CLAIMS PROCESSING AND ADJUDICATION – NETWORK PROVIDERS Sample Clauses

The "Claims Processing and Adjudication – Network Providers" clause defines the procedures and standards for handling and evaluating insurance claims submitted by healthcare providers within an approved network. It typically outlines the required documentation, timelines for submission and review, and the criteria used to determine whether a claim is approved or denied. By establishing clear rules for processing claims, this clause ensures timely payments to network providers and reduces disputes over coverage, thereby streamlining the reimbursement process and promoting efficient administration of health benefits.
CLAIMS PROCESSING AND ADJUDICATION – NETWORK PROVIDERS. 1. CONTRACTOR shall maintain a rules-based and date-sensitive claims system to meet the needs of all standard Medi-Cal beneficiary claims. 2. CONTRACTOR shall establish a claims adjudication process which will accept either paper or electronic claims including, but not limited to, verification that if the Beneficiary has a Share of Cost that the Share of Cost has been met. 3. CONTRACTOR shall maintain timelines in the claims process as follows: a. Claims for services shall be requested to be submitted to CONTRACTOR by the Network Providers within thirty (30) days of the date of services but in no case shall CONTRACTOR process any claim that is initially submitted more than ninety (90) days from the date of service, except as required otherwise by law, rules, or regulation as described in the Licenses and Laws Paragraph of this Agreement. b. CONTRACTOR shall maintain a thirty (30) calendar day or less turnaround on clean claims. Clean claims shall be those that require no additional information (such as provider identification, diagnosis and/or CPT codes) and which can be processed completely upon initial entry. c. When pending a claim for missing data, the Network Provider shall receive notification from CONTRACTOR within fourteen (14) calendar days from the date of receipt. This notification shall include what is needed to continue processing the claim. County of Orange, Health Care Agency ASO Beacon Amendment No. 4 Page 7 of 13 Contract MA-042-18010155 d. CONTRACTOR shall request that the information be returned within fourteen (14) calendar days. 4. CONTRACTOR shall: a. Provide adequately trained claims processing and clerical staff, and suitable equipment. b. Review each completed claim to determine that the services rendered are within the Medi-Cal scope of service, and that applicable prior approvals have been obtained. c. Require that all Network Providers attempt to collect the Share of Cost from beneficiaries and that reimbursement of claims shall be reduced by the beneficiaries’ Share of Cost. d. Have access to the Medi-Cal Eligibility Website to determine client eligibility and any Share of Cost remaining for the date of service. ADMINISTRATOR will provide technical assistance and support as needed to identify client fall-out from eligibility file as it relates to claims payment. e. Process and pay mental health provider professional fees as they relate to inpatient hospital stays and IMD claims. CONTRACTOR will be provided with a bi-weekly (2 t...
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CLAIMS PROCESSING AND ADJUDICATION – NETWORK PROVIDERS. 6 a. CONTRACTOR shall maintain a rules-based and date-sensitive claims system to meet 7 the needs of all standard Medi-Cal beneficiary claims. 8 b. CONTRACTOR shall establish a claims adjudication process which will accept either 9 paper or electronic claims including, but not limited to, verification that if the beneficiaryBeneficiary has 10 a Share of Cost that that the Share of Cost has been met. 11 c. CONTRACTOR shall maintain timelines in the claims process as follows: 12 1) Claims for services shall be requested to be submitted to CONTRACTOR by the 13 network providersNetwork Providers within thirty (30) days of the date of services but in no case shall 14 CONTRACTOR process any claim that is initially submitted more than ninety (90) days from the date 15 of service. 16 2) CONTRACTOR shall maintain a thirty (30) calendar day or less turnaround on 17 clean claims. Clean claims shall be those that require no additional information (such as provider 18 identification, diagnosis and/or CPT codes) and which can be processed completely upon initial entry. 19 3) When pending a claim for missing data, the providerNetwork Provider shall receive 20 notification from CONTRACTOR within fourteen (14) calendar days from the date of receipt. This 21 notification shall include what is needed to continue processing the claim. 22 4) CONTRACTOR shall request that the information be returned within fourteen (14) 23 calendar days. 24 d. CONTRACTOR shall: 25 1) Provide adequately trained claims processing and clerical staff, and suitable 26 equipment. 27 // 28 2) Review each completed claim to determine that the services rendered are within the 29 Medi-Cal scope of service, and that applicable prior approvals have been obtained.
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CLAIMS PROCESSING AND ADJUDICATION – NETWORK PROVIDERS. 1. CONTRACTOR shall maintain a rules-based and date-sensitive claims system to meet the needs of all standard Medi-Cal beneficiary claims. 2. CONTRACTOR shall establish a claims adjudication process which shall accept either paper or electronic claims including, but not limited to, verification that if the Client has a Share of Cost that the Share of Cost has been met. 3. CONTRACTOR shall maintain timelines in the claims process as follows: a. Clean claims for services shall be requested to be submitted to CONTRACTOR by the Network Providers within thirty (30) calendar days of the date of services. CONTRACTOR shall follow all laws, rules, or regulations as described in the Licenses and Laws Paragraph of this Contract. b. CONTRACTOR shall do its best to receive and process all Network Provider claims to avoid exceeding 365 days billing limit and avoiding Medi-Cal stale dated claims and reduced revenue receipts from the State. c. CONTRACTOR should refer to and follow Services Paragraph of this Exhibit A.
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CLAIMS PROCESSING AND ADJUDICATION – NETWORK PROVIDERS. 27 a1. CONTRACTOR shall maintain a rules-based and date-sensitive claims system to meet 28 the needs of all standard Medi-Cal beneficiary claims.
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