Healthcare Payer Contract Evaluation Form
Please complete the following fields to evaluate the healthcare payer contract. All information should be accurate and relevant to the contract review process.
Payer Organization Name
*
Contract Identifier or Reference Number
*
Contract Effective Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contract Expiration Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contract Type
*
Please Select
Fee-for-Service
Value-Based
Capitated
Bundled Payment
Other
Network Status
*
In-Network
Out-of-Network
Reimbursement Model
*
Please Select
Per Service
Per Member Per Month (PMPM)
Shared Savings
Risk-Based
Other
Compliance and Regulatory Review Completed?
*
Yes
No
Key Risks or Concerns Identified
Additional Comments or Recommendations
Submit Evaluation
Should be Empty: