Common use of CLAIMS/ENCOUNTER PROCESSING Clause in Contracts

CLAIMS/ENCOUNTER PROCESSING. The system shall capture and adjudicate all claims and encounters submitted by providers. The major functions of this module(s) include enrollee enrollment verification, provider enrollment verification, claims and encounter edits, benefit determination, pricing, medical review and claims adjudication, and claims payment. Once claims and encounters are processed, the system shall maintain the claims/encounter history file that supports the State’s encounter reporting requirements as well as all of the utilization management and quality assurance functions and other reporting requirements of the Contractor.

CLAIMS/ENCOUNTER PROCESSING. The system shall capture and adjudicate all claims and encounters submitted by providers. The major functions of this module(s) include enrollee enrollment verification, provider enrollment verification, claims and encounter edits, benefit determination, pricing, medical review and claims adjudication, and claims payment. Once claims and encounters are processed, the system shall maintain the claims/encounter history file that supports the State’s 's encounter reporting requirements as well as all of the utilization management and quality assurance functions and other reporting requirements of the Contractorcontractor.

CLAIMS/ENCOUNTER PROCESSING. The system shall capture and adjudicate all claims and encounters submitted by providers. The major functions function of this module(smodule (s) include enrollee enrollment verification, provider enrollment verification, claims and encounter edits, benefit determination, pricing, medical review and claims adjudication, and claims payment. Once claims and encounters are processed, the system shall maintain the claims/encounter history file that supports the State’s encounter reporting requirements as well as all of the utilization management and quality assurance functions and other reporting requirements of the Contractorcontractor.