Capitated Services. For all services for which a Health Plan receives a capitated payment, the Health Plan shall ensure that claims are processed and payment systems comply with the federal requirements set forth in 42 CFR 447.45; 42 CFR 447.46; the processing time frames in s. 641.3155, F.S.; and the requirements below:
a. The date of Health Plan claim payment is the date of the check or other form of payment.
b. For all electronically submitted claims for capitated services, the Health Plan shall:
(1) Within twenty-four (24) hours after the beginning of the next business day after receipt of the claim, provide electronic acknowledgment of the receipt of the claim to the electronic source submitting the claim.
(2) Within twenty (20) calendar days after receipt of the claim, pay the claim or notify the provider or designee that the claim is denied or contested. The notification to the provider of a contested claim shall include an itemized list of additional information or documents necessary to process the claim.
(3) Pay or deny the claim within ninety (90) calendar days after receipt of the claim. Failure to pay or deny the claim within one-hundred twenty (120) calendar days after receipt of the claim creates an uncontestable obligation for the Health Plan to pay the claim.
c. For all non-electronically submitted claims for capitated services, the Health Plan shall:
(1) Within fifteen (15) calendar days after receipt of the claim, provide acknowledgment of receipt of the claim to the provider or designee or provide the provider or designee with electronic access to the status of a submitted claim.
(2) Within forty (40) calendar days after receipt of the claim, pay the claim or notify the provider or designee that the claim is denied or contested. The notification to the provider of a contested claim shall include an itemized list of additional information or documents necessary to process the claim.
(3) Pay or deny the claim within one-hundred twenty (120) calendar days after receipt of the claim. Failure to pay or deny the claim within one-hundred forty (140) calendar days after receipt of the claim creates an uncontestable obligation for the Health Plan to pay the claim.
d. The Health Plan shall reimburse providers for Medicare deductibles and co-insurance payments for Medicare dually eligible members according to the lesser of the following:
(1) The rate negotiated with the provider; or
(2) The reimbursement amount as stipulated in s. 409.908 F.S.
1. Claims Aging Reporti...
Capitated Services. Services performed for a Member by a health care provider with whom the Plan has a contract, directly or indirectly, and where the contract transfers from the Plan the entire risk (without any stop loss or other risk retention by the Plan) that the service may generate a cost greater than the capitation payment.
Capitated Services. All non-behavioral Medicaid-covered services shall not be covered by capitation payments hereunder, but shall be the responsibility of the enrolled Medicaid physical health care provider. These include:
Capitated Services. For all services for which a PSN receives a capitated payment, the PSN shall ensure that claims are processed and payment systems comply with the federal requirements set forth in 42 CFR 447.45, 42 CFR 447.46 and the requirements below:
a. The date of PSN Claim payment is the date of the check or other form of payment.
b. For all electronically submitted Claims for capitated services, the PSN shall:
(1) Within 24 hours after the beginning of the next Business Day after receipt of the Claim, provide electronic acknowledgment of the receipt of the Claim to the electronic source submitting the Claim.
(2) Within twenty (20) Calendar Days after receipt of the Claim, pay the Claim or notify the provider or designee that the Claim is denied or contested. The notification to the provider of a Contested Claim shall include an itemized list of additional information or documents necessary to process the Claim.
(3) Pay or deny the Claim within ninety (90) Calendar Days after receipt of the Claim. Failure to pay or deny the Claim within 120 Calendar Days after receipt of the Claim creates an uncontestable obligation for the PSN to pay the Claim.
c. For all non-electronically submitted Claims for capitated services, the PSN shall:
(1) Within fifteen (15) Calendar Days after receipt of the Claim, provide acknowledgment of receipt of the Claim to the provider or designee or provide the provider or designee with electronic access to the status of a submitted Claim.
(2) Within forty (40) Calendar Days after receipt of the Claim, pay the Claim or notify the provider or designee that the Claim is denied or contested. The notification to the provider of a Contested Claim shall include an itemized list of additional information or documents necessary to process the Claim.
(3) Pay or deny the Claim within 120 Calendar Days after receipt of the Claim. Failure to pay or deny the Claim within 140 Calendar Days after receipt of the Claim creates an uncontestable obligation for the PSN to pay the Claim.
Capitated Services. Capitated Services shall include the following services unless specifically excluded on Attachment A-2:
Capitated Services. Services with Special Arrangements and/or Payment of Out-Of-Plan Providers Pg 92 6.7.
4.1 School Linked CHDP Services: Coordination of Care Pg 92 6.7.
4.2 School Linked CHDP Services: Cooperative Arrangements Pg 92 6.7.4.3 School Linked CHDP Services: Subcontracts Pg 93 6.7.4.4 Early and Periodic Screening, Diagnosis and Treatment EPSDT Supplemental Services, Excluding Case Management Services Pg 93 6.7.4.5
Capitated Services. Physician Group agrees to provide Capitated Services to Enrollees selecting and assigned to Physician Group. The Capitated Services which are to be provided and which are the financial responsibility of Physician Group are described in Attachment A. Physician Group agrees to pay all claims for Capitated Services in accordance with State and Federal regulations governing claims payment by Health Plan and CMP Program. Physician Group agrees that, should Health Plan be required to compensate any provider for Capitated Services. Health Plan shall be reimbursed for such expenditures by Physician Group either through an offset against Capitation Fees, direct payment by Physician Group or combination thereof. Attachment A shall not be amended during the current contract period without mutual consent, except as may be required for continued compliance with Federal and State laws and regulations.
