Common use of Claims Submission and Payment Clause in Contracts

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 by GUIDANTRX within the earlier of: (i) 30 days after each semi-monthly billing cycle for claims submitted by Pharmacy during that cycle; or (ii) the amount proscribed by applicable laws in the jurisdiction in which the prescription is filled. vii. Pharmacy will be reimbursed per the terms and conditions defined in Exhibit A attached to this Agreement and incorporated by reference herein. Other exhibits may be added from time to time and will be valid only if signed by both parties to this Agreement.