Billing for Non Clause Samples

Billing for Non. Capitated Services shall be as follows: A. The provider of Non-Capitated Services may ▇▇▇▇ BLUE CROSS directly, in which case, BLUE CROSS shall reimburse said provider within sixty (60) days, for contracted providers, or within thirty (30) days for non-contracted providers, following receipt of a clean, undisputed claim accompanied by an authorization from PARTICIPATING MEDICAL GROUP; or, B. The provider of Non-Capitated Services may ▇▇▇▇ PARTICIPATING MEDICAL GROUP, in which case, PARTICIPATING MEDICAL GROUP shall ▇▇▇▇ BLUE CROSS for reimbursement. BLUE CROSS shall reimburse PARTICIPATING MEDICAL GROUP within sixty (60) days, for contracted providers, or within thirty (30) days for non-contracted providers, following BLUE CROSS’ receipt of a clean undisputed claim from PARTICIPATING MEDICAL GROUP, on the condition that such claim shall be submitted to BLUE CROSS no later than twelve (12) months after the date of service. This section shall only apply for the following Non-Capitated Services: DME, prosthetics, injectable medications (including chemotherapy drugs and infused substances) and immunosuppressive drugs. In either case described above, BLUE CROSS shall pay contracting providers at the lesser of the then current Blue Cross of California Prudent Buyer Plan Participating Physician Agreement Fee Schedule for the appropriate region, the Medicare Allowed Amount, or the rate negotiated between BLUE CROSS and said provider. In the case of non-contracting providers, BLUE CROSS shall pay at the lesser of: the Medicare Allowed Amount, actual billed charges, or the maximum allowable rate according to the BLUE CROSS Customary and Reasonable charges, or the rate arranged for by a BLUE CROSS SENIOR SECURE Case Manager.