Prompt Claim Payments Clause Samples
Prompt Claim Payments i. The Provider shall submit all claims to Alliance for processing and payments within one- hundred-eighty (180) calendar days from the date of covered service or discharge (whichever is later). However, the Provider’s failure to submit a claim within this time will not invalidate or reduce any claim if it was not reasonably possible for the Provider to submit the claim within that time. In such case, the claim should be submitted as soon as reasonably possible, and in no event, later than one (1) year from the time submittal of the claim is otherwise required.
ii. Alliance shall within eighteen (18) Calendar Days of receiving a Medical Claim notify the provider whether the claim is clean or pend the claim and request from the provider all additional information needed to process the claim.
iii. Alliance shall pay or deny a clean claim the lesser of thirty (30) Calendar Days of receipt of the claim or the first scheduled provider reimbursement cycle following adjudication.
iv. A pended claim shall be paid or denied within thirty (30) Calendar Days of receipt of the requested additional information. If the requested additional information on claim is not submitted within ninety (90) days of the notice requesting the required additional information, Alliance shall deny the claim.
v. Alliance shall reprocess claims in a timely and accurate manner as described in this provision (including interest and penalties if applicable).
vi. If Alliance fails to pay a clean claim in full pursuant to this provision, the Alliance shall pay the Provider interest and penalties. Late Payments will bear interest at the annual rate of eighteen (18) percent beginning on the date following the day on which the claim should have been paid or was underpaid.
vii. Failure to pay a clean claim within thirty (30) days of receipt will result in Alliance paying the Provider penalties equal to one (1) percent of the total amount of the claim per day beginning on the date following the day on which the claim should have been paid or was underpaid.
viii. Alliance shall pay the interest and penalties from subsections vi. and vii. as provided in that subsection and shall not require the Provider to request the interest or the liquidated damages.
Prompt Claim Payments. The PIHP shall use the following provision, verbatim except as allowed In 2. above, in all provider contracts, as applicable: The [Provider] shall submit all claims for a date of service before BH I/DD Tailored Plan Launch, to the [PIHP] for processing and payments within one-hundred-eighty (180) Calendar Days from the date of covered service or discharge (whichever is later). When a Member is retroactively enrolled, the [PIHP] shall not limit the time in which claims may be submitted by the [Provider] to fewer than one hundred eighty (180) Calendar Days from the date of enrollment for health care provider and health care provider facility claims. The [Provider] shall submit all claims with a date of service on or after BH I/DD Tailored Plan Launch, to the [PIHP] for processing and payments within three hundred sixty-five (365) Calendar Days from the date of covered service or discharge (whichever is later). When a Member is retroactively enrolled, the [PIHP] shall not limit the time in which claims may be submitted by the [Provider] to fewer than three hundred sixty-five (365) Calendar Days from the date of enrollment for health care provider or health care provider facility claims. However, the [Provider’s] failure to submit a claim within these timeframes will not invalidate or reduce any claim if it was not reasonably possible for the [Provider] to submit the claim within that time. In such case, the claim should be submitted as soon as reasonably possible, and in no event, later than one (1) year from the time submittal of the claim is otherwise required. For Medical claims (including behavioral health):
1. The [PIHP] shall within eighteen (18) Calendar Days of receiving a Medical Claim notify the [Provider] whether the claim is clean or pend the claim and request from the [Provider] all additional information needed to process the claim. The [PIHP] shall have the capability to request additional information via 277 Health Care Claim Request for Additional Information EDI transaction, via electronic means (including through a portal or email), and via mail. The [PIHP] shall implement the capability for EDI 277 and electronic method (portal or email) no later than BH/IDD Tailored Plan Launch if approved by the Department. If an extension is needed, the [PIHP] may submit a request to the Department’s Contract Administrator including the proposed implementation timeline and an explanation of how provider abrasion will be minimized during the extended imp...
Prompt Claim Payments. The Provider shall submit all claims to Alliance for processing and payments within one- hundred-eighty (180) calendar days from the date of covered service or discharge (whichever is later). However, the Provider’s failure to submit a claim within this time will not invalidate or reduce any claim if it was not reasonably possible for the Provider to submit the claim within that time. In such case, the claim should be submitted as soon as reasonably possible, and in no event, later than one (1) year from the time submittal of the claim is otherwise required.