Utilization Reporting Program Sample Clauses

Utilization Reporting Program. 11.7.1 The Contractor shall submit to ASES on a monthly basis by Service Region health care data reports that should include, among other things: 11.7.1.1 Useful data of Claim experience broken down by diagnosis and health care providers; 11.7.1.2 Claim experience by Enrollee and by coverage (basic, special, dental and pharmacy); 11.7.1.3 Claim cost and benefit utilization levels; 11.7.1.4 Benefits utilization levels or indicators, as well as comparative data such as: (i) hospital inpatient days per year per 1,000 Enrollees, (ii) hospital admission rate per 1,000 Enrollees, (iii) average length of inpatient stays, (iv) number of inpatient and outpatient surgeries, (v) number of outpatient visits per year per Enrollee, and (vi) emergency room visits per 1,000 Enrollee; 11.7.1.5 Cost measures, such as (i) average annual cost per Enrollee, (ii) total hospital inpatient payments, (iii) total surgical payments and (iv) total out of hospital payments; and 11.7.1.6 Demographics of the population of the Service Region. 11.7.2 The Contractor shall assist ASES in analyzing the utilization report data to determine trends, necessary plan design modifications, effectiveness of educations programs for both Enrollees and Providers, the impact of cost-control measures and the appropriateness of cost-management programs. 11.7.3 As part of this program, and in conformance with 42 CFR 438.240(2)(b)(3), the Contractor shall submit to ASES, on a quarterly basis, utilization statistical reports. ASES requires the following reports, with data to be submitted according to specifications determined by ASES: 11.7.3.1 Provider Credentialing Report; 11.7.3.2 Network Providers and Out-of-Network Providers; 11.7.3.3 Ratio of Enrollees to PCPs;