Common use of Billing for Services Clause in Contracts

Billing for Services. Specialty Care (if applicable): a. The Agency shall submit a completed Health Insurance Claim Form 1500 (hereinafter referred to as “HICF”) for all Services rendered during the prior month. b. The HICF form shall be completed in its entirety and shall provide a sufficient description of the Services rendered in order to verify payment (e.g. Client name, unique identifier, County of residency, Services provided, including applicable CPT code, and a charge reflecting the negotiated rate). Any HICF form that is incomplete or which fails to provide the necessary supporting documentation shall be deemed incomplete and rejected. c. The Agency agrees to actively pursue and bill any third-party coverage for available contribution toward the cost of Services incurred by the Client. d. The Agency agrees to reimburse the Recipient any monies that may have been received from any third-party coverage, after payment has been made by the Recipient. Reimbursements shall be any amounts received up to the amount paid by the Recipient. The Agency shall report to the Recipient any payment received from, or any pending claims with, any third-party when submitting requests for reimbursement to the Recipient. e. All completed HICF forms shall be submitted to the Recipient for review and approval no later than the tenth (10th) business day of each month and shall include all supporting documentation necessary for processing. HICF forms received after the fourth (4th) business day of each month shall be deemed as late and may result in delayed, reduced, or denial of payment, in the sole discretion of the Recipient. f. All HICF forms for tests, procedures, and Services that are not listed on the Medicare Part B Fee Schedule will be made at a rate not to exceed 150% of the Medicare Part B Fee Schedule unless otherwise pre- approved in writing through a Recipient waiver. g. For all invoices or requests for payment relating to specialty medical care, the Agency shall provide a copy of the associated authorization form for such Services.

Billing for Services. Specialty Care (if applicable): a. The Agency shall submit a completed Health Insurance Claim Form 1500 (hereinafter referred to as “HICF”) for all Services rendered during the prior month. b. The HICF form shall be completed in its entirety and shall provide a sufficient description of the Services rendered in order to verify payment (e.g. Client name, unique identifier, County of residency, Services provided, including applicable CPT code, and a charge reflecting the negotiated rate). Any HICF form that is incomplete or which fails to provide the necessary supporting documentation shall be deemed incomplete and rejected. c. The Agency agrees to actively pursue and bill xxxx any third-party coverage for available contribution toward the cost of Services incurred by the Client. d. The Agency agrees to reimburse the Recipient any monies that may have been received from any third-party coverage, after payment has been made by the Recipient. Reimbursements shall be any amounts received up to the amount paid by the Recipient. The Agency shall report to the Recipient any payment received from, or any pending claims with, any third-party when submitting requests for reimbursement to the Recipient. e. All completed HICF forms shall be submitted to the Recipient for review and approval no later than the tenth (10th) business day of each month and shall include all supporting documentation necessary for processing. HICF forms received after the fourth (4th) business day of each month shall be deemed as late and may result in delayed, reduced, or denial of payment, in the sole discretion of the Recipient. f. All HICF forms for tests, procedures, and Services that are not listed on the Medicare Part B Fee Schedule will be made at a rate not to exceed 150% of the Medicare Part B Fee Schedule unless otherwise pre- approved in writing through a Recipient waiver. g. For all invoices or requests for payment relating to specialty medical care, the Agency shall provide a copy of the associated authorization form for such Services.

Billing for Services. Specialty Care (if applicable):Medical and Laboratory Services: a. The Agency shall submit a completed Health Insurance Claim Form 1500 (hereinafter referred to as “HICF”) all invoices and/or requests for all Services rendered during the prior month. b. The HICF form shall be completed in its entirety and shall provide a sufficient description of the Services rendered in order to verify payment (e.g. Client name, unique identifier, County of residency, Services provided, including applicable CPT code, and a charge reflecting the negotiated rate). Any HICF form that is incomplete or which fails to provide the necessary supporting documentation shall be deemed incomplete and rejected. c. The Agency agrees to actively pursue and bill any third-party coverage for available contribution toward the cost of Services incurred by the Client. d. The Agency agrees to reimburse the Recipient any monies that may have been received from any third-party coverage, after payment has been made by the Recipient. Reimbursements shall be any amounts received up to the amount paid by the Recipient. The Agency shall report reimbursement/invoice to the Recipient any payment received from, or any pending claims with, any third-party when submitting requests for reimbursement to the Recipient. e. All completed HICF forms shall be submitted to the Recipient for review and approval no later than by the tenth (10th) business day of each month and month. The Agency understands that any unspent funds from any given calendar year shall include all supporting documentation necessary not be carried forward to the following Grant year. b. The Agency shall not receive payment for processing. HICF forms received after work found by the fourth Recipient to be unsatisfactory, or performed in violation of federal, state or local law, ordinance, or regulation. c. Agency (4thsub-recipient) business day of each month invoices shall be deemed as late reviewed by the Recipient and their fiscal staff for appropriateness and thoroughness. If, after review of an invoice, an issue or concern with the sub-recipient is identified, the Recipient’s staff shall be responsible for working with the Agency to resolve the issue or concern. As part of this attempt, the Recipient’s staff may result in delayedrequest clarification of any unusual, reducedmiscellaneous, excessive, or denial potentially unallowable charged invoiced by the Agency. If the explanation is sufficient to render a reasonable judgment on whether the cost is allowable, the Recipient’s office shall contact the Agency who shall provide detailed justifications and support. In the event the Agency fails to provide such justification or clarification, the invoice amount shall be reduced and expenses disallowed. d. Invoices submitted to the Recipient shall contain a minimum level of paymentinformation including, but not limited to,the following: i. Name of Agency; ii. Agency address; iii. Date of invoice; iv. Invoice number; v. Period of performance covered by invoice; vi. Description of goods and services reflected by the xxxxxxxx; vii. Current period of costs (with sufficient detail and backup information); viii. Sub-recipient contact person with respect to the invoice; ix. Statement that the funds expended arereasonable, allowable, and allocable; x. Statement that the costs are in compliance with the sole discretion terms and conditions of the Recipient.Contract; and340b f. All HICF forms for tests, procedures, and Services that are not listed on the Medicare Part B Fee Schedule will be made at a rate not to exceed 150% of the Medicare Part B Fee Schedule unless otherwise pre- approved in writing through a Recipient waiver. g. For all invoices or requests for payment relating to specialty medical care, the e. The Agency shall provide a copy ensure that RWHAP Part A is the payer of last resort. The Agency shall bill any other funding source, including Medicaid and Medicare that the associated authorization form for such ServicesClient may have before utilizing RWHAP Part A funds. In accordance with 45 CFR 75, all program income generated and used shall be tracked and reported to the Recipient’s Office.