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 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. 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. NETWORK PROVIDERS
17 a. CONTRACTOR shall maintain a rules-based and date-sensitive claims system to meet 18 the needs of all standard Medi-Cal beneficiary claims.
19 b. CONTRACTOR shall establish a claims adjudication process which will accept either 20 paper or electronic claims including, but not limited to, verification that if the Beneficiary has a Share of 21 Cost that that the Share of Cost has been met.
22 c. CONTRACTOR shall maintain timelines in the claims process as follows:
23 1) Claims for services shall be requested to be submitted to CONTRACTOR by the 24 Network Providers within thirty (30) days of the date of services but in no case shall CONTRACTOR 25 process any claim that is initially submitted more than ninety (90) days from the date of service.
26 2) CONTRACTOR shall maintain a thirty (30) calendar day or less turnaround on 27 clean claims. Clean claims shall be those that require no additional information (such as provider 28 identification, diagnosis and/or CPT codes) and which can be processed completely upon initial entry.
29 3) When pending a claim for missing data, the Network Provider shall receive 30 notification from CONTRACTOR within fourteen (14) calendar days from the date of receipt. This 31 notification shall include what is needed to continue processing the claim.
32 4) CONTRACTOR shall request that the information be returned within fourteen (14) 33 calendar days.
34 d. CONTRACTOR shall:
35 1) Provide adequately trained claims processing and clerical staff, and suitable 36 equipment. 37 //
1 2) Review each completed claim to determine that the services rendered are within the 2 Medi-Cal scope of service, and that applicable prior approvals have been obtained.
3 e. Share of Cost – CONTRACTOR shall require that all Network Providers attempt to 4 collect the Share of Cost from beneficiaries and that reimbursement of claims shall be reduced by the 5 beneficiaries’ Share of Cost.
6 1) CONTRACTOR shall have access to the Medi-Cal Eligibility Website to determine 7 client eligibility and any Share of Cost remaining for the date of service.
8 2) CONTRACTOR shall ensure that the Network Providers notify the Beneficiary of 9 his/her Share of Cost obligation. The Beneficiary shall be made to understand that when the Share of 10 Cost obligation is met, Medi-Cal will cover the remainder of the unit cost.
11 3) For Beneficiaries with a Share of Cost who have the ability to meet their Share of 12 Cost obligation, CONTRACTOR shall maint...
Claims Processing and Adjudication. NETWORK PROVIDERS
1. CONTRACTOR shall maintain a rules-based and date-sensitive claims system to meet the needs of all standard Medi-Cal beneficiary claims.
2. CONTRACTOR shall establish a claims adjudication process which shall accept either paper or electronic claims including, but not limited to, verification that if the Beneficiary has a Share of Cost that the Share of Cost has been met.
3. CONTRACTOR shall maintain timelines in the claims process as follows:
a. Clean claims for services shall be requested to be submitted to CONTRACTOR by the Network Providers within thirty (30) calendar days of the date of services but in no case shall CONTRACTOR process any claim that is initially submitted more than ninety (90) calendar days from the date of service, except as required otherwise by law, rules, or regulation as described in the Licenses and Laws Paragraph of this Contract.
b. CONTRACTOR shall maintain a thirty (30) calendar day or less turnaround on clean claims. Clean claims shall be those that require no additional information (such as provider identification, diagnosis and/or CPT codes) and which can be processed completely upon initial entry.
c. When pending a claim for missing data, the Network Provider shall receive notification from CONTRACTOR within fourteen (14) calendar days from the date of receipt. This notification shall include what is needed to continue processing the claim.
d. CONTRACTOR shall request that the information be returned within fourteen
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. NETWORK PROVIDERS
1. CONTRACTOR shall maintain a rules-based and date-sensitive claims system to meet the needs of all standard Medi-Cal beneficiary claims.
2. CONTRACTOR shall establish a claims adjudication process which shall accept either paper or electronic claims including, but not limited to, verification that if the Client has a Share of Cost that the Share of Cost has been met.
3. CONTRACTOR shall maintain timelines in the claims process as follows:
a. Clean claims for services shall be requested to be submitted to CONTRACTOR by the Network Providers within thirty (30) calendar days of the date of services. CONTRACTOR shall follow all laws, rules, or regulations as described in the Licenses and Laws Paragraph of this Contract.
b. CONTRACTOR shall do its best to receive and process all Network Provider claims to avoid exceeding 365 days billing limit and avoiding Medi-Cal stale dated claims and reduced revenue receipts from the State.
c. CONTRACTOR should refer to and follow Services Paragraph of this Exhibit A.
Claims Processing and Adjudication. NETWORK PROVIDERS
23 1. CONTRACTOR shall maintain a rules-based and date-sensitive claims system to meet the needs of all standard Medi-Cal beneficiary claims.
24 2. CONTRACTOR shall establish a claims adjudication process which shall accept either paper 25 or electronic claims including, but not limited to, verification that if the Beneficiary has a Share of Cost 26 that the Share of Cost has been met.
