Common use of Claims Processing Requirements Clause in Contracts

Claims Processing Requirements. The CONTRACTOR and any of its subcontractors or providers paying their own claims are required to maintain claims processing capabilities to include, but not be limited to: A. Accepting National Standard Formats for electronic claims submission. In the event that final HIPAA regulations change any formats or data required on the standardized formats, the CONTRACTORS shall be required to adapt their systems accordingly; B. Assigning unique identifiers for all claims received from providers; C. Standardizing protocols for the transfer of claims information between the CONTRACTOR and its subcontractors/providers, audit trail activities, and the communication of data transfer totals and dates; D. Meeting both state and federal standards for processing claims; E. Generating remittance advice to providers; F. Participating in a joint committee for standardizing coding where national coding systems do not apply; G. Accepting from providers and subcontractors national standard codes and, where these codes don’t apply, acceptance of state-assigned codes that have been approved by the HSD joint committee for standardization; H. Editing claims to ensure providers licensed to render the services being billed are submitting services, that services are appropriate in scope and amount, and that enrollees are eligible to receive the service; and I. Developing and maintaining an electronic billing system for all providers submitting bills directly to the CONTRACTOR within six months of the inception of the Agreement. Require all subcontractor benefit managers to meet the same deadline.

Claims Processing Requirements. The CONTRACTOR and any of its subcontractors or providers paying their own claims are required to maintain claims processing capabilities to include, but not be limited to: A. Accepting National Standard Formats for electronic claims submission. In the event that final HIPAA regulations change any formats or data required on the standardized formats, the CONTRACTORS shall be required to adapt their systems accordingly; B. Assigning unique identifiers for all claims received from providers; C. Standardizing protocols for the transfer of claims information between the CONTRACTOR and its subcontractors/providers, audit trail activities, and the communication of data transfer totals and dates; D. Meeting both state and federal standards for processing claims; E. Generating remittance advice to providers; F. Participating in a joint committee for standardizing coding where national coding systems do not apply; G. Accepting from providers and subcontractors national standard codes and, where these codes don’t n't apply, acceptance of state-assigned codes that have been approved by the HSD joint committee for standardization; H. Editing claims to ensure providers licensed to render the services being billed are submitting services, that services are appropriate in scope and amount, and that enrollees are eligible to receive the service; and I. Developing and maintaining an electronic billing system for all providers submitting bills directly to the CONTRACTOR within six months of the inception of the Agreement. Require all subcontractor benefit managers to meet the same deadline.