Common use of Claims Management System Clause in Contracts

Claims Management System. The PIHP shall make timely payments to all providers for clean claims. This includes payment at 90% or higher of all clean claims from affiliates and network subcontractors within 30 days of receipt, and at least 99% of all clean claims within 90 days of receipt, except services rendered under a subcontract in which other timeliness standards have been specified and agreed to by both parties. A clean claim is a valid claim completed in the format and time frames specified by the PIHP and that can be processed without obtaining additional information from the provider of service or a third party. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity. A valid claim is a claim for supports and services that the PIHP is responsible for under this contract. It includes services authorized by the PIHP, and those like Medicare co-pays and deductibles that the PIHP may be responsible for regardless of their authorization. The PIHP shall have an effective provider appeal process to promptly and fairly resolve provider-billing disputes.