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.
Appears in 4 contracts
Samples: Medicaid Managed Specialty Supports and Services Concurrent Waiver Program Agreement, Michigan Abw Non Pregnant Childless Adults Waiver (Adult Benefits Waiver) Section 1115 Demonstration, Medicaid Managed Specialty Supports and Services Concurrent Waiver Program Agreement
