Claims Adjudication. The MCP shall have the capacity to electronically accept and adjudicate all claims to final status (payment or denial). Information on claims submission procedures shall be provided to non-contracting providers within 30 calendar days of a request. The MCP shall inform providers of its ability to electronically process and adjudicate claims and the process for submission. Such information shall be initiated by the MCP and not only in response to provider requests.
Claims Adjudication. The MCP must have the capacity to electronically accept and adjudicate all claims to final status (payment or denial). Information on claims submission procedures must be provided to non-contracting providers within thirty (30) days of a request. The MCP must inform providers of its ability to electronically process and adjudicate claims and the process for submission. Such information must be initiated by the MCP and not only in response to provider requests. The MCP must notify providers who have submitted claims of claims status [paid, denied, pended (suspended)] within one month of receipt by the MCP or its designee. Such notification may be in the form of a claim payment/remittance advice produced on a routine monthly, or more frequent, basis.
Claims Adjudication. Health Plan or its designee shall receive, process and pay in a timely manner claims for Covered Services rendered or authorized by Practitioners in accordance with the authorization procedures as set forth in the Provider Manual. Health Plan shall ensure that Clean Claims are adjudicated promptly in accordance with applicable statutory and regulatory requirements. Health Plan shall work diligently with Provider and Practitioner to resolve any perceived lack of timeliness with regard to claims payment under this Agreement.
Claims Adjudication. Administrator, directly or through a third party Claims Processor, shall adjudicate and process Prescription Claims for Covered Prescription Services in a POS environment in accordance with NCPDP guidelines, standards and guidelines established by the Pharmacy Plan Specifications and applicable Laws and Regulations. Administrator shall pay, on United’s behalf, only:
(i) Clean Claims submitted by the Network Pharmacies in a timely manner in accordance with the Pharmacy Plan Specifications; (ii) Clean Claims submitted by out-of-network pharmacies or other health care providers which have dispensed or furnished Covered Prescription Services to Members under circumstances when applicable Laws and Regulations or the Pharmacy Plan Specifications require payment to such out-of-network pharmacies or other health care professionals; and (iii) Clean Claims in the form of properly submitted requests for reimbursements submitted by Members for Covered Prescription Services dispensed, provided or administered under the Benefit Plans. Subsections (ii) and (iii) will not be processed at POS.
Claims Adjudication. 6.3.1 HCT shall not be liable to make any payments for Covered Services for which Group fails to follow the prior authorization and eligibility verification procedures set forth in this Agreement, HCT’s Provider Manual and other applicable policies and procedures and under the applicable Certificate of Coverage. Further, all or a portion of payment due Group may be denied by HCT if such payment is specifically attributable to Group’s rendering or ordering: (i) services that are not Medically Necessary; (ii) services provided other than at an authorized level of care; or
Claims Adjudication. The Company agrees to act in good faith and in accordance with its standard claims practices applicable for all claims, regardless if reinsured when enforcing the terms and conditions of the Policies in connection with the administration, negotiation, payment, denial or settlement of a claim. The Reinsurer agrees that in regard to all claims on Policies reinsured under this Agreement:
(a) The final decision respecting claims payment is at the sole discretion of the Company.
(b) The Company may approach the Reinsurer for an opinion, but the Reinsurer is not responsible to the Company for a claim decision.
(c) The Company’s contractual liability for claims, as described in this Article, is binding on the Reinsurer, as long as claims have been submitted to and approved by the Reinsurer in accordance with the terms of this Agreement.
Claims Adjudication. The Company agrees to act in good faith and in accordance with its standard claims practices applicable for all claims, regardless if reinsured, when enforcing the terms and conditions of the Policies in connection with the administration, negotiation, payment, denial or settlement of a claim.
Claims Adjudication. 6.3.1 HCT shall not be liable to make any payments for Covered Services for which Provider fails to follow the prior authorization and eligibility verification procedures set forth in this Agreement, HCT’s Provider Manual and other applicable policies and procedures and under the applicable Certificate of Coverage. Further, all or a portion of payment due Provider may be denied by HCT if such payment is specifically attributable to Provider’s rendering or ordering: (i) services that are not Medically Necessary; (ii) services provided other than at an authorized level of care; or (iii) services that are not Covered Services.
6.3.2 Except as otherwise required by law, HCT is not required to compensate Provider for services rendered: (i) prior to or without such verification or confirmation; or (ii) after Provider has been informed that the person is not, or is no longer, a Member, or that coverage is otherwise not available.
6.3.3 Denials related to never-events events shall be determined in accordance with CMS guidelines.
6.3.4 In the event Provider does not agree with a denial of payment determination made, an appeal may be filed in accordance with the appeal procedures set forth in HCT’s prevailing Provider Manual. Provider understands and agrees that Provider has four (4) months from the date of service in which to appeal denial of payment by HCT or six (6) months if coordination of benefit issues exist. After this four
Claims Adjudication. 4.1.1 Following receipt of a Claim, MHSAL shall adjudicate the Claim against the requirements of this Agreement, the applicable provisions of the Manual, any Policy, and any Procedure.
4.1.2 If MHSAL determines that the Claim does not qualify for payment in whole or in part or has not been submitted by the PHARMACY OWNER in accordance with the requirements of this Agreement, the applicable provisions of the Manual, a Policy or Procedure, or any of these, MHSAL may reject the Claim or conditionally accept the Claim with adjustments.
4.1.3 The PHARMACY OWNER shall provide MHSAL with such additional information as MHSAL may require in order for MHSAL to verify any information originally submitted with a Claim.
4.1.4 MHSAL shall endeavor to adjudicate all Claims in near real time. Additionally, MHSAL shall use commercially reasonable efforts to ensure that any systems changes that affect the POS technology are tested before implementation at the Pharmacy level. The PHARMACY OWNER shall ensure that its computer software is upgraded to the satisfaction of MHSAL’s information technology personnel so as to accompany any technology changes that MHSAL may choose to implement in the public interest.
4.1.5 MHSAL will send a Claims Statement to the PHARMACY OWNER reflecting MHSAL’s adjudication of such Claim.
Claims Adjudication. In processing claims, Medical Group shall accept and adjudicate claims for health care service provided to PacifiCare Members in accordance with the provisions of Sections 1371, 1371.1, 1371.2, 1371.22, 1371.35, 1371.36, 1371.37, 1371.38, 1371.4, and 1371.8 of the California Health and Safety Code and Sections 1300.71, 1300.71.38, 1300.71.4, and 1300.77.4 of Title 28 of the California Code of Regulations.
