Care expense to
statutory filings as of December 31.

Step 2: Verify member months reported is accurate

	 	a.	 	Confirm member months with the State of New Jersey

Step 3: Verify the accuracy of dollar amounts reported as capitated premiums

	 	a.	 	Select 5 income statement categories by Rate Cell Grouping (IS).
	 
	 	b.	 	Trace and agree selected cells to the supporting documentation used by the
contractor to complete the IS.
	 
	 	c.	 	Select 4 months of capitated premiums and trace and agree amounts to remittance
advices received from the DMAHS.

Step 4: Verify the accuracy of dollar amounts reported as HIV/AIDS Reimbursable Drugs Revenue.

	 	a.	 	Select 5 income statement categories by Rate Cell Grouping (IS).
	 
	 	b.	 	Trace and agree selected cells to the supporting documentation used by the
contractor to complete the IS.
	 
	 	c.	 	Select 4 months of capitated premiums and trace and agree amounts to remittance
advices received from the DMAHS.

Step 5: Verify the accuracy of dollar amounts reported as EPSDT Incentive Payment Revenue.

	 	a.	 	Select 5 income statement categories by Rate Cell Grouping (IS).
	 
	 	b.	 	Trace and agree selected cells to the supporting documentation used by the
contractor to complete the IS.
	 
	 	d.	 	Select 4 months of capitated premiums and trace and agree amounts to remittance
advices received from the DMAHS.

Step 6: Verify the accuracy of dollar amounts reported as Interest Revenue.

	 	a.	 	Select 5 income statement categories by Rate Cell Grouping (IS).

 

 

	 	b.	 	Trace and agree selected cells to the supporting documentation used by the
contractor to complete the IS.

Step 7: Verify the accuracy of dollar amounts reported as COB.

	 	a.	 	Select 5 income statement categories by Rate Cell Grouping (IS).
	 
	 	b.	 	Trace and agree selected cells to the supporting documentation used by the
contractor to complete the IS.

Step 8: Verify the accuracy of dollar amounts reported as Reinsurance Recoveries.

	 	a.	 	Select 5 income statement categories by Rate Cell Grouping (IS).
	 
	 	b.	 	Trace and agree selected cells to the supporting documentation used by the
contractor to complete the IS.

Step 9: Verify the accuracy of amounts reported as Medical and Hospital Expenses.

	 	a.	 	Select at least one type of Medical and Hospital Expense from each of the
income statement categories by Rate Cell Groupings.
	 
	 	b.	 	Trace and agree selected cells to the supporting documentation used by the
contractor to complete the IS.
	 
	 	c.	 	Select one claim from each of the rate cell groupings selected in step 9a.
	 
	 	d.	 	Trace and agree amount reported in each cell to actual claims paid and an
allocation of expenses incurred but not paid.
	 
	 	e.	 	For the claim selected in step 9c, recalculate the allocation of incurred but
not reported to each income statement to determine if they are in same proportional
amounts as claims paid.
	 
	 	f.	 	For the claim selected in step c, trace and agree the classification of the
medical expense to the classification prescribed by DMAHS in the “HMO Guide for
Reporting Medicaid/NJ Family Care Rate Cell Grouping Costs.” Determine the claims
selected from step 9a and are included in the appropriate IS by Rate Cell Grouping and
that all Medical and Hospital Expenses are classified appropriately in lines 9-27.

Step 10: Verify the accuracy of the amounts reported in Part S — Income.

	 	a.	 	Trace and agree total amounts reported in Part S to amounts reported in the
individual income statements by Rate Cell Groupings.

 

 

Report
#3 Maternity Outcomes

Step 1: Verify the accuracy of amounts reported in Report 3.

	 	a.	 	Trace and agree amounts reported as maternity outcomes to the supporting
documentation used by the contractor to complete the report.
	 
	 	b.	 	Select 5 outcomes from step a.
	 
	 	c.	 	Verify the outcome is reported in the correct region by tracing and agreeing
back to supporting documentation.
	 
	 	d.	 	Verify the outcome is reported in the correct eligibility category by tracing
and agreeing back to supporting documentation.
	 
	 	e.	 	Verify the outcome is reported in the correct category (c-section, vaginal, or
non live birth) by tracing and agreeing back to supporting documentation.
	 
	 	f.	 	Verify the outcome is not an elected abortion by tracing and agreeing back to
supporting documentation.
	 
	 	g.	 	Verify the outcome was reported for outcomes after 12 weeks of gestation by
tracing and agreeing back to supporting documentation.

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