Claims Processing and Payment. With the exception of all USL fixed annuity products, AGLC shall process claims, contestable and non-contestable. AGLC will pay insurance and annuity benefits with a check drawn on an USL bank account. At all times that AGLC is providing claims processing and payment services, AGLC will answer all telephone inquiries as USL and will use USL stationery when communicating in writing with respect to a claim. AGLC expressly understands that all claims decisions shall ultimately be the responsibility of USL and subject to the control and direction of USL. AGLC will comply with all applicable licensing requirements.
Claims Processing and Payment. 4.2.1. AHCCCS Administration and the COUNTY will jointly develop and mutually agree to a claims processing and payment process that complies with both Federal and State laws, regulations, and rules; and is not in conflict with the provisions of this contract.
4.2.2. AHCCCS will process and pay clean claims in accordance with AHCCCS policies and procedures.
Claims Processing and Payment. 1. The Program Administrator, pursuant to its agreement with Governing Board, shall process and pay claims for Benefits under this Contract rendered to Beneficiaries by providers as determined by Governing Board.
Claims Processing and Payment. With respect to the processing of Claims, the Contractor shall provide the following services and perform the following functions:
8.1.1 Take the necessary steps to ensure the effective and smooth transition and execution of all Claims Processing functions.
8.1.2 Process and adjudicate for payment all Claims in accordance with the prevailing NCPDP standards. The Contractor will be responsible for taking all necessary actions to correct any discrepancies, including but not limited to, collection efforts. The Contractor agrees to distribute to the MCOs a Claims rejection report, as required under this Contract.
8.1.3 Charge or pay Network Pharmacies only for the dispensing to an Enrollee of a prescription covered by GHP. This payment shall include the Ingredient Cost, plus a Dispensing Fee less any deductible, Co-Payment or co-insurance paid by the Enrollee and less any amount paid or reimbursed, as the case may be, by another health plan under COB.
8.1.4 Disburse payment of Claims to Network Pharmacies every two (2) Weeks exclusively from funds provided by either the MCOs or ASES, as the case may be, or within such other time period as may be agreed to by ASES and the Contractor, provided that such disbursement of payments of Claims will be made within twenty-one (21) days of their receipt by the Contractor. In no event shall the Contractor be liable to pay Claims other than with the funds provided by either the MCOs or ASES.
8.1.5 Provide ASES with the adjudicated Claims Data and reports set forth in this Contract, in the media and format established in this Contract or in any other form established by ASES, and provide the MCOs with the adjudicated Claims Data and the reports set forth in this Contract, as detailed in this Contract, in the media and format established in this Contract or in any other form mutually agreed to by the Parties.
8.1.6 The Contractor will adjudicate Claims submitted by Network Pharmacies based on the Pharmacy Contracts, including online edits for Prior Authorization regulation and other edits that may be necessary for the accurate payment of Claims and according to the Covered Pharmacy Services as determined by ASES. The Contractor’s Claims Processing System will have the capacity to handle Coordination of Benefits (“COB”) with another party which is or may be liable for payment and which provides the Contractor the necessary COB Information on a daily basis. The Contractor shall submit to ASES on the last Business Day of March,...
Claims Processing and Payment. Effective as of the Implementation Date, and for so long as Company has paid Network the applicable Capitation Amount due and owed by Company to Network, and for so long as Network has not been notified of a breach of its obligations hereunder pursuant to Section 6.D hereof and such breach is continuing, Network agrees to provide Network Provider Claims Management Services (as defined herein and in Attachment F) for Home Health Services provided to Network Members, including claim processing and payment, and such other provider payment services as set forth in this section 1.I.
Claims Processing and Payment. Lifemark shall pay claims to Participating Providers for all approved Covered Services rendered to Members in accordance with the contracts entered into between Participating Providers and the Plan, the RFA, any contract between TDHS and the Plan, and this Agreement. Lifemark shall have the authority and discretion to interpret the requirements of the RFA, the contract between TDHS and the Plan, and the contracts between the Plan and providers with respect to payment of claims to Participating Providers. Claims payments shall be made by checks or drafts signed by Lifemark as the Plan's dispersing agent out of the account established in accordance with Section 2.2.4 hereof, and Lifemark shall provide the Plan with a copy of all check registers for claims payment checks. Lifemark shall notify the Plan by facsimile or electronic transmission within the greater of forty-eight (48) hours or two (2) business days prior to releasing a check from such account in an amount equal to or greater than [x]*. The Plan shall not unreasonably withhold its approval of such expenditure, and, the Plan shall provide a written explanation to Lifemark of any disapproval of such an expenditure. The Plan's failure to disapprove the issuance of such check within the notice period shall be deemed to be approval of the issuance.
Claims Processing and Payment. For the PHMS, the Contractor receives approximately 1,375 claims per year from hospitals, physicians, and other providers as necessary and appropriate to provide the needed level of care. The Contractor is responsible for reviewing all claims to ensure that County responsibility for the patient has been verified. County responsibility is verified with a signed County Treatment Authorization Request (TAR), or certification by HCA that services were provided to a person for whom County is claiming medical responsibility. Claims submitted after 180 days from the date of service must have supporting documentation to indicate the claim was in a third-party payor process and subsequently denied. Claims submitted after 274 days from the date of services shall be denied. These timeframes are subject to change at the request of the County and in consideration of its negotiated agreement with PHMS providers. Hospital and physician claims are paid at rates negotiated by HCA. For services provided at UCI Medical Center, HCA has a contract in place, which identifies the percentage of billed charges or Resource-Based Relative Value Scale (RBRVS) for corresponding hospital and physician services and the Contractor will be provided a copy of the UCI Medical Center contract. Contractor shall provide an address and email address/secure website for submission of claims and correspondence by authorized providers, which address may be modified upon mutual written agreement between Contractor and County’s Project Manager. Paper claims shall be submitted to the following address: Advanced Medical Management County of Orange TB Network Program XX Xxx 0000 Xxxx Xxxxx, XX 00000 Electronic claims may be submitted on Contractor’s website: xxxxx://xxx.xx All claims shall be processed (suspended, approved, or denied) within ten (10) working days of receipt by Contractor. Approved claims shall be disbursed on a bi-weekly basis. If the number of claims received by the Contractor during any ten-day work period exceeds the average number of claims received during the three (3) working ten-day work periods, the Contractor shall have additional working days which shall be mutually agreed upon by both parties.
Claims Processing and Payment. Xxxxxx Xxxxxxxxxx, Third Party Accounts Manager-DFSM/Claims 000 X. Xxxxxxxxx St., MD8200 Phoenix, AZ 85034 Phone: (000) 000-0000 E-Mail: Xxxxxxxx.Xxxxxxxxxx@xxxxxxxx.xxx
Claims Processing and Payment. 1. Subject to Article III, Section F regarding funding of the claims payment account, Paramount shall process claims for benefits and pay such claims using Paramount's normal claim determination, payment and audit procedures, and applicable cost control standards, in accordance with the terms of the Plan and this Agreement. Paramount agrees to pass on to the group 100% of the discounts obtained from providers. If a prescription drug plan is offered through Paramount, the cost to the Plan Sponsor will be based on the average wholesale price (AWP), less any discounts, plus a dispensing fee and pharmacy benefits manager (PBM) administrative fee less the member copay. Paramount will retain all pharmaceutical drug rebates. Payment for claims will be made from funds provided by the Plan Sponsor in accordance with Article III, Section F, infra.
2. Paramount will administer the appeal of claim denials and other eligible matters in accordance with the terms of the Plan. With the exception of final external review decisions, Plan Sponsor is the ultimate decision maker regarding the interpretation of the Plan and the denial or payment of claims. It is further expressly understood and agreed that in connection with the administration of appeals, unless otherwise indicated on the Implementation Page / Declaration, it is Plan Sponsor's duty-to contract with three
Claims Processing and Payment. Process Claims and determine payment levels based on the appropriate allowable charge, pursuant to the terms of the Benefit Plan as construed by Contractor, incurred and timely submitted on or after the Effective Date.
