Form CMS-10233 Regional PPO Risk-Sharing Reconciliation Cost Report

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Overview

Cover Page
Summary
Plan 001
Plan 002
Plan 003
Claims Lag Data - Plan 001
Claims Lag Data - Plan 002
Claims Lag Data - Plan 003
Indiv 2007 RPPO by bid id

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Sheet 1: Cover Page

	Regional Preferred Provider Organization Risk-Sharing Reconciliation
	Submission Cover Sheet
1	Name and Address of Organization:
		Test Organization
		1234 Hospital Drive
		Anytown, USA 99999
2	Reporting Period:									Contract Number:
		From:		1/1/2006
										R-xxxx
		To:		12/31/2006
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST
REPORT MAY BE PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW
CERTIFICATION BY OFFICER OF THE ORGANIZATION
I HEREBY CERTIFY that I have examined the accompanying RPPO Risk-Sharing Reconciliation, the allocation of expenses and services, and the attached Worksheets for the period from 01/01/2006 to 12/31/2006and that to the best of my knowledge and belief they are true and correct statements prepared from the books and records of the Organization in accordance with applicable instructions, except as noted.
	SIGNATURE (Officer or Administrator of the Organization)						DATE
	TITLE						PHONE NUMBER
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is xxx-xxxx. If you have any comments or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, C3-13-06, Baltimore, Maryland 21244-1850.
	0
	0

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Sheet 2: Summary

I.	General Information
1.	Contract Number:	R1111
4.	Contract Year:	2006
6.	Organization Name:	Test Organization
8.	MA Region:	11
9.	MA Region Name	Michigan
II.	Summary
Plan ID	Risk Sharing Target Amount	Allowed Medical Expense for Risk Sharing (AME)	Difference	CMS' Share of Risk Corridors			Risk Sharing Payment Adjustment
				<= 3.0%	> 3.0% and <= 8.0%	Greater than 8.0%	Total	Part A	Part B
001	$11,965,168.00	$11,824,950.00	$140,218.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
002	$10,972,730.00	$11,824,950.00	($852,220.00)	$0.00	$261,519.05	$0.00	$261,519.05	$135,754.54	$125,764.51
003	$11,825,388.00	$10,611,710.13	$1,213,677.87	$0.00	($295,634.70)	($6,691.17)	($302,325.87)	($156,937.36)	($145,388.51)
All		Savings	$501,675.87	$0.00	($34,115.65)	($6,691.17)	($40,806.82)	($21,182.82)	($19,624.00)

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Sheet 3: Plan 001

SECTION #1 - ENROLLMENT, REVENUE, AND TARGET RATIOS
I.	General Information	(c)	(d)
1.	Contract Number:	R1111
2.	Plan ID:	001
3.	Segment	0
4.	Contract Year:	2007
5.	Bid ID	R1111_001_0
6.	Organization Name:	Test Organization
7.	Plan Name:	Test Plan 1
8.	MA Region:	11
9.	MA Region Name	Michigan
II.	Enrollment
	Non-ESRD CY member months	16,400
III.	Actual Plan Revenue
1.	CY A/B capitation payment for non-ESRD enrollees		$12,000,000.00
2.	Adjustments (Specify other types in c.)
a.	Secondary payor	($20,000.00)
b.	User fees	($2,000.00)
c.
d.	Summary of Adjustments		($22,000.00)
3.	Rebatable Integrated Benefits (RIBs)
a.	MA Rebates to Reduce A/B Cost Sharing	$900,000.00
b.	Other Mandatory Supplemental Benefits	$1,100,000.00
c.	Subtotal Payments for RIBs		$2,000,000.00
4.	Basic Enrollee Billed Premium (excl. Opt. Supp.)		$0.00
5.	Allowed Revenue for Risk Sharing		$13,978,000.00
IV.	Risk Sharing Target Ratio (from bid)
1.	Projected Net Medical Cost (Med-Cov + RIBs) pmpm		$888.23
2.	Proj. Required Revenue (Med-Cov + RIBs)pmpm		$1,006.32
3.	Medical Benefit Ratio Target (Target Ratio)		85.6%
V.	Risk Sharing Target Amount
1.	Allowed Revenue for Risk Sharing		$13,978,000.00
2.	Target Ratio		85.6%
3.	Risk Sharing Target Amount = 1 x 2		$11,965,168.00
VI.	Claims Adjustment Ratio
1.	Proj. Net Medical Cost (Med-Cov + Non-Cov) pmpm		$850.20
2.	Projected Medical Expense for Risk Sharing pmpm		$850.20
3.	Claims Adjustment Ratio		100.00%
SECTION #2 - MEDICAL EXPENSES
I.	Actual Medical Expenses
1.	Member Months:
		In Network and OON Claims		Total
		Incurred during current CY and	Claims	Incurred
	(b)	Paid through 12 months after current CY	Reserve	Claims
2.	Medicare-Covered Services
a.	Inpatient Facility	$5,500,000.00	$50,000.00	$5,550,000.00
b.	Skilled Nursing Facility	$440,000.00	$4,000.00	$444,000.00
c.	Home Health	$450,000.00	$3,500.00	$453,500.00
d.	Ambulance	$75,000.00	$750.00	$75,750.00
e.	DME/Prosthetics/Supplies	$300,000.00	$3,000.00	$303,000.00
f.	OP Facility - Emergency	$60,000.00	$600.00	$60,600.00
g.	OP Facility - Surgery	$210,000.00	$21,000.00	$231,000.00
h.	OP Facility - Other	$80,000.00	$800.00	$80,800.00
i.	Professional	$4,000,000.00	$40,000.00	$4,040,000.00
j.	Part B Rx	$500,000.00	$5,000.00	$505,000.00
k.	Other Medicare Part B	$50,000.00	$500.00	$50,500.00
l.	Subtotal	$11,665,000.00	$129,150.00	$11,794,150.00
3.	Non-Covered services
a.	Transportation			$0.00
b.	Dental			$0.00
c.	Vision			$0.00
d.	Hearing	$80,000.00	$800.00	$80,800.00
e.	Health & Education			$0.00
f.	Other Non-Covered			$0.00
g.	Subtotal	$80,000.00	$800.00	$80,800.00
4.	Outside Claim System (Specify other types)
a.	Coordination of Benefits	($50,000.00)	$0.00	($50,000.00)
b.	Subrogation			$0.00
c.	Reinsurance			$0.00
d.	Part B Rx Rebates			$0.00
e.				$0.00
f.	Subtotal	$(50,000.00)	$-	$(50,000.00)
5.	Total Medical Expenses	$11,695,000.00	$129,950.00	$11,824,950.00
II.	Medical Expenses for Risk Sharing
1.	Total Medical Expenses			$11,824,950.00
2.	Claims Adjustment Ratio			100.00%
3.	Medical Expenses for Risk Sharing			$11,824,950.00
SECTION #3 - RISK SHARING RECONCILIATION RATIOS
I.	Risk Sharing Amounts
1.	Risk Sharing Target Amount (Target Amount)		$11,965,168.00
2.	Allowed Medical Expense for Risk Sharing (AME)		$11,824,950.00
3.	Difference $	Savings	$140,218.00
4.	Difference %		1.2%
II.	Risk Sharing Target Corridors
1	Threshold Limits	Risk Sharing Corridors		Risk Sharing Amount	CMS Share %
	92% Target Amount	Greater than 8.0%	$11,007,954.56	$0.00	2.5%
	92% - 97% Target Amount	> 3.0% and <= 8.0%	$598,258.40	$0.00	50.0%
	97% - 100% or 100% - 103%	<= 3.0%	$358,955.04	$140,218.00	0.0%
	103% - 108% Target Amount	> 3.0% and <= 8.0%	$0.00	$0.00	50.0%
	108% Target Amount	Greater than 8.0%	$0.00	$0.00	2.5%
2.			$11,965,168.00	$140,218.00
3.	Non-ESRD Member Months	16,400
4.	Risk Sharing Corridors	CMS Share $	Plan Share $	Total
	Greater than 8.0%	$0.00	$0.00	$0.00
	> 3.0% and <= 8.0%	$0.00	$0.00	$0.00
	<= 3.0%	$0.00	$140,218.00	$140,218.00
5.	Total $	$0.00	$140,218.00	$140,218.00
6.	Total PMPM	$0.00	$8.55
III.	Risk Sharing Payment Adjustment
1.	Payment to Plan (if loss)	$0.00
2.	Payment to CMS (if savings)	$0.00
	(Negative adjustment to plan payment)
3a	Part A Payment	$0.00
3b	Part B Payment	$0.00
NOTES (Section/line#)

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Sheet 4: Plan 002

Section #1 - ENROLLMENT, REVENUE, and TARGET RATIOS
I.	General Information	(c)	(d)
1.	Contract Number:	R1111
2.	Plan ID:	002
3.	Segment	0
4.	Contract Year:	2007
5.	Bid ID	R1111_002_0
6.	Organization Name:	Test Organization
7.	Plan Name:	Test Plan 2
8.	MA Region:	11
9.	MA Region Name	Michigan
II.	Enrollment
	Non-ESRD CY member months	16,400
III.	Actual Plan Revenue
1.	CY A/B capitation payment for non-ESRD enrollees		$12,000,000.00
2.	Adjustments (Specify other types in c.)
a.	Secondary payor	($20,000.00)
b.	User fees	($2,000.00)
c.
d.	Summary of Adjustments		($22,000.00)
3.	Rebatable Integrated Benefits (RIBs)
a.	MA Rebates to Reduce A/B Cost Sharing	$0.00
b.	Other Mandatory Supplemental Benefits	$0.00
c.	Subtotal Payments for RIBs		$0.00
4.	Basic Enrollee Billed Premium (excl. Opt. Supp.)		$2,000,000.00
5.	Allowed Revenue for Risk Sharing		$13,978,000.00
IV.	Risk Sharing Target Ratio (from bid)
1.	Projected Net Medical Cost (Med-Cov + RIBs) pmpm		$666.09
2.	Proj. Required Revenue (Med-Cov + RIBs)pmpm		$872.11
3.	Medical Benefit Ratio Target (Target Ratio)		78.5%
V.	Risk Sharing Target Amount (from bid)
1.	Allowed Revenue for Risk Sharing		$13,978,000.00
2.	Target Ratio		78.5%
3.	Risk Sharing Target Amount = 1 x 2		$10,972,730.00
VI.	Claims Adjustment Ratio
1.	Proj. Net Medical Cost (Med-Cov + Non-Cov) pmpm		$682.10
2.	Projected Medical Expense for Risk Sharing pmpm		$682.09
3.	Claims Adjustment Ratio		100.00%
SECTION #2 - MEDICAL CLAIMS
I.	Actual Claims
1.	Member Months:
		In Network and OON Claims		Total
		Incurred during current CY and	Claims	Incurred
	(b)	Paid through 12 months after current CY	Reserve	Claims
2.	Medicare-Covered Services
a.	Inpatient Facility	$5,500,000.00	$50,000.00	$5,550,000.00
b.	Skilled Nursing Facility	$440,000.00	$4,000.00	$444,000.00
c.	Home Health	$450,000.00	$3,500.00	$453,500.00
d.	Ambulance	$75,000.00	$750.00	$75,750.00
e.	DME/Prosthetics/Supplies	$300,000.00	$3,000.00	$303,000.00
f.	OP Facility - Emergency	$60,000.00	$600.00	$60,600.00
g.	OP Facility - Surgery	$210,000.00	$21,000.00	$231,000.00
h.	OP Facility - Other	$80,000.00	$800.00	$80,800.00
i.	Professional	$4,000,000.00	$40,000.00	$4,040,000.00
j.	Part B Rx	$500,000.00	$5,000.00	$505,000.00
k.	Other Medicare Part B	$50,000.00	$500.00	$50,500.00
l.	Subtotal	$11,665,000.00	$129,150.00	$11,794,150.00
3.	Non-Covered services
a.	Transportation			$0.00
b.	Dental			$0.00
c.	Vision			$0.00
d.	Hearing	$80,000.00	$800.00	$80,800.00
e.	Health & Education			$0.00
f.	Other Non-Covered			$0.00
g.	Subtotal	$80,000.00	$800.00	$80,800.00
4.	Outside Claim System (Specify other types)
a.	Coordination of Benefits	($50,000.00)	$0.00	($50,000.00)
b.	Subrogation			$0.00
c.	Reinsurance			$0.00
d.	Part B Rx Rebates			$0.00
e.				$0.00
f.	Subtotal	$(50,000.00)	$-	$(50,000.00)
5.	Total Medical Expenses	$11,695,000.00	$129,950.00	$11,824,950.00
II.	Medical Expenses for Risk Sharing
1.	Total Medical Expenses			$11,824,950.00
2.	Claims Adjustment Ratio			100.00%
3.	Medical Expenses for Risk Sharing			$11,824,950.00
SECTION #3 - RISK SHARING RECONCILIATION RATIOS
I.	Risk Sharing Amounts
1.	Risk Sharing Target Amount (Target Amount)		$10,972,730.00
2.	Allowed Medical Expense for Risk Sharing (AME)		$11,824,950.00
3.	Difference $	Loss	($852,220.00)
4.	Difference %		-7.8%
II.	Risk Sharing Target Corridors
1	Threshold Limits	Risk Sharing Corridors		Risk Sharing Amount	CMS Share %
	92% Target Amount	Greater than 8.0%	$0.00	$0.00	2.5%
	92% - 97% Target Amount	> 3.0% and <= 8.0%	$0.00	$0.00	50.0%
	97% - 100% or 100% - 103%	<= 3.0%	$329,181.90	$329,181.90	0.0%
	103% - 108% Target Amount	> 3.0% and <= 8.0%	$548,636.50	$523,038.10	50.0%
	108% Target Amount	Greater than 8.0%	$10,094,911.60	$0.00	2.5%
2.			$10,972,730.00	$852,220.00
3.	Non-ESRD Member Months	16,400
4.	Risk Sharing Corridors	CMS Share $	Plan Share $	Total
	Greater than 8.0%	$0.00	$0.00	$0.00
	> 3.0% and <= 8.0%	$261,519.05	$261,519.05	$523,038.10
	<= 3.0%	$0.00	$329,181.90	$329,181.90
5.	Total $	$261,519.05	$590,700.95	$852,220.00
6.	Total PMPM	$15.95	$36.02
III.	Risk Sharing Payment Adjustment
1.	Payment to Plan (if loss)	$261,519.05
2.	Payment to CMS (if savings)	$0.00
	(Negative adjustment to plan payment)
3a	Part A Payment	$135,754.54
3b	Part B Payment	$125,764.51
NOTES (Section/line#)

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Sheet 5: Plan 003

Section #1 - ENROLLMENT, REVENUE, and TARGET RATIOS
I.	General Information	(c)	(d)
1.	Contract Number:	R1111
2.	Plan ID:	003
3.	Segment	0
4.	Contract Year:	2007
5.	Bid ID	R1111_003_0
6.	Organization Name:	Test Organization
7.	Plan Name:	Test Plan 3
8.	MA Region:	11
9.	MA Region Name	Michigan
II.	Enrollment
	Non-ESRD CY member months	16,400
III.	Actual Plan Revenue
1.	CY A/B capitation payment for non-ESRD enrollees		$12,000,000.00
2.	Adjustments (Specify other types in c.)
a.	Secondary payor	($20,000.00)
b.	User fees	($2,000.00)
c.
d.	Summary of Adjustments		($22,000.00)
3.	Rebatable Integrated Benefits (RIBs)
a.	MA Rebates to Reduce A/B Cost Sharing	$900,000.00
b.	Other Mandatory Supplemental Benefits	$1,100,000.00
c.	Subtotal Payments for RIBs		$2,000,000.00
4.	Basic Enrollee Billed Premium (excl. Opt. Supp.)		$0.00
5.	Allowed Revenue for Risk Sharing		$13,978,000.00
IV.	Risk Sharing Target Ratio (from bid)
1.	Projected Net Medical Cost (Med-Cov + RIBs) pmpm		$449.23
2.	Proj. Required Revenue (Med-Cov + RIBs)pmpm		$529.50
3.	Medical Benefit Ratio Target (Target Ratio)		84.6%
V.	Risk Sharing Target Amount (from bid)
1.	Allowed Revenue for Risk Sharing		$13,978,000.00
2.	Target Ratio		84.6%
3.	Risk Sharing Target Amount = 1 x 2		$11,825,388.00
VI.	Claims Adjustment Ratio
1.	Proj. Net Medical Cost (Med-Cov + Non-Cov) pmpm		$499.24
2.	Projected Medical Expense for Risk Sharing pmpm		$448.04
3.	Claims Adjustment Ratio		89.74%
SECTION #2 - MEDICAL CLAIMS
I.	Actual Claims
1.	Member Months:
		In Network and OON Claims		Total
		Incurred during current CY and	Claims	Incurred
	(b)	Paid through 12 months after current CY	Reserve	Claims
2.	Medicare-Covered Services
a.	Inpatient Facility	$5,500,000.00	$50,000.00	$5,550,000.00
b.	Skilled Nursing Facility	$440,000.00	$4,000.00	$444,000.00
c.	Home Health	$450,000.00	$3,500.00	$453,500.00
d.	Ambulance	$75,000.00	$750.00	$75,750.00
e.	DME/Prosthetics/Supplies	$300,000.00	$3,000.00	$303,000.00
f.	OP Facility - Emergency	$60,000.00	$600.00	$60,600.00
g.	OP Facility - Surgery	$210,000.00	$21,000.00	$231,000.00
h.	OP Facility - Other	$80,000.00	$800.00	$80,800.00
i.	Professional	$4,000,000.00	$40,000.00	$4,040,000.00
j.	Part B Rx	$500,000.00	$5,000.00	$505,000.00
k.	Other Medicare Part B	$50,000.00	$500.00	$50,500.00
l.	Subtotal	$11,665,000.00	$129,150.00	$11,794,150.00
3.	Non-Covered services
a.	Transportation			$0.00
b.	Dental			$0.00
c.	Vision			$0.00
d.	Hearing	$80,000.00	$800.00	$80,800.00
e.	Health & Education			$0.00
f.	Other Non-Covered			$0.00
g.	Subtotal	$80,000.00	$800.00	$80,800.00
4.	Outside Claim System (Specify other types)
a.	Coordination of Benefits	($50,000.00)	$0.00	($50,000.00)
b.	Subrogation			$0.00
c.	Reinsurance			$0.00
d.	Part B Rx Rebates			$0.00
e.				$0.00
f.	Subtotal	$(50,000.00)	$-	$(50,000.00)
5.	Total Medical Expenses	$11,695,000.00	$129,950.00	$11,824,950.00
II.	Medical Expenses for Risk Sharing
1.	Total Medical Expenses			$11,824,950.00
2.	Claims Adjustment Ratio			89.74%
3.	Medical Expenses for Risk Sharing			$10,611,710.13
SECTION #3 - RISK SHARING RECONCILIATION RATIOS
I.	Risk Sharing Amounts
1.	Risk Sharing Target Amount (Target Amount)		$11,825,388.00
2.	Allowed Medical Expense for Risk Sharing (AME)		$10,611,710.13
3.	Difference $	Savings	$1,213,677.87
4.	Difference %		10.3%
II.	Risk Sharing Target Corridors
1	Threshold Limits	Risk Sharing Corridors		Risk Sharing Amount	CMS Share %
	92% Target Amount	Greater than 8.0%	$10,879,356.96	$267,646.83	2.5%
	92% - 97% Target Amount	> 3.0% and <= 8.0%	$591,269.40	$591,269.40	50.0%
	97% - 100% or 100% - 103%	<= 3.0%	$354,761.64	$354,761.64	0.0%
	103% - 108% Target Amount	> 3.0% and <= 8.0%	$0.00	$0.00	50.0%
	108% Target Amount	Greater than 8.0%	$0.00	$0.00	2.5%
2.			$11,825,388.00	$1,213,677.87
3.	Non-ESRD Member Months	16,400
4.	Risk Sharing Corridors	CMS Share $	Plan Share $	Total
	Greater than 8.0%	$6,691.17	$260,955.66	$267,646.83
	> 3.0% and <= 8.0%	$295,634.70	$295,634.70	$591,269.40
	<= 3.0%	$0.00	$354,761.64	$354,761.64
5.	Total $	$302,325.87	$911,352.00	$1,213,677.87
6.	Total PMPM	$18.43	$55.57
III.	Risk Sharing Payment Adjustment
1.	Payment to Plan (if loss)	$0.00
2.	Payment to CMS (if savings)	($302,325.87)
	(Negative adjustment to plan payment)
3a	Part A Payment	($156,937.36)
3b	Part B Payment	($145,388.51)
NOTES (Section/line#)

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Sheet 6: Claims Lag Data - Plan 001

Regional Preferred Provider Organization Risk-Sharing Reconciliation
Claims Reserves Supporting Schedule
Plan Name
"R" Number	RXXXX
Contract Period	CY 2006
Instructions:
The purpose of this worksheet is to provide a guide to creating a detailed claims data worksheet. This worksheet shows the minimum data elements that are required to be submitted with this Risk-Sharing reconciliation. There should be a seperate Claims Reserve worksheet for each Plan that is reporting claim reserves.
Use the following format to provide the required information. Use the service categories that the organization typically uses when developing reserves. If they are more general than those provided in Section #2 of the Plan worksheet, please indicate how each of the categories presented in Section #2 of the Plan worksheet relates to the more general categories. If the projected reserve for in-network services is a different percentage than for out-of-network services, please provide separate claims lag data for in and out-of-network claims. If not, combine this data. Do not complete this worksheet for a specific category IF there the Plan is not claiming any expenses for claims not yet paid (i.e. projected reserves) for that category in Section #2 of the Plan worksheet.
CLAIMS INCURRED FROM JANUARY - DECEMBER 2006 AND PAID THROUGH THE CURRENT REPORTING DATE
Service Category	Incurred Month	Paid Month	Total In-network $	Total Out of Network $	Total $	GRAND TOTAL FOR CATEGORY
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
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Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-		Note: This number should match Section #2 of the respective Plan worksheet.
Inpatient Hospital					$-
Inpatient Hospital					$-	$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-		Note: This number should match Worksheet #2 (Medical Expenses)
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-	$-

---

Sheet 7: Claims Lag Data - Plan 002

Regional Preferred Provider Organization Risk-Sharing Reconciliation
Claims Reserves Supporting Schedule
Plan Name
"R" Number	RXXXX
Contract Period	CY2006
Instructions:
The purpose of this worksheet is to provide a guide to creating a detailed claims data worksheet. This worksheet shows the minimum data elements that are required to be submitted with this Risk-Sharing reconciliation. There should be a seperate Claims R
Use the following format to provide the required information. Use the service categories that the organization typically uses when developing reserves. If they are more general than those provided in Section #2 of the Plan worksheet, please indicate how
CLAIMS INCURRED FROM JANUARY - DECEMBER 2006 AND PAID THROUGH THE CURRENT REPORTING DATE
Service Category	Incurred Month	Paid Month	Total In-network $	Total Out of Network $	Total $	GRAND TOTAL FOR CATEGORY
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-		Note: This number should match Section #2 of the respective Plan worksheet.
Inpatient Hospital					$-
Inpatient Hospital					$-	$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-		Note: This number should match Worksheet #2 (Medical Expenses)
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-	$-

---

Sheet 8: Claims Lag Data - Plan 003

Regional Preferred Provider Organization Risk-Sharing Reconciliation
Claims Reserves Supporting Schedule
Plan Name
"R" Number	RXXXX
Contract Period	CY 2006
Instructions:
The purpose of this worksheet is to provide a guide to creating a detailed claims data worksheet. This worksheet shows the minimum data elements that are required to be submitted with this Risk-Sharing reconciliation. There should be a seperate Claims R
Use the following format to provide the required information. Use the service categories that the organization typically uses when developing reserves. If they are more general than those provided in Section #2 of the Plan worksheet, please indicate how
CLAIMS INCURRED FROM JANUARY - DECEMBER 2006 AND PAID THROUGH THE CURRENT REPORTING DATE
Service Category	Incurred Month	Paid Month	Total In-network $	Total Out of Network $	Total $	GRAND TOTAL FOR CATEGORY
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-
Inpatient Hospital					$-		Note: This number should match Section #2 of the respective Plan worksheet.
Inpatient Hospital					$-
Inpatient Hospital					$-	$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-		Note: This number should match Worksheet #2 (Medical Expenses)
Skilled Nursing Facility					$-
Skilled Nursing Facility					$-	$-

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Sheet 9: Indiv 2007 RPPO by bid id

bid_id	Organization	Plan Name	MA-PD	Region #	Region	Region cont'd 1)	Region cont'd 2)	Net Medical Cost	Non-medical expense	Gain/loss margin	Required Revenue	Target Ratio	Total Medical Expense	Net Medical Expense in bid	RIBs	Medical Expense for Risk Sharing	Claims Adjust. Ratio
R1111_001_0	Test Organization	Test Plan 1	Y	11	Michigan			888.23	30.25	44.18	1,006.32	85.6	850.20	950.23	99.52	850.20	100.00%
R1111_002_0	Test Organization	Test Plan 2	Y	11	Michigan			666.09	116.00	92.72	872.11	78.5	682.10	557.40	108.69	682.09	100.00%
R1111_003_0	Test Organization	Test Plan 3	Y	11	Michigan			449.23	72.50	11.01	529.50	84.6	499.24	425.23	20.02	448.04	89.74%