Common use of Claims Processing Requirements Clause in Contracts

Claims Processing Requirements. The MCO must process and adjudicate all provider claims for Medically Necessary health care Covered Services that are filed within the timeframes specified in Uniform Managed Care Manual Chapter 2.0, "Claims Manual," and pharmacy claims in that are filed in accordance with the timeframes specified in Uniform Managed Care Manual Chapter 2.2, "Pharmacy Claims Manual." The MCO is subject to contractual remedies, including liquidated damages and interest, if the MCO does not process and adjudicate claims in accordance with the procedures and the timeframes listed in Uniform Managed Care Manual Chapters 2.0 and 2.2. The MCO must administer an effective, accurate, and efficient claims payment process in compliance with federal laws and regulations, applicable state laws and rules, and the Contract, including Uniform Managed Care Manual Chapters 2.0 and 2.2. In addition, a Medicaid MCO must be able to accept and process provider claims in compliance with the Texas Medicaid Provider Procedures Manual. The MCO and its Subcontractors cannot directly or indirectly charge or hold a Member or Provider responsible for claims adjudication or transaction fees. The MCO must maintain an automated claims processing system that registers the date a claim is received by the MCO the detail of each claim transaction (or action) at the time the transaction occurs, and has the capability to report each claim transaction by date and type to include interest payments. The claims system must maintain information at the claim and line detail level. The claims system must maintain adequate audit trails and report accurate claims performance measures to HHSC. The MCO's claims system must maintain online and archived files. The MCO must keep online automated claims payment history for the most current 18 months. The MCO must retain other financial information and records, including all original claims forms, for the time period established in Attachment A, "Uniform Managed Care Contract Terms and Conditions," Section 9.01, "Record Retention and Audit." All claims data must be easily sorted and produced in formats as requested by HHSC. The MCO must offer its Providers/Subcontractors the option of submitting and receiving claims information through electronic data interchange (EDI) that allows for automated processing and adjudication of claims. EDI processing must be offered as an alternative to the filing of paper claims. Electronic claims must use HIPAA-compliant electronic formats. HHSC reserves the right to require the MCO to receive initial electronic claims through an HHSC-contracted vendor at a future date. This function will allow Providers to send claims to one location, which will then identify where the claim should be submitted. The MCO will be expected to have an interface that allows receipt of these electronic submissions. If HHSC implements this requirement, then the MCO must maintain a mechanism to receive claims in addition to the HHSC claims portal. Providers must be able to send claims directly to the MCO or its Subcontractor. The MCO must provide a web portal that supports Batch Processing for Network Providers. Batch Processing is a billing technique that uses a single program loading to process many individual jobs, tasks, or requests for service. Specifically in managed care, batch billing is a technique that allows providers to send billing information all at once in a "batch" rather than in separate individual transactions. The MCO must make an electronic funds transfer (EFT) payment process (for direct deposit) available to Network Providers.

Claims Processing Requirements. The MCO must process and adjudicate all provider claims for Medically Necessary health care Covered Services that are filed within the timeframes specified in Uniform Managed Care Manual Chapter 2.0, "“Claims Manual," ” and pharmacy claims in that are filed in accordance with the timeframes specified in Uniform Managed Care Manual Chapter 2.2, "“Pharmacy Claims Manual." ” The MCO is subject to contractual remedies, including liquidated damages and interest, if the MCO does not process and adjudicate claims in accordance with the procedures and the timeframes listed in Uniform Managed Care Manual Chapters 2.0 and 2.2. The MCO must administer an effective, accurate, and efficient claims payment process in compliance with federal laws and regulations, applicable state laws and rules, and the Contract, including Uniform Managed Care Manual Chapters 2.0 and 2.2. In addition, a Medicaid MCO must be able to accept and process provider claims in compliance with the Texas Medicaid Provider Procedures Manual. The MCO Manual and its Subcontractors cannot directly or indirectly charge or hold a Member or Provider responsible for claims adjudication or transaction feesTexas Medicaid Bulletins. The MCO must maintain an automated claims processing system that registers the date a claim is received by the MCO the detail of each claim transaction (or action) at the time the transaction occurs, and has the capability to report each claim transaction by date and type to include interest payments. The claims system must maintain information at the claim and line detail level. The claims system must maintain adequate audit trails and report accurate claims performance measures to HHSC. The MCO's ’s claims system must maintain online and archived files. The MCO must keep online automated claims payment history for the most current 18 months. The MCO must retain other financial information and records, including all original claims forms, for the time period established in Attachment A, "Uniform Managed Care Contract Terms and Conditions," Section 9.01, "“Record Retention and Audit." ” All claims data must be easily sorted and produced in formats as requested by HHSC. The MCO must offer its Providers/Subcontractors the option of submitting and receiving claims information through electronic data interchange (EDI) that allows for automated processing and adjudication of claims. EDI processing must be offered as an alternative to the filing of paper claims. Electronic claims must use HIPAA-compliant electronic formats. HHSC reserves the right to require the MCO to receive initial electronic claims through an HHSC-contracted vendor at a future date. This function will allow Providers to send claims to one location, which will then identify where the claim should be submitted. The MCO will be expected to have an interface that allows receipt of these electronic submissions. If HHSC implements this requirement, then the MCO must maintain a mechanism to receive claims in addition to the HHSC claims portal. Providers must be able to send claims directly to the MCO or its Subcontractor. The MCO must provide a web portal that supports Batch Processing for Network Providers. Batch Processing is a billing technique that uses a single program loading to process many individual jobs, tasks, or requests for service. Specifically in managed care, batch billing is a technique that allows providers to send billing information all at once in a "“batch" ” rather than in separate individual transactions. The MCO must make an electronic funds transfer (EFT) payment process (for direct deposit) available to Network Providers.

Claims Processing Requirements. The MCO must process and adjudicate all provider claims for Medically Necessary health care Covered Services that are filed within the timeframes specified in Uniform Managed Care Manual Chapter 2.0, "Claims Manual," , and pharmacy claims in that are filed in accordance with the timeframes specified in Uniform Managed Care Manual Chapter 2.2, "Pharmacy Claims Manual." , and beginning September 1, 2014, Nursing Facility claims that are filed in accordance with the timeframes specified in Uniform Managed Care Manual Chapter 2.3, Nursing Facility Claims Manual. The MCO is subject to contractual remedies, including liquidated damages and interest, if the MCO does not process and adjudicate claims in accordance with the procedures and the timeframes listed in Uniform Managed Care Manual Chapters 2.0 2.0, 2.1, 2.2, and 2.22.3. The MCO must administer an effective, accurate, and efficient claims payment process in compliance with federal laws and regulations, applicable state laws and rules, and the Contract, including Uniform Managed Care Manual Chapters 2.0 2.0, 2.1, 2.2, and 2.22.3. In addition, a Medicaid MCO must be able to accept and process provider claims in compliance with the Texas Medicaid Provider Procedures Manual. The MCO and its Subcontractors cannot directly or indirectly charge or hold a Member or Provider responsible for claims adjudication or transaction fees. The MCO must maintain an automated claims processing system that registers the date a claim is received by the MCO the detail of each claim transaction (or action) at the time the transaction occurs, and has the capability to report each claim transaction by date and type to include interest payments. The claims system must maintain information at the claim and line detail level. The claims system must maintain adequate audit trails and report accurate claims performance measures to HHSC. The MCO's claims system must maintain online and archived files. The MCO must keep online automated claims payment history for the most current 18 months. The MCO must retain other financial information and records, including all original claims forms, for the time period established in Attachment A, "Uniform Managed Care Contract Terms and Conditions," Section 9.01, "Record Retention and Audit." All claims data must be easily sorted and produced in formats as requested by HHSC. The MCO must offer its Providers/Subcontractors the option of submitting and receiving claims information through electronic data interchange (EDI) that allows for automated processing and adjudication of claims. EDI processing must be offered as an alternative to the filing of paper claims. Electronic claims must use HIPAA-compliant electronic formats. HHSC reserves the right to require the MCO to receive initial electronic claims through an HHSC-contracted vendor at a future date. This function will allow Providers to send claims to one location, which will then identify where the claim should be submitted. The MCO will be expected to have an interface that allows receipt of these electronic submissions. If HHSC implements this requirement, then the MCO must maintain a mechanism to receive claims in addition to the HHSC claims portal. Providers must be able to send claims directly to the MCO or its Subcontractor. The MCO must provide a web provider portal that supports Batch Processing functionality to reduce administrative burden on Network Providers at no cost to the Providers. A provider portal brings information together from diverse sources in a uniform way. The provider portal functionality must include the following. • Client eligibility verification • Submission of electronic claims • Prior Authorization requests • Claims appeals and reconsiderations • Exchange of clinical data and other documentation necessary for Network Providersprior authorization and claim processing To the extent possible, the provider portal should support both online and batch processing as applicable to the information being exchanged. Batch Processing is a billing technique that uses a single program loading to process many individual jobs, tasks, or requests for service. Specifically in managed care, batch billing is a technique that allows providers Providers to send billing information all at once in a "batch" batch rather than in separate individual transactions. To facilitate the exchange of clinical data and other relevant documentation, the Provider Portal must provide a secure exchange of information between the Provider and MCO, including, as applicable, a Subcontractor of the MCO. The MCO must make an electronic funds transfer (EFT) payment process (for direct deposit) available to Network Providers.. The MCO may deny a claim submitted by a provider for failure to file in a timely manner as provided for in Uniform Managed Care Manual Chapters 2.0, 2.1, 2.2, and 2.3. The MCO must not pay any claim submitted by a provider:

Claims Processing Requirements. The MCO must process and adjudicate all provider claims for Medically Necessary health care Covered Services that are filed within the timeframes specified in Uniform Managed Care Manual Chapter 2.0, "“Claims Manual," ” and pharmacy claims in that are filed in accordance with the timeframes specified in Uniform Managed Care Manual Chapter 2.2, "“Pharmacy Claims Manual." ” The MCO is subject to contractual remedies, including liquidated damages and interest, if the MCO does not process and adjudicate claims in accordance with the procedures and the timeframes listed in Uniform Managed Care Manual Chapters 2.0 and 2.2. The MCO must administer an effective, accurate, and efficient claims payment process in compliance with federal laws and regulations, applicable state laws and rules, and the Contract, including Uniform Managed Care Manual Chapters 2.0 and 2.2. In addition, a Medicaid MCO must be able to accept and process provider claims in compliance with the Texas Medicaid Provider Procedures Manual. The MCO Manual and its Subcontractors cannot directly or indirectly charge or hold a Member or Provider responsible for claims adjudication or transaction feesTexas Medicaid Bulletins. The MCO must maintain an automated claims processing system that registers the date a claim is received by the MCO the detail of each claim transaction (or action) at the time the transaction occurs, and has the capability to report each claim transaction by date and type to include interest payments. The claims system must maintain information at the claim and line detail level. The claims system must maintain adequate audit trails and report accurate claims performance measures to HHSC. The MCO's claims system must maintain online and archived files. The MCO must keep online automated claims payment history for the most current 18 months. The MCO must retain other financial information and records, including all original claims forms, for the time period established in Attachment A, "Uniform Managed Care Contract Terms and Conditions," Section 9.01, "“Record Retention and Audit." ” All claims data must be easily sorted and produced in formats as requested by HHSC. The MCO must offer its Providers/Subcontractors the option of submitting and receiving claims information through electronic data interchange (EDI) that allows for automated processing and adjudication of claims. EDI processing must be offered as an alternative to the filing of paper claims. Electronic claims must use HIPAA-compliant electronic formats. HHSC reserves the right to require the MCO to receive initial electronic claims through an HHSC-contracted vendor at a future date. This function will allow Providers to send claims to one location, which will then identify where the claim should be submitted. The MCO will be expected to have an interface that allows receipt of these electronic submissions. If HHSC implements this requirement, then the MCO must maintain a mechanism to receive claims in addition to the HHSC claims portal. Providers must be able to send claims directly to the MCO or its Subcontractor. The MCO must provide a web portal that supports Batch Processing for Network Providers. Batch Processing is a billing technique that uses a single program loading to process many individual jobs, tasks, or requests for service. Specifically in managed care, batch billing is a technique that allows providers to send billing information all at once in a "“batch" ” rather than in separate individual transactions. The MCO must make an electronic funds transfer (EFT) payment process (for direct deposit) available to Network Providers.

Claims Processing Requirements. The MCO must process and adjudicate all provider claims for Medically Necessary health care Covered Services that are filed within the timeframes specified in Uniform Managed Care Manual Chapter 2.0, "Claims Manual," , and pharmacy claims in that are filed in accordance with the timeframes specified in Uniform Managed Care Manual Chapter 2.2, "Pharmacy Claims Manual." , and beginning March 1, 2015, Nursing Facility claims that are filed in accordance with the timeframes specified in Uniform Managed Care Manual Chapter 2.3, Nursing Facility Claims Manual. The MCO is subject to contractual remedies, including liquidated damages and interest, if the MCO does not process and adjudicate claims in accordance with the procedures and the timeframes listed in Uniform Managed Care Manual Chapters 2.0 2.0, 2.1, 2.2, and 2.22.3. The MCO must administer an effective, accurate, and efficient claims payment process in compliance with federal laws and regulations, applicable state laws and rules, and the Contract, including Uniform Managed Care Manual Chapters 2.0 2.0, 2.1, 2.2, and 2.22.3. In addition, a Medicaid MCO must be able to accept and process provider claims in compliance with the Texas Medicaid Provider Procedures Manual. The MCO and its Subcontractors cannot directly or indirectly charge or hold a Member or Provider responsible for claims adjudication or transaction fees. The MCO must maintain an automated claims processing system that registers the date a claim is received by the MCO the detail of each claim transaction (or action) at the time the transaction occurs, and has the capability to report each claim transaction by date and type to include interest payments. The claims system must maintain information at the claim and line detail level. The claims system must maintain adequate audit trails and report accurate claims performance measures to HHSC. The MCO's claims system must maintain online and archived files. The MCO must keep online automated claims payment history for the most current 18 months. The MCO must retain other financial information and records, including all original claims forms, for the time period established in Attachment A, "Uniform Managed Care Contract Terms and Conditions," Section 9.01, "Record Retention and Audit." All claims data must be easily sorted and produced in formats as requested by HHSC. The MCO must offer its Providers/Subcontractors the option of submitting and receiving claims information through electronic data interchange (EDI) that allows for automated processing and adjudication of claims. EDI processing must be offered as an alternative to the filing of paper claims. Electronic claims must use HIPAA-compliant electronic formats. HHSC reserves the right to require the MCO to receive initial electronic claims through an HHSC-contracted vendor at a future date. This function will allow Providers to send claims to one location, which will then identify where the claim should be submitted. The MCO will be expected to have an interface that allows receipt of these electronic submissions. If HHSC implements this requirement, then the MCO must maintain a mechanism to receive claims in addition to the HHSC claims portal. Providers must be able to send claims directly to the MCO or its Subcontractor. The MCO must provide a web provider portal that supports Batch Processing functionality to reduce administrative burden on Network Providers at no cost to the Providers. A provider portal brings information together from diverse sources in a uniform way. The provider portal functionality must include the following. • Client eligibility verification • Submission of electronic claims • Prior Authorization requests • Claims appeals and reconsiderations • Exchange of clinical data and other documentation necessary for Network Providersprior authorization and claim processing To the extent possible, the provider portal should support both online and batch processing as applicable to the information being exchanged. Batch Processing is a billing technique that uses a single program loading to process many individual jobs, tasks, or requests for service. Specifically in managed care, batch billing is a technique that allows providers Providers to send billing information all at once in a "batch" batch rather than in separate individual transactions. To facilitate the exchange of clinical data and other relevant documentation, the Provider Portal must provide a secure exchange of information between the Provider and MCO, including, as applicable, a Subcontractor of the MCO. The MCO must make an electronic funds transfer (EFT) payment process (for direct deposit) available to Network Providers.. The MCO may deny a claim submitted by a provider for failure to file in a timely manner as provided for in Uniform Managed Care Manual Chapters 2.0, 2.1, 2.2, and 2.3. The MCO must not pay any claim submitted by a provider:

Claims Processing Requirements. The MCO must process and adjudicate all provider claims for Medically Necessary health care Covered Services that are filed within the timeframes specified in Uniform Managed Care Manual Chapter 2.0, "“Claims Manual," ” and pharmacy claims in that are filed in accordance with the timeframes specified in Uniform Managed Care Manual Chapter 2.2, "“Pharmacy Claims Manual." ” The MCO is subject to contractual remedies, including liquidated damages and interest, if the MCO does not process and adjudicate claims in accordance with the procedures and the timeframes listed in Uniform Managed Care Manual Chapters 2.0 and 2.2. The MCO must administer an effective, accurate, and efficient claims payment process in compliance with federal laws and regulations, applicable state laws and rules, and the Contract, including Uniform Managed Care Manual Chapters 2.0 and 2.2. In addition, a Medicaid MCO must be able to accept and process provider claims in compliance with the Texas Medicaid Provider Procedures Manual. The MCO Manual and its Subcontractors cannot directly or indirectly charge or hold a Member or Provider responsible for claims adjudication or transaction feesTexas Medicaid Bulletins. The MCO must maintain an automated claims processing system that registers the date a claim is received by the MCO the detail of each claim transaction (or action) at the time the transaction occurs, and has the capability to report each claim transaction by date and type to include interest payments. The claims system must maintain information at the claim and line detail level. The claims system must maintain adequate audit trails and report accurate claims performance measures to HHSC. The MCO's ’s claims system must maintain online and archived files. The MCO must keep online automated claims payment history for the most current 18 months. The MCO must retain other financial information and records, including all original claims forms, for the time period established in Attachment A, "Uniform Managed Care Contract Terms and Conditions," Section 9.01, "“Record Retention and Audit." ” All claims data must be easily sorted and produced in formats as requested by HHSC. The MCO must offer its Providers/Subcontractors the option of submitting and receiving claims information through electronic data interchange (EDI) that allows for automated processing and adjudication of claims. EDI processing must be offered as an alternative to the filing of paper claims. Electronic claims must use HIPAA-compliant electronic formats. HHSC reserves the right to require the MCO to receive initial electronic claims through an HHSC-contracted vendor at a future date. This function will allow Providers to send claims to one location, which will then identify where the claim should be submitted. The MCO will be expected to have an interface that allows receipt of these electronic submissions. If HHSC implements this requirement, then the MCO must maintain a mechanism to receive claims in addition to the HHSC claims portal. Providers must be able to send claims directly to the MCO or its Subcontractor. The MCO must provide a web portal that supports Batch Processing for Network Providers. Batch Processing is a billing technique that uses a single program loading to process many individual jobs, tasks, or requests for service. Specifically in managed care, batch billing is a technique that allows providers to send billing information all at once in a "“batch" ” rather than in separate individual transactions. The MCO must make an electronic funds transfer (EFT) payment process (for direct deposit) available to Network Providers.