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It records whether the issuer was on the exchange in 2023, SADP status, and the issuer HIOS ID, then summarizes in-network and out-of-network claim counts by received, denied, and resubmitted status in calendar year 2023, plus internal and external appeal metrics. Includes required-field instructions and CMS PRA disclosure statements.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/kaiser-2023-ind-il-claims-plan-year-2025-v50-qhp-transparency-in-coverage-reporting/355246/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/kaiser-2023-ind-il-claims-plan-year-2025-v50-qhp-transparency-in-coverage-reporting/355246.png","ImageObject",442,249,{"name":88,"@type":89},"4398046744996","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-22",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What does the form collect for Plan Year 2025 v5.0?","Question",{"text":108,"@type":109},"It collects issuer and claims transparency data, including issuer exchange status, HIOS ID, counts of in-network and out-of-network claims by received/denied/resubmitted status in calendar year 2023, and internal/external appeal outcomes.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Which fields are required to complete the template?",{"text":113,"@type":109},"All fields marked with an asterisk (*) are required. The form also provides instructions for validating or finalizing the template using the Validate and Finalize buttons or shortcuts.",{"name":115,"@type":106,"acceptedAnswer":116},"What does the PRA Disclosure Statement explain?",{"text":117,"@type":109},"It states that responses are not required unless a valid OMB control number is displayed, provides an estimated burden time, and directs where to write for accuracy/time-estimate comments, along with guidance not to send sensitive applications or claims to the PRA office.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},355246,1791513123,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":60,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":129,"file_id":130,"file_url":131,"file_type":132,"file_size":133,"view_count":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":134,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":135,"faqs":136,"seo_title":137,"seo_description":61,"update_tm":138,"read_time":4},4398046744996,"OMB control number: 0938-1310/Expiration date: 04/30/2025  \nAll fields with an asterisk ( * ) are required. To validate the template, press Validate button or Ctrl + Shift + I. To finalize the template, press Finalize button or Ctrl + Shift + F.  \nCenters for Medicare & Medicaid Services (CMS) Qualified Health Plan (QHP) Transparency in Coverage Reporting  \nPlan Year 2025 v5.0  \n\n| General Information |  |\n| --- | --- |\n| Was this Issuer on the Exchange in 2023?* | Yes |\n| SADP Only?* | No |\n| Issuer HIOS ID* | 40513 |\n| Issuer Level Data |  |\n| Number of Issuer Level In-Network Claims with Date(s) of Service (DOS) in 2023 That Were Also Received in Calendar Year 2023* | 574,240 |\n| Number of Issuer Level In-Network Claims with DOS in 2023 That Were Also Denied in Calendar Year 2023* | 29,570 |\n| Number of Issuer Level In-Network Claims with DOS in 2023 That Were Also Resubmitted in Calendar Year 2023* | 3,912 |\n| Number of Issuer Level Out-of-Network Claims with DOS in 2023 That Were Also Received in Calendar Year 2023* | 131,912 |\n| Number of Issuer Level Out-of-Network Claims with DOS in 2023 That Were Also Denied in Calendar Year 2023* | 31,182 |\n| Number of Issuer Level Out-of-Network Claims with DOS in 2023 That Were Also Resubmitted in Calendar Year 2023* | 1,092 |\n| Number of Issuer Level Internal Appeals Filed in Calendar Year 2023* | 200 |\n| Number of Issuer Level Internal Appeals Overturned from Calendar Year 2023 Appeals* | 48 |\n| Number of Issuer Level External Appeals Filed in Calendar Year 2023* | 14 |\n| Number of Issuer Level External Appeals Overturned from Calendar Year 2023 Appeals* | 2 |\n| Notes: |  |\n| Please enter any comments/notes here. |  |\n\nPRA 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) .","cbCaivrIHfkF7SIZ","https://ap.wps.com/l/cbCaivrIHfkF7SIZ","pdf",112421,"English","# General Information\n## Issuer HIOS ID and Exchange Status\n## Issuer Level Claims (In-Network)\n## Issuer Level Claims (Out-of-Network)\n## Internal and External Appeals\n## Notes and Comments\n# PRA Disclosure Statement","[{\"question\":\"What does the form collect for Plan Year 2025 v5.0?\",\"answer\":\"It collects issuer and claims transparency data, including issuer exchange status, HIOS ID, counts of in-network and out-of-network claims by received/denied/resubmitted status in calendar year 2023, and internal/external appeal outcomes.\"},{\"question\":\"Which fields are required to complete the template?\",\"answer\":\"All fields marked with an asterisk (*) are required. The form also provides instructions for validating or finalizing the template using the Validate and Finalize buttons or shortcuts.\"},{\"question\":\"What does the PRA Disclosure Statement explain?\",\"answer\":\"It states that responses are not required unless a valid OMB control number is displayed, provides an estimated burden time, and directs where to write for accuracy/time-estimate comments, along with guidance not to send sensitive applications or claims to the PRA office.\"}]","Kaiser 2023 IND IL Claims - Plan Year 2025 v5.0 - QHP Transparency in Coverage Reporting | PDF",1790117053]