Common use of Payment Errors Clause in Contracts

Payment Errors. 4.8.1 Payment Error in Excess of $500,000. If the STATE determines that there has been an error in its payment to the MCO pursuant to Article 4 that resulted in overpayment or underpayment in excess of $500,000 due to reasons not including rate-setting methodology, or Fraud or Abuse by the MCO or the Enrollee, the STATE or the MCO may make a claim under this section. Independent Audit. The STATE or the MCO may request an independent audit of the payment error prior to recovery or offset by the STATE of the overpayment or underpayment amount. (1) The STATE shall select the independent auditor and shall determine the scope of the audit, and shall involve the MCO in discussions to determine the scope of the audit and selection of the auditor. (2) The MCO must request the audit in writing within sixty (60) days from actual receipt of the STATE's written notice of overpayment.‌ (3) Neither the STATE nor the MCO shall be bound by the results of the audit. (4) The STATE shall not be obligated to honor the MCO’s request for an independent audit if in fact sufficient funds are not available for this purpose or if in fact an independent auditor cannot be obtained at a reasonable cost. This does not preclude the MCO from obtaining an independent audit at its own expense; however the MCO must give reasonable notice of the audit to the STATE and must provide the STATE with a copy of any final audit results. Inspection Procedures. The STATE and the MCO shall work together to develop reasonable procedures for the inspection of STATE documentation to determine the accuracy of payment amounts pursuant to Article 4. Two Year Limit to Assert Claim. (1) The STATE shall not assert any claim for, seek the reimbursement of, or make any adjustment for any alleged overpayment made by the STATE to the MCO under section 4.1 of this Contract more than two (2) years after the date such payment was actually received by the MCO from the STATE. (2) The MCO shall not assert any claim for, seek the payment of, or make any adjustment for any alleged underpayment made by the STATE to the MCO under Article 4 of this Contract more than two (2) years after the date such payment was actually received by the MCO from the STATE. The MCO must have filed a timely appeal of risk factors under section 4.8 in order to assert any claims regarding risk adjusted payments.

Payment Errors. 4.8.1 ‌ Report to the STATE of Overpayment of Capitation Payment The MCO shall report to the STATE within sixty (60) calendar days when the MCO has identified capitation payments or other payments in excess of amounts specified in the Contract pursuant to 42 CFR § 438.608(c)(3).‌ Payment Error in Excess of $500,000. If the STATE determines that there has been an error in its payment to the MCO pursuant to Article 4 that resulted in overpayment or underpayment in excess of $500,000 due to reasons not including rate-rate- setting methodology, or Fraud or Abuse by the MCO or the Enrollee, the STATE or the MCO may make a claim under this section. section.‌ Independent Audit. The STATE or the MCO may request an independent audit of the payment error prior to recovery or offset by the STATE of the overpayment or underpayment amount. (1) . The STATE shall select the independent auditor and shall determine the scope of the audit, and shall involve the MCO in discussions to determine the scope of the audit and selection of the auditor. (2) . The MCO must request the audit in writing within sixty (60) days from actual receipt of the STATE's written notice of overpayment.‌ (3) overpayment. Neither the STATE nor the MCO shall be bound by the results of the audit. (4) . The STATE shall not be obligated to honor the MCO’s request for an independent audit if in fact sufficient funds are not available for this purpose or if in fact an independent auditor cannot be obtained at a reasonable cost. This does not preclude the MCO from obtaining an independent audit at its own expense; however the MCO must give reasonable notice of the audit to the STATE and must provide the STATE with a copy of any final audit results. Inspection Procedures. The STATE and the MCO shall work together to develop reasonable procedures for the inspection of STATE documentation to determine the accuracy of payment amounts pursuant to Article 4. Two Year Limit to Assert Claim. (1) . The STATE shall not assert any claim for, seek the reimbursement of, or make any adjustment for any alleged overpayment made by the STATE to the MCO under section 4.1 of this Contract more than two (2) years after the date such payment was actually received by the MCO from the STATE. (2) . The MCO shall not assert any claim for, seek the payment of, or make any adjustment for any alleged underpayment made by the STATE to the MCO under Article 4 of this Contract more than two (2) years after the date such payment was actually received by the MCO from the STATE. The MCO must have filed a timely appeal of risk factors under section 4.8 in order to assert any claims regarding risk adjusted payments.

Payment Errors. ‌ 4.8.1 Payment Error in Excess of $500,000. If the STATE determines that there has been an error in its payment to the MCO pursuant to Article 4 that resulted in overpayment or underpayment in excess of $500,000 due to reasons not including rate-setting methodology, or Fraud or Abuse by the MCO or the Enrollee, the STATE or the MCO may make a claim under this section. section.‌ Independent Audit. The STATE or the MCO may request an independent audit of the payment error prior to recovery or offset by the STATE of the overpayment or underpayment amount. (1) The STATE shall select the independent auditor and shall determine the scope of the audit, and shall involve the MCO in discussions to determine the scope of the audit and selection of the auditor. (2) The MCO must request the audit in writing within sixty (60) days from actual receipt of the STATE's written notice of overpayment.‌overpayment. (3) Neither the STATE nor the MCO shall be bound by the results of the audit. (4) The STATE shall not be obligated to honor the MCO’s request for an independent audit if in fact sufficient funds are not available for this purpose or if in fact an independent auditor cannot be obtained at a reasonable cost. This does not preclude the MCO from obtaining an independent audit at its own expense; however the MCO must give reasonable notice of the audit to the STATE and must provide the STATE with a copy of any final audit results. Inspection Procedures. The STATE and the MCO shall work together to develop reasonable procedures for the inspection of STATE documentation to determine the accuracy of payment amounts pursuant to Article 4. Two Year Limit to Assert Claim. (1) The STATE shall not assert any claim for, seek the reimbursement of, or make any adjustment for any alleged overpayment made by the STATE to the MCO under section 4.1 of this Contract more than two (2) years after the date such payment was actually received by the MCO from the STATE. (2) The MCO shall not assert any claim for, seek the payment of, or make any adjustment for any alleged underpayment made by the STATE to the MCO under Article 4 of this Contract more than two (2) years after the date such payment was actually received by the MCO from the STATE. The MCO must have filed a timely appeal of risk factors under section 4.8 in order to assert any claims regarding risk adjusted payments.