Common use of Encounter Data/Claims Clause in Contracts

Encounter Data/Claims. Provider shall submit to SelectCare, no later than forty-five (45) calendar days from the date of service, encounter data for capitated services and claims for any services to be paid at fee-for-service rates per this Agreement. Such information shall be in such form as prescribed by SelectCare. If Provider is compensated on a capitated basis, and it is determined that Provider cannot meet this requirement, the capitation amounts outlined in Exhibit A shall be reduced. Provider shall be provided notice of its inability to meet the requirement to timely submit encounter data prior to penalizing Provider and will be given thirty (30) days from the date of the notice to cure such breach to the satisfaction of SelectCare. If there is no cure of the breach to the satisfaction of SelectCare, SelectCare may reduce the capitation payments to Provider by twenty percent (20%). If Provider continues to be in breach of this requirement, SelectCare shall have the right to terminate this Agreement immediately upon written notice to the Provider. Provider agrees that SelectCare s shall be permitted to prepare and disclose to a third party a report of “quality data.” For purposes of this Section 5.9, quality data shall be limited to: (i) utilization data of SelectCare and Participating Providers in the aggregate; (ii) HEDIS reporting data; (iii) Member satisfaction data; (iv) overall compliance with NCQA or other comparable quality standards; and (v) Member disenrollment data; provided, however, that quality data shall not include any information that identifies an individual Member or that is privileged or confidential under applicable peer review or patient confidentiality laws.

Encounter Data/Claims. Provider shall submit to SelectCare, no later than forty-five (45) calendar days from the date of service, encounter data for capitated services and claims for any services to be paid at fee-for-service rates per this Agreement. Such information shall be in such form as prescribed by SelectCare. If Provider is compensated on a capitated basis, and it is determined that Provider cannot meet this requirement, the capitation amounts outlined in Exhibit A shall be reduced. Provider shall be provided notice of its inability to meet the requirement to timely submit encounter data prior to penalizing Provider and will be given thirty (30) days from the date of the notice to cure such breach to the satisfaction of SelectCare. If there is no cure of the breach to the satisfaction of SelectCare, SelectCare may reduce the capitation payments to Provider by twenty percent (20%). If Provider continues to be in breach of this requirement, SelectCare shall have the right to terminate this Agreement immediately upon written notice to the Provider. Provider agrees that SelectCare s shall be permitted to prepare and disclose to a third party a report of “quality data.” For purposes of this Section 5.9, quality data shall be limited to: (i) utilization data of SelectCare and Participating Providers in the aggregate; (ii) HEDIS reporting data; (iii) Member satisfaction data; (iv) overall compliance with NCQA or other comparable quality standards; and (v) Member disenrollment data; provided, however, that quality data shall not include any information that identifies an individual Member or that is privileged or confidential under applicable peer review or patient confidentiality laws.For