Common use of Claims Submission and Payment Clause in Contracts

Claims Submission and Payment. Subject to Applicable Law, Hospital agrees: (a) to accept the rates contained in the applicable Service and Rate Schedule(s), regardless of where services are provided, as payment in full for Covered Services (including for services that would be Covered Services but for the Member's exhaustion of benefits (e.g., above the annual maximum)); (b) that it is responsible for and will promptly pay all Hospital Providers for services rendered, and that it will require all Hospital Providers to look solely to Hospital for payment; (c) to submit complete, clean, electronic claims for Covered Services provided by Hospital and Hospital Providers, containing all information needed to process the claims, within one hundred and eighty (180) days of the date of service or discharge, as applicable, or from the date of receipt of the primary payer's explanation of benefits if Company or Payer is the secondary payer. This requirement will be waived if Hospital provides notice to Company, along with appropriate evidence, of extraordinary circumstances outside of Hospital's control that resulted in a delayed submission; (d) to respond within forty-five (45) days to Company or Payer requests for additional information regarding submitted claims; (e) Subject to Applicable law, to notify Company of any underpayment or payment/claim denial dispute within one hundred and eighty (180) days from date of payment and to follow Company's dispute and appeal Policies for resolution; (f) to notify Company promptly after becoming aware of any overpayment (e.g., a duplicate payment or payment for services rendered to a patient who was not a Member) and to cooperate with Company for the prompt return of any overpayment. In the event of Hospital's failure to cooperate with this section, Company shall have the right to offset any overpaid amount against future claims; (g) that Company and Payers will not be obligated to pay for claims not submitted, completed or disputed/appealed as required above, or that are billed in violation of Applicable Law, this Agreement or Company Policies, and that Members may not be billed for any such claims; (h) in the event that Hospital acquires or takes operational responsibility for another Participating Provider, the then current agreement between Company and such Participating Provider will remain in place and apply to Covered Services provided by such Participating Provider for the longer of: (i) one (1) year; or (ii) the expiration of the then current term of such agreement. Notwithstanding the foregoing, Company may notify Hospital with at least sixty (60) days' prior written notice that the terms of this Agreement shall sooner apply to such Participating Provider.

Claims Submission and Payment. Subject to Applicable Law, Hospital Provider agrees: (a) : to accept the rates contained in the applicable Service and Rate Schedule(s), regardless of where services are provided, as payment in full for Covered Services (including for services that would be Covered Services but for the Member's ’s exhaustion of benefits (e.g., above the annual maximum)); (b) ; that it is responsible for and will promptly pay all Hospital Group Providers for services rendered, and that it will require all Hospital Group Providers to look solely to Hospital Provider for payment; (c) ; to submit complete, clean, electronic claims for Covered Services provided by Hospital Provider and Hospital Group Providers, containing all information needed to process the claims, within one three hundred and eighty (180) sixty five days of the date of service or discharge, as applicable, or from the date of receipt of the primary payer's ’s explanation of benefits if Company or Payer is the secondary payer. This requirement will be waived if Hospital Provider provides notice to Company, along with appropriate evidence, of extraordinary circumstances outside of Hospital's Provider’s control that resulted in a delayed submission; (d) ; to respond within forty-five (45) days to Company or Payer requests for additional information regarding submitted claims; (e) Subject to Applicable law, ; to notify Company of any underpayment or payment/claim denial dispute within one hundred and eighty (180) days no later than 12 months from the date of payment service or 60 calendar days after the payment, denial, or partial denial of a timely claim submission, whichever is later and to follow Company's ’s dispute and appeal Policies for resolution; (f) ; to notify Company promptly after becoming aware of any overpayment (e.g., a duplicate payment or payment for services rendered to a patient who was not a Member) and to cooperate with Company for the prompt return of any overpayment. In the event of Hospital's Provider’s failure to cooperate with this section, Company shall have the right to offset any overpaid amount against future claims; (g) ; that Company and Payers will not be obligated to pay for claims not submitted, completed or disputed/appealed as required above, or that are billed in violation of Applicable Law, this Agreement or Company Policies, and that Members may not be billed for any such claims; (h) ; in the event that Hospital Provider acquires or takes operational responsibility for another Participating Provider, the then current agreement between Company and such Participating Provider will remain in place and apply to Covered Services provided by such Participating Provider for the longer of: (i) one (1) year; or (ii) the expiration of the then current term of such agreement. Notwithstanding the foregoing, Company may notify Hospital Provider with at least sixty (60) days' ’ prior written notice that the terms of this Agreement shall sooner apply to such Participating Provider. Company and the Ohio Department of Medicaid (ODM)have the right to audit or review its paid claim, and recover any identified overpayments as allowed under ODM’s Ohio Resilience Through Integrated and Excellence (OhioRISE) Plan Provider Agreement with the company and Ohio Revised Code (ORC) 5164.57.

Claims Submission and Payment. Subject to Applicable Law, Hospital Provider agrees: (a) to accept the rates contained in the applicable Service and Rate Schedule(s), regardless of where services are provided, as payment in full for Covered Services (including for services that would be Covered Services but for the Member's ’s exhaustion of benefits (e.g., above the annual maximum)); (b) that it is responsible for and will promptly pay all Hospital Group Providers for services rendered, and that it will require all Hospital Group Providers to look solely to Hospital Provider for payment; (c) to submit complete, clean, electronic claims for Covered Services provided by Hospital Provider and Hospital Group Providers, containing all information needed to process the claims, within one three hundred and eighty (180) sixty five days of the date of service or discharge, as applicable, or from the date of receipt of the primary payer's ’s explanation of benefits if Company or Payer is the secondary payer. This requirement will be waived if Hospital Provider provides notice to Company, along with appropriate evidence, of extraordinary circumstances outside of Hospital's Provider’s control that resulted in a delayed submission; (d) to respond within forty-five (45) days to Company or Payer requests for additional information regarding submitted claims; (e) Subject to Applicable law, to notify Company of any underpayment or payment/claim denial dispute within one hundred and eighty (180) days no later than 12 months from the date of payment service or 60 calendar days after the payment, denial, or partial denial of a timely claim submission, whichever is later and to follow Company's ’s dispute and appeal Policies for resolution; (f) to notify Company promptly after becoming aware of any overpayment (e.g., a duplicate payment or payment for services rendered to a patient who was not a Member) and to cooperate with Company for the prompt return of any overpayment. In the event of Hospital's Provider’s failure to cooperate with this section, Company shall have the right to offset any overpaid amount against future claims; (g) that Company and Payers will not be obligated to pay for claims not submitted, completed or disputed/appealed as required above, or that are billed in violation of Applicable Law, this Agreement or Company Policies, and that Members may not be billed for any such claims; (h) in the event that Hospital Provider acquires or takes operational responsibility for another Participating Provider, the then current agreement between Company and such Participating Provider will remain in place and apply to Covered Services provided by such Participating Provider for the longer of: (i) one (1) year; or (ii) the expiration of the then current term of such agreement. Notwithstanding the foregoing, Company may notify Hospital Provider with at least sixty (60) days' ’ prior written notice that the terms of this Agreement shall sooner apply to such Participating Provider. (i) Company and the Ohio Department of Medicaid (ODM)have the right to audit or review its paid claim, and recover any identified overpayments as allowed under ODM’s Ohio Resilience Through Integrated and Excellence (OhioRISE) Plan Provider Agreement with the company and Ohio Revised Code (ORC) 5164.57.

Claims Submission and Payment. Subject to Applicable Law/Accreditation, Hospital agrees: (a) to accept the rates contained in the applicable Service and Rate Schedule(s), regardless of where services are provided, as payment in full for Covered Services (including for services that would be Covered Services but for the Member's ’s exhaustion of benefits (e.g., above the annual maximum)); (b) that it is responsible for and will promptly pay all Hospital Providers for services rendered, and that it will require all Hospital Providers to look solely to Hospital for payment; (c) to submit complete, clean, electronic claims for Covered Services provided by Hospital and Hospital Providers, containing all information needed to process the claims, within one hundred and eighty twenty (180120) days of the date of service or discharge, as applicable, or from the date of receipt of the primary payer's ’s explanation of benefits if Company or Payer is the secondary payer. This requirement will be waived if Hospital provides notice to Company, along with appropriate evidence, of extraordinary circumstances outside of Hospital's ’s control that resulted in a delayed submission; (d) to respond within forty-five (45) days to Company or Payer requests for additional information regarding submitted claims; (e) Subject to Applicable law, to notify Company of any underpayment underpayment, or payment/payment or claim denial dispute within one hundred and eighty (180) days from date of payment and to follow Company's ’s dispute and appeal Policies for resolution; (f) to notify Company promptly after becoming aware of any overpayment (e.g., a duplicate payment or payment for services rendered to a patient who was not a Member) and to cooperate with Company for the prompt return of any overpayment. In the event of Hospital's Provider’s failure to cooperate with this section, Company shall have the right to offset any overpaid amount against future claims; (g) that Company and Payers will not be obligated to pay for claims not submitted, completed or disputed/appealed as required above, or that are billed in violation of Applicable Law/Accreditation, this Agreement or Company Policies, and that Members may not be billed for any such claims;. (h) in the event that Hospital acquires or takes operational responsibility for another Participating ProviderProvider practice or facility, then the then current agreement between Company and such Participating Provider will remain in place and apply to Covered Services provided by such Participating Provider for the longer of: (i) one (1) year; or (ii) until the expiration of the then current term of such participation agreement. Notwithstanding the foregoing, Company may notify Hospital with at least sixty (60) days' prior written notice that the terms of this Agreement shall sooner apply to such Participating Provider.

Claims Submission and Payment. Subject to Applicable Law, Hospital Provider agrees: (a) to accept the rates contained in the applicable Service and Rate Schedule(s), regardless of where services are provided, as payment in full for Covered Services (including for services that would be Covered Services but for the Member's ’s exhaustion of benefits (e.g., above the annual maximum));. (b) that it is responsible for and will promptly pay all Hospital Group Providers for services rendered, and that it will require all Hospital Group Providers to look solely to Hospital Provider for payment; (c) to submit complete, clean, electronic claims for Covered Services provided by Hospital Provider and Hospital Group Providers, containing all information needed to process the claims, within one hundred and eighty twenty (180120) days of the date of service or discharge, as applicable, or from the date of receipt of the primary payer's ’s explanation of benefits if Company or Payer is the secondary payer. This requirement will be waived if Hospital Provider provides notice to Company, along with appropriate evidence, of extraordinary circumstances outside of Hospital's Provider’s control that resulted in a delayed submission;. (d) to respond within forty-five (45) days to Company or Payer requests for additional information regarding submitted claims; (e) Subject to Applicable law, to notify Company of any underpayment underpayment, or payment/payment or claim denial dispute dispute, within one hundred and eighty (180) days from date of payment and to follow Company's ’s dispute and appeal Policies for resolution; (f) to notify Company promptly after becoming aware of any overpayment (e.g., a duplicate payment or payment for services rendered to a patient who was not a Member) and to cooperate with Company for the prompt return of any overpayment. In the event of Hospital's Provider’s failure to cooperate with this section, Company shall have the right to offset any overpaid amount against future claims;. (g) that Company and Payers will not be obligated to pay for claims not submitted, completed or disputed/appealed as required above, or that are billed in violation of Applicable Law, this Agreement or Company Policies, and that Members may not be billed for any such claims;. (h) in the event that Hospital Provider acquires or takes operational responsibility for another Participating ProviderProvider or practice, then the then current agreement between Company and such Participating Provider will remain in place and apply to Covered Services provided by such Participating Provider for the longer of: (i) one (1) year; or (ii) until the expiration of the then current term of such participation agreement. Notwithstanding the foregoing, Company may notify Hospital with at least sixty (60) days' prior written notice that the terms of this Agreement shall sooner apply to such Participating Provider.

Claims Submission and Payment. Subject to Applicable Law, Hospital Xxxxxxxx agrees: (a) to accept the rates contained in the applicable Service and Rate Schedule(s), regardless of where services are provided, as payment in full for Covered Services (including for services that would be Covered Services but for the Member's exhaustion of benefits (e.g., above the annual maximum)); (b) that it is responsible for and will promptly pay all Hospital Facility Providers for services rendered, and that it will require all Hospital Facility Providers to look solely to Hospital Facility for payment; (c) to submit complete, clean, electronic claims for Covered Services provided by Hospital Facility and Hospital Facility Providers, containing all information needed to process the claims, within one hundred and eighty (180) days of the date of service or discharge, as applicable, or from the date of receipt of the primary payer's explanation of benefits if Company or Payer is the secondary payer. This requirement will be waived if Hospital Facility provides notice to Company, along with appropriate evidence, of extraordinary circumstances outside of HospitalFacility's control that resulted in a delayed submission; (d) to respond within forty-five (45) days to Company or Payer requests for additional information regarding submitted claims; (e) Subject to Applicable law, to notify Company of any underpayment or payment/claim denial dispute within one hundred and eighty (180) days from date of payment and to follow Company's dispute and appeal Policies for resolution; (f) to notify Company promptly after becoming aware of any overpayment (e.g., a duplicate payment or payment for services rendered to a patient who was not a Member) and to cooperate with Company for the prompt return of any overpayment. In the event of HospitalFacility's failure to cooperate with this section, Company shall have the right to offset any overpaid amount against future claims; (g) that Company and Payers will not be obligated to pay for claims not submitted, completed or disputed/appealed as required above, or that are billed in violation of Applicable Law, this Agreement or Company Policies, and that Members may not be billed for any such claims; (h) in the event that Hospital Facility acquires or takes operational responsibility for another Participating Provider, the then current agreement between Company and such Participating Provider will remain in place and apply to Covered Services provided by such Participating Provider for the longer of: (i) one (1) year; or (ii) the expiration of the then current term of such agreement. Notwithstanding the foregoing, Company may notify Hospital Facility with at least sixty (60) days' prior written notice that the terms of this Agreement shall sooner apply to such Participating Provider.

Claims Submission and Payment. Subject to Applicable Law, Hospital Provider agrees: (a) to accept the rates contained in the applicable Service and Rate Schedule(s), regardless of where services are provided, as payment in full for Covered Services (including for services that would be Covered Services but for the Member's exhaustion of benefits (e.g., above the annual maximum)); (b) that it is responsible for and will promptly pay all Hospital Group Providers for services rendered, and that it will require all Hospital Group Providers to look solely to Hospital Provider for payment; (c) to submit complete, clean, electronic claims for Covered Services provided by Hospital Provider and Hospital Group Providers, containing all information needed to process the claims, within one hundred and eighty (180) days of the date of service or discharge, as applicable, or from the date of receipt of the primary payer's explanation of benefits if Company or Payer is the secondary payer. This requirement will be waived if Hospital Provider provides notice to Company, along with appropriate evidence, of extraordinary circumstances outside of HospitalProvider's control that resulted in a delayed submission; (d) to respond within forty-five (45) days to Company or Payer requests for additional information regarding submitted claims; (e) Subject to Applicable law, to notify Company of any underpayment or payment/claim denial dispute within one hundred and eighty (180) days from date of payment and to follow Company's dispute and appeal Policies for resolution; (f) to notify Company promptly after becoming aware of any overpayment (e.g., a duplicate payment or payment for services rendered to a patient who was not a Member) and to cooperate with Company for the prompt return of any overpayment. In the event of HospitalProvider's failure to cooperate with this section, Company shall have the right to offset any overpaid amount against future claims; (g) that Company and Payers will not be obligated to pay for claims not submitted, completed or disputed/appealed as required above, or that are billed in violation of Applicable Law, this Agreement or Company Policies, and that Members may not be billed for any such claims; (h) in the event that Hospital Provider acquires or takes operational responsibility for another Participating Provider, the then current agreement between Company and such Participating Provider will remain in place and apply to Covered Services provided by such Participating Provider for the longer of: (i) one (1) year; or (ii) the expiration of the then current term of such agreement. Notwithstanding the foregoing, Company may notify Hospital Provider with at least sixty (60) days' prior written notice that the terms of this Agreement shall sooner apply to such Participating Provider.