Most capitation reports are available at a consolidated or site level, while there are two reports that offer data sorted at a physician level.

The Eligibility Report (BRM 42I and 42P) lists all members eligible for benefits for at least one day in the month. It contains member information, including names, addresses, Plan codes and benefit information. Capitation amounts are not included in the report, but may be listed in the Remittance Detail Report. The Eligibility Report is sorted by the member's last name. All records in this report are 512 bytes long. There are four record types: header, detail, coordination of benefits (COB) and trailer. Data expressed in the X format is left-justified and blank-filled. Data expressed in the nine format is right-justified and zero-filled.

The Eligibility Report is available monthly at the consolidated, site or physician levels and alphabetically lists all members eligible for at least one day in the reporting month. PPGs must use this report to verify that a member is eligible to receive services for the dates of service.

PPGs may use the Eligibility Report in conjunction with the Remittance Detail Report to verify that they have received the correct capitation payment and that the capitation includes members added retroactively. The summary portion of this report lists the number of members or contracts eligible with the PPG at least one day during the month and at month's end. The Eligibility Report is distributed monthly by site level but may be requested at the physician consolidated level for primary PPGs.

The Eligibility Report reflects membership information as is on the date the report is run. If a newly added member or employer group is not included by the date the report is run or if an existing employer group has not reported all membership changes, the Eligibility Report will not reflect this information. Refer to the Eligibility Guarantee discussion under the Claims and Provider Reimbursement topic for more information.

The Eligibility Report is generated at the end of the month for the following month.

The Activity Analysis Report (BRM 11M) provides non-dollar activity, such as additions and cancellations of members, and should be used to update members' files, including retroactive adjudication of affected claims. It also reflects changes to a member's status, such as Plan code, address and effective date. Multiple transactions for a member are sorted by prioritization of activity codes and report by prioritization. The Activity Analysis Report is sorted by the member's last name. All records in the report are 339 bytes long. There are three record types: header, detail and trailer. Data expressed in the X format is left-justified and blank-filled. Data expressed in the nine format is right-justified and zero-filled.

The Activity Analysis Report is available monthly at the consolidated or site level (all member-related activities during the prior month), and may be requested at the consolidated level for primary PPGs. This report identifies and summarizes the following membership activity for the reporting period:

PPGs may use the report to update their eligibility database, note new members, monitor retroactive cancellations, or identify members who should receive new member welcome letters.

Refer to Frequently Asked Questions (PDF) for more information.

The Remittance Detail Report (BRM 12A) provides capitation remittance amounts per member. The amount reflected consists of the current month’s capitation amount plus any adjustments made in the current month for retroactivity. The Remittance Detail Report is sorted by the member's last name. All records in this report are 194 bytes long. There are three record types: header, detail and trailer. Data expressed in the X format is left-justified and blank- filled. Data expressed in the nine format is right-justified and zero-filled. All dollar amount fields are signed (-, +) and contain assumed decimals.

The Remittance Detail Report is available monthly at the consolidated, site or physician level. The report displays the capitation remittance for each member and is used to reconcile monthly capitation payments and review adjustments made to capitation. The amounts reported are the current month capitation amounts plus any retroactive or current adjustment amounts. The report lists all members.

The summary portion of the report helps PPGs maintain accrual-based accounting records. It specifies the total capitation paid for the reporting month in the Net Remittance field. The report also summarizes adjustments made to this amount by adjustment type and month.

The Eligibility Summary by Group Report (BRM 13A and 13B) lists all employer groups with active members enrolled with a specific provider for the month being reported. This report is sorted by the employer group name. All records in this report are 142 bytes long. This report has three record types: header, detail and trailer. Data expressed in the X format is left-justified and blank-filled. Data expressed in the nine format is right-justified and zero-filled.

The Eligibility Summary by Group Report is available monthly at the consolidated or site level. It includes the employer group, the number of members the PPG enrolled, and identifies each employer group's Plan code and rerate month. The PPG may use this report to verify a group's open enrollment, Plan code, benefits or copayment amount.

The SB 260 Reconciliation Report BRM 28provides enrollment and capitation payment summary at the product level for the prior 18 months. All records in this report are 1024 bytes long. This report has three record types: header, detail and trailer. Data expressed in the X format is left-justified and blank-filled. Data expressed in the nine format is right-justified and zero-filled.

Health Net offers providers these capitation reports through the portal as a default to help reconcile eligibility and remittance payments.