HOSPITAL listed listed IPAs) is % 1. CHARGE) paid listed Total $ Paid listed in = in the total $ applicable 4 in row Calendar below 1 Year or most below column current 12 1 months (Estimate Percent = breakout of of of $ in amount in dollar dollar specific this column of amount row C1 into dollar listed in percentage listed column by entity paid in 1 for in next 3 listed each columns) in 1 for row) each 1 row) are for paid each row) IN-NETWORK Dollars. Percent. Multi, For dollars paid for to Providers for ALL commercial members FOR ALL OUTPATIENT 1: SERVICES (i.e., services ACO, Note: for which there is NO 2: ASSOCIATED HOSPITAL CHARGE) 3: in this row do not total 100% Provide the dollars (As above) (As (As (As (As (As paid to providers through above) above) traditional FFS payments in the applicable calendar year or most recent 12 months
Percent HOSPITAL CHARGE) Total $ Paid in the applicable Calendar Year or most current 12 months (Estimate breakout of amount in this column into percentage by entity paid in next 3 columns) listed of dollar listed in 1 for each row) listed below of dollar listed in 1 for each row) IPAs) paid listed below of dollar amount listed in column 1 for each row) is % listed in 4 are paid 1. = total $ in row 1 column 1 = $ in specific row C1 IN-NETWORK dollars paid for to Providers for ALL commercial members FOR ALL OUTPATIENT SERVICES (i.e., services for which there is NO ASSOCIATED HOSPITAL CHARGE) Dollars. Percent. Multi, 1: ACO, 2: 3: For Note: in this row do not total 100% Provide the dollars paid to providers through traditional FFS payments in the applicable calendar year or most recent 12 months (As above) (As (As (As above) (As (As above)
2017-QHP-Certification-Application-DRAFT-1-21-16.docx