$ Paid listed in in the listed column 3 in applicable paid Please column Calendar under select 1. Year or listed which most payment contracted = current 12 category entities are total $ in months below paid in row 1 Estimate Estimated column 3 column 1 breakout of amount of dollar = $ in in this amount specific column of listed in row C1 into dollar column 1 percentage for each by row contracted listed entity paid in in next 2 columns 1 for each row Total IN-NETWORK dollars paid Dollars. Percent. Multi, For for to Providers for ALL commercial members for HOSPITAL SERVICES 1: ACO, 2: PCMH, 3: Medical Note: 4: Primary Care, provided 5: in this Specialists row do not total 100% Provide the total dollars paid to (As above) (As (As (As (As providers through traditional FFS above) payments in the applicable calendar year or most recent 12 months Provide the total dollars paid to (As above) (As (As (As above) (As providers through bundled payment programs without quality components in the
$ Paid in the applicable Calendar Year or most current 12 months Estimate breakout of amount in this column into percentage by contracted entity paid in next 2 columns listed of dollar listed in 1 for each row paid under listed payment category below Estimated of dollar amount listed in column 1 for each row listed in column 3 Please select which contracted entities are paid in column 3 in column 1. = total $ in row 1 column 1 = $ in specific row C1 Total IN-NETWORK dollars paid for to Providers for ALL commercial members for HOSPITAL SERVICES Dollars. Percent. Multi, 1: ACO, 2: PCMH, 3: Medical 4: Primary Care, 5: Specialists For Note: provided in this row do not total 100% Provide the total dollars paid to providers through traditional FFS payments in the applicable calendar year or most recent 12 months (As above) (As (As above) (As (As Provide the total dollars paid to providers through bundled payment programs without quality components in the (As above) (As (As (As above) (As
2017-QHP-Certification-Application-DRAFT-1-21-16.docx