Bundling and Other Computerized Claim Editing Sample Clauses

Bundling and Other Computerized Claim Editing. (a) Company agrees to cooperate with and promote the establishment of one or more claim-editing software packages acceptable to Physicians and health plans and a mutually acceptable process for modifying such software package(s) to accommodate future evolution of CPT® and/or other billing rules or conventions. Company shall cause one or more suitable Company employees to provide reasonable assistance to such development efforts. Company agrees to adopt, without customization, any software developed pursuant to such development efforts if and when (1) designees of Class Counsel, which shall include the American Medical Association and State Medical Societies for States in which collectively 75% of the Physicians practice, certify their support of such software; and (2) other health insurers providing coverage to not less than seventy-five (75%) of natural persons insured through commercial insurance plans agree to adopt such software on the same basis. To the extent that any such agreed upon software is inconsistent with the terms of this Agreement, this Agreement shall be deemed to be modified to conform to the agreed-upon software, effective upon such adoption. The Parties agree to consult to determine actions necessary to effectuate this commitment that will be consistent with applicable law. (b) Pending adoption of such revised software product, Company agrees to take actions necessary on Company’s part to cause the claim-editing software program it uses in the interim to continue to produce editing results consistent with the standards set forth in this § 7.20(b) and, if Company has actual knowledge of non-conformity with such standards, to take reasonable actions necessary on its part to promptly modify such software to any extent necessary to conform to such standards; provided that nothing in this paragraph is intended or shall be construed to require Company to pay for anything other than Covered Services for Plan Members, to make payment at any particular rates, to limit Company’s right to deny or adjust claims based on reasonable belief of fraudulent, abusive or other inappropriate billing practices (so long as the Physician has been given the opportunity to provide clinical records and Company has reviewed any clinical records so provided), or to supersede Individually Negotiated Contracts that specifically provide for alternative payment logic when the doctor has requested in writing that alternative payment logic, which is contained in Individ...

Bundling and Other Computerized Claim Editing. Company agrees to take actions necessary on Company’s part to cause the claim-editing software program it uses to continue to produce editing results consistent with the standards set forth in this § 7.20 and, if Company has actual knowledge of non-conformity with such standards, to take reasonable actions necessary on its part to promptly modify such software to any extent necessary to conform to such standards; provided that nothing in this paragraph is intended or shall be construed to require Company to pay for anything other than Covered Services for Plan Members, to make payment at any particular rates, to limit Company’s right to deny, pend or adjust claims based on a reasonable belief of fraudulent or abusive (whether intentional or unintentional) billing practices (so long as the Physician has been given the opportunity to provide Clinical Information and Company has reviewed any Clinical Information so provided before denying or adjusting the claims). For purposes of this § 7.20 only, if any change to CPT® affects Company’s obligations hereunder, Company will promptly develop plans to cause its Physician payment practices to be consistent with the commitments set forth in this § 7.20. Except as set forth below, the obligations set forth below in this § 7.20 shall take effect on the date set forth in Exhibit G. The parties agree that all references to the AMA CPT® book and to CPT® Codes in this § 7.20 refer to the AMA CPT® book and the CPT® Codes listed in the AMA CPT® book in effect at the time the services were provided. (a) Company will process and separately reimburse those codes listed in the AMA CPT® book as modifier 51 exempt CPT® Codes without reducing payment under Company’s Multiple Procedure Logic, provided that the AMA CPT® book provides that such services are appropriately reported together. (b) Company will process and separately reimburse codes listed in the AMA CPT® book as add-on billing codes without reducing payment under Company’s Multiple Procedure Logic; provided that the AMA CPT® book provides that such add-on CPT® Codes are appropriately billed with proper primary procedure codes. (c) (i) Company shall not require a Physician to submit Clinical Information of their patient encounters solely because the Physician seeks payment for both surgical procedures and CPT® evaluation and management services for the same patient on the same date of service, provided that the correct CPT® evaluation and management code, surgical code a...