Network Cost Template

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					    State of Michigan - Dental RFP

Dental Network Cost - Data Collection Template

Worksheets:


If your bid assumes that more than one network will be provided to the State of Michigan's population, you must complete worksheet tabs 2 and 3 for each provided network. For example,
if a vendor has proposed an arrangement for the State of Michigan whereby claims may be paid under Network A and Network B, then the vendor must complete worksheet tabs 2 and 3 of
this workbook for Network A and then repeat completion of worksheet tabs 2 and 3 of this workbook for Network B. All vendors must also complete worksheet tabs 1, 4 and 5. Throughout
this workbook, when we refer to network or in-network providers, we mean providers that the vendor is contracted with to accept a negotiated fee schedule for all covered services.

1. Average Billed Charge
Complete this table, by filling in the average billed or eligible charge (prior to discount) for each ADA code, by indicated 3 digit zipcode location. The average should include all charges for
these codes (in and non-network).

2. GP Fee Schedule
Complete this table, by filling in the fee schedule maximum (in-network maximum allowed charge) for each ADA code, by 3 digit zipcode. Some dental vendors have separate fee
schedules for Generalists vs. Specialists. Only the generalist fee schedule information should be provided on this tab.

3. SP Fee Schedule
Complete this table, by filling in the fee schedule maximum (in-network maximum allowed charge) for the specialty services ADA codes, by 3 digit zipcode. ADA Codes 3XXX
(endodontics), 4XXX (periodontics), and 7XXX (surgery) are generally performed by specialists. If the vendor does not have separate fee schedules, enter the same information here that
was entered on the GP Fee Schedule tab.

4. R&C Amount
Complete this table, by filling in the Reasonable & Customary amount.

5. Network Utilization Percentages
Complete this table, by filling the percentage of claims that are estimated to be in-network for each network. Vendor should also provide an estimate of out-of-network claims.




                                                                                              Page 1 of 6
   State of Michigan - Dental RFP

                                               Average Billed Charges by 3 Digit ZIP Code
ADA Code   Zip 480   Zip 481    Zip 483   Zip 488       Zip 489        Zip 490         Zip 492   Zip 494   Zip 497   Zip 498
D0120
D0140
D0150
D0210
D0220
D0230
D0272
D0274
D0330
D1110
D1120
D1203
D1204
D1351
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2740
D2750
D2751
D2752
D2790
D2791
D2792
D2920
D2950
D2954
D3310
D3320
D3330
D4341
D4910
D7140
D7210
D7230
D7240
D9110
D9241



                                                                 Page 2 of 6
   State of Michigan - Dental RFP

                            In-Network Providers (Contracted Providers) Fee Schedule Maximum - GENERAL PRACTITIONER
ADA Code   Zip 480   Zip 481       Zip 483        Zip 488       Zip 489        Zip 490     Zip 492      Zip 494    Zip 497   Zip 498
D0120
D0140
D0150
D0210
D0220
D0230
D0272
D0274
D0330
D1110
D1120
D1203
D1204
D1351
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2740
D2750
D2751
D2752
D2790
D2791
D2792
D2920
D2950
D2954
D3310
D3320
D3330
D4341
D4910
D7140
D7210
D7230
D7240
D9110
D9241



                                                                     Page 3 of 6
   State of Michigan - Dental RFP

                               In-Network Providers (Contracted Providers) Fee Schedule Maximum - SPECIALIST
ADA Code   Zip 480   Zip 481    Zip 483       Zip 488       Zip 489        Zip 490       Zip 492     Zip 494   Zip 497   Zip 498
D3310
D3320
D3330
D4341
D4910
D7140
D7210
D7230
D7240




                                                                   Page 4 of 6
   State of Michigan - Dental RFP

                                                    Reasonable & Customary Amount
ADA Code   Zip 480   Zip 481    Zip 483   Zip 488        Zip 489      Zip 490       Zip 492   Zip 494   Zip 497   Zip 498
D0120
D0140
D0150
D0210
D0220
D0230
D0272
D0274
D0330
D1110
D1120
D1203
D1204
D1351
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2740
D2750
D2751
D2752
D2790
D2791
D2792
D2920
D2950
D2954
D3310
D3320
D3330
D4341
D4910
D7140
D7210
D7230
D7240
D9110
D9241



                                                                Page 5 of 6
    State of Michigan - Dental RFP

                                                    In-Network (Contracted) and Out-of-Network Utilization
                                    Contracted
 Network Name*       % Claims        Network
Network A                              Yes
Network B                              Yes
Network C                              Yes
Network D                              Yes
Out-of-Network                         No
Total**                    100%

*Replace Network A, Network B, etc. with the actual name of the network that will be offered to the State of Michigan's population.
**Cells B4-B9 must add up to 100%.

Important Note: All vendors must also complete worksheet tab 5. When we refer to network or in-network providers, we mean providers
that the vendor is contracted with to accept a negotiated fee schedule for all covered services. The percentage of out-of-network claims that
you complete on tab 5 must represent the estimate of claims dollars that wil be paid by out-of-network (or non-contracted) providers.




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