Claims Adjudication Process Clause Samples
Claims Adjudication Process. A. In accordance with the Welf. & Inst. Code §14705(c), claims for federal funds in reimbursement for services shall comply with eligibility and service requirements under applicable federal and state law.
B. The Contractor shall certify each claim submitted to the Department in accordance with Cal. Code Regs., tit. 9, § 1840.112 and 42 C.F.R. § 433.51, at the time the claims are submitted to the Department. The Contractor's Chief Financial Officer or his or her equivalent, or an individual with authority delegated by the county auditor-controller, shall sign the certification, declaring, under penalty of perjury, that the Contractor has incurred an expenditure to cover the services included in the claims to satisfy the requirements for FFP. The Contractor's Mental Health Director or an individual with authority delegated by the Mental Health Director shall sign the certification, declaring, under penalty of perjury that, to the best of his or her knowledge and belief, the claim is in all respects true, correct, and in accordance with the law and meets the requirements of Cal. Code Regs., tit. 9, § 1840.112(b). The Contractor shall have mechanisms that support the Mental Health Director's certification, including the certification that the services for which claims were submitted were actually provided to the beneficiary. If the Department requires additional information from the Contractor that will be used to establish Department payments to the Contractor, the Contractor shall certify that the additional information provided is in accordance with 42 C.F.R. § 438.604.
C. Claims not meeting federal and/or state requirements shall be returned to Contractor as not approved for payment, along with a reason for denial. Claims meeting all Health Insurance Portability and Accountability Act (HIPAA) transaction requirements and any other applicable federal or state privacy laws or regulations and certified by the Contractor in accordance with Cal. Code Regs., tit. 9, § 1840.112, shall be processed for adjudication.
D. Good cause justification for late claim submission is governed by applicable federal and state laws and regulations and is subject to approval by the Department.
E. In the event that the Department or the Contractor determines that changes requiring a change in the Contractor’s or Department’s obligation must be made relating to either the Department’s or the Contractor’s claims submission and adjudication systems due to federal or state law change...
Claims Adjudication Process. A. In accordance with Section 5718(c) of the Welfare and Institutions Code, claims for federal funds in reimbursement for services shall comply with eligibility and service requirements under applicable federal and state law.
B. The Contractor shall certify each claim submitted to the Department in accordance with Title 9, CCR, Section 1840.112, at the time the claims are submitted to the Department. The Contractor's Chief Financial Officer or his or her equivalent, or an individual with authority delegated by the county auditor-controller, shall sign the certification, declaring, under penalty of perjury, that the Contractor has incurred an expenditure to cover the services included in the claims to satisfy the requirements for federal financial participation. The Contractor's Mental Health Director or an individual with authority delegated by the Mental Health Director shall sign the certification, declaring, under penalty of perjury that, to the best of his or her knowledge and belief, the claim is in all respects true, correct, and in accordance with the law and meets the requirements of Title 9, CCR, Section 1840.112(b). The Contractor shall have mechanisms that support the Mental Health Director's certification, including the certification that the services for which claims were submitted were actually provided to the beneficiary. If the Department requires additional information from the Contractor that will be used to establish Department payments to the Contractor, the Contractor shall certify that the additional information provided is in accordance with Title 42, CFR, Section 438.604.
C. Claims not meeting federal and/or state requirements shall be returned to Contractor as not approved for payment, along with a reason for denial. Claims meeting all HIPAA transaction requirements and certified by the Contractor in accordance with Title 9, CCR, Section 1840.112, shall be processed and submitted by the Department to DHCS within 30 days for adjudication.
D. Good cause justification for late claim submission is governed by regulation (Title 9, CCR, Section 1840.110) and is subject to approval by the Department of Health Care Services.
E. In the event that the Department or the Contractor determines that significant changes must be made relating to either the Department’s or the Contractor’s claims submission and adjudication systems due to federal or state law changes or business requirements, both the Department and the Contractor agree to provide ...