Claims Submission and Payment Clause Samples
The Claims Submission and Payment clause outlines the procedures and requirements for submitting invoices or claims for payment under a contract. It typically specifies the documentation needed, the format and timing for submitting claims, and the process by which payments will be reviewed and made. For example, it may require that claims be submitted within a certain number of days after services are rendered and that supporting evidence, such as receipts or progress reports, be included. This clause ensures that both parties have a clear understanding of how and when payments will be processed, reducing the risk of disputes and delays related to compensation.
Claims Submission and Payment. Subject to Applicable Law, Provider agrees: to accept the rates contained in the applicable Service and Rate Schedule(s), regardless of where services are provided, as payment in full for Covered Services (including for services that would be Covered Services but for the Member’s exhaustion of benefits (e.g., above the annual maximum)); that it is responsible for and will promptly pay all Group Providers for services rendered, and that it will require all Group Providers to look solely to Provider for payment; to submit complete, clean, electronic claims for Covered Services provided by Provider and Group Providers, containing all information needed to process the claims, within three hundred sixty five days of the date of service or discharge, as applicable, or from the date of receipt of the primary payer’s explanation of benefits if Company or Payer is the secondary payer. This requirement will be waived if Provider provides notice to Company, along with appropriate evidence, of extraordinary circumstances outside of Provider’s control that resulted in a delayed submission; to respond within forty-five (45) days to Company or Payer requests for additional information regarding submitted claims; to notify Company of any underpayment or payment/claim denial dispute within no later than 12 months from the date of service or 60 calendar days after the payment, denial, or partial denial of a timely claim submission, whichever is later and to follow Company’s dispute and appeal Policies for resolution; to notify Company promptly after becoming aware of any overpayment (e.g., a duplicate payment or payment for services rendered to a patient who was not a Member) and to cooperate with Company for the prompt return of any overpayment. In the event of Provider’s failure to cooperate with this section, Company shall have the right to offset any overpaid amount against future claims; that Company and Payers will not be obligated to pay for claims not submitted, completed or disputed/appealed as required above, or that are billed in violation of Applicable Law, this Agreement or Company Policies, and that Members may not be billed for any such claims; in the event that Provider acquires or takes operational responsibility for another Participating Provider, the then current agreement between Company and such Participating Provider will remain in place and apply to Covered Services provided by such Participating Provider for the longer of: (i) one (1) year; or (ii) t...
Claims Submission and Payment. Members shall review and approve timesheets of their Providers to determine accuracy and appropriateness. No SDCB Provider shall exceed forty (40) hours paid work in a consecutive seven (7) Calendar Day period. Payments to SDCB Providers shall comply with State and federal minimum wage statutes and regulations. Timesheets must be submitted and processed on a two (2) week pay schedule according to HCA’s prescribed payroll payment schedule. The FMA shall be responsible for processing payments for approved services and goods. The CONTRACTOR shall reimburse the FMA for authorized SDCB services provided by Providers at the appropriate rate for the self-directed HCBS, which includes applicable payroll taxes. Value Added Services The CONTRACTOR may offer Value Added Services to its Members that are not Covered Services (see Attachments 1 and 4). The CONTRACTOR is encouraged to consider the unique and unmet needs of Members and, where appropriate, their families or Caregivers when proposing Value Added Services. Value Added Services must be prior approved in writing by HCA. The cost of Value Added Services will not be included in the Capitation Rate. All Value Added Services shall be identifiable and measurable through the use of unique payment and/or processing codes, approved by HCA. At the CONTRACTOR’s request, HCA may assist in identifying a compliant code. The CONTRACTOR shall send Members notices of Adverse Benefit Determination regarding Value Added Services that comply with the requirements in the Managed Care Policy Manual. Denial of a Value Added Service will not be considered an Adverse Benefit Determination for purposes of Appeals or Fair Hearings. Provider Network
Claims Submission and Payment. Sections 4.1 and 4.2 of the Agreement are deleted in their entirety and the following are substituted therefor, and the following new Section 4.4 is added to the Agreement:
Claims Submission and Payment. CONTRACTOR must comply with article 20A.18B of the Texas Insurance Code regarding prompt payment of physicians and providers and any applicable regulations. Providers are required to comply with chapter 146 of the Texas Civil Practice and Remedies Code regarding timely billing.
Claims Submission and Payment. Provider shall comply with all claim submittal obligations of the State Contract. Provider shall promptly submit claims information needed to Company to make payment within six months of the Covered Service being provided to an Enrollee. Health Plan may not impose requirements to file claims within a shorter period. (State Contract 1.
14.1.1). Except for those exceptions set forth in § 1.16.5 of the State Contract, resubmitted claims must be filed within an additional six months thereafter. (State Contract §§ 1.16.5 and 1.16.6)
Claims Submission and Payment. Pharmacies shall transmit to Pharmacy BenefitDirect at their expense, Claims conforming to the National Council for Prescription Drug Programs (“NCPDP”) standard format. “Claims” shall refer to the vehicle for transmitting prescription claim information to Pharmacy BenefitDirect by Pharmacies. Claims shall be submitted to Pharmacy BenefitDirect on a Universal Claim from “UCF” or for EDT Claims through one of the major switching companies, currently Envoy and NDC, or Pharmacy BenefitDirect’s direct dial network.
Claims Submission and Payment. Provide for prompt submission of claims information needed to make payment within six months of the covered service being provided to a Dental Health Plan Enrollee. • Performance-based Provider Payments/Incentive Plans. Describe, as applicable, any performance- based Provider payment(s)/incentive plan(s) to which the Participating Provider is subject.
Claims Submission and Payment. Pharmacy’s claims for Covered Services provided to Enrollees under this Agreement shall be processed and paid as follows:
i. At the time Pharmacy delivers Covered Services to an Enrollee, Pharmacy shall submit its Claim for such Covered Services by means of the Designated Claim Adjudication System. When delivering Covered Services to an Enrollee, Pharmacy shall price such services as set forth on Designated Claim Adjudication System. In addition, subject to the pharmacist’s professional judgment, Pharmacy shall comply with the Drug Utilization Review (“DUR”) advice, if any, provided with respect to such Enrollee by the Designated Claim Adjudication System.
ii. Claims will be transmitted using telecommunications standards established by The Department of Health and Human Services Administrative Simplification or any successor organization (currently, the National Council for Prescription Drug Program’s (NCPDP) Telecommunications Standard Version D.0) Any Claim submitted will include, but not be limited to, the National Drug Code on the package from which the medication was dispensed.
iii. For Enrollees having both primary and secondary coverage for their pharmacy benefit, Pharmacy agrees to submit an initial Claim to the primary carrier and then submit the results of the primary adjudication, via the NCPDP defined “COB segment”, to the secondary carrier.
iv. Pharmacy agrees to submit either the Prescriber’s DEA number or NPI number with each Claim submitted to the Designated Claim Adjudication System. Default and /or “dummy” prescriber identification numbers are not acceptable. Health care professional identification numbers shall be considered invalid if the Health Care Professional’s identification numbers (DEA or NPI) submitted by Pharmacy with the prescription Claim is not the Health Care Professional’s identification number provided on or with the prescription by such party; or if the Health Care Professional’s identification number submitted by Pharmacy with the prescription Claim does not correspond to the actual prescriber of the prescription.
v. GUIDANTRX may refuse to submit to Plan Sponsors any claims which are not submitted via the Designated Claim Adjudication System by Pharmacy as provided above. Claims for payment must be submitted within one hundred eighty (180) days of date of service. Claims submitted after such window are not eligible for payment.
vi. Pharmacy will be paid via Electronic Funds Transfer (EFT) or other means as determined b...
Claims Submission and Payment. Section 4.1.4 is deleted in its entirety and the following is substituted therefor, and the following additional paragraph is added to Section 4.2, immediately following the end of subsection 4.2.4:
Claims Submission and Payment. 4.6.12.1 Members shall review and approve timesheets of their providers to determine accuracy and appropriateness.
4.6.12.2 No SDCB provider shall exceed forty (40) hours paid work in a consecutive seven (7) Calendar Day period.
4.6.12.3 Timesheets must be submitted and processed on a two (2) week pay schedule according to HSD’s prescribed payroll payment schedule.
4.6.12.4 The FMA shall be responsible for processing payments for approved Centennial Care services and goods.
4.6.12.5 The CONTRACTOR shall reimburse the FMA for authorized SDCB services provided by providers at the appropriate rate for the self-directed HCBS, which includes applicable payroll taxes.