Claims Payment. The Reinsurer will be liable to the Company for its share of the benefits owed under the express contractual terms of the Reinsured Policies and as specified under the terms of this Agreement. The Reinsurer will not participate in any ex gratia payments made by the Company (i.e., payments the Company is not required to make under the Reinsured Policy terms.) The payment of death benefits by the Reinsurer will be in one lump sum regardless of the mode of settlement under the Reinsured Policy. Benefit payments from the Reinsurer will be due within 30 days of the claim satisfying the requirements established under this Agreement. The Reinsurer’s share of any interest payable under the terms of a Reinsured Policy or applicable law which is based on the death benefits paid by the Company, will be payable provided that the Reinsurer will not be liable for interest accruing on or after the date of the Company’s payment of benefits. The Reinsurer will make payment to the Company for each such claim. For Waiver of Premium claims, the Company will continue to pay premiums for reinsurance, except premiums for disability reinsurance. The Reinsurer will pay its proportionate share of the gross premium waived by the Company on the Reinsured Policy, including its share of the premiums for benefits that remain in effect during disability. For claims on Accelerated Benefit riders reinsured under this Agreement, the benefit amount payable by the Reinsurer will be calculated by multiplying the total accelerated death benefit rider payout by the ratio of the reinsured Net Amount at Risk, as defined in Exhibit C-1, to the face amount of the Reinsured Policy.
Claims Payment. If HEBP determines that a claim for benefits is a Valid Claim, or if Plan Administrator directs HEBP, in writing, to honor a claim for benefits, HEBP will arrange for the payment of the claim pursuant to the terms of this Agreement and Addendum A: Transfer Payment and Other Financial Responsibilities.
Claims Payment. Not later than 11:00 a.m. New York City time on (a) the fifth Business Day following the earlier of (i) any date on which any claim against the Company for payment being made under a TE Support Instrument and (ii) any date on which any written claim by a Customer is made that the Contractor or the applicable Supported Party has failed to make a payment to a Customer when such payment is due and payable under the terms of the applicable Supported Obligation, in each case, the Contractor will pay the Company the amount claimed (the “Claimed Amount”); provided that if and for so long as, in the case of this clause (ii), (x) the Contractor or applicable Supporting Party is disputing its liability to the claiming Customer under the applicable Supported Obligation and (y) the Contractor is in compliance with its obligations under Article V of this Agreement with respect to such dispute, then until such disputed liability has been determined by a final non-appealable court judgment or arbitral award or pursuant to a written settlement or admission approved by the Company and the Contractor, the Contractor’s obligation to pay the Claimed Amount to the Company under this Section 4.01 shall not be deemed to have occurred and the Unused TE Support Commitment shall be reduced by an amount equal to the Claimed Amount (the period of such suspension, a “Dispute Period”) and (b) the first Business Day following any payment by the Company of a Claimed Amount under any TE Support Instrument, the Contractor will reimburse the Company the amount paid (the “Disbursed Amount”). A credit exposure fee will accrue on any Claimed Amount or Disbursed Amount that is not paid by the time required by the preceding sentence (after giving effect to any Dispute Period) (an “Outstanding Amount” and when the Outstanding Amount (excluding Claimed Amounts during a Dispute Period) shall at any time exceed $1,000,000 in the aggregate, a “Payment Failure Event” shall be deemed to have occurred) at a per annum rate equal to the current interest rate determined at the default rate of the funded term loans under the Credit Agreement, which fee shall accrue daily and be payable in cash upon demand.
Claims Payment. Payor or its designee shall make or arrange for payment of Complete Claims consistent with the terms of the Agreement and applicable state and federal laws and regulations.
Claims Payment. The Reinsurer will be liable to the Company for the benefits reinsured and the reinsurance will not exceed the Company's contractual liability under the terms of its policies. The payment of death claims by the Reinsurer will be in one lump sum regardless of the mode of settlement under the original policy. The Reinsurer's share of interest, which is based on the death proceeds paid by the Company, will be payable in addition to the death claim settlement. The Reinsurer will pay to the Company premiums at the rate applicable to the original policy on any policy approved for a waiver of premium claim, provided always that the waiver of premium benefit applicable to such benefits has been reinsured under this Agreement.
Claims Payment. The Reinsurer will be liable to the Company for its share of the benefits owed under the express contractual terms of the Reinsured Policies and as specified under the terms of this Agreement. The Reinsurer will not participate in any ex gratia payments made by the Company (i.e., payments the Company is not required to make under the Reinsured Policy terms.) The payment of death benefits by the Reinsurer will be in one lump sum regardless of the mode of settlement under the Reinsured Policy. Benefit payments from the Reinsurer will be due within 30 days of the claim satisfying the requirements established under this Agreement. The Reinsurer’s share of any interest payable under the terms of a Reinsured Policy or applicable law which is based on the death benefits paid by the Company, will be payable provided that the Reinsurer will not be liable for interest accruing on or after the date of the Company’s payment of benefits. The Reinsurer’s share will be based upon the same interest rate and days used by the Company to calculate their interest paid. The Reinsurer will make payment to the Company for each such claim. I486326US-14 (02-21-2014) (QT #06655US13)
Claims Payment a. Claims that are subject to payment under this Contract by Contractor from Non-Participating Providers who are enrolled with OHA will be billed to Contractor consistent with the requirements of OAR 410-120-1280, 410-120-1295 and 410-120-1300. Contractor shall pay Non-Participating Providers for Covered Services, consistent with the provisions of ORS 414.743, OAR 410-120-1340 and OAR 410-141-3420.
b. Contractor may require Participating Providers to submit all xxxxxxxx for Members to Contractor within four months of the date of service, except under the following circumstances:
(1) Billing is delayed due to eligibility issues;
(2) Pregnancy of the Member;
(3) Medicare is the primary payer;
(4) Cases involving third party resources;
(5) Covered Services provided by Non-Participating Providers that are enrolled with OHA; or
(6) Other circumstances in which there are reasonable grounds for delay (which does not include a Subcontractor’s failure to verify Member eligibility).
c. Contractor shall have written procedures for processing Claims submitted for payment from any source. The procedures shall specify time frames for and include:
(1) Date stamping Claims when received;
(2) Determining within a specific number of days from receipt whether a Claim is valid or non-valid;
(3) The specific number of days allowed for follow up of pended Claims to obtain additional information;
(4) The specific number of days following receipt of additional information that a determination must be made;
(5) Sending notice of the decision with Appeal rights to the Member when the determination is made to deny the Claim;
(6) Making Appeal rights available upon request to a Member’s authorized Representative who may be either a Participating Provider or a Non-participating Provider when the determination is made to deny a Claim for payment; and
(7) The date of payment, which is the date of the check or date of other form of payment.
d. Contractor shall pay or deny at least 90% of Valid Claims within 45 days of receipt and at least 99% of Valid Claims within 60 days of receipt. Contractors shall make an initial determination on 99% of all Claims submitted within 60 days of receipt. The date of receipt is the date the
e. Claims that are subject to payment under this Contract by Contractor from Non-Participating Providers who are enrolled with OHA will be billed to Contractor consistent with the requirements of OAR 410-120-1280 and 410-120-1300. If a Provider is not enrolled with OH...
Claims Payment. If Contractor fails to pay or deny ninety-eight per cent (98%) or more of any type of clean claims within the required timeframe, Contractor shall pay liquidated damages in the amount of five thousand, seven hundred dollars ($5,700) for each deficient claims type. For the purposes of this section, there are six claims types: professional paper claims, professional electronic claims, facility paper claims, facility electronic claims, pharmacy paper claims, and pharmacy electronic claims.
Claims Payment. A. The Reinsurer will be liable to the Company for the benefits reinsured and, except as provided in the Retention and Limit Article, the reinsurance provided hereunder will not exceed the Company’s contractual liability under the terms of its Policies less the amount retained. The payment of death claims by the Reinsurer will be in one lump sum regardless of the mode of settlement under the Policy. Such a lump sum will be the Reinsurer’s share of the face amount of the Policy. The Reinsurer’s share of interest, which is based on the death proceeds paid by the Company, will be payable in addition to the death claim settlement. Such interest is not considered a claim expense.
B. For claims on Accelerated Benefits riders reinsured under this Contract, the benefit amount payable by the Reinsurer will be calculated by multiplying the total accelerated death benefit rider payout by the ratio of the reinsured amount to the face amount. The Company’s retention and the amount of the reinsurance shall be reduced proportionately as a result of an Accelerated Benefit claims payment.
C. Should any claim be settled on a reduced compromise basis, or should a contested claim be settled for a reduced sum, the Company and the Reinsurer will participate in such reductions in proportion to their respective liabilities under the Policy or Policies reinsured.
D. The Reinsurer may pay its share of the death benefit if it does not deem it advisable to contest the claim.
Claims Payment. Consistent with C.4.6(2)of its proposal, the Contractor shall develop and implement a system for processing and paying covered health claims on behalf of the high risk pool program.
1. This system shall encompass claims receipt through final payment, or denial, through a fully automated claim adjudication system that is consistent with industry standards for comparable commercial health insurance carriers or health plan administrators, such that claims are adjudicated in a timely and accurate manner, and all necessary functions are performed to assure timely and accurate claims adjudication, and timely and accurate claims payment. Claims handling and claims payment processes and policies in all respects shall comply with State and federal law. The system shall have at a minimum the following capabilities:
a) automated eligibility verification that coverage has not terminated on the date of loss;
b) benefit plan information stored on the system;
c) automatic calculation of deductibles, co-insurance, co-pays, out-of-pocket limits, and lifetime maximum accumulations;
d) individual claim history stored on the system and automatically updated;
e) ability to distinguish claims by diagnosis code;
f) automated calculation of cost containment provisions;
g) identification and collection of claim overpayments;
h) procedures for review of “medically necessary” determinations;
i) automated production of an Explanation of Benefits; and
j) automated tracking of individual deductible limits, annual individual out of pocket limits, and any other internal limits such as limits on days, sessions, visits, etc., consistent with industry standards.
2. xx percent (xx%) of all eligible claims, which contain all information necessary for an accurate adjudication (“Clean Claims”),, shall be paid within 30 calendar days of receipt.
3. xx percent (xx%) of individual Clean Claim payments for a month shall be accurate.
4. During or after the claim adjudication process, if a claim overpayment occurs or is discovered by the Contractor, the Federal government or its designee, a provider, the participant or any other party, the Contractor will make all reasonable efforts to recover the overpayment on behalf of the high risk pool program.
5. The Contractor shall also be responsible for making available information relating to the proper manner of submitting a claim for benefits to the high risk pool program and distributing forms upon which claim submissions shall be made, or making provis...
