Common use of Claims Payment Clause in Contracts

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 provision for the acceptance and processing of electronically-filed claims. 6. Contractor shall provide pharmacy benefit management services for the high risk pool program, including: a) Administration of a benefit structure consistent with C.4.8 of its proposal. b) Perform pharmacy claim processing and payment functions on behalf of the high risk pool program from receipt of both paper and electronic claims, through final payment or denial on a fully automated claim adjudication system in a timely and accurate manner and all other necessary functions to assure timely adjudication of claims and payment of benefits to eligible persons under the high risk pool program; c) A formulary that promotes therapeutic and economic value for enrollees and the high risk pool program and covers all therapeutic diagnostic categories; d) Drug utilization review designed to effectively and efficiently identify and address instances of potential fraud and abuse, as well as key prescribing and utilization patterns; e) Administration of pharmacy benefits shall at all times comply with all standards required under state and federal laws and regulations, in a manner consistent with industry standards for comparable commercial health insurance carriers, or health plan administrators; and f) Procedures to ensure that manufacturer rebates earned from prescriptions covered by the federal high risk pool shall accrue to the benefit of the federal program, and shall be separately tracked and credited.

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 Ninety-five percent (xx%95%) 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 Ninety-five percent (xx%95%) 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 provision for the acceptance and processing of electronically-filed claims. 6. Contractor shall provide pharmacy benefit management services for the high risk pool program, including: a) Administration of a benefit structure consistent with C.4.8 of its proposal. b) Perform pharmacy claim processing and payment functions on behalf of the high risk pool program from receipt of both paper and electronic claims, through final payment or denial on a fully automated claim adjudication system in a timely and accurate manner and all other necessary functions to assure timely adjudication of claims and payment of benefits to eligible persons under the high risk pool program; c) A formulary that promotes therapeutic and economic value for enrollees and the high risk pool program and covers all therapeutic diagnostic categories; d) Drug utilization review designed to effectively and efficiently identify and address instances of potential fraud and abuse, as well as key prescribing and utilization patterns; e) Administration of pharmacy benefits shall at all times comply with all standards required under state and federal laws and regulations, in a manner consistent with industry standards for comparable commercial health insurance carriers, or health plan administrators; and f) Procedures to ensure that manufacturer rebates earned from prescriptions covered by the federal high risk pool shall accrue to the benefit of the federal program, and shall be separately tracked and credited. 7. Claims Database--Contractor will use best efforts to ensure that adequate information is captured during the claim payment process to allow HHS to evaluate individual and overall high risk pool program health care utilization. Contractor shall provide HHS reports upon request concerning utilization that are in a mutually agreeable electronic format, to include the ability to routinely update claims files as necessary, report individual claims histories as well as claims experience by category of condition or treatment, and fully document the claims adjudication process. The Claims database shall contain for each claimant an identification number, claim number, date(s) of service, treatment by descriptor and treatment code, provider name and provider number, date and type of service, amount billed, amount allowed, and amount paid, enrollee responsibility. In all respects, claims and utilization data shall be maintained, and available for reporting to and analysis by HHS or any designee, in a manner consistent with industry standards for comparable commercial health insurance carriers, or health plan administrators.

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, a subcontractor, 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 provision for the acceptance and processing of electronically-filed claims. 6. Contractor shall provide pharmacy benefit management services for the high risk pool program, including: a) Administration of a benefit structure consistent with C.4.8 of its proposal. b) Perform pharmacy claim processing and payment functions on behalf of the high risk pool program from receipt of both paper and electronic claims, through final payment or denial on a fully automated claim adjudication system in a timely and accurate manner and all other necessary functions to assure timely adjudication of claims and payment of benefits to eligible persons under the high risk pool program; c) A formulary that promotes therapeutic and economic value for enrollees and the high risk pool program and covers all therapeutic diagnostic categories; d) Drug utilization review designed to effectively and efficiently identify and address instances of potential fraud and abuse, as well as key prescribing and utilization patterns; e) Administration of pharmacy benefits shall at all times comply with all standards required under state and federal laws and regulations, in a manner consistent with industry standards for comparable commercial health insurance carriers, or health plan administrators; and f) Procedures to ensure that manufacturer rebates earned from prescriptions covered by the federal high risk pool shall accrue to the benefit of the federal program, and shall be separately tracked and credited.