Annual Shadow Claims Workplan and Ongoing Monitoring Sample Clauses

Annual Shadow Claims Workplan and Ongoing Monitoring. The MCO must have written policies and procedures to address its submission of shadow claims to the State. At least annually, or on a schedule determined at the discretion of the State, the MCO must submit a shadow claims workplan that addresses the MCO’s strategy for monitoring the following: • Timeliness of MCO’s Shadow Claims Submission to the State’s Fiscal Agent: OMPP recognizes that the out of network provider filing limit for submission of claims to the MCO is 365 calendar days per 42 CFR 447.45(d)(4), and that this filing requirement may prevent timely receipt of claims by the MCO from some providers. Therefore, the MCO must submit all shadow claims within fifteen months of the earliest date of service on the claim. In addition, the MCO must submit 100 percent of its adjudicated claims within 30 days of adjudication. The State may require the MCO to submit a corrective action plan to address non-compliance issues or may assess liquidated damages if the MCO fails to comply with these timeliness requirements. • Compliance with Pre-cycle Edits: OMPP’s fiscal agent will assess each shadow claim for compliance with pre-cycle edits. The MCO must have 98 percent of each shadow claims batch pass all pre-cycle edits. The MCO must then correct and resubmit any shadow claims that did not pass the pre-cycle edits. The fiscal agent receiving the shadow claims will treat each resubmitted batch as a new submission that must achieve the 98 percent standard. The fiscal agent will include each resubmitted shadow claims batch in the overall average of calendar month batch submissions. For submissions that fall below the 98 percent standard, OMPP will assess liquidated damages per claim type, in accordance with the schedule in Section 8.2 of this Attachment.