Company Obligation to Pay for Covered Services. Company shall make payments to Group for Covered Services on a timely basis consistent with the claims payment procedure described at 42 U.S.C. § 1396a(a)(37)(A). Company agrees to pay Group for non-capitated Covered Services rendered to Members according to the lesser of (i) Group’s actual billed charges or (ii) the rates set forth in the Services and Compensation Schedule, attached hereto and made a part hereof. Company must pay ninety percent (90%) of all such Clean Claims from Group within thirty (30) days following actual receipt; provided, further, Company must pay ninety-nine percent (99%) of all Clean Claims from Group within ninety (90) days following actual receipt. Group and Participating Group Physicians will make best commercial efforts to utilize online explanation of benefits or electronic remittance of advice (or combination thereof) and electronic funds transfer in lieu of receiving paper equivalents to the extent such services are available from Company. Company reserves the right to recoup any overpayment or payment made in error (e.g., a duplicate payment or payment for services rendered by Group to a patient who was not a Member and amounts identified through routine investigative reviews of records or audits) against any other monies due to Group under this Agreement. In the event that Group identifies any overpayments by Company, Group shall, as required under Section 6402(a) of the Patient Protection and Affordable Care Act, report and return any and all such overpayments to Company within sixty (60) days of Group’s identification of any and all such overpayments. In addition, when reporting and returning any such overpayments by Company, Group must provide Company with a written reason for the overpayment (e.g., excess payment under coordination of benefits, etc.). To the extent, if any, that the compensation under certain Plans is in the form of capitation payments or a case- based rate methodology, Group acknowledges the financial risks to Group of this arrangement and has made an independent analysis of the adequacy of this arrangement. Group, therefore, agrees and covenants not to bring any action asserting the inadequacy of these arrangements or that Group was in any way improperly induced by Company to accept the rate of payment, including, but not limited to, causes of actions for damages, rescission or termination alleging fraud or negligent misrepresentation or improper inducement. Furthermore, to the extent that the compe...
Company Obligation to Pay for Covered Services. Company shall make payments to Provider for Covered Services on a timely basis consistent with the claims payment procedure described at 42 U.S.C. § 1396a(a)(37)(A). Company agrees to pay Provider for Covered Services rendered to Members according to the rates set forth in the Services and Compensation Schedule, attached hereto and made a part hereof.
Company Obligation to Pay for Covered Services. Subject to applicable law and the terms of each applicable Product Addendum, and except for applicable Member copayments, coinsurance and deductibles, Company agrees: (a) when it is the Payer, to pay Provider for Covered Services rendered to Members; and (b) when it is not the Payer, to notify Payers to forward payment to Provider for Covered Services rendered to the applicable Members, according to the rates set forth in the applicable Service and Rate Schedule, within forty-five (45) days of actual receipt by Company/Payer of a Clean Claim. Provider will utilize online explanation of benefits, electronic remittance of advice and electronic funds transfer, in lieu of receiving paper equivalents. While Company may remit payment for claims on behalf of Payers who are not Company Affiliates, Provider and Company acknowledge that Company has no legal responsibility for the payment of such claims for Covered Services rendered to a Payer’s Members; provided, however, that Company agrees to use commercially reasonable efforts to assist Provider, as appropriate, in collecting any such payments. Company or its designee may perform pre-payment reviews of certain claims. This review may include, but not be limited to, a request for itemized bills or more specific detail with respect to claims contracted on a percentage of charges basis. Provider acknowledges that, as a result of the review, payment may be denied for, among other things, duplicate charges, errors in billing or categorization of capital equipment. Company and/or its designees may, from time to time, notify Provider or Group Providers of overpayments, and Provider agrees to return any such overpayment or payment made in error (e.g., a duplicate payment or payment for services rendered to a patient who was not a Member) within a reasonable period of time. In the event Company is unable to secure the return of any such payment within such reasonable time, Company reserves the right to offset such payment against any other monies due under this Agreement provided that Provider has been provided with at least ten (10) days prior written notice and Provider has otherwise failed to return such payment. To the extent, if any, that the compensation under certain Plans is in the form of capitation payments or a diagnosis/case-based rate methodology, Provider acknowledges the financial risks to Provider of this arrangement and has made an independent analysis of the adequacy of this arrangement. Provider, theref...
Company Obligation to Pay for Covered Services. Company shall make payments to Facility for Covered Services on a timely basis consistent with the claims payment procedure described at 42 U.S.C. § 1396a(a)(37)(A). Company agrees to pay Facility for non-capitated Covered Services rendered to Members according to the lesser of (i) Facility’s actual billed charges or (ii) the rates set forth in the Services and Compensation Schedule, attached hereto and made a part hereof. Company must pay all claims in accordance with State Contract and regulatory requirements. .. Facility will make best commercial efforts to utilize online explanation of benefits or electronic remittance of advice (or combination thereof) and electronic funds transfer in lieu of receiving paper equivalents to the extent such services are available from Company. Company reserves the right in accordance with State Contract and New Jersey Department of Banking and Insurance regulations, to recoup any overpayment or payment made in error (e.g., a duplicate payment or payment for services rendered by Facility to a patient who was not a Member and amounts identified through routine investigative reviews of records or audits) against any other monies due to Facility under this Agreement. In the event that Facility identifies any overpayments by Company, Facility shall, as required under Section 6402(a) of the Patient Protection and Affordable Care Act, report and return any and all such overpayments to Company within sixty (60) days of Facility’s identification of any and all such overpayments. In addition, when reporting and returning any such overpayments by Company, Facility must provide Company with a written reason for the overpayment (e.g., excess payment under coordination of benefits, etc.). To the extent, if any, that the compensation under certain Plans is in the form of capitation payments or a case-based rate methodology, Facility acknowledges the financial risks to Facility of this arrangement and has made an independent analysis of the adequacy of this arrangement. Facility, therefore, agrees and covenants not to bring any action asserting the inadequacy of these arrangements or that Facility was in any way improperly induced by Company to accept the rate of payment, including, but not limited to, causes of actions for damages, rescission or termination alleging fraud or negligent misrepresentation or improper inducement. Notwithstanding anything in this Agreement to the contrary, subcontractors agree to seek compensation solely f...
