Common use of Obligation to Submit Claims Clause in Contracts

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 responsible pursuant to this Agreement. Group agrees to permit rebundling to the primary procedure those services considered part of, incidental to, or inclusive of primary procedure and to allow Company to make other adjustments for inappropriate billing or coding (e.g., duplicative procedures or claim submissions, mutually exclusive procedures, gender/procedure mismatches, age/procedure mismatches). To the extent Group is billing on a CMS 1500, as of the Effective Date, in performing rebundling and making adjustments for inappropriate billing or coding, Company utilizes a commercial software package (as modified by Company for all Participating Providers in the ordinary course of Company’s business) which commercial software package relies upon Medicare/Medicaid and other industry standards in the development of its rebundling logic.

Obligation to Submit Claims. Group agrees to submit Clean Claims for non-capitated services to Company for Provider Physician Services rendered to Members by Participating Group ProvidersPhysicians. With respect to Government Programs, Group agrees to submit claim and risk adjustment encounter data related to a Member enrolled in a Government Program in the form and manner as specified by Company, Company and Group certifies that any such data is accurate, complete and truthful. Group and Participating Group Providers Physicians 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 Physicians represent that, where necessary, they have obtained signed assignments of benefits authorizing payment for Providers Physicians 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 requests paper submissions or 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 Government Sponsor, will not be obligated to make payments for ▇▇▇▇▇▇▇▇ received more than one hundred and twenty (120) days (or such other period required by applicable state law or regulation) 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, Company may waive this limitation will be waived in the event requirement if Group provides notice to Company, along with appropriate evidence, of other extraordinary circumstances outside the control of Group that resulted in the delayed submission. In addition, unless Group notifies Company of any its payment disputes within one hundred eighty (180) days, or such longer time other period 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 If Group does not bill timely ▇▇▇▇ Company or plan Government Sponsors, or disputes dispute 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 from Government Sponsors, Company or Members. Group shall pay on a timely basis all Participating Providers, employees, independent contractors and subcontractors who render Covered Services to Members of Company’s Medicare/Medicaid Plans for which Group is financially responsible pursuant to this Agreement. Group agrees to permit rebundling claim editing to the primary procedure those services considered part of, incidental to, or inclusive of the primary procedure and to allow Company to make other adjustments for inappropriate billing or coding (e.g., rebundling, duplicative procedures or claim submissions, mutually exclusive procedures, gender/procedure mismatches, age/procedure mismatches). To the extent Group is billing on a CMS 15001500 form, as of the Effective Date, in performing rebundling and making adjustments for inappropriate billing or coding, Company utilizes a commercial software package (as modified by Company for all Participating Providers Physicians in the ordinary course of Company’s business) which commercial software package relies upon Medicare/Medicaid Government Programs and other industry standards in the development of its rebundling logic. Subject to applicable law: (i) Company may update internal payment systems in response to additions, deletions, and changes to Government Sponsor, CMS, or other industry source codes without obtaining any consent from Group, Participating Group Physicians, or any other party, and Company will provide, at the written request of Group, a copy of the fee schedule in effect at the time of such request; (ii) Company shall not be responsible for communicating such routine changes of this nature, and will update any applicable payment schedules on a prospective basis within ninety (90) days from the date of publication or such longer period as Company determines appropriate in its sole discretion; and (iii) Company shall have no obligation to retroactively adjust claims.