{"text_format":"1","workbook":"xlsx","n_sheets":4,"sheets":["Submission Coversheet ","Provider Submission Form","Data Validation","Sheet1"],"not_rendered":{"charts":0,"images":2,"macros":1,"external_links":0,"defined_names":3,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Submission Coversheet ","index":0,"n_rows":25,"n_cols":2,"rows_kept":25,"cut":false,"hidden":false,"merged":[]}
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[]
[null,"Provider Submission Form File Fields"]
[]
[null,"Provider Submission Form Completion Instructions"]
[]
[null,"Provider Submission Form File Fields"]
[null,"Submission Date: Date form submitted to MassHealth"]
[null,"Provider Name: Name of Provider/Practice submitted recoupment review request"]
[null,"Provider National Provider Identifier (NPI): Unique 10-digit identifier issued to providers "]
[null,"MassHealth Provider ID: A 10-character ID, made up of 9-digit base number and an alpha service location. This is also known as a PID/SL"]
[null,"MCO Name: Name of Payer/Managed Care Organization that initiated the original recoupment"]
[null,"Member Last Name: Last Name of member for whom Provider is requesting a recoupment be reprocessed "]
[null,"Member Last Name: Name of member for whom Provider is requesting a recoupment be reprocessed e.g., John Smith"]
[null,"Active Member ID: 12-digit number that is currently used to identify MassHealth members"]
[null,"Inactive Member MassHealth ID (if known): The 12-digit duplicate or inactive MassHealth member Identification number"]
[null,"Date of Service Recouped:  Date on which the service was rendered and the claim was recouped"]
[null,"Service Name: Name of service for which recoupment was initiated"]
[null,"Amount Recouped: Total amount recouped by the MCO for specific service (should be reported as a negative value)"]
[null,"EOB (optional): Explanation of Benefit (EOB) code "]
[null,"Using the Provider Submission Tracker"]
[null,"Drop down menus are found when the user must choose from a list; this limits input errors and typos"]

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[]
[null,null,null,null,null,null,{"$f":"CONCATENATE(\"Recoupment Submission - \",C5,\" - \",TEXT(TODAY(),\"mm.dd.yyyy\"))","v":"Recoupment Submission -  - 01.09.2020"}]
[null,"Provider Completes All Information, 1 Member Claim Per Row"]
[null,"Submission Date","Provider Name","Provider National Provider Identifier (NPI)","MassHealth \nProvider ID","MCO Name","Member First Name","Member Last Name","Active Member \nMassHealth ID","Other Member \nMassHealth ID\n(if known)","Date of \nService Recouped","Service Name"," Amount\nRecouped (negative value)","EOB (optional)"]

{"sheet":"Data Validation","index":2,"n_rows":21,"n_cols":2,"rows_kept":21,"cut":false,"hidden":true,"merged":[[1,21,1,22]]}
["Plan","Behavioral Health Vendor"]
["BMC HealthNet Plan Community Alliance","Beacon Health Strategies"]
["BMC HealthNet Plan Mercy Alliance","Beacon Health Strategies"]
["BMC HealthNet Plan Signature Alliance","Beacon Health Strategies"]
["BMC HelthNet Plan Southcoast Alliance","Beacon Health Strategies"]
["Berkshire Fallon Health Collaborative","Beacon Health Strategies"]
["Fallon 365 Care","Beacon Health Strategies"]
["Wellforce Care Plan","Beacon Health Strategies/Optum "]
["Be Healthy Partnership","N/A"]
["My Care Family","N/A"]
["Tufts Health Together with Atrius Health","N/A"]
["Tufts Health Together with BIDCO","N/A"]
["Tufts Health Together with BACO","Beacon Health Strategies"]
["Tufts Health Together with CHA","MBHP"]
["MBHP","Beacon Health Strategies"]
["MCO - BMC","N/A"]
["MCO - Tufts"]
["MCO - Celticare "]
["MCO - NHP"]
["MCO -Fallon "]
["MCO - HNE "]

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