Form CMS-10572 QHP Issuer Data Collection - Appendix A2

Press TAB and directional arrow keys to read through the document. Template instructions in cell A2. Table values begin OMB control number:0938-1310/Expiration date: XX/XX/XXXX
All 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.
Appendix A2. Transparency in Coverage Reporting by Qualified Health Plan Issuers - Plan Year 2024

General Information
Was this Issuer on the Exchange in 2022?*
SADP Only?*
Issuer HIOS ID*
Issuer Level Data
Number of In-Network Issuer Level Claims with Date(s) of Service (DOS) in 2022 That Were Also Received in Calendar
Year 2022*
Number of In-Network Issuer Level Claims with DOS in 2022 That Were Also Denied in Calendar Year 2022*
Number of In-Network Issuer Level Claim Resubmissions with DOS in 2022 That Were Also Received in Calendar Year
2022*
Number of Out-of-Network Issuer Level Claims with DOS in 2022 That Were Also Received in Calendar Year 2022*
Number of Out-of-Network Issuer Level Claims with DOS in 2022 That Were Also Denied in Calendar Year 2022*
Number of Out-of-Network Issuer Level Claim Resubmissions with DOS in 2022 That Were Also Received in Calendar
Year 2022*
Number of Issuer Level Internal Appeals Filed in Calendar Year 2022*
Number of Issuer Level Internal Appeals Overturned from Calendar Year 2022 Appeals*
Number of Issuer Level External Appeals Filed in Calendar Year 2022*
Number of Issuer Level External Appeals Overturned from Calendar Year 2022 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 XXXX-XXXX. 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).

Press TAB and directional arrow keys to read through the document. Template instructions in cell B1. Table values begin in cell A7. All 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.
All plan IDs submitted via Plans & Benefits Template(s) must be included in this template.
DRAFT Centers for Medicare & Medicaid Services (CMS) Qualified Health Plan (QHP) Transparency in Coverage Reporting
Plan Year 2024
Plan Level Data

Plan ID*

Number of Plan
Level In-Network
Claims with DOS in
2022 That Were
Also Received in
Calendar Year 2022*

Number of Plan
Level In-Network
Claims with DOS in
2022 That Were
Also Denied in
Calendar Year 2022*

Number of Plan
Level In-Network
Resubmissions with
DOS in 2022 That
Were Also Received
in Calendar Year
2022*

Number of Plan
Level Out-ofNetwork Claims with
DOS in 2022 That
Were Also Received
in Calendar Year
2022*

Number of Plan
Level Out-ofNetwork Claims with
DOS in 2022 That
Were Also Denied in
Calendar Year 2022*

Number of Plan Level
Out-of-Network
Resubmissions with DOS
in 2022 That Were Also
Received in Calendar
Year 2022*

Number of Plan Level
Claims with DOS in 2022
That Were Also Denied
Due to Enrollment
Status in Calendar Year
2022*

Number of Plan Level
Claims with DOS in 2022
That Were Also Denied
Due to Enrollee Benefit
Limit Reached in
Calendar Year 2022*

Number of Plan Level
Claims with DOS in 2022
That Were Also Denied
Due to Investigational,
Cosmetic, or
Experimental Procedure
in Calendar Year 2022*

Number of Plan Level
Claims with DOS in 2022
That Were Also Denied
Due to Prior
Authorization or
Referral Required in
Calendar Year 2022*

Number of Plan Level
Claims with DOS in 2022
That Were Also Denied
Due to Services
Excluded or Not
Covered in Calendar
Year 2022*

Number of Plan Level
Claims with DOS in 2022
That Were Also Denied
Due to Lack of Medical
Necessity, Excluding
Behavioral Health, in
Calendar Year 2022*

Number of Plan Level
Claims with DOS in 2022
That Were Also Denied
Due to Lack of Medical
Necessity, Behavioral
Health only, in Calendar
Year 2022*

Number of Plan Level
Claims with DOS In 2022
That Were Denied Due
to Out of Network
Provider/Claims in
Calendar Year 2022*

Number of Plan Level
Claims with DOS In 2022
That Were Denied Due
to Administrative
Reasons in Calendar
Year 2022*

Number of Plan Level
Claims with DOS in 2022
That Were Also Denied
for "Other" Reasons in Notes: (Please enter any
comments/notes here.)
Calendar Year 2022*