Fillable Dd Form 2570 - Third Party Collection Program - Report On Program Results printable pdf download

SEGMENT REPORTED (X one)

REPORT CONTROL SYMBOL

THIRD PARTY COLLECTION PROGRAM -

DD-HA(Q)1986

INPATIENT

REPORT ON PROGRAM RESULTS

OUTPATIENT

1. QUARTER ENDING

2. REPORTING MEDICAL TREATMENT FACILITY (MTF)

3. DEFENSE MEDICAL INFORMATION SYSTEM

(DMIS) ID NO.

(YYYYMM)

PART I

4. REPORTING PERIOD (See Note 1)

NO. OF NON-ACTIVE

NO. CLAIMS DIVIDED

FISCAL YEAR

DUTY INPATIENT

NO. OF

BY DISPOSITIONS/

TOTAL $ AMOUNT

(FY)

DISPOSITIONS/VISITS

CLAIMS

COLLECTIONS

VISITS (%)

BILLED/CHARGES

(1)

(2)

(3)

(4)

(5)

(6)

a. CURRENT FY

PRIOR YEAR (PY)

b. PY 1

c. PY 2

$ ADJUSTMENTS

$ AMOUNT

$ AMOUNT REMAINING

UNCOLLECTED (See Note 3)

AND REFUNDS

COLLECTED PY 2

COLLECTED PY 1

COLLECTED

(See Note 2)

(6)-[(7)+(8)+(9)+(10)]

CURRENT FY

(7)

(8)

(9)

(10)

(11)

0.00

a. CURRENT FY

0.00

b. PY 1

0.00

c. PY 2

PART II

5. DISTRIBUTION OF REMAINING UNCOLLECTED AMOUNTS

6. UNCOLLECTED AMOUNTS SUBDIVIDED BY FY

REASON

($) (See Notes 1 and 4)

CODES

a. FY

b. FY

c. FY

OPEN CLAIMS (Requires additional follow-up action by Medical Treatment

Facility for resolution)

TRANSFERRED TO EXTERNAL AGENT (e.g., JAG) (Excluding Third Party

Liability Cases)

REASON CODES 3-7. THIRD PARTY REDUCED / DENIED PAYMENT FOR INVALID REASONS (Requires additional debt collection/legal action)

MTF NOT A PARTICIPATING HOSPITAL

PLAN EXCLUDES MILITARY HOSPITALS OR BENEFICIARIES

PATIENT HAD NO OBLIGATION TO PAY

INSURER PAID PATIENT DIRECTLY

OTHER (Explain)

0.00

TOTAL OF ALL OPEN CLAIMS (Reason Codes 1 through 7)

REASON CODES 8-16. CLOSED CLAIMS. THIRD PARTY PAID IN FULL OR REDUCED/DENIED PAYMENTS

(No further action required because unpaid amount is not a valid claim)

AMOUNT OF COVERAGE (i.e. plan pays less than 100%)

PATIENT NOT COVERED, CARE PROVIDED NOT COVERED, OR POLICY

EXPIRED

CHAMPUS AND/OR INCOME SUPPLEMENTAL PLANS

MEDICARE SUPPLEMENTAL PLANS

HEALTH MAINTENANCE ORGANIZATION (HMO)

(i.e. nonemergency out-of-plan care not covered)

MTF DID NOT COMPLY WITH UTILIZATION REVIEW PROCEDURES (i.e. pre-

admission screening, concurrent review, second surgical opinions, etc.)

REFUNDS

PATIENT COPAYS AND DEDUCTIBLES

OTHER (Explain) (Example - third party provided lower prevailing rate vs.

amount billed)

0.00

TOTAL OF ALL CLOSED CLAIMS (Reason Codes 8 through 16)

NOTES:

1. All activity for amounts claimed and collected shall be reported in the fiscal year that the services were rendered (i.e. care provided in FY

1989 will be reported as an FY 1989 claim and collection, regardless of the year payment is received). This requires cut-off billing for all

inpatients at fiscal year end.

2. Amounts reported in Part I, Column (7) for each fiscal year shall equal the subtotal for Reason Codes 8-16 in Part II, for the respective

fiscal years.

3. Amounts reported in Part I, Column (11) for each fiscal year shall equal the subtotal for Reason Codes 1-7 in Part II, for the respective

fiscal years.

4. Each quarterly report shall be cumulative for the current and two prior fiscal years.

DD FORM 2570, JUN 2001

PREVIOUS EDITION IS OBSOLETE.

Adobe Professional 7.0

Reset

Dd Form 2570 - Third Party Collection Program - Report On Program Results

Related Articles

Related forms

Related Categories