CMS-10572 Data Submission Template

OMB control number: 0938-1310/Expiration date: XX/XX/20XX

Centers for Medicare & Medicaid Services (CMS) Qualified Health Plan (QHP) Transparency in Coverage Reporting
Plan Year 20XX
Please complete the fields below, following the instructions in the Transparency in Coverage QHP Issuer Instruction Guide.
General Information
Was this plan on the Exchange in 20XX?
Issuer Name
Issuer D/B/A, if Applicable
Issuer HIOS ID
Plan ID
Issuer Point of Contact Name
Issuer Point of Contact E-mail Address
Issuer Point of Contact Phone Number
Issuer Backup Point of Contact
Issuer Backup Point of Contact E-mail Address
Issuer Backup Point of Contact Phone Number
20XX Issuer Data: Reporting of all fields is required for 20XX
Claims Payment Policies & Other Information URL
Number of Claims Received in Calendar Year 20XX for Services Rendered in 20XX
Number of Claims Denied in Calendar Year 20XX
Number of Internal Appeals Filed in Calendar Year 20XX
Number of Internal Appeals Overturned from Calendar Year 20XX Appeals
Number of External Appeals Filed in Calendar Year 20XX
Number of External Appeals Overturned from Calendar Year 20XX Appeals
Notes: (Please enter any comments/notes here.)

PRA Disclosure Statement: PRA Disclosure Statement: 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 0938-1310. The time required to complete
this information collection is estimated to average 2520 minutes, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do
not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed,
forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Marketplace Call Center at 1-800-318-2596
(TTY: 1-855-889-4325).

Center for Medicare & Medicaid Services (CMS) Qualified Health Plan Transparency in Coverage Reporting
Plan Year 20XX

Please complete the fields below, following the instructions in the Transparency in Coverage QHP Issuer Instruction Guide.

General Information

Issuer HIOS
ID
Plan ID

State

20XX Plan Data: Reporting of all fields is required for 20XX

Number of Claims
Denied in Calendar
Year 20XX

Number of Claims
Denied Due to
Referral or Prior
Authorization
Required in Calendar
Year 20XX

Number of Claims
Denied Due to Out Of
Network
Provider/Claims in
Calendar Year 20XX

Number of Claims
Denied Due to
Services Excluded or
Not Covered in
Calendar 20XX

Number of Claims Denied
Due to Not Medically
Necessary, excluding
Behavioral Health in
Calendar Year 20XX

Notes
Number of Claims Denied
Due to Not Medically
Necessary, including
Behavioral Health in
Calendar Year 20XX

Number of Claims
Denied Due to
Other in Calendar Notes: (Please enter any
Year 20XX
comments/notes here.)