Claims Processing Capability. The Contractor shall demonstrate and maintain the capability to process and pay provider claims for services rendered to the Contractor’s members, in compliance with HIPAA, including National Provider Identification (NPI). The Contractor shall be able to price specific procedures or encounters (depending on the agreement between the provider(s) and the Contractor) and to maintain detailed records of remittances to providers. OMPP must pre- approve the Contractor’s delegation of any claims processing function to a sub-contractor, and the Contractor must notify OMPP and secure OMPP’s approval of any change to sub- contracting arrangements for claims processing. The Contractor shall develop policies and procedures to monitor claims adjudication accuracy and shall submit its policies and procedures for monitoring its claims adjudication accuracy to OMPP for review and approval. The out-of-network provider filing limit for submission of claims to the Contractor is twelve
Claims Processing Capability. The MCO must demonstrate and maintain the capability to control, process and pay provider claims for services rendered to the MCO’s members. The MCO must have the capability to collect and generate service-specific procedure and diagnosis data on a per member basis, to price specific procedures or encounters (depending on the agreement between the provider and the MCO) and to maintain detailed records of remittances to providers. The MCO must develop internal criteria for determining an acceptable level of claims adjudication accuracy and encounter submission accuracy. The MCO must develop policies and procedures to monitor claims adjudication accuracy against its internal standards. The MCO must submit its internal standards for determining an acceptable level of claims adjudication accuracy and its policies and procedures for monitoring its claims adjudication accuracy against the MCO’s internal criteria to OMPP for review and approval. The State recommends that the MCO establish its internal claims processing and financial accuracy standards to be no less than 97 percent claims processing accuracy and 99 percent financial accuracy. Each year as part of the MCO’s annual Quality Management and Improvement Program Plan Summary Report, the MCO must detail its claims adjudication accuracy monitoring activities, corrective actions that were implemented as a result of the monitoring and submit any changes to its internal standards. Additionally, in the annual Quality Management and Improvement Program Plan Summary Report, the MCO must submit descriptions of all incentives and penalties it imposed on providers to encourage claims and encounter submission accuracy.
