Capitation Payments to Managed Care Organization Sample Clauses

Capitation Payments to Managed Care Organization. Payment to the MCO will be based on the enrollment data transmitted from the Department’s eligibility vendor to its Fiscal Agent each month for MCO-eligible members that have completed the enrollment process through the Department’s Enrollment Broker. The MCO must notify BMS in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) calendar days from the day inconsistency was determined by the MCO. BMS agrees to provide to the MCO information needed to determine the source of the inconsistency within ten (10) business days after receiving written notice of the request to furnish such information. BMS will recoup overpayments or reimburse underpayments as soon as administratively possible. The adjusted payment (representing reinstated enrollees) for each month of coverage will be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before BMS. In full consideration of Contract services rendered by the MCO, BMS agrees to pay the MCO monthly payments. BMS capitation payments to the MCO will apply to the time period July 1, 2023, through June 30, 2024 (State Fiscal Year 2024). The MCO assumes risk for the cost of services covered under this Contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contract. The MCO must accept as payment in full, the amount paid by BMS. Except for emergency services, no payment will be made for services furnished by a provider other than the MCO provider, if the services were available under the provider Contract unless otherwise authorized by the MCO. Payments provided for under the Contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by the Centers for Medicare & Medicaid (CMS). CMS may deny payment for new enrollees to the State if its determination is not timely contested by the MCO per 42 CFR §438.726(b) and §438.730. BMS is obligated to make payment either by mail or electronic transfer to the MCO. Capitation payments will be made for the month in which services are being provided according to the payment schedule for the month, as set forth in this Contract. BMS rese...