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pdfPBP 2015 Data Entry System Screens
Plan Deductible LPPO/RPPO Base 1
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 1 of 67
PBP 2015 Data Entry System Screens
Plan Deductible LPPO/RPPO Base 2
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 2 of 67
PBP 2015 Data Entry System Screens
Plan Deductible LPPO/RPPO Base 3
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 3 of 67
PBP 2015 Data Entry System Screens
Plan Deductible LPPO/RPPO Base 4
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 4 of 67
PBP 2015 Data Entry System Screens
Plan Deductible LPPO/RPPO Base 5
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 5 of 67
PBP 2015 Data Entry System Screens
Plan Deductible LPPO/RPPO Base 6
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 6 of 67
PBP 2015 Data Entry System Screens
Plan Deductible (Combined) – Base 1
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 7 of 67
PBP 2015 Data Entry System Screens
Plan Deductible (Combined) – Base 2
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 8 of 67
PBP 2015 Data Entry System Screens
Plan Deductible (In‐Network)
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 9 of 67
PBP 2015 Data Entry System Screens
Plan Deductible (Out‐of‐Network)
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 10 of 67
PBP 2015 Data Entry System Screens
Plan Deductible (Non‐Network)
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 11 of 67
PBP 2015 Data Entry System Screens
Max Enrollee Cost Limit (Combined) – Base 1
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 12 of 67
PBP 2015 Data Entry System Screens
Max Enrollee Cost Limit (Combined) – Base 2
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 13 of 67
PBP 2015 Data Entry System Screens
Max Enrollee Cost Limit (In‐Network)
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 14 of 67
PBP 2015 Data Entry System Screens
Max Enrollee Cost Limit (Out‐of‐Network)
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 15 of 67
PBP 2015 Data Entry System Screens
Max Enrollee Cost Limit (Non‐Network)
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 16 of 67
PBP 2015 Data Entry System Screens
Max Plan Benefit Coverage
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 17 of 67
PBP 2015 Data Entry System Screens
Max Plan Benefit Coverage (Non‐Network)
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 18 of 67
PBP 2015 Data Entry System Screens
Plan Premium/Rebate Reduction
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 19 of 67
PBP 2015 Data Entry System Screens
MMP – Medicaid/plan covered cost sharing
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 20 of 67
PBP 2015 Data Entry System Screens
PFFS Balance Billing
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 21 of 67
PBP 2015 Data Entry System Screens
MSA Annual Deductible/Deposit
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 22 of 67
PBP 2015 Data Entry System Screens
Notes
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 23 of 67
PBP 2015 Data Entry System Screens
Optional Supplemental – Management Screen
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 24 of 67
PBP 2015 Data Entry System Screens
Optional Supplemental – Label and Premium
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 25 of 67
PBP 2015 Data Entry System Screens
Optional Supplemental – Service Categories
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 26 of 67
PBP 2015 Data Entry System Screens
Optional Supplemental – OON Stepup
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 27 of 67
PBP 2015 Data Entry System Screens
Optional Supplemental – OON Optional
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 28 of 67
PBP 2015 Data Entry System Screens
Step Up #10b Transportation Services – Base 1
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 29 of 67
PBP 2015 Data Entry System Screens
Step Up #10b Transportation Services – Base 2
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 30 of 67
PBP 2015 Data Entry System Screens
Step Up #10b Transportation Services – Base 3
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 31 of 67
PBP 2015 Data Entry System Screens
Step Up #16a Preventive Dental – Base 1
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 32 of 67
PBP 2015 Data Entry System Screens
Step Up #16a Preventive Dental – Base 2
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 33 of 67
PBP 2015 Data Entry System Screens
Step Up #16a Preventive Dental – Base 3
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 34 of 67
PBP 2015 Data Entry System Screens
Step Up #16a Preventive Dental – Base 4
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 35 of 67
PBP 2015 Data Entry System Screens
Step Up #16a Preventive Dental – Base 5
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 36 of 67
PBP 2015 Data Entry System Screens
Step Up #16b Comprehensive Dental – Base 1
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 37 of 67
PBP 2015 Data Entry System Screens
Step Up #16b Comprehensive Dental – Base 2
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 38 of 67
PBP 2015 Data Entry System Screens
Step Up #16b Comprehensive Dental – Base 3
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 39 of 67
PBP 2015 Data Entry System Screens
Step Up #16b Comprehensive Dental – Base 4
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 40 of 67
PBP 2015 Data Entry System Screens
Step Up #16b Comprehensive Dental – Base 5
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 41 of 67
PBP 2015 Data Entry System Screens
Step Up #16b Comprehensive Dental – Base 6
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 42 of 67
PBP 2015 Data Entry System Screens
Step Up #17a Eye Exams – Base 1
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 43 of 67
PBP 2015 Data Entry System Screens
Step Up #17a Eye Exams – Base 2
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 44 of 67
PBP 2015 Data Entry System Screens
Step Up #17a Eye Exams – Base 3
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 45 of 67
PBP 2015 Data Entry System Screens
Step Up #17b Eyewear – Base 1
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 46 of 67
PBP 2015 Data Entry System Screens
Step Up #17b Eyewear – Base 2
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 47 of 67
PBP 2015 Data Entry System Screens
Step Up #17b Eyewear – Base 3
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 48 of 67
PBP 2015 Data Entry System Screens
Step Up #17b Eyewear – Base 4
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 49 of 67
PBP 2015 Data Entry System Screens
Step Up #17b Eyewear – Base 5
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 50 of 67
PBP 2015 Data Entry System Screens
Step Up #17b Eyewear – Base 6
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 51 of 67
PBP 2015 Data Entry System Screens
Step Up #18a Hearing Exams – Base 1
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 52 of 67
PBP 2015 Data Entry System Screens
Step Up #18a Hearing Exams – Base 2
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 53 of 67
PBP 2015 Data Entry System Screens
Step Up #18a Hearing Exams – Base 3
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 54 of 67
PBP 2015 Data Entry System Screens
Step Up #18a Hearing Exams – Base 4
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 55 of 67
PBP 2015 Data Entry System Screens
Step Up #18b Hearing Aids – Base 1
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 56 of 67
PBP 2015 Data Entry System Screens
Step Up #18b Hearing Aids – Base 2
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 57 of 67
PBP 2015 Data Entry System Screens
Step Up #18b Hearing Aids – Base 3
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 58 of 67
PBP 2015 Data Entry System Screens
Step Up #18b Hearing Aids – Base 4
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 59 of 67
PBP 2015 Data Entry System Screens
Step Up #18b Hearing Aids – Base 5
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 60 of 67
PBP 2015 Data Entry System Screens
Step Up #7b Chiropractic Services – Base 1
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 61 of 67
PBP 2015 Data Entry System Screens
Step Up #7b Chiropractic Services – Base 2
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 62 of 67
PBP 2015 Data Entry System Screens
Step Up #7b Chiropractic Services – Base 3
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 63 of 67
PBP 2015 Data Entry System Screens
Step Up #7b Chiropractic Services – Base 4
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 64 of 67
PBP 2015 Data Entry System Screens
Step Up #7f Podiatry Services – Base 1
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 65 of 67
PBP 2015 Data Entry System Screens
Step Up #7f Podiatry Services – Base 2
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 66 of 67
PBP 2015 Data Entry System Screens
Step Up #7f Podiatry Services – Base 3
Fu Associates, Ltd.
CY 2015 PBP – Section D
12/20/2013
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 67 of 67
| File Type | application/pdf |
| File Title | Microsoft Word - PBP_2015_screenshots_section_d_2013_11_20.docx |
| Author | bloss |
| File Modified | 2013-12-20 |
| File Created | 2013-12-20 |