Common use of Action to Deny Payment in Whole or Part for a Service Clause in Contracts

Action to Deny Payment in Whole or Part for a Service. (A) The Contractor shall provide a written Notice of Action to the requesting Provider of decisions to deny payment in whole or in part. (B) The Contractor shall also mail the Enrollee a written Notice of Action at the time of the Action affecting a claim if the denial reason is that: (1) the service was not authorized by the Contractor, and the Enrollee could be liable for payment if the Enrollee gave advance written consent that he or she would pay for the specific service; or (2) the Enrollee requested continued services during an Appeal or State fair hearing and the Appeal or State fair hearing decision was adverse to the Enrollee. (C) A Notice of Action to the Enrollee is not necessary under the following circumstances: (1) the Provider billed the Contractor in error for a non-authorized service; or (2) the claim included a technical error (incorrect data including procedure code, diagnosis code, Enrollee name or Medicaid identification number, date of service, etc.).

Action to Deny Payment in Whole or Part for a Service. (A) The Contractor shall provide a written Notice of Action to notify the requesting Provider of decisions to deny payment in whole or in part. (B) The Contractor shall also mail the Enrollee a written Notice of Action at the time of the Action affecting a claim if the denial reason is that: (1) the service was not authorized by the Contractor, and the Enrollee could be liable for payment if the Enrollee gave advance written consent that he or she would pay for the specific service; or (2) the Enrollee requested continued services during an Appeal or State fair hearing and the Appeal or State fair hearing decision was adverse to the Enrollee. (C) A Notice of Action to the Enrollee is not necessary under the following circumstances: (1) the Provider billed the Contractor in error for a non-authorized service; or; (2) the claim included a technical error (incorrect data including procedure code, diagnosis code, Enrollee name or Medicaid CHIP identification number, date of service, etc.); or (3) the Enrollee became eligible after the first of the month, but received a service during that month before becoming CHIP eligible.