Common use of Cost Avoidance Clause in Contracts

Cost Avoidance. In accordance with Department requirements in the Managed Care Policy and Procedure Guide, the CONTRACTOR must have processes, methods and resources necessary to receive TPL data from the Department and to identify third-party coverage for its members. This information will be used in managing Provider payment at the front end before the Claim is paid. The CONTRACTOR must have appropriate edits in the Claims system to ensure that Claims are properly coordinated when other insurance is identified. The CONTRACTOR’s Medicaid reimbursement and Third Party payment cannot exceed the amount the Provider has agreed to accept as payment in full from the Third Party payer. If the probable existence of TPL has been established at the time the Claim is filed, the CONTRACTOR must reject the Claim and return it to the Provider for a determination of the amount of any TPL. The CONTRACTOR shall ▇▇▇▇ or inform the Provider to ▇▇▇▇ the third-party coverage within thirty (30) Days of identification. For certain services, the CONTRACTOR should not cost-avoid Claims and will pursue recovery under a policy known as “Pay & Chase”. See the Managed Care Policy and Procedure Guide for list of services. While Providers of such services are encouraged to file with any liable Third Party before the CONTRACTOR, if they choose not to do so, the CONTRACTOR will pay the Claims and ▇▇▇▇ liable Third Parties directly through a Benefit Recovery Program. The CONTRACTOR shall deny payment on a Claim that has been denied by a known Third Party payer, as defined in Section 10 of this contract, when the reason for denial is the Provider or Medicaid Managed Care Member’s failure to follow prescribed Procedures, including but not limited to, failure to obtain Prior Authorization, timely filing, etc. Post-Payment Recovery Post-payment recovery is necessary in cases where the CONTRACTOR has not established the probable existence of a liable Third Party at the time services were rendered or paid for, for members who become retroactively eligible for Medicare, or in situations when the CONTRACTOR was unable to cost-avoid. The CONTRACTOR must have Procedures in place to ensure that a Provider who has been paid by the CONTRACTOR and subsequently receives reimbursement from a Third Party repays the CONTRACTOR either the full amount paid by Medicaid or the full amount paid by the Third Party, whichever is less. CONTRACTOR Post-Payment Recovery Requirements In accordance with Department requirements in the Managed Care Policy and Procedure Guide, the CONTRACTOR must have established Procedures for recouping post-payment. The Procedures must be available for review upon request by the Department. The CONTRACTOR must void Encounters for Claims that are recouped in full. The CONTRACTOR will submit a replacement Encounter for Recoupments that result in an adjusted Claim value. The CONTRACTOR shall seek reimbursement in accident/trauma-related cases when Claims in the aggregate equal or exceed $250. The CONTRACTOR shall report all recoveries it collects outside of the Claims processing system, including settlements. The CONTRACTOR shall treat such recoveries as offsets to medical expenses for the purposes of reporting. Retroactive Eligibility for Medicare The Department or its designee will notify the CONTRACTOR when Medicaid Managed Care Members become retroactively eligible for Medicare. The Department will recoup premium payments that do not reflect the dual status of the member. The Managed Care Policy and Procedure Guide provides specific Procedures for Subcontractor Recoupment of Medicaid payments while the member had dual Medicare and Medicaid coverage. Third-Party Liability Reporting Disenrollment Requests The CONTRACTOR must submit a Disenrollment request if it has identified the presence of Third Party resource that results in the individual’s being ineligible for Enrollment in CONTRACTOR’s Health Plan. Third-Party Liability Recoveries by the Department After one hundred and eighty (180) Days from the date of payment of a Claim subject to recovery, the Department reserves the right to attempt recovery independent of any action by the CONTRACTOR. The Department will retain all funds received as a result of any state-initiated recovery or Subrogation action.

Cost Avoidance. In accordance with Department requirements in the Managed Care Policy and Procedure Guide, the CONTRACTOR must have processes, methods and resources necessary The Contractor shall take reasonable measures to receive TPL data from the Department and to identify third-party coverage for its membersdetermine all legally liable parties. This information will refers to any individual, entity or program that is or may be used in managing Provider payment liable to pay all or part of the expenditures for covered services. The Contractor shall cost-avoid a claim if it has established the probable existence of a liable party at the front end before time the Claim claim is paidfiled. The CONTRACTOR must have appropriate edits in Establishing liability takes place when the Claims system Contractor receives confirmation that another party is, by statute, contract, or agreement, legally responsible for the payment of a claim for a healthcare item or service delivered to ensure that Claims are properly coordinated when other insurance is identified. The CONTRACTOR’s Medicaid reimbursement and Third Party payment cannot exceed the amount the Provider has agreed to accept as payment in full from the Third Party payera member. If the probable existence of TPL has been a party’s liability cannot be established at the time Contractor must adjudicate the Claim is filed, the CONTRACTOR must reject the Claim and return it to the Provider for a determination of the amount of any TPLclaim. The CONTRACTOR Contractor must then utilize post payment recovery which is described in further detail below. If AHCCCS determines that the Contractor is not actively engaged in cost avoidance activities the Contractor shall ▇▇▇▇ be subject to sanctions. Members with CRS Condition: Members under 21 years of age who are determined to have a qualifying CRS condition will be enrolled with the CRS Contractor. Members with private insurance or inform Medicare may use their private insurance or Medicare provider networks to obtain services including those for the Provider CRS condition. The CRS Contractor is responsible for payment for services provided to ▇▇▇▇ the third-party its enrolled members according to CRS coverage within thirty (30) Days of identification. For certain services, the CONTRACTOR should not cost-avoid Claims and will pursue recovery under a policy known as “Pay & Chase”type. See ACOM Policy 426 for CRS Contractor coverage responsibilities and coordination of benefits. If the Managed Care member has Medicare coverage, ACOM Policy and Procedure Guide for list of services. While Providers of such services are encouraged to file with any liable Third Party before the CONTRACTOR, if they choose not to do so, the CONTRACTOR will pay the Claims and ▇▇▇▇ liable Third Parties directly through a Benefit Recovery Program. The CONTRACTOR 201 shall deny payment on a Claim that has been denied by a known Third Party payer, as defined in Section 10 of this contract, when the reason for denial is the Provider or Medicaid Managed Care Member’s failure to follow prescribed Procedures, including but not limited to, failure to obtain Prior Authorization, timely filing, etcapply. Post-Payment Recovery payment Recoveries: Post-payment recovery (pay and chase) is necessary in cases where the CONTRACTOR Contractor has not established the probable existence of a liable Third Party party at the time services were rendered or paid for, for members who become retroactively eligible for Medicare, or in situations when the CONTRACTOR was unable to cost-avoid. The CONTRACTOR following sections set forth requirements for Contractor recovery actions including recoupment activities, other recoveries and total plan case requirements. Recoupments: The Contractor must have Procedures follow the protocols established in place to ensure that a Provider who has been paid by the CONTRACTOR and subsequently receives reimbursement from a Third Party repays the CONTRACTOR either the full amount paid by Medicaid or the full amount paid by the Third Party, whichever is less. CONTRACTOR Post-Payment Recovery Requirements In accordance with Department requirements in the Managed Care ACOM Policy and Procedure Guide, the CONTRACTOR must have established Procedures for recouping post-payment412. The Procedures must be available for review upon request by the Department. The CONTRACTOR Contractor must void Encounters encounters for Claims claims that are recouped in full. The CONTRACTOR will submit a replacement Encounter for Recoupments For recoupments that result in an adjusted Claim claim value. The CONTRACTOR shall seek reimbursement in accident/trauma-related cases when Claims in , the aggregate equal or exceed $250. The CONTRACTOR shall report all recoveries it collects outside of the Claims processing system, including settlements. The CONTRACTOR shall treat such recoveries as offsets to medical expenses for the purposes of reporting. Retroactive Eligibility for Medicare The Department or its designee will notify the CONTRACTOR when Medicaid Managed Care Members become retroactively eligible for Medicare. The Department will recoup premium payments that do not reflect the dual status of the member. The Managed Care Policy and Procedure Guide provides specific Procedures for Subcontractor Recoupment of Medicaid payments while the member had dual Medicare and Medicaid coverage. Third-Party Liability Reporting Disenrollment Requests The CONTRACTOR Contractor must submit a Disenrollment request if it has identified the presence of Third Party resource that results in the individual’s being ineligible for Enrollment in CONTRACTOR’s Health Plan. Third-Party Liability Recoveries by the Department After one hundred and eighty (180) Days from the date of payment of a Claim subject to recovery, the Department reserves the right to attempt recovery independent of any action by the CONTRACTOR. The Department will retain all funds received as a result of any state-initiated recovery or Subrogation actionreplacement encounters.