File Format for QAR Cost Reporting Summary Report

User Roles:

AM

AR

D

V

Field # Field Sample Data Description Derived
Field
1 Recipient ABC Healthcare Name of report recipient No
2 Recipient Role Account Manager Role of person as assigned by the RDS Secure Website No
3 Recipient Vendor John Jacobson Name of individual associated with Vendor No
4 Cost Reporting Alert 101 Numeric value of Alert No
5 Cost Reporting Alert Description No Reports: Interim Cost Reporting Open Text description of Alert No
6 Plan Sponsor ID 6843 A unique number assigned to a Plan Sponsor for the duration of their participation in the RDS Program No
7 Organization Name Ironclad Technologies The legal entity name of the Plan Sponsor No
8 Account Manager Name Louis Barlow Name of Account Manager associated with the Plan Sponsor No
9 Authorized Representative Name Joseph Mascis Name of Authorized Representative associated with the Plan Sponsor No
10 Authorized Representative Verification Status Approved Indicates whether the Plan Sponsor has approved the Authorized Representative to act on the Plan Sponsor's behalf No
11 Application ID 84361 A unique number assigned to an Application that does not change No
12 Plan Name AzureMed Name associated with the Application No
13 Plan Year Start Date 2008-01-01 The beginning date defining the Plan Year No
14 Plan Year End Date 2008-12-31 The ending date defining the Plan Year No
15 Application Status Reconciliation Cost Reporting Opened Current Status of the Application No
16 Application Status Date 2009-09-18 The date associated with the latest Application Status No
17 Interim Payment Frequency Monthly Indicates how frequently the Plan Sponsor can request payment on the Application No
18 Total Paid To Date 52132.82 Total amount that has been paid to date for the Application No
19 Retiree Submissions Ready Closed Open/Closed indicator of whether or not retiree files were accepted by CMS' RDS Center Yes
20 Retiree List Submission Method RDS Secure Website to RDS Center Retiree data submission method to CMS' RDS Center; defined during the Application Process No
21 Submitter ID 130845 Submitter ID associated to the Vendor, Plan Sponsor, VDSA, or MIR submitting retiree files No
22 Submitter Name Gregory Gillis Submitter name associated to the Vendor, Plan Sponsor, VDSA, or MIR submitting retiree files No
23 Retiree List Response Method RDS Secure Website to RDS Center The method by which retiree data is communicated to the Submitter or Plan Sponsor. No
24 Weekly Notification File Delivery Method RDS Secure Website only Delivery method for notifications from CMS' RDS Center concerning Qualifying Covered Retirees No
25 Last Covered Retiree List Created Date 2009-06-04 The last date that a Covered Retiree List was generated for the Application No
26 Payment Setup Complete Yes A Yes/No indicator that all steps of Payment Setup are complete Yes
27 Cost Report Ready Final Open Indicates whether Cost Reports are ready to be accepted by CMS' RDS Center Yes
28 Reconciliation Deadline Date 2010-03-31 Date Reconciliation must be completed by to avoid an overpayment No
29 Last Completed Recon Step 5 The Reconciliation step last completed by the Plan Sponsor No
30 Recon Step Date/Time 2010-09-18 13:42:05 Date and time the Plan Sponsor completed the Reconciliation step No
31 Benefit Option Name UboiA Name of a particular benefit design, category of benefits, or cost-sharing arrangement offered within a group health plan No
32 Unique Benefit Option Identifier 00ASO2002 A unique identifier for each Benefit Option on the Application No
33 UBOI Eligible Retiree Count 14 Unique number of eligible retirees associated with the Benefit Option No
34 Multiple Cost Reporters Assigned No A Yes/No indicator that multiple sources have been assigned to report costs for the Benefit Option Yes
35 Costs Accepted From Another Reporting Source Yes: Interim Costs Greater Than Zero Indicates if a Benefit Option has costs greater than zero from more than one source No
36 Cost Reporter Type A01 Vendor Identifier or the text "Plan Sponsor" No
37 Last Cost Report Accepted File Receipt Date/Time 2008-08-02 14:18:07 The file receipt date/time associated with the last Cost Report for the Benefit Option accepted by CMS' RDS Center No
38 Last Cost Report Accepted Processed Date 2008-08-03 The date a Cost Report submitted by the Cost Reporter was last accepted by CMS' RDS Center for the given Benefit Option No
39 Last Cost Report Accepted Status Included in Payment Request This is the most current status associated with the last Cost Report accepted by CMS' RDS Center No
40 Last Cost Report Accepted Status Date 2008-10-21 The date associated with the Last Cost Report Accepted Status No
41 Last Cost Report Accepted Type Interim The timing of the most recently accepted Cost Report (Interim or Final) No
42 Last Cost Report Accepted Allowable Retiree Cost 45452.98 The total Allowable Retiree Costs for the Benefit Option included in the last Cost Report accepted by CMS' RDS Center No
43 Last Cost Report Rejected File Receipt Date/Time 2008-09-18 12:12:07 File receipt date and time associated with the last Cost Report for the Benefit Option rejected by CMS' RDS Center No
44 Last Cost Report Rejected File Processed Date 2008-09-20 The date a Mainframe Cost Report submitted by the Cost Reporter was last rejected by CMS' RDS Center for the Benefit Option No
45 Last Cost Report Rejected Status Mainframe Errors Detected Indicates that errors were detected in the Mainframe Cost Report No
46 Last Cost Report Rejected Type Final The timing of the most recently rejected Cost Report (Interim or Final) No
47 Last Cost Report Rejected Allowable Retiree Cost 82321.56 The total Allowable Retiree Costs for the Benefit Option included in the last Cost Report rejected by CMS' RDS Center No