Claims Processing Capability Sample Clauses

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.
Sample 1
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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
Sample 1

Related to Claims Processing Capability

  • Claims Processing BCBSM will process Provider's Clean Claims submitted in accordance with this Agreement in a timely fashion.

  • Local Circuit Switching Capability, including Tandem Switching Capability 4.1.3.1 Definition 4.1.3.2 Notwithstanding BellSouth’s general duty to unbundle local circuit switching, BellSouth shall not be required to unbundle local circuit switching for <<customer_name>> when <<customer_name>> serves end-users with four (4) or more voice-grade (DS-0) equivalents or lines in locations served by BellSouth’s local circuit switches, which are in the following MSAs: Atlanta, GA; Miami, FL; Orlando, FL; Ft. Lauderdale, FL; Charlotte-Gastonia-Rock Hill, NC; Greensboro-Winston Salem-High Point, NC; Nashville, TN; and New Orleans, LA, and BellSouth has provided non-discriminatory cost based access to the Enhanced Extended Link (EEL) throughout Density Zone 1 as determined by NECA Tariff No. 4 as in effect on January 1, 1999. 4.1.3.3 In the event that <<customer_name>> orders local circuit switching for a single end user account name at a single physical end user location with four (4) or more 2-wire voice-grade loops from a BellSouth central office in an MSA listed above, BellSouth shall charge <<customer_name>> the market based rate in Exhibit C for use of the local circuit switching functionality for the affected facilities. 4.1.3.4 A featureless port is one that has a line port, switching facilities, and an interoffice port. A featured port is a port that includes all features then capable or a number of then capable features specifically requested by <<customer_name>>. Any features that are not currently then capable but are technically feasible through the switch can be requested through the NBR/BFR process. 4.1.3.5 BellSouth will provide to <<customer_name>> customized routing of calls: (i) to a requested directory assistance services platform; (ii) to an operator services platform pursuant to Section 10 of Attachment 2; (iii) for <<customer_name>>’s PIC’ed toll traffic in a two (2) PIC environment to an alternative OS/DA platform designated by <<customer_name>>. <<customer_name>> customers may use the same dialing arrangements as BellSouth customers. 4.1.3.6 Remote Switching Module functionality is included in Switching Capability. The switching capabilities used will be based on the line side features they support. 4.1.3.7 Switching Capability will also be capable of routing local, intraLATA, interLATA, and calls to international customer’s preferred carrier; call features (e.g. call forwarding) and Centrex capabilities. 4.1.3.8 Where required to do so in order to comply with an effective Commission order, BellSouth will provide to <<customer_name>> purchasing local BellSouth switching and reselling BellSouth local exchange service under Attachment 1, selective routing of calls to a requested directory assistance services platform or operator services platform. <<customer_name>> customers may use the same dialing arrangements as BellSouth customers, but obtain a <<customer_name>> branded service.

  • Testing Capabilities 7.2.2.10.2.1 LIS Acceptance Testing is provided where equipment is available, with the following test lines: seven-digit access to balance (100 type), milliwatt (102 type), nonsynchronous or synchronous, automatic transmission measuring (105 type), data transmission (107 type), loop-around, short circuit, open circuit, and non-inverting digital loop-back (108 type), and such other acceptance testing that may be needed to ensure that the service is operational and meets the applicable technical parameters. 7.2.2.10.2.2 In addition to LIS acceptance testing, other tests are available (e.g., additional cooperative acceptance testing, automatic scheduled testing, cooperative scheduled testing, manual scheduled testing, and non-scheduled testing). Charges for such testing are identified in Section 7.3.5.

  • Claims Process We intend to appoint the senior trustee as the authorized representative to take action on behalf of holders of each series of the notes under the guarantee. The authorized representative will agree to make a demand of the FDIC upon our failure to pay interest or principal on any series of the notes when due. As provided in the FDIC’s regulations, a holder will also have the option to elect not to be represented by the authorized representative. Upon our failure to pay interest or principal, the authorized representative and a holder that has elected not to be so represented must follow the FDIC’s required procedures for making a demand under the guarantee. In addition to the procedures described below, the authorized representative will be required when making a demand, to the extent not previously provided in the master agreement, to provide the FDIC with information regarding its authority, including: its financial and organizational capacity to act as representative, its exclusive authority to act on behalf of each noteholder and its fiduciary responsibility to the noteholders when acting as such, as established by the senior indenture, and its authority to make the assignment of each noteholder’s right, title, and interest in the notes to the FDIC. Any demand under the guarantee must be accompanied by a proof of claim, satisfactory in form and content to the FDIC, which includes evidence of the occurrence of a payment default and the claimant’s ownership of the applicable notes. The claimant must provide to the FDIC an assignment, satisfactory in form and content to the FDIC, of the noteholder’s right, title and interest in the notes to the FDIC and the transfer to the FDIC of any claim in any insolvency proceeding against us. The assignment must also grant to the FDIC the right to receive any and all distributions on the note from the proceeds of any bankruptcy. If a holder receives a payment on a note from a bankruptcy, any obligation of the FDIC under the guarantee would be reduced proportionally. Demands must be made by the authorized representative or by a holder that elects not to be represented by the authorized representative within 60 days of the occurrence of the payment default. Upon payment by the FDIC of any amount under the guarantee, the FDIC will be subrogated to the rights of the recipient noteholder against us, including in respect of any insolvency proceeding, to the extent of such payment.

  • Data Collection, Processing and Usage The Company collects, processes and uses the International Participant’s personal data, including the International Participant’s name, home address, email address, and telephone number, date of birth, social insurance number or other identification number, salary, citizenship, job title, any shares of Common Stock or directorships held in the Company, and details of all Equity Awards or any other equity compensation awards granted, canceled, exercised, vested, or outstanding in the International Participant’s favor, which the Company receives from the International Participant or the Employer. In granting the Equity Award under the Plan, the Company will collect the International Participant’s personal data for purposes of allocating shares of Common Stock and implementing, administering and managing the Plan. The Company’s legal basis for the collection, processing and usage of the International Participant’s personal data is the International Participant’s consent.

  • Subprocessing The data importer shall not subcontract any of its processing operations performed on behalf of the data exporter under the Clauses without the prior written consent of the data exporter. Where the data importer subcontracts its obligations under the Clauses, with the consent of the data exporter, it shall do so only by way of a written agreement with the subprocessor which imposes the same obligations on the subprocessor as are imposed on the data importer under the Clauses. Where the subprocessor fails to fulfil its data protection obligations under such written agreement the data importer shall remain fully liable to the data exporter for the performance of the subprocessor's obligations under such agreement.

  • Processing Grievances The Association Representative involved and the grieving supervisor shall not leave work or disrupt departmental routine to discuss grievances without first requesting permission from his/her immediate superior, which shall not be unreasonably withheld. The Association Representative and the grieving supervisor shall be allowed a reasonable amount of time during working hours while on the Appointing Authority's premises when a grievance is investigated or presented in Steps 1 and 2.

  • Sub-processing 11.1 The data importer shall not subcontract any of its processing operations performed on behalf of the data exporter under the Clauses without the prior written consent of the data exporter. Where the data importer subcontracts its obligations under the Clauses, with the consent of the data exporter, it shall do so only by way of a written agreement with the sub-processor which imposes the same obligations on the sub- processor as are imposed on the data importer under the Clauses. Where the sub-processor fails to fulfil its data protection obligations under such written agreement the data importer shall remain fully liable to the data exporter for the performance of the sub-processor’s obligations under such agreement. 11.2 The prior written contract between the data importer and the sub-processor shall also provide for a third-party beneficiary clause as laid down in Clause 3 for cases where the data subject is not able to bring the claim for compensation referred to in paragraph 1 of Clause 6 against the data exporter or the data importer because they have factually disappeared or have ceased to exist in law or have become insolvent and no successor entity has assumed the entire legal obligations of the data exporter or data importer by contract or by operation of law. Such third-party liability of the sub-processor shall be limited to its own processing operations under the Clauses. 11.3 The provisions relating to data protection aspects for sub-processing of the contract referred to in paragraph 1 shall be governed by the law of the Member State in which the data exporter is established, namely ........................................ 11.4 The data exporter shall keep a list of sub-processing agreements concluded under the Clauses and notified by the data importer pursuant to Clause 5(j), which shall be updated at least once a year. The list shall be available to the data exporter’s data protection supervisory authority.

  • Problem Solving Employees and supervisors are encouraged to attempt to resolve on an informal basis, at the earliest opportunity, a problem that could lead to a grievance. If the matter is not resolved by informal discussion, or a problem-solving meeting does not occur, it may be settled in accordance with the grievance procedure. Unless mutually agreed between the Employer and the Union problem-solving discussions shall not extend the deadlines for filing a grievance. The Union Xxxxxxx or in their absence, the Local Union President, or Area Xxxxxxx, or Chief Xxxxxxx, either with the employee or alone, shall present to the appropriate supervisor a written request for a meeting. If the supervisor agrees to a problem- solving meeting, this meeting shall be held within fourteen (14) calendar days of receipt of the request. The supervisor, employee, Union Xxxxxxx, and up to one (1) other management person shall attempt to resolve the problem through direct and forthright communication. If another member of management is present that person will not be hearing the grievance at Step Two, should it progress to that Step. The employee, the Union Xxxxxxx or in their absence, the Local Union President, or Area Xxxxxxx, or Chief Xxxxxxx, may participate in problem-solving activities on paid time, in accordance with Article 31, Union Rights, Section 1H.

  • Interconnection Customer Drawings Within one hundred twenty (120) days after the date of Initial Operation, unless the Interconnection Parties agree on another mutually acceptable deadline, the Interconnection Customer shall deliver to the Transmission Provider and the Interconnected Transmission Owner final, “as-built” drawings, information and documents regarding the Customer Interconnection Facilities, including, as and to the extent applicable: a one-line diagram, a site plan showing the Customer Facility and the Customer Interconnection Facilities, plan and elevation drawings showing the layout of the Customer Interconnection Facilities, a relay functional diagram, relaying AC and DC schematic wiring diagrams and relay settings for all facilities associated with the Interconnection Customer's step-up transformers, the facilities connecting the Customer Facility to the step-up transformers and the Customer Interconnection Facilities, and the impedances (determined by factory tests) for the associated step-up transformers and the Customer Facility. As applicable, the Interconnection Customer shall provide Transmission Provider and the Interconnected Transmission Owner specifications for the excitation system, automatic voltage regulator, Customer Facility control and protection settings, transformer tap settings, and communications.

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