Obligation to Submit Claims Sample Clauses
Obligation to Submit Claims. Group agrees to submit Clean Claims for non-capitated services to Company for Provider Services rendered to Members by Participating Group Providers. With respect to Government Programs, Group agrees to submit claim and risk adjustment data related to a Member enrolled in a Government Program in the form and manner as specified by Company, Group certifies that any such data is accurate, complete and truthful. Group and Participating Group Providers will make best commercial efforts to submit a minimum of eighty-five percent (85%) of its Member claims electronically to Company. Group and Participating Group Providers represent that, where necessary, they have obtained signed assignments of benefits authorizing payment for Providers Services to be made directly to Group. For claims Group submits electronically, Group shall not submit a claim to Company in paper form unless Company fails to pay or otherwise respond to electronic claims submission in accordance with the time frames required under this Agreement or applicable law or regulation. Group agrees that Company, or the applicable Plan Sponsor, will not be obligated to make payments for ▇▇▇▇▇▇▇▇ received more than one hundred and twenty (120) days from (a) the date of service or, (b) the date of receipt of the primary payer’s explanation of benefits when Company is the secondary payer. This limit is ninety-five (95) days for Medicaid and CHIP plans. Except for Medicaid and CHIP plans, this limitation will be waived in the event Group provides notice to Company, along with appropriate evidence, of extraordinary circumstances outside the control of Group that resulted in the delayed submission. In addition, unless Group notifies Company of any payment disputes within one hundred eighty (180) days, or such longer time as required by applicable state law or regulation, of receipt of payment from Company, such payment will be considered full and final payment for the related claims. Except as otherwise required under applicable Federal, or state law or regulation, or a Plan, if Group does not bill Company or plan Sponsors, or disputes any payment, timely as provided in this Section 4.1.1, Group’s claim for payment will be deemed waived and Group will not seek payment form Plan Sponsors, Company or Members. Group shall pay on a timely basis all employees, independent contractors and subcontractors who render Covered Services to Members of Company’s Medicare/Medicaid Plans for which Group is financially respon...
Obligation to Submit Claims. Provider agrees to submit Clean Claims to Company for non-capitated Provider Services rendered to Members. Provider represents that, where necessary, it has obtained signed assignments of benefits authorizing payment for Provider Services to be made directly to Provider and/or Group Providers. Provider will submit all claims electronically using the HIPAA required ASC X12N 837—Health Care Claim: Professional for professional claims and the ASC X12N 837—Health Care Claim: Institutional for institutional claims or an industry standard successor format (“Electronic Claim”). Provider shall not submit a claim in paper form unless Company or the applicable Payer, fails to pay or otherwise respond to electronic claims submission in accordance with the timeframes required under this Agreement, or applicable law or regulation. Provider agrees that Company, or the applicable Payer, will not be obligated to make payments for billing received more than one hundred and twenty (120) days from: (a) the date of service or date of discharge, as applicable; or (b) from the date of receipt of the primary payer’s explanation of benefits when Company or Payer is the secondary payer. This requirement will be waived in the event Provider provides notice to Company, along with appropriate evidence, of extraordinary circumstances outside the control of Provider that resulted in the delayed submission. In addition, unless Provider notifies Company of any payment dispute or dispute regarding claim denial within one hundred eighty (180) days or such longer time as required by applicable state law or regulation, of receipt of payment or claim denial, such payment or claim denial will be considered full and final payment or determination for the related claims. If Provider does not bill Company or Payer, or timely dispute any payment as provided in this Section, Provider’s claim for payment will be deemed waived and Provider will not seek payment from Payer, Company or Members. Provider agrees to permit rebundling to the primary procedure those services considered part of, incidental to, or inclusive of the primary procedure and to allow other adjustments for inappropriate billing or coding (e.g., duplicative procedures or claim submissions, mutually exclusive procedures, gender/procedure mismatches, age/procedure mismatches). In performing rebundling and making adjustments for inappropriate billing or coding, Company may utilize one or more commercial software packages (as modified by...