Provider Payment Sample Clauses
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Provider Payment. In accordance with Section 1932(f) of the Social Security Act (42 U.S.C. §1396a-2) the Contractor shall pay all in-and out-of-network providers on a timely basis, consistent with the claims payment procedure described in 42 C.F.R. §§ 447.45, 447.46, 438.60, Section 1902 (a)(37), upon receipt of all clean claims for covered services rendered to covered members who are enrolled with the Contractor. 42 C.F.R. § 447.45 defines timely processing of claims as: • Adjudication (pay or deny) of ninety per cent (90%) of all clean claims within thirty (30) days of the date of receipt. • Adjudication (pay or deny) of ninety-nine per cent (99%) of all clean claims within ninety (90) days of the date of receipt. • Adjudication (pay or deny) all other claims within twelve (12) months of the date of receipt. (See 42 C.F.R. § 447.45 for timeframe exceptions).This requirement shall not apply to network providers who are not paid by the Contractor on a fee-for- service basis and will not override any existing negotiated payment scheduled between the Contractor and its providers. This requirement applies to Virginia FAMIS clean claims. The Contractor shall notify the Department forty-five (45) days in advance of any proposal to modify claims operations and processing that shall include relocation of any claims processing operations. Any expenses incurred by the Department or its contractors to adapt to the Contractor’s claims processing operational changes (including but not limited to costs for site visits) shall be borne by the Contractor. The Contractor must make available to providers an electronic means of submitting claims. In addition, the Contractor shall make every effort to assure at least sixty (60%) percent of claims received from providers are submitted electronically. The Contractor must pay interest charges on claims in compliance with requirements set forth in § 38.2-4306.1 of the Code of Virginia. Specifically interest upon the claim proceeds paid to the subscriber, claimant, or assignee entitled thereto shall be computed daily at the legal rate of interest from the date of thirty calendar days from the Contractor’s receipt of “proof of loss” to the date of claim payment. "Proof of loss" means the date on which the Contractor has received all necessary documentation reasonably required by the Contractor to make a determination of benefit coverage. This requirement does not apply to claims for which payment has been or will be made directly to health care prov...
Provider Payment. 4.10.4.1 With the exceptions noted below, the Contractor shall negotiate rates with Providers and such rates shall be specified in the Provider Contract. DCH prefers that Contractors pay Providers on a Fee for Service basis, however if the Contractor does enter into a capitated arrangement with Providers, the Contractor shall continue to require all Providers to submit detailed Encounter Data, including those Providers that may be paid a Capitation Payment.
4.10.4.2 The Contractor shall be responsible for issuing an IRS Form (1099) in accordance with all federal laws, regulations and guidelines.
4.10.4.3 When the Contractor negotiates a contract with a Critical Access Hospital (CAH), pursuant to Section 4.8.6 of the GF Contract, the Contractor shall pay the CAH a payment rate based on 101% allowable costs incurred by the CAH. DCH may require the Contractor to adjust the rate paid to CAHs if so directed by the State of Georgia’s Appropriations Act.
4.10.4.3.1 A critical access hospital must provide notice to a care management organization and the Department of Community Health of any alleged breaches in its contract by such care management organization.
4.10.4.3.2 If a critical access hospital satisfies the requirement of Title 33 of the Official Code of Georgia Annotated (HB1234), and if the Department of Community Health concludes, after notice and hearing, that a care management organization has substantively and repeatedly breached a term of its contract with a critical access hospital, the department is authorized to require the care management organization to pay damages to the critical access hospital in an amount not to exceed three times the amount owed. Notwithstanding the foregoing, nothing in Title 33 of the Official Code of Georgia Annotated (HB1234) shall be interpreted to limit the authority of the Department of Community Health to establish additional penalties or fines against a care management organization for failure to comply with the contract between a care management organization and the Department of Community Health.
4.10.4.4 When the Contractor negotiates a contract with a FQHC and/or a RHC, as defined in Section 1905(a)(2)(B) and 1905(a)(2)(C) of the Social Security Act, the Contractor shall, at minimum, pay the PPS rates for Core Services and other ambulatory services per encounter. The rates are established as described in §1001.1 of the Manual. At Contractor’s discretion, it may pay more than the PPS rate for these services.
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Provider Payment. The Contract must include a provider payment provision that describes the methodology to be used as a basis for payment to the provider. However, the agreement shall not include a rate methodology that provides for an automatic increase in rates. This provision shall be consistent with the Reimbursement Policy required under G.S. 58-3-227(a)(5).
Provider Payment. The contract must include a provider payment provision that describes the methodology to be used as a basis for payment to the provider. However, the agreement shall not include a rate methodology that provides for an automatic increase in rates. Provider agrees to send 837 HIPAA compliant transactions and to receive 835 Remittances or to participate in the PIHP’s web-based billing process.
Provider Payment. 5.1 Medavie Blue Cross agrees to make payment to the Provider or its Assignee (in cases where the Provider has assigned payment to a third party) every second week of the amount due for claims received by Medavie Blue Cross from the Provider together with a payment summary for the claims submitted during the relevant claim period.
5.2 The Provider or its Assignee (in cases where the Provider has assigned payment to a third party) shall examine and verify the accuracy of the payment summary so received and shall notify Medavie Blue Cross in writing of any error or omission therein or arising therefrom within thirty (30) days of its receipt, failing which the Provider, the Assignee and any party claiming thereunder shall lose the right to dispute the accuracy of the information contained in the payment summary and/or the adjustment of the claim made by Medavie Blue Cross shown in the payment summary.
5.3 Notwithstanding the foregoing, if an error in a claim or in the payment thereof is identified by Medavie Blue Cross, it may, at its sole and unfettered discretion, adjust the claim at any time, regardless of when the error is discovered, who is responsible for the error and whether or not the claim has been paid. The amount of the error so adjusted shall become immediately due and payable.
Provider Payment. 5.1 Medavie Blue Cross agrees to make payments to the Provider or its Assignee (in cases where the Provider has assigned payment to a third party) for claims submitted during the relevant claim period on a weekly basis, only where the Provider has met all of the following criteria: a) the Provider is an approved Medavie provider, b) the Provider is registered for electronic claims, c) the Provider is registered for direct deposit, c) the Provider accesses the online payment summary (ePayment Summary). Medavie Blue Cross agrees to make payment to the Provider or its Assignee (in cases where the Provider has assigned payment to a third party) where the Provider (or its Assignee) are paid by cheque, together with an online Payment Summary (ePayment Summary), every second week of the amount due for claims received by Medavie Blue Cross from the Provider for the claims submitted during the relevant claim period.
5.2 The Provider or its Assignee (in cases where the Provider has assigned payment to a third party) shall examine and verify the accuracy of the payment summary so received and shall notify Medavie Blue Cross in writing of any error or omission therein or arising therefrom within thirty (30) days of its receipt, failing which the Provider, the Assignee and any party claiming thereunder shall lose the right to dispute the accuracy of the information contained in the payment summary and/or the adjustment of the claim made by Medavie Blue Cross shown in the payment summary.
5.3 Notwithstanding the foregoing, if an error in a claim or in the payment thereof is identified by Medavie Blue Cross, it may, at its sole and unfettered discretion, adjust the claim at any time, regardless of when the error is discovered, who is responsible for the error and whether or not the claim has been paid. The amount of the error so adjusted shall become immediately due and payable.
Provider Payment. 4.10.4.1 With the exceptions noted below, the Contractor shall negotiate rates with Providers and such rates shall be specified in the Provider Contract. DCH prefers that Contractors pay Providers on a Fee for Service basis, however if the Contractor does enter into a capitated arrangement with Providers, the Contractor shall continue to require all Providers to submit detailed Encounter Data, including any Providers that may be paid a Capitation Payment.
4.10.4.2 The Contractor shall be responsible for issuing to Provider IRS Form 1099s in accordance with all federal laws, regulations and guidelines.
4.10.4.3 When the Contractor negotiates a contract with a Critical Access Hospital (CAH), pursuant to Section 4.8.6 of the GHF Contract, the Contractor shall pay the CAH a payment rate based on allowable costs incurred by the CAH, in accordance with the Georgia Medicaid Policies and Procedures Manual.
4.10.4.4 When the Contractor negotiates a contract with a FQHC and/or a RHC, as defined in Section 1905(a)(2)(B) and 1905(a)(2)(C) of the Social Security Act, the Contractor shall pay the FQHC/RHC rates that are comparable to rates paid to other similar Providers providing similar services.
4.10.4.5 Upon receipt of notice from DCH that it is due funds from a Provider, the Contractor shall reduce payment to the Provider for all claims submitted by that Provider by one hundred percent (100%), or such other amount as DCH may elect, until such time as the amount owed to DCH is recovered. The Contractor shall promptly remit any such funds recovered to DCH in the manner specified by the DCH. To that end, the Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH.
4.10.4.6 The Contractor shall adjust its negotiated rates with Providers to reflect budgetary changes to the Medical Assistance program, as directed by the Commissioner of DCH, to the extent such adjustments can be made within funds appropriated to DCH and available for payment to the Contractor. The Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH.
Provider Payment
Provider Payment