Common use of Claims Processing Requirements Clause in Contracts

Claims Processing Requirements. 4.10.1 HMO and claims processing subcontractors must comply with 28 TAC Chapter 21, Subchapter T regarding "Submission of Clean Claims", to the extent these rules are not in conflict with provisions of this contract. 4.10.2 HMO must use a HHSC approved or identified claim format that contains all data fields for final adjudication of the claim. The required data fields must be Page 34 of 173 complete and accurate. The HHSC required data fields are identified in HHSC's "HMO Encounter Data Claims Submission Manual." 4.10.3 HMO and claims processing subcontractors must comply with HHSC's Texas Medicaid Managed Care Claims Manual (Claims Manual), as amended or modified. The Claims Manual is incorporated herein by reference and contains HHSC's claims processing and reporting requirements. HHSC will provide the HMO reasonable notice of changes to the Claims Manual. For purposes of this section only, "reasonable notice" will generally mean 60 days advance written notice of system changes and 30 days advance written notice of other changes, unless in HHSC's sole discretion, changes in federal or state laws, rules, regulations, or policies warrant a shorter time period for notice. 4.10.4 HMO must forward claims submitted to HMO in error to either: 1) the correct HMO if the correct HMO can be determined from the claim or is otherwise known to HMO; 2) the State's claims administrator; or 3) the provider who submitted the claim in error, along with an explanation of why the claim is being returned. 4.10.5 HMO must not pay any claim submitted by a provider who has been excluded or suspended from the Medicare or Medicaid programs for fraud and abuse when HMO has knowledge of the exclusion or suspension. 4.10.6 All provider clean claims must be adjudicated (finalized as paid or denied adjudicated) within 30 days from the date the claim is received by HMO. HMO must pay providers interest on a claim that is not adjudicated within 30 days from either: (1) the date the HMO receives the clean claim, or (2) the date the claim becomes clean. HMO must pay providers interest at an 18% annual rate, calculated daily for the full period in which the clean claim remains unadjudicated beyond the 30-day claims processing deadline. HMO must comply with the Texas Medicaid Managed Care Claims Manual to determine the principal amount for the interest payment computation. HMO will be held to a minimum performance level of 90% of all clean claims paid or denied within 30 days of receipt and 99% of all clean claims paid or denied within 90 days of receipt. Failure to meet these performance levels is a default under this contract and could lead to damages or sanctions as outlined in Article 17. The performance levels are subject to changes if required to comply with federal and state laws or regulations. 4.10.6.1 All claims and appeals submitted to HMO and claims processing subcontractors must be paid-adjudicated (clean claims), denied-adjudicated (clean claims), or denied for additional information (unclean claims) to providers within 30 days from the date the claim is received by HMO. Providers must be sent a written notice for each claim that is denied for additional information (unclean claims) identifying the claim, all reasons why the claim is being denied, the date the claim was received by HMO, all information required from the provider in order for HMO to adjudicate the claim, and the date by which the requested information must be received from the provider. 4.10.6.2 Claims that are suspended (pended internally) must be subsequently paid-adjudicated, denied-adjudicated, or denied for additional information (pended externally) within 30 days from date of receipt. No claim can be suspended for a period exceeding 30 days from date of receipt of the claim. 4.10.6.3 HMO must identify each data field of each claim form that is required from the provider in order for HMO to adjudicate the claim. HMO must inform all network providers about the required fields no later than 30 days prior to the effective date of the contract or as a provision within HMO/provider contract. Out-of-network providers must be informed of all required fields if the claim is denied for additional information. The required fields must include those required by HMO and HHSC. 4.10.7 HMO is subject to Article 16, Default and Remedies, for claims that are not processed on a timely basis as required by this contract and the Claims Manual. Notwithstanding the provisions of Section 4.10.4, HMO's failure to adjudicate (paid, denied, or external pended) at least ninety percent (90%) of all claims within thirty (30) days of receipt and ninety-nine percent (99%) within ninety (90) days of receipt for the contract year to date is a default under Article 16 of this contract. 4.10.8 HMO must comply with the standards adopted by the U.S. Department of Health and Human Services under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, regarding submitting and receiving claims information through electronic data interchange (EDI) that allows for automated processing and adjudication of claims within the federally mandated timeframes (see 45 C.F.R. parts 160 through 164). 4.10.9 For claims requirements regarding retroactive PCP changes for mandatory Members, see Section 7.8.12.2.

Claims Processing Requirements. 4.10.1 HMO and claims processing subcontractors must comply with 28 TAC Chapter 21, Subchapter T regarding "Submission of Clean Claims", to the extent these rules are not in conflict with provisions of this contract. 4.10.2 HMO must use a HHSC approved or identified claim format that contains all data fields for final adjudication of the claim. The required data fields must be Page 34 of 173 complete and accurate. The HHSC required data fields are identified in HHSC's "HMO Encounter Data Claims Submission Manual." 4.10.3 HMO and claims processing subcontractors must comply with HHSCTDH's Texas Medicaid Managed Care Claims Manual (Claims Manual), as amended or modified. The Claims Manual is incorporated herein by reference and which contains HHSCTDH's claims processing and reporting requirements. HHSC will provide the HMO reasonable notice of must comply with any changes to the Claims Manual. For purposes of this section only, "reasonable notice" will generally mean 60 days advance written Manual with appropriate notice of system changes and 30 days advance written notice of other changes, unless in HHSC's sole discretion, changes in federal or state laws, rules, regulations, or policies warrant a shorter time period for noticefrom TDH. 4.10.4 4.10.2 HMO must forward claims submitted to HMO in error to either: 1) the correct HMO if the correct HMO can be determined from the claim or is otherwise known to HMO; 2) the State's claims administrator; or 3) the provider who submitted the claim in error, along with an explanation of why the claim is being returned. 4.10.5 4.10.3 HMO must not pay any claim submitted by a provider who has been excluded or suspended from the Medicare or Medicaid programs for fraud and abuse when HMO has knowledge of the exclusion or suspension. 4.10.6 4.10.4 All provider clean claims must be adjudicated (finalized as paid or denied adjudicated) within 30 days from the date the claim is received by HMO. HMO must pay providers interest on a clean claim that which is not adjudicated within 30 days from either: (1) the date the HMO receives the clean claim, or (2) the date the claim is received by HMO or becomes clean. HMO must pay providers interest clean at an a rate of 1.5% per month (18% annual rate, calculated daily annual) for the full period in which each month the clean claim remains unadjudicated beyond the 30-day claims processing deadline. HMO must comply with the Texas Medicaid Managed Care Claims Manual to determine the principal amount for the interest payment computationunadjudicated. HMO will be held to a minimum performance level of 90% of all clean claims paid or denied within 30 days of receipt and 99% of all clean claims paid or denied within 90 days of receipt. Failure to meet these performance levels is a default under this contract and could lead to damages or sanctions as outlined in Article 17XVII. The performance levels are subject to changes if required to comply with federal and state laws or regulations. 4.10.6.1 4.10.4.1 All claims and appeals submitted to HMO and claims processing subcontractors must be paid-adjudicated (clean claims), denied-adjudicated (clean claims), or denied for additional information (unclean claims) to providers within 30 days from the date the claim is received by HMO. Providers must be sent a written notice for each claim that is denied for additional information (unclean claims) identifying the claim, all reasons why the claim is being denied, the date the claim was received by HMO, all information required from the provider in order for HMO to adjudicate the claim, and the date by which the requested information must be received from the provider.. 1999 Renewal Contract Harrxx Xxxvice Area 32 August 9, 1999 4.10.6.2 4.10.4.2 Claims that are suspended (pended internally) must be subsequently paid-adjudicated, denied-adjudicated, or denied for additional information (pended externally) within 30 days from date of receipt. No claim can be suspended for a period exceeding 30 days from date of receipt of the claim. 4.10.6.3 4.10.4.3 HMO must identify each data field of each claim form that is required from the provider in order for HMO to adjudicate the claim. HMO must inform all network providers about the required fields no later than 30 days prior to the effective date of the contract or as a provision within HMO/provider contract. Out-of-network providers must be informed of all required fields if the claim is denied for additional information. The required fields must include those required by HMO and HHSCTDH. 4.10.7 4.10.5 HMO is subject to Article 16XVI, Default and Remedies, for claims that are not processed on a timely basis as required by this contract and the Claims Manual. Notwithstanding the provisions of Section Articles 4.10.4, HMO's failure to adjudicate (paid, denied, or external pended) at least ninety percent (90%) of all claims within thirty (30) days of receipt 4.10.4.1 and ninety-nine percent (99%) within ninety (90) days of receipt for the contract year to date is a default under Article 16 of this contract4. 4.10.8 HMO must comply with the standards adopted by the U.S. Department of Health and Human Services under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, regarding submitting and receiving claims information through electronic data interchange (EDI) that allows for automated processing and adjudication of claims within the federally mandated timeframes (see 45 C.F.R. parts 160 through 164). 4.10.9 For claims requirements regarding retroactive PCP changes for mandatory Members, see Section 7.8.12.2.

Claims Processing Requirements. 4.10.1 HMO and claims processing subcontractors must comply with 28 TAC Chapter 21, Subchapter T regarding ss.ss.21.2801 through 21.2816 "Submission of Clean Claims", to the extent these rules they are not in conflict with provisions of this contract. 4.10.2 HMO must use a HHSC TDH approved or identified claim format that contains all data fields for final adjudication of the claim. The required data fields must be Page 34 of 173 complete and accurate. The HHSC TDH required data fields are identified in HHSCTDH's "HMO Encounter Data Claims Submission Manual."" 12/21/00 4.10.3 HMO and claims processing subcontractors must comply with HHSCTDH's Texas Medicaid Managed Care Claims Manual (Claims Manual), as amended or modified. The Claims Manual is incorporated herein by reference and which contains HHSCTDH's claims processing and reporting requirements. HHSC will provide the HMO reasonable notice of must comply with any changes to the Claims Manual. For purposes of this section only, "reasonable notice" will generally mean 60 days advance written Manual with appropriate notice of system changes and 30 days advance written notice of other changes, unless in HHSC's sole discretion, changes in federal or state laws, rules, regulations, or policies warrant a shorter time period for noticefrom TDH. 4.10.4 HMO must forward claims submitted to HMO in error to either: 1) the correct HMO HMO, if the correct HMO can be determined from the claim or is otherwise known to HMO; 2) the State's claims administrator; or 3) the provider who submitted the claim in error, along with an explanation of why the claim is being returned. 4.10.5 HMO must not pay any claim submitted by a provider who has been excluded or suspended from the Medicare or Medicaid programs for fraud and abuse when HMO has knowledge of the exclusion or suspension. 4.10.6 All provider clean claims must be adjudicated (finalized as paid or denied adjudicated) within 30 days from the date the claim is received by HMO. HMO must pay providers interest on a clean claim that which is not adjudicated within 30 days from either: (1) the date the HMO receives the clean claim, or (2) the date the claim is received by HMO or becomes clean. HMO must pay providers interest clean at an a rate of 1.5% per month (18% annual rate, calculated daily annual) for the full period in which each month the clean claim remains unadjudicated beyond the 30-day claims processing deadline. HMO must comply with the Texas Medicaid Managed Care Claims Manual to determine the principal amount for the interest payment computationunadjudicated. HMO will be held to a minimum performance level of 90% of all clean claims paid or denied within 30 days of receipt and 99% of all clean claims paid or denied within 90 days of receipt. Failure to meet these performance levels is a default under this contract and could lead to damages or sanctions as outlined in Article 17XVII. The performance levels are subject to changes if required to comply with federal and state laws or regulations. 4.10.6.1 All claims and appeals submitted to HMO and claims processing subcontractors must be paid-adjudicated (clean claims), denied-adjudicated (clean claims), or denied for additional information (unclean claims) to providers within 30 days from the date the claim is received by HMO. Providers must be sent a written notice for each claim that is denied for additional information (unclean claims) identifying the claim, all reasons why the claim is being denied, the date the claim was received by HMO, all information required from the provider in order for HMO to adjudicate the claim, and the date by which the requested information must be received from the provider. 4.10.6.2 Claims that are suspended (pended internally) must be subsequently paid-adjudicated, denied-adjudicated, or denied for additional information (pended externally) within 30 days from date of receipt. No claim can be suspended for a period exceeding 30 days from date of receipt of the claim.. 12/21/00 4.10.6.3 HMO must identify each data field of each claim form that is required from the provider in order for HMO to adjudicate the claim. HMO must inform all network providers about the required fields no later than 30 days prior to the effective date of the contract or as a provision within HMO/provider contract. Out-of-network providers must be informed of all required fields if the claim is denied for additional information. The required fields must include those required by HMO and HHSCTDH. 4.10.7 HMO is subject to Article 16XVI, Default and Remedies, for claims that are not processed on a timely basis as required by this contract and the Claims Manual. Notwithstanding the provisions of Section Articles 4.10.4, HMO's failure to adjudicate (paid, denied, or external pended) at least ninety percent (90%) of all claims within thirty (30) days of receipt 4.10.4.1 and ninety-nine percent (99%) within ninety (90) days of receipt for the contract year to date is a default under Article 16 of this contract4. 4.10.8 HMO must comply with the standards adopted by the U.S. Department of Health and Human Services under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, regarding submitting and receiving claims information through electronic data interchange (EDI) that allows for automated processing and adjudication of claims within the federally mandated timeframes (see 45 C.F.R. parts 160 through 164). 4.10.9 For claims requirements regarding retroactive PCP changes for mandatory Members, see Section 7.8.12.2.

Claims Processing Requirements. 4.10.1 HMO and claims processing subcontractors must comply with 28 TAC Chapter 21, Subchapter T regarding xx.xx. 21.2801 through 21.2816 "Submission of Clean Claims", to the extent these rules they are not in conflict with provisions of this contract. 4.10.2 HMO must use a HHSC TDH approved or identified claim format that contains all data fields for final adjudication of the claim. The required data fields must be Page 34 of 173 complete and accurate. The HHSC TDH required data fields are identified in HHSCTDH's "HMO Encounter Data Claims Submission Manual." 4.10.3 HMO and claims processing subcontractors must comply with HHSCTDH's Texas Medicaid Managed Care Claims Manual (Claims Manual), as amended or modified. The Claims Manual is incorporated herein by reference and which contains HHSCTDH's claims processing and reporting requirements. HHSC will provide the HMO reasonable notice of must comply with any changes to the Claims Manual. For purposes of this section only, "reasonable notice" will generally mean 60 days advance written Manual with appropriate notice of system changes and 30 days advance written notice of other changes, unless in HHSC's sole discretion, changes in federal or state laws, rules, regulations, or policies warrant a shorter time period for noticefrom TDH. 4.10.4 HMO must forward claims submitted to HMO in error to either: 1) the correct HMO HMO, if the correct HMO can be determined from the claim or is otherwise known to HMO; 2) the State's claims administrator; or 3) the provider who submitted the claim in error, along with an explanation of why the claim is being returned. 4.10.5 HMO must not pay any claim submitted by a provider who has been excluded or suspended from the Medicare or Medicaid programs for fraud and abuse when HMO has knowledge of the exclusion or suspension. 4.10.6 All provider clean claims must be adjudicated (finalized as paid or denied adjudicated) within 30 days from the date the claim is received by HMO. HMO must pay providers interest on a clean claim that which is not adjudicated within 30 days from either: (1) the date the HMO receives the clean claim, or (2) the date the claim is received by HMO or becomes clean. HMO must pay providers interest clean at an a rate of 1.5% per month (18% annual rate, calculated daily annual) for the full period in which each month the clean claim remains unadjudicated beyond the 30-day claims processing deadline. HMO must comply with the Texas Medicaid Managed Care Claims Manual to determine the principal amount for the interest payment computationunadjudicated. HMO will be held to a minimum performance level of 90% of all clean claims paid or denied within 30 days of receipt and 99% of all clean claims paid or denied within 90 days of receipt. Failure to meet these performance levels is a default default: under this contract and could lead to damages or sanctions as outlined in Article 17XVI. The performance levels are subject to changes if required to comply with federal and state laws or regulations. 4.10.6.1 All claims and appeals submitted to HMO and claims processing subcontractors must be paid-adjudicated (clean claims), denied-adjudicated (clean claims), or denied for additional information (unclean claims) to providers within 30 days from the date the claim is received by HMO. Providers must be sent a written notice for each claim that is denied for additional information (unclean claims) identifying the claim, all reasons why the claim is being denied, the date the claim was received by HMO, all information required from the provider in order for HMO to adjudicate the claim, and the date by which the requested information must be received from the provider. 4.10.6.2 Claims that are suspended (pended internally) must be subsequently paid-adjudicated, denied-adjudicated, or denied for additional information (pended externally) within 30 days from date of receipt. No claim can be suspended for a period exceeding 30 days from date of receipt of the claim. 4.10.6.3 HMO must identify each data field of each claim form that is s required from the provider in order for HMO to adjudicate the claim. HMO must inform all network providers about the required fields no later than 30 days prior to the effective date of the contract or as a provision within HMO/provider contract. Out-of-network providers must be informed of all required fields if the claim is denied for additional information. The required fields must include those required by HMO and HHSCTDH. 4.10.7 HMO is subject to Article 16XVI, Default and Remedies, for claims that are not processed on a timely basis as required by this contract and the Claims Manual. Notwithstanding the provisions of Section Articles 4.10.4, HMO's failure to adjudicate (paid, denied, or external pended) at least ninety percent (90%) of all claims within thirty (30) days of receipt 4.10.4.1 and ninety-nine percent (99%) within ninety (90) days of receipt for the contract year to date is a default under Article 16 of this contract4. 4.10.8 HMO must comply with the standards adopted by the U.S. Department of Health and Human Services under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, regarding submitting and receiving claims information through electronic data interchange (EDI) that allows for automated processing and adjudication of claims within the federally mandated timeframes (see 45 C.F.R. parts 160 through 164). 4.10.9 For claims requirements regarding retroactive PCP changes for mandatory Members, see Section 7.8.12.2.

Claims Processing Requirements. 4.10.1 HMO and claims processing subcontractors must comply with 28 TAC Chapter 21, Subchapter T regarding "Submission of Clean Claims", to the extent these rules are not in conflict with provisions of this contract. 4.10.2 HMO must use a HHSC approved or identified claim format that contains all data fields for final adjudication of the claim. The required data fields must be Page 34 of 173 complete and accurate. The HHSC required data fields are identified in HHSC's "HMO Encounter Data Claims Submission Manual." 4.10.3 HMO and claims processing subcontractors must comply with HHSCTDH's Texas Medicaid Managed Care Claims Manual (Claims Manual), as amended or modified. The Claims Manual is incorporated herein by reference and which contains HHSCTDH's claims processing and reporting requirements. HHSC will provide the HMO reasonable notice of must comply with any changes to the Claims Manual. For purposes of this section only, "reasonable notice" will generally mean 60 days advance written Manual with appropriate notice of system changes and 30 days advance written notice of other changes, unless in HHSC's sole discretion, changes in federal or state laws, rules, regulations, or policies warrant a shorter time period for noticefrom TDH. 4.10.4 4.10.2 HMO must forward claims submitted to HMO in error to either: 1) the correct HMO if the correct HMO can be determined from the claim or is otherwise known to HMO; 2) the State's claims administrator; or 3) the provider who submitted the claim in error, along with an explanation of why the claim is being returned. 4.10.5 4.10.3 HMO must not pay any claim submitted by a provider who has been excluded or suspended from the Medicare or Medicaid programs for fraud and abuse when HMO has knowledge of the exclusion or suspension. 4.10.6 4.10.4 All provider clean claims must be adjudicated (finalized as paid or denied adjudicated) within 30 days from the date the claim is received by HMO. HMO must pay providers interest on a clean claim that which is not adjudicated within 30 days from either: (1) the date the HMO receives the clean claim, or (2) the date the claim is received by HMO or becomes clean. HMO must pay providers interest clean at an a rate of 1.5% per month (18% annual rate, calculated daily annual) for the full period in which each month the clean claim remains unadjudicated beyond the 30-day claims processing deadline. HMO must comply with the Texas Medicaid Managed Care Claims Manual to determine the principal amount for the interest payment computationunadjudicated. HMO will be held to a minimum performance level of 90% of all clean claims paid or denied within 30 days of receipt and 99% of all clean claims paid or denied within 90 days of receipt. Failure to meet these performance levels is a default under this contract and could lead to damages or sanctions as outlined in Article 17XVII. The performance levels are subject to changes if required to comply with federal and state laws or regulations. 4.10.6.1 4.10.4.1 All claims and appeals submitted to HMO and claims processing subcontractors must be paid-adjudicated (clean claims), denied-adjudicated (clean claims), or denied for additional information (unclean claims) to providers within 30 days from the date the claim is received by HMO. Providers must be sent a written notice for each claim that is denied for additional information (unclean claims) identifying the claim, all reasons why the claim is being denied, the date the claim was received by HMO, all information required from the provider in order for HMO to adjudicate the claim, and the date by which the requested information must be received from the provider. 4.10.6.2 4.10.4.2 Claims that are suspended (pended internally) must be subsequently paid-adjudicated, denied-adjudicated, or denied for additional information (pended externally) within 30 days from date of receipt. No claim can be suspended for a period exceeding 30 days from date of receipt of the claim.. 1999 Renewal Contract Tarrant Service Area 32 August 9, 1999 33 4.10.6.3 4.10.4.3 HMO must identify each data field of each claim form that is required from the provider in order for HMO to adjudicate the claim. HMO must inform all network providers about the required fields no later than 30 days prior to the effective date of the contract or as a provision within HMO/provider contract. Out-of-network providers must be informed of all required fields if the claim is denied for additional information. The required fields must include those required by HMO and HHSCTDH. 4.10.7 4.10.5 HMO is subject to Article 16XVI, Default and Remedies, for claims that are not processed on a timely basis as required by this contract and the Claims Manual. Notwithstanding the provisions of Section Articles 4.10.4, HMO's failure to adjudicate (paid, denied, or external pended) at least ninety percent (90%) of all claims within thirty (30) days of receipt 4.10.4.1 and ninety-nine percent (99%) within ninety (90) days of receipt for the contract year to date is a default under Article 16 of this contract4. 4.10.8 HMO must comply with the standards adopted by the U.S. Department of Health and Human Services under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, regarding submitting and receiving claims information through electronic data interchange (EDI) that allows for automated processing and adjudication of claims within the federally mandated timeframes (see 45 C.F.R. parts 160 through 164). 4.10.9 For claims requirements regarding retroactive PCP changes for mandatory Members, see Section 7.8.12.2.

Claims Processing Requirements. 4.10.1 HMO and claims processing subcontractors Subcontractors must comply with 28 TAC Chapter 21, Subchapter T regarding "Submission of Clean Claims", to the extent these rules are not in conflict with provisions of this contract. 4.10.2 HMO must use a HHSC approved or identified claim format that contains all data fields for final adjudication of the claim. The required data fields must be Page 34 of 173 complete and accurate. The HHSC required data fields are identified in HHSC's "HMO Encounter Data Claims Submission Manual." 4.10.3 HMO and claims processing subcontractors must comply with HHSCTDH's Texas Medicaid Managed Care Claims Manual (Claims Manual), as amended or modified. The Claims Manual is incorporated herein by reference and which contains HHSCTDH's claims processing and reporting requirements. HHSC will provide the HMO reasonable notice of changes to the Claims Manual. For purposes of this section only, "reasonable notice" will generally mean 60 days advance written notice of system changes and 30 days advance written notice of other changes, unless in HHSC's sole discretion, changes in federal or state laws, rules, regulations, or policies warrant a shorter time period for notice. 4.10.4 4.10.2 HMO must forward claims submitted to HMO in error to either: 1) the correct HMO if the correct HMO can be determined from the claim or is otherwise known to HMO; 2) the State's claims administrator; or 3) the provider who submitted the claim in error, along with an explanation of why the claim is being returned. 4.10.5 4.10.3 HMO must not pay any claim submitted by a provider who is under investigation for or has been excluded or suspended from the Medicare or Medicaid programs for fraud and abuse when HMO has knowledge is on actual or constructive notice of the investigation, exclusion or suspension. 4.10.6 4.10.4 All provider clean claims must be adjudicated (finalized as paid or denied adjudicated) within 30 days from the date the claim is received by HMO. HMO must pay providers interest on a clean claim that which is not adjudicated within 30 days from either: (1) the date the HMO receives the clean claim, or (2) the date the claim is received by HMO or becomes clean. HMO must pay providers interest clean at an a rate of 1.5% per month (18% annual rate, calculated daily annual) for the full period in which each month the clean claim remains unadjudicated beyond the 30-day claims processing deadline. HMO must comply with the Texas Medicaid Managed Care Claims Manual to determine the principal amount for the interest payment computation. HMO will be held to a minimum performance level of 90% of all clean claims paid or denied within 30 days of receipt and 99% of all clean claims paid or denied within 90 days of receipt. Failure to meet these performance levels is a default under this contract and could lead to damages or sanctions as outlined in Article 17. The performance levels are subject to changes if required to comply with federal and state laws or regulationsunadjudicated. 4.10.6.1 4.10.4.1 All claims and appeals submitted to HMO and claims processing subcontractors Subcontractors must be paid-adjudicated (clean claims), denied-adjudicated (clean claims), or denied for additional information (unclean claims) to providers within 30 days from the date the claim is received by HMO. Providers must be sent a written notice for each claim that is denied for additional information (unclean claims) identifying the claim, all reasons why the claim is being denied, the date the claim was received by HMO, all information required from the provider in order for HMO to adjudicate the claim, and the date by which the requested information must be received from the provider. 4.10.6.2 4.10.4.2 Claims that are suspended (pended internally) must be subsequently paid-adjudicated, denied-adjudicated, or denied for additional information (pended externally) within El Paso Service Area HMO Contract 30 days from date of receipt. No claim can be suspended for a period exceeding 30 days from date of receipt of the claim. 4.10.6.3 4.10.4.3 HMO must identify each data field of each claim form that is required from the provider in order for HMO to adjudicate the claim. HMO must inform all network providers about the required fields no later than at least 30 days prior to the effective date of the contract service area Implementation Date or as a provision within HMO/provider contract. Out-of-Out of network providers must be informed of all required fields if the claim is denied for additional information. The required fields must include those required by HMO and HHSCTDH. 4.10.7 4.10.5 HMO is subject to the Remedies and Sanctions Article 16, Default and Remedies, of this contract for claims that are not processed on a timely basis as required by this contract and the Claims Manual. Notwithstanding the provisions of Section 4.10.4, HMO's failure to adjudicate (paid, denied, or external pended) at least ninety percent (90%) of all claims within thirty (30) days of receipt and ninety-nine percent (99%) within ninety (90) days of receipt for the contract year to date is a default under Article 16 of this contract. 4.10.8 4.10.6 HMO must comply with offer to its Subcontractors the standards adopted by the U.S. Department option of Health and Human Services under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, regarding submitting and receiving claims information through electronic data interchange (EDI) that allows for automated processing and adjudication of claims within claims. EDI processing must be offered as an alternative to the federally mandated timeframes (see 45 C.F.R. parts 160 through 164)filing of paper claims. 4.10.9 For claims requirements regarding retroactive PCP changes for mandatory Members, see Section 7.8.12.2.

Claims Processing Requirements. 4.10.1 HMO and claims processing subcontractors Subcontractors must comply with 28 TAC Chapter 21, Subchapter T regarding "Submission of Clean Claims", to the extent these rules are not in conflict with provisions of this contract. 4.10.2 HMO must use a HHSC approved or identified claim format that contains all data fields for final adjudication of the claim. The required data fields must be Page 34 of 173 complete and accurate. The HHSC required data fields are identified in HHSC's "HMO Encounter Data Claims Submission Manual." 4.10.3 HMO and claims processing subcontractors must comply with HHSC's Texas Medicaid Managed Care Claims Manual (Claims Manual), as amended or modifiedwhich contains claims processing requirements. The HMO must comply with any changes to Claims Manual is incorporated herein by reference and contains HHSC's claims processing and reporting requirements. HHSC will provide the HMO reasonable with appropriate notice of changes to the Claims Manual. For purposes of this section only, "reasonable notice" will generally mean 60 days advance written notice of system changes and 30 days advance written notice of other changes, unless in HHSC's sole discretion, changes in federal or state laws, rules, regulations, or policies warrant a shorter time period for notice. 4.10.4 HMO must forward claims submitted to HMO in error to either: 1) the correct HMO if the correct HMO can be determined from the claim or is otherwise known to HMO; 2) the State's claims administrator; or 3) the provider who submitted the claim in error. TDHS/HMO CONTRACT August 11, along with an explanation of why the claim is being returned.1999 4.10.5 4.10.2 HMO must not pay any claim submitted by a provider who has been excluded or suspended from the Medicare or Medicaid programs for fraud and abuse when the HMO has knowledge of the exclusion or suspension. 4.10.6 4.10.3 All provider clean claims must be adjudicated (finalized as paid or denied adjudicated) within 30 days from the date the claim is received by the HMO. HMO must pay providers interest on a clean claim that which is not adjudicated within 30 days from either: (1) the date the HMO receives the clean claim, or (2) the date the claim is received by the HMO or becomes clean. HMO must pay providers interest clean at an a rate of 1.5% per month (18% annual rate, calculated daily annual) for the full period in which each month the clean claim remains unadjudicated beyond the 30-day claims processing deadline. HMO must comply with the Texas Medicaid Managed Care Claims Manual to determine the principal amount for the interest payment computationunadjudicated. HMO will be held to a minimum performance level of 90% of all clean claims paid or denied within 30 days of receipt and 99% of all clean claims paid or denied within 90 days of receipt. Failure to meet these performance levels is a default under this contract and could lead to damages or sanctions as outlined in Article 17XVII. The performance levels are subject to changes if required to comply with federal and state laws or regulations. 4.10.6.1 4.10.3.1 All claims and appeals submitted to HMO and claims processing subcontractors must be paid-adjudicated (clean claims), denied-adjudicated (clean claims), or denied for additional information (unclean claims) to providers within 30 days from the date the claim is received by HMO. Providers must be sent a written notice for each claim that is denied for additional information (unclean claims) identifying the claim, all reasons why the claim is being denied, the date the claim was received by HMO, all information required from the provider in order for the HMO to adjudicate the claim, and the date by which the requested information must be received from the provider. 4.10.6.2 4.10.3.2 Claims that are suspended (pended internally) must be subsequently paid-adjudicated, denied-adjudicated, or denied for additional information (pended externally) within 30 days from date of receipt. No claim can be suspended for a period exceeding 30 days from date of receipt of the claim. 4.10.6.3 4.10.3.3 HMO must identify each data field of each claim form that is required from the provider in order for the HMO to adjudicate the claim. HMO must inform all network providers about the required fields no later than 30 days prior to the effective date of the contract or as a provision within the HMO/provider contract. Out-of-Out of network providers must be informed of all required fields if the claim is denied for additional information. The required fields must include those required by the HMO and HHSCTDHS. 4.10.7 4.10.4 HMO is subject to the Remedies and Sanctions Article 16, Default and Remedies, of this contract for claims that are not processed on a timely basis as required by this contract and the Claims Manual. Notwithstanding Not withstanding the provisions of Section 4.10.4Articles 4.10.3, HMO's failure to adjudicate (paid4.10.3.1 and 4.10.3.2, denied, or external pended) sanctions will be applied if at least ninety percent (90%) of all claims are not adjudicated (paid, denied, or external pended) within thirty (30) days of receipt and ninety-ninety nine percent (99%) within with in ninety (90) days of receipt for the contract year to date is date. TDHS/HMO CONTRACT August 11, 1999 4.10.5 HMO agrees that when it receives written notification from TDHS that a default under Article 16 of this contractprovider's funds be held because the provider has changed ownership, has an unpaid judgment, sanction, monetary penalty or audit exception, or has failed to meet some other legal requirement, the HMO will place the provider's funds on hold until it receives further notification from TDHS. Upon notification to the HMO, the HMO must either pay the claim or remit the held funds to TDHS. 4.10.8 4.10.6 HMO must comply with the standards adopted by the U.S. Department of Health and Human Services under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, regarding submitting and receiving claims information through electronic data interchange (EDI) that allows for automated processing and adjudication of claims within two or three years, as applicable, from the federally mandated timeframes (see 45 C.F.R. parts 160 through 164)date the rules promulgated under HIPAA are adopted. 4.10.9 For claims requirements regarding retroactive PCP changes for mandatory Members, see Section 7.8.12.2.

Claims Processing Requirements. 4.10.1 HMO and claims processing subcontractors must comply with 28 TAC Chapter 21, Subchapter T regarding "Submission of Clean Claims", to the extent these rules are not in conflict with provisions of this contract. 4.10.2 HMO must use a HHSC approved or identified claim format that contains all data fields for final adjudication of the claim. The required data fields must be Page 34 of 173 complete and accurate. The HHSC required data fields are identified in HHSC's "HMO Encounter Data Claims Submission Manual." 4.10.3 HMO and claims processing subcontractors must comply with HHSCTDH's Texas Medicaid Managed Care Claims Manual (Claims Manual), as amended or modified. The Claims Manual is incorporated herein by reference and which contains HHSCTDH's claims processing and reporting requirements. HHSC will provide the HMO reasonable notice of changes to the Claims Manual. For purposes of this section only, "reasonable notice" will generally mean 60 days advance written notice of system changes and 30 days advance written notice of other changes, unless in HHSC's sole discretion, changes in federal or state laws, rules, regulations, or policies warrant a shorter time period for notice. 4.10.4 4.10.2 HMO must forward claims submitted to HMO in error to either: 1) either the correct HMO if the correct HMO can be determined from the claim or is otherwise known to HMO; 2) HMO or the State's claims administrator; or 3) to the provider who submitted the claim in error, along with an explanation of why the claim is being returned. 4.10.5 4.10.3 HMO must not pay any claim submitted by a provider who is under investigation for or has been excluded or suspended from the Medicare or Medicaid programs for fraud and abuse when HMO has knowledge is on actual or constructive notice of the investigation, exclusion or suspension. 4.10.6 4.10.4 All provider clean claims must be adjudicated (finalized as paid or denied adjudicated) within 30 days from the date the claim is received by HMO. HMO must pay providers interest on a clean claim that which is not adjudicated within 30 days from either: (1) the date the HMO receives the clean claim, or (2) the date the claim is received by HMO or becomes clean. HMO must pay providers interest clean at an a rate of 1.5% per month (18% annual rate, calculated daily annual) for the full period in which each month the clean claim remains unadjudicated beyond the 30-day claims processing deadline. HMO must comply with the Texas Medicaid Managed Care Claims Manual to determine the principal amount for the interest payment computation. HMO will be held to a minimum performance level of 90% of all clean claims paid or denied within 30 days of receipt and 99% of all clean claims paid or denied within 90 days of receipt. Failure to meet these performance levels is a default under this contract and could lead to damages or sanctions as outlined in Article 17. The performance levels are subject to changes if required to comply with federal and state laws or regulationsunadjudicated. 4.10.6.1 4.10.4.1 All claims and appeals submitted to HMO and claims processing subcontractors must be paid-paid- adjudicated (clean claims), denied-adjudicated (clean claims), or denied for additional information (unclean claims) to providers within 30 days from the date the claim is received by HMO. Providers must be sent a written notice for each claim that is denied for additional information (unclean claims) identifying the claim, all reasons why the claim is being denied, the date the claim was received by HMO, all information required from the provider in order for HMO to adjudicate the claim, and the date by which the requested information must be received from the provider. 4.10.6.2 4.10.4.2 Claims that are suspended (pended internally) must be subsequently paid-adjudicated, denied-denied- adjudicated, or denied for additional information (pended externally) within 30 days from date of receipt. No claim can be suspended for a period exceeding 30 days from date of receipt of the claim. 4.10.6.3 4.10.4.3 HMO must identify each data field of each claim form that is required from the provider in order for HMO to adjudicate the claim. HMO must inform all network providers about the required fields no later than at least 30 days prior to the effective date of the contract service area Implementation Date or as a provision within HMO/provider contract. Out-of-Out of network providers must be informed of all required fields if the claim is denied for Dallas Service Area Contract 29 additional information. The required fields must include those required by HMO and HHSCTDH. 4.10.7 4.10.5 HMO is subject to the Remedies and Sanctions Article 16, Default and Remedies, of this Contract for claims that are not processed on a timely basis as required by this contract Contract and the Claims Manual. Notwithstanding the provisions of Section 4.10.4, HMO's failure to adjudicate (paid, denied, or external pended) at least ninety percent (90%) of all claims within thirty (30) days of receipt and ninety-nine percent (99%) within ninety (90) days of receipt for the contract year to date is a default under Article 16 of this contract. 4.10.8 4.10.6 HMO must comply with offer to its Subcontractors the standards adopted by the U.S. Department option of Health and Human Services under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, regarding submitting and receiving claims information through electronic data interchange (EDI) that allows for automated processing and adjudication of claims within claims. EDI processing must be offered as an alternative to the federally mandated timeframes (see 45 C.F.R. parts 160 through 164)filing of paper claims. 4.10.9 For claims requirements regarding retroactive PCP changes for mandatory Members, see Section 7.8.12.2.