Common use of Claims Payment Clause in Contracts

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 Member 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 30 days of receipt and at least 99% of Valid Claims within 90 days of receipt. Contractors shall make an initial determination on 99% of all Valid Claims submitted within 60 days of receipt. The Date of Receipt of a Claim is the date the Contractor receives the claim, as indicated by its date stamp on the claim. Contractor and its Subcontractors may, by mutual agreement, establish an alternative payment schedule not to exceed the minimum requirements. 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 OHA on the Date of Service, but the Provider becomes enrolled pursuant to OAR 410-120-1260(6) “Provider Enrollment”, the claim shall be processed by Contractor as a claim from a Non- Participating Provider. Payment to Non-Participating Providers shall be consistent with the provisions of OAR 410-120-1340. f. Contractor shall pay Indian Health Care Providers for Covered Services provided to those AI/AN enrolled with the Contractor who are eligible to receive services from such Providers, as follows: (1) Participating Indian Health Care Providers are paid at a rate equal to the rate negotiated between the Contractor and the Participating Provider involved, which for a FQHC may not be less than the level and amount of payment which the Contractor would make for the services if the services were furnished by a Participating Provider which is not a FQHC. (2) Non-Participating Indian Health Care Providers that are not a FQHC must be paid at a rate that is not less than the level and amount of payment which the Contractor would make for the services if the services were furnished by a Participating Provider which is not an Indian Health Care Provider. (3) Non-Participating Indian Health Care Providers that are a FQHC must be paid at a rate equal to the amount of payment that the Contractor would pay a FQHC that is a Participating Provider with respect to the Contractor but is not an Indian Health Care Provider for such services. g. Contractor shall make prompt payment to Indian Health Care Providers including Indian Tribe, Tribal Organization or Urban Indian Organization, in accordance with FFS timely payment, including paying of 90% of all Valid Claims from providers, within 30 days of the date of h. In accordance with Section 5006 of the American Reinvestment and Recovery Act of 2009 (ARRA), Contractor shall not impose fees, premiums or similar charges on Indians served by an Indian health care provider, Indian Health Services (HIS); an Indian Tribe, Tribal Organization, or Urban Indian Organization (I/T/U) or through referral under contract health services (CHS). i. Contractor shall pay for Emergency Services that are received from Non-Participating Providers as specified in OAR 410-141-3140. (1) Require all Providers to comply with the reporting requirements as a condition of payment from Contractor; (2) Require all Providers to identify Provider-Preventable Conditions that are associated with claims for CCO Payment or with courses of treatment furnished to Members for which CCO Payment would otherwise be available; and (3) Report all identified Provider-Preventable Conditions in a form or frequency as may be specified by OHA; and (4) Not make payment to Providers for Provider-Preventable Conditions that are Health Care-Acquired Conditions or that meet the following criteria as specified in 42 CFR (i) Is identified in the State plan. (ii) Has been found by the State, based upon a review of medical literature by qualified professionals, to be reasonably preventable through the application of procedures supported by evidence-based guidelines. (iii) Has a negative consequence for the Member. (iv) Is auditable. (v) Includes, at a minimum, wrong surgical or other invasive procedure performed on a Member; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong Member.

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 date of Serviceservice, 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 Claims submitted for payment from any source. The procedures shall specify time frames for and include: (1) Date stamping claims Claims when received; (2) Determining within a specific number of days from receipt whether a claim Claim is valid or non-valid; (3) The specific number of days allowed for follow up of pended claims 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 claimClaim; (6) Making Appeal rights available upon request to a Member’s authorized Member Representative who may be either a Participating Provider or a Non-participating Provider when the determination is made to deny a claim 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 30 45 days of receipt and at least 99% of Valid Claims within 90 60 days of receipt. Contractors shall make an initial determination on 99% of all Valid Claims submitted within 60 days of receipt. The Date date of Receipt of a Claim receipt is the date the Contractor receives the claim, as indicated by its date stamp on the claim. Contractor and its Subcontractors may, by mutual agreement, establish an alternative payment schedule not to exceed the minimum requirements.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 OHA on the Date date of Serviceservice, but the Provider becomes enrolled pursuant to OAR 410-120-1260(6) “Provider Enrollment”, the claim Claim shall be processed by Contractor as a claim Claim from a Non- Participating Provider. Payment to of Non-Participating Providers shall be consistent with the provisions of OAR 410-120-1340. f. Contractor shall pay Indian Health Care Providers for Covered Services provided to those AI/AN enrolled with the Contractor who are eligible to receive services from such Providersproviders, as follows: (1) Participating Indian Health Care Providers are paid at a rate equal to the rate negotiated between the Contractor and the Participating Provider involved, which for a FQHC Federally Qualified Health Center (FQHC) may not be less than the level and amount of payment which the Contractor would make for the services if the services were furnished by a Participating Provider which is not a FQHC. (2) Non-Participating Indian Health Care Providers that are not a FQHC must be paid at a rate that is not less than the level and amount of payment which the Contractor would make for the services if the services were furnished by a Participating Provider which is not an Indian Health Care Provider. (3) Non-Participating Indian Health Care Providers that are a FQHC must be paid at a rate equal to the amount of payment that the Contractor would pay a FQHC that is a Participating Provider with respect to the Contractor but is not an Indian Health Care Provider for such services. g. Contractor shall make prompt payment to Indian Health Care Providers including Indian Tribe, Tribal Organization or Urban Indian Organization, in accordance with FFS timely payment, including paying of 90% of all Valid Claims from providers, within 30 days of the date ofthat are Participating Providers. h. In accordance with Section 5006 of the American Reinvestment and Recovery Act of 2009 (ARRA), Contractor shall not impose fees, premiums or similar charges on Indians served by an Indian health care provider, Indian Health Services (HIS); an Indian Tribe, Tribal Organization, or Urban Indian Organization (I/T/U) or through referral under contract health services (CHS). i. Contractor shall pay for Emergency Services that are received from Non-Participating Providers as specified in OAR 410-141-3140. (1) Require all Providers to comply with the reporting requirements as a condition of payment from Contractor; (2) Require all Providers to identify Provider-Preventable Conditions that are associated with claims for CCO Payment or with courses of treatment furnished to Members for which CCO Payment would otherwise be available; and (3) Report all identified Provider-Preventable Conditions in a form or frequency as may be specified by OHA; and (4) Not make payment to Providers for Provider-Preventable Conditions that are Health Care-Acquired Conditions or that meet the following criteria as specified in 42 CFR (i) Is identified in the State plan. (ii) Has been found by the State, based upon a review of medical literature by qualified professionals, to be reasonably preventable through the application of procedures supported by evidence-based guidelines. (iii) Has a negative consequence for the Member. (iv) Is auditable. (v) Includes, at a minimum, wrong surgical or other invasive procedure performed on a Member; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong Member.

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 information on the member’s Appeal rights to the Member when the determination is made to deny the claim; (6) Making information on Appeal rights available upon request to a Member’s authorized Member Representative who may be either a Participating Provider or a Non-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 30 days of receipt and at least 99% of Valid Claims within 90 days of receipt. Contractors shall make an initial determination on 99% of all Valid Claims submitted within 60 days of receipt. The Date of Receipt of a Claim is the date the Contractor receives the claim, as indicated by its date stamp on the claim. Contractor and its Subcontractors may, by mutual agreement, establish an alternative payment schedule not to exceed the minimum requirements. 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 OHA on the Date of Service, but the Provider becomes enrolled pursuant to OAR 410-120-1260(6) “Provider Enrollment”, the claim shall be processed by Contractor as a claim from a Non- Participating Provider. Payment to Non-Participating Providers shall be consistent with the provisions of OAR 410-120-1340.) f. Contractor shall pay Indian Health Care Providers for Covered Services provided to those AI/AN enrolled with the Contractor who are eligible to receive services from such Providers, as follows: (1) Participating Indian Health Care Providers are paid at a rate equal to the rate negotiated between the Contractor and the Participating Provider involved, which for a FQHC may not be less than the level and amount of payment which the Contractor would make for the services if the services were furnished by a Participating Provider which is not a FQHC. (2) Non-Participating Indian Health Care Providers that are not a FQHC must be paid at a rate that is not less than the level and amount of payment which the Contractor would make for the services if the services were furnished by a Participating Provider which is not an Indian Health Care Provider. (3) Non-Participating Indian Health Care Providers that are a FQHC must be paid at a rate equal to the amount of payment that the Contractor would pay a FQHC that is a Participating Provider with respect to the Contractor but is not an Indian Health Care Provider for such services. g. Contractor shall make prompt payment to Indian Health Care Providers including Indian Tribe, Tribal Organization or Urban Indian Organization, in accordance with FFS timely payment, including paying of 90% of all Valid Claims from providers, within 30 days of the date ofof receipt; and paying 99 percent of all valid claims from providers within 90 days of the date of receipt per 42 §CFR 447.45 and 42 CFR §447.46. h. In accordance with Section 5006 of the American Reinvestment and Recovery Act of 2009 (ARRA), Contractor shall not impose fees, premiums or similar charges on Indians served by an Indian health care provider, Indian Health Services (HIS); an Indian Tribe, Tribal Organization, or Urban Indian Organization (I/T/U) or through referral under contract health services (CHS). i. Contractor shall pay for Emergency Services that are received from Non-Participating Providers as specified in OAR 410-141-3140. (1) Require all Providers to comply with the reporting requirements as a condition of payment from Contractor; (2) Require all Providers to identify Provider-Preventable Conditions that are associated with claims for CCO Payment or with courses of treatment furnished to Members for which CCO Payment would otherwise be available; and (3) Report all identified Provider-Preventable Conditions in a form or frequency as may be specified by OHA; and (4) Not make payment to Providers for Provider-Preventable Conditions that are Health Care-Acquired Conditions or that meet the following criteria as specified in 42 CFR (ia) Is identified in the State plan. (iib) Has been found by the State, based upon a review of medical literature by qualified professionals, to be reasonably preventable through the application of procedures supported by evidence-based guidelines. (iiic) Has a negative consequence for the Member. (ivd) Is auditable. (ve) Includes, at a minimum, wrong surgical or other invasive procedure performed on a Member; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong Member.

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 Member 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 30 days of receipt and at least 99% of Valid Claims within 90 days of receipt. Contractors shall make an initial determination on 99% of all Valid Claims claims submitted within 60 days of receipt. The Date of Receipt of a Claim is the date the Contractor receives the claim, as indicated by its date stamp on the claim. Contractor and its Subcontractors may, by mutual agreement, establish an alternative payment schedule not to exceed the minimum requirements. 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 OHA on the Date of Service, but the Provider becomes enrolled pursuant to OAR 410-120-1260(6) “Provider Enrollment”, the claim shall be processed by Contractor as a claim from a Non- Participating Provider. Payment to Non-Participating Providers shall be consistent with the provisions of OAR 410-120-1340. f. Contractor shall pay Indian Health Care Providers for Covered Services provided to those AI/AN enrolled with the Contractor who are eligible to receive services from such Providers, as follows: (1) Participating Indian Health Care Providers are paid at a rate equal to the rate negotiated between the Contractor and the Participating Provider involved, which for a FQHC may not be less than the level and amount of payment which the Contractor would make for the services if the services were furnished by a Participating Provider which is not a FQHC. (2) Non-Participating Indian Health Care Providers that are not a FQHC must be paid at a rate that is not less than the level and amount of payment which the Contractor would make for the services if the services were furnished by a Participating Provider which is not an Indian Health Care Provider. (3) Non-Participating Indian Health Care Providers that are a FQHC must be paid at a rate equal to the amount of payment that the Contractor would pay a FQHC that is a Participating Provider with respect to the Contractor but is not an Indian Health Care Provider for such services. g. Contractor shall make prompt payment to Indian Health Care Providers including Indian Tribe, Tribal Organization or Urban Indian Organization, in accordance with FFS timely payment, including paying of 90% of all Valid Claims valid claims from providers, within 30 days of the date ofof receipt; and paying 99 percent of all clean claims from providers within 90 days of the date of receipt per 42 CFR 447.45 and 42 CFR 447.46. h. In accordance with Section 5006 of the American Reinvestment and Recovery Act of 2009 (ARRA), Contractor shall not impose fees, premiums or similar charges on Indians served by an Indian health care provider, Indian Health Services (HIS); an Indian Tribe, Tribal Organization, or Urban Indian Organization (I/T/U) or through referral under contract health services (CHS). i. Contractor shall pay for Emergency Services that are received from Non-Participating Providers as specified in OAR 410-141-3140. (1) Require all Providers to comply with the reporting requirements as a condition of payment from Contractor; (2) Require all Providers to identify Provider-Preventable Conditions that are associated with claims for CCO Payment or with courses of treatment furnished to Members for which CCO Payment would otherwise be available; and (3) Report all identified Provider-Preventable Conditions in a form or frequency as may be specified by OHA; and (4) Not make payment to Providers for Provider-Preventable Conditions that are Health Care-Acquired Conditions or that meet the following criteria as specified in 42 CFR (i) Is identified in the State plan. (ii) Has been found by the State, based upon a review of medical literature by qualified professionals, to be reasonably preventable through the application of procedures supported by evidence-based guidelines. (iii) Has a negative consequence for the Member. (iv) Is auditable. (v) Includes, at a minimum, wrong surgical or other invasive procedure performed on a Member; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong Member.

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 resourcesThird 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 information on the Member’s Appeal rights to the Member when the determination is made to deny the claim; (6) Making information on Appeal rights available upon request to a Member’s authorized Member Representative who may be either a Participating Provider or a Non-participating Provider when the determination is made to deny a claim for payment; andNon- (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 30 days of receipt and at least 99% of Valid Claims within 90 days of receipt. Contractors shall make an initial determination on 99% of all Valid Claims submitted within 60 days of receipt. The Date of Receipt of a Claim is the date the Contractor receives the claim, as indicated by its date stamp on the claim. Contractor and its Subcontractors may, by mutual agreement, establish an alternative payment schedule not to exceed the minimum requirements. 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 OHA on the Date of Service, but the Provider becomes enrolled pursuant to OAR 410-120-1260(6) “Provider Enrollment”, the claim shall be processed by Contractor as a claim from a Non- Participating Provider. Payment to Non-Participating Providers shall be consistent with the provisions of OAR 410-120-1340.OHA f. Contractor shall pay Indian Health Care Providers for Covered Services provided to those AI/AN enrolled with the Contractor who are eligible to receive services from such Providers, as follows: (1) Participating Indian Health Care Providers are paid at a rate equal to the rate negotiated between the Contractor and the Participating Provider involved, which for a FQHC may not be less than the level and amount of payment which the Contractor would make for the services if the services were furnished by a Participating Provider which is not a FQHC. (2) Non-Participating Indian Health Care Providers that are not a FQHC must be paid at a rate that is not less than the level and amount of payment which the Contractor would make for the services if the services were furnished by a Participating Provider which is not an Indian Health Care Provider. (3) Non-Participating Indian Health Care Providers that are a FQHC must be paid at a rate equal to the amount of payment that the Contractor would pay a FQHC that is a Participating Provider with respect to the Contractor but is not an Indian Health Care Provider for such services. g. Contractor shall make prompt payment to Indian Health Care Providers including Indian Tribe, Tribal Organization or Urban Indian Organization, in accordance with FFS timely payment, including paying of 90% of all Valid Claims from providersProviders, within 30 days of the date ofof receipt; and paying 99 percent of all Valid Claims from Providers within 90 days of the date of receipt per 42 §CFR 447.45 and 42 CFR §447.46. h. In accordance with Section 5006 of the American Reinvestment and Recovery Act of 2009 (“ARRA”), Contractor shall not impose fees, premiums or similar charges on Indians served by an Indian health care providerHealth Care Provider, Indian Health Services (HIS); an Indian Tribe, Tribal Organization, or Urban Indian Organization (I/T/U) or through referral Referral under contract health services Contract Health Services (“CHS”). i. Contractor shall pay for Emergency Services that are received from Non-Participating Providers as specified in OAR 410-141-3140. (1) Require all Providers to comply with the reporting requirements as a condition of payment from Contractor; (2) Require all Providers to identify Provider-Preventable Conditions that are associated with claims for CCO Payment or with courses of treatment furnished to Members for which CCO Payment would otherwise be available; and (3) Report all identified Provider-Preventable Conditions in a form or frequency form, frequency, and provided to OHA as may be specified by OHAOHA from time to time; and (4) Not make payment to Providers for Provider-Preventable Conditions that are Health Care-Acquired Conditions or that meet the following criteria as specified in 42 CFR (ia) Is identified in the State plan. (iib) Has been found by the State, based upon a review of medical literature by qualified professionals, to be reasonably preventable through the application of procedures supported by evidenceEvidence-based Based guidelines. (iiic) Has a negative consequence for the Member. (ivd) Is auditable. (ve) Includes, at a minimum, wrong surgical or other invasive procedure performed on a Member; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong Member.

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 Member 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 30 days of receipt and at least 99% of Valid Claims within 90 days of receipt. Contractors shall make an initial determination on 99% of all Valid Claims submitted within 60 days of receipt. The Date of Receipt of a Claim is the date the Contractor receives the claim, as indicated by its date stamp on the claim. Contractor and its Subcontractors may, by mutual agreement, establish an alternative payment schedule not to exceed the minimum requirements. 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 OHA on the Date of Service, but the Provider becomes enrolled pursuant to OAR 410-120-1260(6) “Provider Enrollment”, the claim shall be processed by Contractor as a claim from a Non- Participating Provider. Payment to Non-Participating Providers shall be consistent with the provisions of OAR 410-120-1340. f. Contractor shall pay Indian Health Care Providers for Covered Services provided to those AI/AN enrolled with the Contractor who are eligible to receive services from such Providers, as follows: (1) Participating Indian Health Care Providers are paid at a rate equal to the rate negotiated between the Contractor and the Participating Provider involved, which for a FQHC may not be less than the level and amount of payment which the Contractor would make for the services if the services were furnished by a Participating Provider which is not a FQHC. (2) Non-Participating Indian Health Care Providers that are not a FQHC must be paid at a rate that is not less than the level and amount of payment which the Contractor would make for the services if the services were furnished by a Participating Provider which is not an Indian Health Care Provider. (3) Non-Participating Indian Health Care Providers that are a FQHC must be paid at a rate equal to the amount of payment that the Contractor would pay a FQHC that is a Participating Provider with respect to the Contractor but is not an Indian Health Care Provider for such services. g. Contractor shall make prompt payment to Indian Health Care Providers including Indian Tribe, Tribal Organization or Urban Indian Organization, in accordance with FFS timely payment, including paying of 90% of all Valid Claims from providers, within 30 days of the date ofof receipt; and paying 99 percent of all valid claims from providers within 90 days of the date of receipt per 42 CFR 447.45 and 42 CFR 447.46. h. In accordance with Section 5006 of the American Reinvestment and Recovery Act of 2009 (ARRA), Contractor shall not impose fees, premiums or similar charges on Indians served by an Indian health care provider, Indian Health Services (HIS); an Indian Tribe, Tribal Organization, or Urban Indian Organization (I/T/U) or through referral under contract health services (CHS). i. Contractor shall pay for Emergency Services that are received from Non-Participating Providers as specified in OAR 410-141-3140. (1) Require all Providers to comply with the reporting requirements as a condition of payment from Contractor; (2) Require all Providers to identify Provider-Preventable Conditions that are associated with claims for CCO Payment or with courses of treatment furnished to Members for which CCO Payment would otherwise be available; and (3) Report all identified Provider-Preventable Conditions in a form or frequency as may be specified by OHA; and (4) Not make payment to Providers for Provider-Preventable Conditions that are Health Care-Acquired Conditions or that meet the following criteria as specified in 42 CFR (i) Is identified in the State plan. (ii) Has been found by the State, based upon a review of medical literature by qualified professionals, to be reasonably preventable through the application of procedures supported by evidence-based guidelines. (iii) Has a negative consequence for the Member. (iv) Is auditable. (v) Includes, at a minimum, wrong surgical or other invasive procedure performed on a Member; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong Member.