2012-13
Colorado Immunization Program (CIP)
ACA RIZO Monthly Report

* Today's Date

* Name of Agency

* Are there any changes to the contact information for your agency's ACA RIZO Project contact person? (name, address, phone #, email)

Yes

No

If yes, please list changes here:

* For which month are you reporting?

* How are things going with your ACA RIZO project?

Please describe the status of your RIZO on-site project, including progress toward your goals, or other project-related comments:

RIZO Claim Information

Please enter all claim data for the most recent month. RIZO and school-located clinic data are to be entered together. Do not enter cumulative data. Values entered should reflect a snapshot of activity that occurred in the last month only. Given the cycle time of claim processing, data entered for “# claims submitted” and “$ amount submitted” will not correlate to the “$ amount paid” column, as they do not likely reflect the same claims.

When entering data, please itemize data by payer source, showing the claim details for admin fees separately from vaccine fees in the corresponding rows. If a specific payer does not itemize reimbursements for admin fee separately from vaccine, you may mark “Yes” in the field for combining admin and vaccine fees. In those cases only, all claim data should be entered in the admin row, with the vaccine row left blank.

Special notes: If the dropdown menu is missing a payer source, please contact Jodi Maturo at 303-692-2753 to have it added.

1. Medicaid

	Medicaid admin & vaccine fee combined?		Medicaid existing contract?

	Medicaid # of claims	Medicaid $ amount submitted	Medicaid $ amount paid
Admin fees only:
Vaccine fees only:

2. Medicare

	Medicare admin & vaccine fee combined?		Medicare existing contract?

	Medicare # of claims	Medicare $ amount submitted	Medicare $ amount paid
Admin fees only:
Vaccine fees only:

3. CHP+

	CHP+ admin & vaccine fee combined?		CHP+ existing contract?

	CHP+ # of claims	CHP+ $ amount submitted	CHP+ $ amount paid
Admin fees only:
Vaccine fees only:

4. Rocky Mountain Health Plan

	Rocky Mountain Health Plan admin & vaccine fee combined?		Rocky Mountain Health Plan existing contract?

	Rocky Mountain Health Plan # of claims	Rocky Mountain Health Plan $ amount submitted	Rocky mountain Health Plan $ amount paid
Admin fees only:
Vaccine fees only:

5. Anthem BC/BS

	Anthem BC/BS admin & vaccine fee combined?		Anthem BC/BS existing contract?

	Anthem BC/BS # of claims	Anthem BC/BS $ amount submitted	Anthem BC/BS $ amount paid
Admin fees only:
Vaccine fees only:

Do you have additional Payer data to enter?

Yes

No

* Indicates Response Required

2012-13 Colorado Immunization Program (CIP) ACA RIZO Monthly Report

RIZO Claim Information

2012-13
Colorado Immunization Program (CIP)
ACA RIZO Monthly Report