Claims Processing and Adjudication. NETWORK PROVIDERS
Claims Processing and Adjudication. AR-35 The Contractor shall establish and perform all aspects of claims processing, claims reimbursement, adjudication, and claims payment in accordance with the Plan Design. AR-36 Pursuant to paragraph 110.123(5)(g), F.S., and PG-16 the Contractor shall provide written notice to Participants if any payment to any provider remains unpaid thirty- five (35) Calendar Days after receipt of the claim. Contractor shall provide the Department with a monthly report listing those Participants having Claims not finalized within the thirty-five (35) day timeframe and the status of any such Claims.
Claims Processing and Adjudication. The Vendor shall establish and perform all aspects of claims processing, claims reimbursement, point-of-sale transactions, adjudication, and payment in accordance with the Plan Design in Exhibit C. 33 Pursuant to paragraph 110.123(5)(g), Florida Statutes, the Vendor shall provide written notice to Participants if any payment to any provider remains unpaid thirty-five (35) calendar days after receipt of the Claim. Vendor shall provide the Department with a monthly report listing those Participants having Claims not finalized within the thirty-five (35) day timeframe and the status of any such Claims.
Claims Processing and Adjudication. The Company will exercise the discretionary fiduciary authority to process and adjudicate claims under the plan(s). This authority encompasses all determinations and findings necessary to process and adjudicate claims, such as the discretionary authority to construe and apply the plan(s), make findings of fact, and determine whether services or supplies are medically necessary (within the meaning of the plan(s)) or otherwise satisfy the medical standards or guidelines required for payment of benefits under the plan(s) (such as, for example, the requirement that medical services or supplies not be experimental or investigational). The Company will include within the benefit booklet a description of its claims procedures.
Claims Processing and Adjudication. The Awarded Respondent shall establish and perform all aspects of claims processing, coordination of benefits, claims reimbursement, point-of-sale transactions, claim adjudication and payment in accordance with the Benefits Document. The Awarded Respondent shall verify benefits and eligibility before authorizing services.
Claims Processing and Adjudication a. Contractor shall establish and perform all aspects of Claims processing, coordination of benefits, adjudication, and payment in accordance with the Summary Plan Description. Contractor shall verify benefits and eligibility before authorizing services.
Claims Processing and Adjudication. The Contractor shall establish and perform all aspects of claims processing, claims reimbursement, point-of-sale transactions, adjudication, and claims payment in accordance with the Plan Design in Attachment 4: Plan Benefits Schedule and in accordance with PG-16. Pursuant to paragraph 110.123(5)(g), F.S., the Contractor shall provide written notice to Participants if any payment to any provider remains unpaid thirty-five (35) Calendar Days after receipt of the claim. Contractor shall provide the Department with a monthly report listing those Participants having Claims not finalized within the thirty-five (35) day timeframe and the status of any such Claims.
Claims Processing and Adjudication. 16 Claims Timeliness AR-33 Measured from the date the claim is received in the office (day 1) to the date the processed claim reaches final action determination (includes weekends and holidays). Average turn- around time for claims processing will not exceed twenty (20) days for ninety-seven percent (97%) of all claims submitted by Participants. Quarterly $2,000 per percentage point, or fraction thereof, below ninety-seven percent (97%). (Total number of original claims processed within twenty (20) days / total number of original claims processed during the quarter) For electronically submitted claims, Day 1 is the date the claim was received, irrespective of the time of day and including weekends and holidays. For paper claims, Day 1 is the date that the claim was stamped upon receipt. Pended claims will be measured as the total amount of time prior to being pended and the time from removal of pending status to completed processing. Turn- around time for pended claims will be applied to the quarter the claim was either paid or denied.
Claims Processing and Adjudication
