CLAIMS PROCESSING AND ADJUDICATION – NETWORK PROVIDERS Sample Clauses

CLAIMS PROCESSING AND ADJUDICATION – NETWORK PROVIDERS. 10 1. CONTRACTOR shall maintain a rules-based and date-sensitive claims system to meet the 11 needs of all standard Medi-Cal beneficiary claims. 12 2. CONTRACTOR shall establish a claims adjudication process which will accept either 13 paper or electronic claims including, but not limited to, verification that if the Beneficiary has a Share of 14 Cost that the Share of Cost has been met. 15 3. CONTRACTOR shall maintain timelines in the claims process as follows: 16 a. Claims for services shall be requested to be submitted to CONTRACTOR by the 17 Network Providers within thirty (30) days of the date of services but in no case shall CONTRACTOR 18 process any claim that is initially submitted more than ninety (90) days from the date of service, except 19 as required otherwise by law, rules, or regulation as described in the Licenses and Laws Paragraph of 20 this Agreement. 21 b. CONTRACTOR shall maintain a thirty (30) calendar day or less turnaround on clean 22 claims. Clean claims shall be those that require no additional information (such as provider 23 identification, diagnosis and/or CPT codes) and which can be processed completely upon initial entry. 24 c. When pending a claim for missing data, the Network Provider shall receive notification 25 from CONTRACTOR within fourteen (14) calendar days from the date of receipt. This notification 26 shall include what is needed to continue processing the claim. 27 d. CONTRACTOR shall request that the information be returned within fourteen (14) 28 calendar days. 29 4. CONTRACTOR shall: 30 a. Provide adequately trained claims processing and clerical staff, and suitable equipment. 31 b. Review each completed claim to determine that the services rendered are within the 32 Medi-Cal scope of service, and that applicable prior approvals have been obtained. 33 c. Share of Cost – CONTRACTOR shall require that all Network Providers attempt to 34 collect the Share of Cost from beneficiaries and that reimbursement of claims shall be reduced by the 35 beneficiaries’ Share of Cost. 36 d. CONTRACTOR shall have access to the Medi-Cal Eligibility Website and MEDS to 37 determine client eligibility and any Share of Cost remaining for the date of service. 1 e. CONTRACTOR shall have access to the weekly inpatient and monthly IMD list as 2 they relate to paying inpatient and IMD claims. These lists will be provided by ADMINISTRATOR. 3 f. CONTRACTOR shall ensure that the Network Providers notify the Beneficiary of 4 his/her Share of ...
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CLAIMS PROCESSING AND ADJUDICATION – NETWORK PROVIDERS. 36 a. CONTRACTOR shall maintain a rules-based and date-sensitive claims system to meet 37 the needs of all standard Medi-Cal beneficiary claims. 1 b. CONTRACTOR shall establish a claims adjudication process which will accept either 2 paper or electronic claims including, but not limited to, verification that if the Beneficiary has a Share of 3 Cost that the Share of Cost has been met. 4 c. CONTRACTOR shall maintain timelines in the claims process as follows: 5 1) Claims for services shall be requested to be submitted to CONTRACTOR by the 6 Network Providers within thirty (30) days of the date of services but in no case shall CONTRACTOR 7 process any claim that is initially submitted more than ninety (90) days from the date of service, except 8 as required otherwise by law, rules, or regulation as described in the Licenses and Laws Paragraph of 9 this Agreement 10 2) CONTRACTOR shall maintain a thirty (30) calendar day or less turnaround on 11 clean claims. Clean claims shall be those that require no additional information (such as provider 12 identification, diagnosis and/or CPT codes) and which can be processed completely upon initial entry. 13 3) When pending a claim for missing data, the Network Provider shall receive 14 notification from CONTRACTOR within fourteen (14) calendar days from the date of receipt. This 15 notification shall include what is needed to continue processing the claim. 16 4) CONTRACTOR shall request that the information be returned within fourteen (14) 17 calendar days. 18 d. CONTRACTOR shall: 19 1) Provide adequately trained claims processing and clerical staff, and suitable 20 equipment. 21 2) Review each completed claim to determine that the services rendered are within the 22 Medi-Cal scope of service, and that applicable prior approvals have been obtained. 23 e. Share of Cost – CONTRACTOR shall require that all Network Providers attempt to 24 collect the Share of Cost from beneficiaries and that reimbursement of claims shall be reduced by the 25 beneficiaries’ Share of Cost. 26 1) CONTRACTOR shall have access to the Medi-Cal Eligibility Website to determine 27 client eligibility and any Share of Cost remaining for the date of service. 28 2) CONTRACTOR shall ensure that the Network Providers notify the Beneficiary of 29 his/her Share of Cost obligation. The Beneficiary shall be made to understand that when the Share of 30 Cost obligation is met, Medi-Cal will cover the remainder of the unit cost. 31 3) For Beneficiaries with a...
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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.
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CLAIMS PROCESSING AND ADJUDICATION – NETWORK PROVIDERS. 27 a1. CONTRACTOR shall maintain a rules-based and date-sensitive claims system to meet 28 the needs of all standard Medi-Cal beneficiary claims.
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