Common use of Cost Avoidance Activities Clause in Contracts

Cost Avoidance Activities. i. The PCO must take measures to avoid initial payment of Claims, whenever possible, where federal or private insurance-type resources are available. The PCO must report all funds that are cost avoided to the Department via Encounter Data submissions. The use of the appropriate HIPAA 837 Loop(s) for Medicare and Other Insurance Paid (OIP) shall indicate that TPL has been pursued and the amount which has been cost-avoided. ii. The PCO may not deny or delay approval of otherwise covered treatment or services based upon TPL considerations. The PCO may neither unreasonably delay payment nor deny payment of Claims unless the probable existence of TPL is established at the time the Claim is adjudicated.