Common use of CLAIMS PROCESSING AND ADJUDICATION – NETWORK PROVIDERS Clause in Contracts

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 Cost obligation. The Beneficiary shall be made to understand that when the Share of 5 Cost obligation is met, Medi-Cal will cover the remainder of the unit cost. 6 g. For Beneficiaries with a Share of Cost who have the ability to meet their Share of Cost 7 obligation, CONTRACTOR shall maintain authorization procedures that include ongoing review of a 8 Beneficiary’s Share of Cost status. CONTRACTOR will make all reasonable efforts to ensure that all 9 authorized services are eligible for Medi-Cal reimbursement. 10 h. CONTRACTOR shall ensure that a Beneficiary with a Share of Cost was eligible for 11 Medi-Cal on the date of service during the adjudication process of the Network Provider’s claim. 12 i. The spend-down of Share of Cost is the amount remaining for the month of the date of 13 service, or the amount of the service, whichever is less. 14 j. CONTRACTOR shall maintain procedures regarding the referral of Beneficiaries who: 15 1.) Are unable to pay their Share of Cost and for whom the denial of mental health 16 services based on inability to pay Share of Cost would result in a significant functional impairment, or 17 2.) CONTRACTOR is unable to determine if they have met their Share of Cost for 18 other Medi-Cal services received and for whom the denial of Mental Health Services based on inability 19 to pay Share of Cost would result in a significant functional impairment. 20 k. The Network Provider shall send in a claim form, reflecting the gross amount, Share of 21 Cost amount (if applicable) and the balance due after the Share of Cost has been met. 22 l. If the Network Provider’s claim is sent with a balance due, CONTRACTOR shall 23 verify Share of Cost remaining to avoid double payment, as well as verify if payment is correct due to 24 Share of Cost reporting lag. 25 5. Other Health Coverage – CONTRACTOR shall direct Beneficiaries with Other Health 26 Coverage that includes behavioral health coverage to seek services through Network Providers who take 27 the Other Health Coverage in which they are enrolled. 28 a. CONTRACTOR shall direct Beneficiaries who obtain Other Health Coverage that 29 includes behavioral health coverage, and who have been receiving services by an ASO Network 30 Provider to seek services as soon as possible through other Providers who take Other Health Coverage 31 in which they have become enrolled. 32 b. CONTRACTOR shall direct Beneficiaries with Other Health Coverage that does not 33 include behavioral health coverage to seek services through COUNTY for a level of care assessment 34 and further treatment if medically necessary. 35 c. CONTRACTOR shall direct Beneficiaries who obtain Other Health Coverage that does 36 not include behavioral health coverage after they have been seeing an ASO Network Provider to seek 37 // 1 services as soon as possible through COUNTY for a level of care assessment and further treatment if 2 medically necessary. 3 d. This is subject to change if the DHCS rules change regarding accepting claims for 4 Other Health Coverage that does not include behavioral health coverage. 5 e. CONTRACTOR shall direct inpatient providers who submit claims for Beneficiaries

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.. County of Orange, Health Care Agency ASO Beacon Amendment No. 4 Page 7 of 13 Contract MA-042-18010155 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 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 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. ADMINISTRATOR will provide technical assistance and support as needed to identify client fall-out from eligibility file as it relates to claims payment. 1 e. Process and pay mental health provider professional fees as they relate to inpatient hospital stays and IMD claims. CONTRACTOR shall have access to the will be provided with a bi-weekly (2 time per week) inpatient and monthly IMD list as 2 they relate to paying inpatient and IMD claims. These lists will be report provided by ADMINISTRATOR. 3 f. CONTRACTOR shall ensure Ensure that the Network Providers notify the Beneficiary of 4 his/her Share of Cost obligation. The Beneficiary shall be made to understand that when the Share of 5 Cost obligation is met, Medi-Cal will cover the remainder of the unit cost. 6 g. For Beneficiaries with a Share of Cost who have the ability to meet their Share of Cost 7 obligation, CONTRACTOR shall maintain authorization procedures that include ongoing review of a 8 Beneficiary’s Share of Cost status. CONTRACTOR will make all reasonable efforts to ensure that all 9 authorized services are eligible for Medi-Cal reimbursement. 10 h. CONTRACTOR shall ensure Ensure that a Beneficiary with a Share of Cost was eligible for 11 Medi-Cal on the date of service during the adjudication process of the Network Provider’s claim. 12 i. The spend-down of Share of Cost is the amount remaining for the month of the date of 13 service, or the amount of the service, whichever is less. 14 j. CONTRACTOR shall maintain Maintain procedures regarding the referral of Beneficiaries who: 15 1.) Are unable to pay their Share of Cost and for whom the denial of mental health 16 services based on inability to pay Share of Cost would result in a significant functional impairment, or 17 2.) CONTRACTOR is unable to determine if they have met their Share of Cost for 18 other Medi-Cal services received and for whom the denial of Mental Health Services based on inability 19 to pay Share of Cost would result in a significant functional impairment.. County of Orange, Health Care Agency Contract MA-042-18010155 20 k. l. The Network Provider shall send in a claim form, reflecting the gross amount, Share of 21 Cost amount (if applicable) and the balance due after the Share of Cost has been met. 22 l. If the Network Provider’s claim is sent with a balance due, CONTRACTOR shall 23 verify Share of Cost remaining to avoid double payment, as well as verify if payment is correct due to 24 Share of Cost reporting lag. 25 5. Other Health Coverage – CONTRACTOR shall direct Beneficiaries with Other Health 26 Coverage that includes behavioral health coverage to seek services through Network Providers who take 27 the Other Health Coverage in which they are enrolled. 28 a. CONTRACTOR shall direct Beneficiaries who obtain Other Health Coverage that 29 includes behavioral health coverage, and who have been receiving services by an ASO Network 30 Provider to seek services as soon as possible through other Providers who take Other Health Coverage 31 in which they have become enrolled. 32 b. CONTRACTOR shall direct Beneficiaries with Other Health Coverage that does not 33 include behavioral health coverage to seek services through COUNTY for a level of care assessment 34 and further treatment if medically necessary. 35 c. CONTRACTOR shall direct Beneficiaries who obtain Other Health Coverage that does 36 not include behavioral health coverage after they have been seeing an ASO Network Provider to seek 37 // 1 services as soon as possible through COUNTY for a level of care assessment and further treatment if 2 medically necessary. 3 d. This is subject to change if the DHCS rules change regarding accepting claims for 4 Other Health Coverage that does not include behavioral health coverage. 5 e. CONTRACTOR shall direct inpatient providers who submit claims for Beneficiaries

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 shall 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 Clean claims for services shall be requested to be submitted to CONTRACTOR by the 17 Network Providers within thirty (30) calendar days of the date of services but in no case shall CONTRACTOR 18 process any claim that is initially submitted more than ninety (90) calendar 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 AgreementContract. 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 e. CONTRACTOR shall actively adjudicate or resolve any of CONTRACTOR’s 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 Cost obligation. The Beneficiary shall be made to understand that when the Share of 5 Cost obligation is met, Medi-Cal will cover the remainder of the unit cost. 6 g. For Beneficiaries with a Share of Cost who have the ability to meet their Share of Cost 7 obligation, CONTRACTOR shall maintain authorization procedures that include ongoing review of a 8 Beneficiary’s Share of Cost status. CONTRACTOR will make all reasonable efforts to ensure that all 9 authorized services are eligible for Medi-Cal reimbursement. 10 h. CONTRACTOR shall ensure that a Beneficiary with a Share of Cost was eligible for 11 Medi-Cal on the date of service during the adjudication process of the Network Provider’s claim. 12 i. The spend-down of Share of Cost is the amount remaining for the month of the date of 13 service, or the amount of the service, whichever is less. 14 j. CONTRACTOR shall maintain procedures regarding the referral of Beneficiaries who: 15 1.) Are unable to pay their Share of Cost and for whom the denial of mental health 16 services based on inability to pay Share of Cost would result in a significant functional impairment, or 17 2.) CONTRACTOR is unable to determine if they have met their Share of Cost for 18 other Medi-Cal services received and for whom the denial of Mental Health Services based on inability 19 to pay Share of Cost would result in a significant functional impairment. 20 k. The Network Provider shall send in a claim form, reflecting the gross amount, Share of 21 Cost amount (if applicable) and the balance due after the Share of Cost has been met. 22 l. If the Network Provider’s claim is sent with a balance due, CONTRACTOR shall 23 verify Share of Cost remaining to avoid double payment, as well as verify if payment is correct due to 24 Share of Cost reporting lag. 25 5. Other Health Coverage – CONTRACTOR shall direct Beneficiaries with Other Health 26 Coverage that includes behavioral health coverage to seek services through Network Providers who take 27 the Other Health Coverage in which they are enrolled. 28 a. CONTRACTOR shall direct Beneficiaries who obtain Other Health Coverage that 29 includes behavioral health coverage, and who have been receiving services by an ASO Network 30 Provider to seek services as soon as possible through other Providers who take Other Health Coverage 31 in which they have become enrolled. 32 b. CONTRACTOR shall direct Beneficiaries with Other Health Coverage that does not 33 include behavioral health coverage to seek services through COUNTY for a level of care assessment 34 and further treatment if medically necessary. 35 c. CONTRACTOR shall direct Beneficiaries who obtain Other Health Coverage that does 36 not include behavioral health coverage after they have been seeing an ASO Network Provider to seek 37 // 1 services as soon as possible through COUNTY for a level of care assessment and further treatment if 2 medically necessary. 3 d. This is subject to change if the DHCS rules change regarding accepting claims for 4 Other Health Coverage that does not include behavioral health coverage. 5 e. CONTRACTOR shall direct inpatient providers who submit claims for Beneficiaries

CLAIMS PROCESSING AND ADJUDICATION – NETWORK PROVIDERS. 10 22 1. CONTRACTOR shall maintain a rules-based and date-sensitive claims system to meet the 11 23 needs of all standard Medi-Cal beneficiary claims. 12 24 2. CONTRACTOR shall establish a claims adjudication process which will accept either 13 25 paper or electronic claims including, but not limited to, verification that if the Beneficiary has a Share of 14 26 Cost that the Share of Cost has been met. 15 27 3. CONTRACTOR shall maintain timelines in the claims process as follows: 16 28 a. Claims for services shall be requested to be submitted to CONTRACTOR by the 17 29 Network Providers within thirty (30) days of the date of services but in no case shall CONTRACTOR 18 30 process any claim that is initially submitted more than ninety (90) days from the date of service, except 19 31 as required otherwise by law, rules, or regulation as described in the Licenses and Laws Paragraph of 20 32 this Agreement. 21 33 b. CONTRACTOR shall maintain a thirty (30) calendar day or less turnaround on clean 22 34 claims. Clean claims shall be those that require no additional information (such as provider 23 35 identification, diagnosis and/or CPT codes) and which can be processed completely upon initial entry.. 36 // 37 // 24 1 c. When pending a claim for missing data, the Network Provider shall receive notification 25 2 from CONTRACTOR within fourteen (14) calendar days from the date of receipt. This notification 26 3 shall include what is needed to continue processing the claim. 27 4 d. CONTRACTOR shall request that the information be returned within fourteen (14) 28 5 calendar days. 29 6 4. CONTRACTOR shall: 30 7 a. Provide adequately trained claims processing and clerical staff, and suitable equipment. 31 8 b. Review each completed claim to determine that the services rendered are within the 32 9 Medi-Cal scope of service, and that applicable prior approvals have been obtained. 33 10 c. Share of Cost – CONTRACTOR shall require that all Network Providers attempt to 34 11 collect the Share of Cost from beneficiaries and that reimbursement of claims shall be reduced by the 35 12 beneficiaries’ Share of Cost. 36 13 d. CONTRACTOR shall have access to the Medi-Cal Eligibility Website and MEDS to 37 14 determine client eligibility and any Share of Cost remaining for the date of service. 1 15 e. CONTRACTOR shall have access to the weekly inpatient and monthly IMD list as 2 16 they relate to paying inpatient and IMD claims. These lists will be provided by ADMINISTRATOR. 3 17 f. CONTRACTOR shall ensure that the Network Providers notify the Beneficiary of 4 18 his/her Share of Cost obligation. The Beneficiary shall be made to understand that when the Share of 5 19 Cost obligation is met, Medi-Cal will cover the remainder of the unit cost. 6 20 g. For Beneficiaries with a Share of Cost who have the ability to meet their Share of Cost 7 21 obligation, CONTRACTOR shall maintain authorization procedures that include ongoing review of a 8 22 Beneficiary’s Share of Cost status. CONTRACTOR will make all reasonable efforts to ensure that all 9 23 authorized services are eligible for Medi-Cal reimbursement. 10 24 h. CONTRACTOR shall ensure that a Beneficiary with a Share of Cost was eligible for 11 25 Medi-Cal on the date of service during the adjudication process of the Network Provider’s claim. 12 26 i. The spend-down of Share of Cost is the amount remaining for the month of the date of 13 27 service, or the amount of the service, whichever is less. 14 28 j. CONTRACTOR shall maintain procedures regarding the referral of Beneficiaries who: 15 29 1.) Are unable to pay their Share of Cost and for whom the denial of mental health 16 30 services based on inability to pay Share of Cost would result in a significant functional impairment, or 17 31 2.) CONTRACTOR is unable to determine if they have met their Share of Cost for 18 32 other Medi-Cal services received and for whom the denial of Mental Health Services based on inability 19 33 to pay Share of Cost would result in a significant functional impairment. 20 34 k. The Network Provider shall send in a claim form, reflecting the gross amount, Share of 21 35 Cost amount (if applicable) and the balance due after the Share of Cost has been met. 22 l. If the Network Provider’s claim is sent with a balance due, CONTRACTOR shall 23 verify Share of Cost remaining to avoid double payment, as well as verify if payment is correct due to 24 Share of Cost reporting lag. 25 5. Other Health Coverage – CONTRACTOR shall direct Beneficiaries with Other Health 26 Coverage that includes behavioral health coverage to seek services through Network Providers who take 27 the Other Health Coverage in which they are enrolled. 28 a. CONTRACTOR shall direct Beneficiaries who obtain Other Health Coverage that 29 includes behavioral health coverage, and who have been receiving services by an ASO Network 30 Provider to seek services as soon as possible through other Providers who take Other Health Coverage 31 in which they have become enrolled. 32 b. CONTRACTOR shall direct Beneficiaries with Other Health Coverage that does not 33 include behavioral health coverage to seek services through COUNTY for a level of care assessment 34 and further treatment if medically necessary. 35 c. CONTRACTOR shall direct Beneficiaries who obtain Other Health Coverage that does 36 not include behavioral health coverage after they have been seeing an ASO Network Provider to seek // 37 // 1 services as soon as possible through COUNTY for a level of care assessment and further treatment if 2 medically necessary. 3 d. This is subject to change if the DHCS rules change regarding accepting claims for 4 Other Health Coverage that does not include behavioral health coverage. 5 e. CONTRACTOR shall direct inpatient providers who submit claims for Beneficiaries//