HOSPITAL below payment column) Numerator CHARGE) category Please = $ in of below select specific dollar which row C1 amount of listed in dollar column amount of entities 1 for listed in dollar are paid each column amount row) 1 for listed in each column 1 row) for each row) Total Dollars. Percent. Percent. Percent. Multi, For 1 dollars 1: ACO, paid for Unknown 2: PCMH, to Note: 3: Medical Providers for ALL provided in this row do not members total 100% FOR ALL SERVICES (i.e., services for which there is NO HOSPITAL CHARGE) Provide Dollars. Percent. Percent. Percent. Multi, For 2 the total N/A OK. N/A OK. N/A OK. N/A OK. dollars paid to 1: ACO, Unknown 2: PCMH, providers Note: 3: Medical through provided FFS in this row payments
HOSPITAL CHARGE) of dollar amount listed in column 1 for each row) below of dollar amount listed in column 1 for each row) payment category below of dollar amount listed in column 1 for each row) column) Please select which entities are paid Numerator = $ in specific row C1 Total dollars paid for to Providers for ALL members FOR ALL SERVICES (i.e., services for which there is NO HOSPITAL CHARGE) Dollars. Percent. Percent. Percent. Multi, 1: ACO, 2: PCMH, 3: Medical For Unknown Note: provided in this row do not total 100% 1 Provide the total dollars paid to providers through FFS payments Dollars. N/A OK. Percent. N/A OK. Percent. N/A OK. Percent. N/A OK. Multi, 1: ACO, 2: PCMH, 3: Medical For Unknown Note: provided in this row 2
Qualified%20Health%20Plan%20Certification%20Application%20Fourth%20Quarter%202017%20Smal....docx