Claims Submission and Payment. Members shall review and approve timesheets of their Providers to determine accuracy and appropriateness. No SDCB Provider shall exceed forty (40) hours paid work in a consecutive seven (7) Calendar Day period. Payments to SDCB Providers shall comply with State and federal minimum wage statutes and regulations. Timesheets must be submitted and processed on a two (2) week pay schedule according to HCA’s prescribed payroll payment schedule. The FMA shall be responsible for processing payments for approved services and goods. The CONTRACTOR shall reimburse the FMA for authorized SDCB services provided by Providers at the appropriate rate for the self-directed HCBS, which includes applicable payroll taxes. Value Added Services The CONTRACTOR may offer Value Added Services to its Members that are not Covered Services (see Attachments 1 and 4). The CONTRACTOR is encouraged to consider the unique and unmet needs of Members and, where appropriate, their families or Caregivers when proposing Value Added Services. Value Added Services must be prior approved in writing by HCA. The cost of Value Added Services will not be included in the Capitation Rate. All Value Added Services shall be identifiable and measurable through the use of unique payment and/or processing codes, approved by HCA. At the CONTRACTOR’s request, HCA may assist in identifying a compliant code. The CONTRACTOR shall send Members notices of Adverse Benefit Determination regarding Value Added Services that comply with the requirements in the Managed Care Policy Manual. Denial of a Value Added Service will not be considered an Adverse Benefit Determination for purposes of Appeals or Fair Hearings. Provider Network
Claims Submission and Payment. Sections 4.1 and 4.2 of the Agreement are deleted in their entirety and the following are substituted therefor, and the following new Section 4.4 is added to the Agreement:
Claims Submission and Payment. Subject to Applicable Law, Provider agrees:
Claims Submission and Payment. CONTRACTOR must comply with article 20A.18B of the Texas Insurance Code regarding prompt payment of physicians and providers and any applicable regulations. Providers are required to comply with chapter 146 of the Texas Civil Practice and Remedies Code regarding timely billing.
Claims Submission and Payment. Provider shall comply with all claim submittal obligations of the State Contract. Provider shall promptly submit claims information needed to Company to make payment within six months of the Covered Service being provided to an Enrollee. Health Plan may not impose requirements to file claims within a shorter period. (State Contract 1.14.1.1). Except for those exceptions set forth in § 1.16.5 of the State Contract, resubmitted claims must be filed within an additional six months thereafter. (State Contract §§ 1.16.5 and 1.16.6)
Claims Submission and Payment. Section 4.1.4 is deleted in its entirety and the following is substituted therefor, and the following additional paragraph is added to Section 4.2, immediately following the end of subsection 4.2.4:
Claims Submission and Payment. Provide for prompt submission of claims information needed to make payment within six months of the covered service being provided to a Dental Health Plan Enrollee. • Performance-based Provider Payments/Incentive Plans. Describe, as applicable, any performance- based Provider payment(s)/incentive plan(s) to which the Participating Provider is subject.
Claims Submission and Payment. Pharmacy’s claims for Covered Services provided to Enrollees under this Agreement shall be processed and paid as follows:
Claims Submission and Payment. Pharmacies shall transmit to Pharmacy BenefitDirect at their expense, Claims conforming to the National Council for Prescription Drug Programs (“NCPDP”) standard format. “Claims” shall refer to the vehicle for transmitting prescription claim information to Pharmacy BenefitDirect by Pharmacies. Claims shall be submitted to Pharmacy BenefitDirect on a Universal Claim from “UCF” or for EDT Claims through one of the major switching companies, currently Envoy and NDC, or Pharmacy BenefitDirect’s direct dial network.
Claims Submission and Payment. Subject to Applicable Law, Hospital agrees:
