Calculating PARTICIPATING MEDICAL GROUP PMPM Non. Capitated Expenses. The Non-Capitated Expenses shall include actual expenses incurred by BLUE CROSS to provide Non-Capitated Services to Members, as authorized or referred by the PARTICIPATING MEDICAL GROUP. Expenses above the Case Management Stop-Loss Threshold, as set forth in Section 9.03, and expenses incurred by Members or former Members covered under the Extension of Benefits provision of the Benefit Agreements are excluded from PARTICIPATING MEDICAL GROUP’s Non-Capitated Expenses for purposes of determining the Non-Capitated Performance Settlement. BLUE CROSS shall accrue Non-Capitated Expenses by each PARTICIPATING MEDICAL GROUP by the calendar year the services were incurred and paid through one hundred and twenty (120) days (April 30) after year-end. Beginning in year two (2) of this Agreement, any claims received after calculation of the final Non-Capitated Performance Settlement will be charged to the following year’s Non-Capitated Expenses. Any Non-Capitated Services treatments that begin in one calendar year and extend into the next year shall accrue to the year the treatment began. Notwithstanding the aforementioned, any claims for Non-Capitated Services or Shared Risk Services (as defined in the CALIFORNIACARE Medical Services Agreement in effect for years prior to 1997) paid after April 30, 1997 will be charged to the 1997 Non-Capitated Expense. PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expense is the quotient of PARTICIPATING MEDICAL GROUP’s Non-Capitated Expenses divided by PARTICIPATING MEDICAL GROUP’s calendar year Member Months. BLUE CROSS shall provide PARTICIPATING MEDICAL GROUP with quarterly reports advising them of their Non-Capitated Expenses. The Operations Manual describes the PARTICIPATING MEDICAL GROUP reports.
Calculating PARTICIPATING MEDICAL GROUP PMPM Non. Capitated Expenses. The Non-Capitated Expenses shall include actual expenses incurred by BLUE CROSS to provide Non-Capitated Services to Members, as authorized or referred by the PARTICIPATING MEDICAL GROUP. Expenses above the Case Management Stop-Loss Threshold, as set forth in Section 9.03, and expenses incurred by Members or former Members covered under the Extension of Benefits provision of the Benefit Agreements are excluded from PARTICIPATING MEDICAL GROUP’s Non-Capitated Expenses for purposes of determining the Non-Capitated Performance Settlement. BLUE CROSS shall accrue Non-Capitated Expenses by each PARTICIPATING MEDICAL GROUP by the calendar year the services were incurred and paid through March 31st after year-end. Beginning in year two (2) of this Agreement, any claims received after calculation of the final Non-Capitated Performance Settlement will be charged to the following year’s Non-Capitated Expenses. Any Non-Capitated Service admissions, including, but not limited to, inpatient hospital, skilled nursing facility, hospice and alternative birthing center admissions that occur in one calendar year and extend into the next year shall accrue to the year the admission occurred. Notwithstanding the aforementioned, any claims for Non-Capitated Services or Shared Risk Services (as defined in the CALIFORNIACARE Medical Services Agreement in effect for years prior to the Initial Term of this Agreement) paid after the March 31st immediately following the effective date hereof will be charged to the Non-Capitated Expense for the first calendar year, or portion thereof, of this Agreement.
