Common use of Capitated Services Clause in Contracts

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 Reporting a. The Health Plan shall submit a separate Claims Aging Report of claims submitted and processed for subcapitated providers and for providers of services for which the Health Plan is reimbursed by the Agency on a capitated basis. The Health Plan shall use the template for HMOs and Capitated PSNs, as specified in the Health Plan Report Guide, for these providers. b. The reporting specified in a. above is in addition to the separate Claims Aging Report requirements for FFS claims in accordance with Attachment II, Item C., Claims, sub- item 7.

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 Reporting a. The Health Plan shall submit a separate Claims Aging Report of claims submitted and processed for subcapitated providers and for providers of services for which the Health Plan health plan is reimbursed by the Agency on a capitated basis. The Health Plan shall use the template for HMOs and Capitated PSNs, as specified in the Health Plan Report Guide, for these providers. b. The reporting specified in a. above is in addition to the separate Claims Aging Report requirements for FFS claims in accordance with Attachment II, Item C., Claims, sub- item 7.

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 and 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 and 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 Reporting a. The Health Plan shall submit a separate Claims Aging Report of claims submitted and processed for subcapitated providers and for providers of services for which the Health Plan is reimbursed by the Agency on a capitated basis. The Health Plan shall use the template for HMOs and Capitated PSNs, as specified in the Health Plan Report Guide, for these providers. b. The reporting specified in a. above is in addition to the separate Claims Aging Report requirements for FFS claims in accordance with Attachment II, Item C., Claims, sub- item 7.forty