Compensation and Billing. 6.1 The Facility shall only seek payment from EGID for the provision of Covered Services. The Facility agrees to accept the amount of the Allowable Fee for Covered Services as payment in full and agrees to only request payment from the Member for deductible, co-insurance and amounts for defined Non-Covered Services attributable to the Member’s Health Choice Plan. The payment shall be calculated and limited to the methodologies defined by this Contract. 6.2 When the Allowable Fee exceeds billed charges, EGID shall pay the appropriate percentage of the Allowable Fee and Member shall pay the appropriate percentage of billed charges unless the Member has met the stop loss limitation and then EGID shall pay the Allowable Fee and the Member has no liability. 6.3 When processing inpatient claims, EGID shall determine the MS-DRG Allowable Fee for non- transfer cases according to the following formula: Skilled Nursing Facility Services, Day Treatment and Residential treatment will be reimbursed utilizing the per diem methodology. In no event shall a per diem qualify as an Outlier. These benefits shall be allowed when the Member has received Medically Necessary Covered Services subject to the following policy limitations and conditions: a) EGID shall pay the appropriate percentage of the MS-DRG Allowable Fee and the Member shall pay the remainder of the MS-DRG Allowable Fee unless the Member has met the stop loss limitation, and then EGID shall pay one hundred percent (100%) of the MS-DRG Allowable Fee and the Member has no liability. b) The MS-DRG shall be controlling, subject to EGID’s approval and Article X of the Contract. c) The MS-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed Current Procedural Terminology code Allowable Fees. d) EGID may reduce its payment by any deductibles, coinsurance and co- payments owed by the Member. e) EGID shall include the day of admission but not the day of discharge when computing the number of facility days provided to a Member. Observation Facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits. f) In the case of a transfer, the Transfer Allowable Fee for the transferring Facility shall be calculated as follows: Transfer Allowable Fee = (MS-DRG Allowable Fee/Geometric Mean Length of Stay) x (Length of Stay + 1 day) The total Transfer Allowable Fee paid to the transferring Facility shall be capped at the amount of the MS-DRG Allowable Fee for a non-transfer case. EGID shall allow payment to the receiving Facility, if it is also the final discharging Facility, at the MS- DRG Allowable Fee as if it were an original admission. g) EGID shall use the current version of the CMS MS-DRG grouper to categorize what shall constitute a procedure. XXXX’s and the Member’s financial liability shall be limited to the Allowable Fee as determined by XXXX. h) The Facility agrees not to charge more for Medical Services to Members than the amount normally charged by the Facility to other patients for similar services. i) For Outlier cases, EGID shall base its payment to the Facility using an Outlier Allowable Fee plus the MS-DRG Allowable Fee. The following formula shall be utilized to calculate the Outlier Allowable Fee: Outlier Allowable Fee = [Billed Charges – (MS-DRG Allowable Fee + Outlier Threshold)] x Marginal Cost Factor 6.4 When processing Outpatient claims, XXXX agrees to pay the Facility the Allowable Fee based on appropriate billing according to the following: a) If a procedure does not have an Allowable Fee, EGID will allow a percentage of the billed charges for Covered Services. b) EGID shall pay the appropriate percentage of the Allowable Fee and the Member shall pay the remainder based on the Member’s plan of benefits unless the Member has met the stop loss limitation, and then EGID shall pay 100% of the Allowable Fee and the Member has no liability.
Appears in 2 contracts
Samples: Network Facility Contract, Network Facility Contract
Compensation and Billing. 6.1 The Facility Provider shall only seek payment only from EGID DRS for the provision of Covered Services. The Facility agrees to accept the amount of the Allowable Fee for Covered Services Infusion Therapy services except as payment provided in full and agrees to only request payment from the Member for deductible, co-insurance and amounts for defined Non-Covered Services attributable to the Member’s Health Choice Planparagraph 6.3. The payment from DRS shall be calculated and limited to the methodologies defined by this Contractamounts referred to in paragraph 6.2.
6.2 When the Allowable Fee exceeds billed charges, EGID shall DRS agrees to pay the appropriate percentage of Provider’s billed charge for each procedure or the Allowable Fee and Member fee set by DRS for that procedure, whichever is less. DRS shall pay have the appropriate percentage of billed charges unless the Member has met the stop loss limitation and then EGID shall pay the Allowable Fee and the Member has no liability.
6.3 When processing inpatient claims, EGID shall determine the MS-DRG Allowable Fee for non- transfer cases according to the following formula: Skilled Nursing Facility Services, Day Treatment and Residential treatment will be reimbursed utilizing the per diem methodology. In no event shall a per diem qualify as an Outlier. These benefits shall be allowed when the Member has received Medically Necessary Covered Services subject to the following policy limitations and conditions:
a) EGID shall pay the appropriate percentage of the MS-DRG Allowable Fee and the Member shall pay the remainder of the MS-DRG Allowable Fee unless the Member has met the stop loss limitation, and then EGID shall pay one hundred percent (100%) of the MS-DRG Allowable Fee and the Member has no liability.
b) The MS-DRG shall be controlling, subject to EGID’s approval and Article X of the Contract.
c) The MS-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed Current Procedural Terminology code Allowable Fees.
d) EGID may reduce its payment by any deductibles, coinsurance and co- payments owed by the Member.
e) EGID shall include the day of admission but not the day of discharge when computing the number of facility days provided to a Member. Observation Facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits.
f) In the case of a transfer, the Transfer Allowable Fee for the transferring Facility shall be calculated as follows: Transfer Allowable Fee = (MS-DRG Allowable Fee/Geometric Mean Length of Stay) x (Length of Stay + 1 day) The total Transfer Allowable Fee paid to the transferring Facility shall be capped at the amount of the MS-DRG Allowable Fee for a non-transfer case. EGID shall allow payment to the receiving Facility, if it is also the final discharging Facility, at the MS- DRG Allowable Fee as if it were an original admission.
g) EGID shall use the current version of the CMS MS-DRG grouper right to categorize what shall constitute a procedure. XXXX’s DRS and the Memberbeneficiary’s financial liability shall be limited to the Allowable Fee procedure’s allowable as determined by XXXX.DRS, paid by applying appropriate coding methodology, whether the Provider has billed appropriately or not.
h) 6.3 The Facility Provider agrees to accept the payment from DRS as full and complete payment for services for recipients of public assistance. If the patient is a recipient of Medical Assistance, Rehabilitation Services only, payment from the Department shall represent payment in full except the Provider may collect an amount not to charge more for exceed that shown on DRS form, DRS-C-100, Medical Services Authorization.
6.4 The Provider shall refund within 30 days of discovery to Members than DRS any overpayments made by DRS.
6.5 The Provider shall bill DRS on forms acceptable to DRS within 1 year of providing the amount normally charged medical services. The Provider shall use the current HCPCS codes, CPT codes and ICD codes, when applicable. The Provider shall furnish, upon request at no cost, all information, including medical records, reasonable required by DRS to verify and substantiate the Facility provision of medical services and the charges for such services if the beneficiary and the Provider are seeking reimbursement through DRS.
6.6 DRS shall reimburse the Provider within 30 days of receipt of xxxxxxxx that are accurate, complete and otherwise in accordance with Article VI of this Contract. DRS will not be responsible for delay of reimbursement due to other patients circumstances beyond DRS’ control.
6.7 The Provider agrees to release all Provider liens for similar services.which payment has been made for Title XIX by DRS and notify DRS. However, this provision does not affect the Provider’s entitlement to file a lien or liens for non-pre-authorized services.
i) For Outlier cases, EGID 6.8 DRS shall base its payment have the right at all reasonable times and to the Facility using an Outlier Allowable Fee plus extent permitted by law to inspect and duplicate all medical and billing records relating to medical services rendered to beneficiaries at no cost to DRS or the MS-DRG Allowable Fee. The following formula shall be utilized to calculate the Outlier Allowable Fee: Outlier Allowable Fee = [Billed Charges – (MS-DRG Allowable Fee + Outlier Threshold)] x Marginal Cost Factor
6.4 When processing Outpatient claims, XXXX agrees to pay the Facility the Allowable Fee based on appropriate billing according to the following:
a) If a procedure does not have an Allowable Fee, EGID will allow a percentage of the billed charges for Covered Services.
b) EGID shall pay the appropriate percentage of the Allowable Fee and the Member shall pay the remainder based on the Member’s plan of benefits unless the Member has met the stop loss limitation, and then EGID shall pay 100% of the Allowable Fee and the Member has no liability.beneficiary.
Appears in 2 contracts
Samples: Infusion Therapy Contract, Infusion Therapy Contract
Compensation and Billing. 6.1 The Facility Provider shall only seek payment only from EGID DRS for the provision of Covered Services. The Facility agrees to accept the amount of the Allowable Fee for Covered Services Medical services except as payment provided in full and agrees to only request payment from the Member for deductible, co-insurance and amounts for defined Non-Covered Services attributable to the Member’s Health Choice Planparagraphs 6.3. The payment from DRS shall be calculated and limited to the methodologies defined by this Contractamounts referred to in paragraph 6.2.
6.2 When the Allowable Fee exceeds billed charges, EGID shall DRS agrees to pay the appropriate percentage of Provider's billed charge for each procedure or the Allowable Fee and Member fee set by DRS for that procedure, whichever is less. DRS shall pay have the appropriate percentage of billed charges unless the Member has met the stop loss limitation and then EGID shall pay the Allowable Fee and the Member has no liability.
6.3 When processing inpatient claims, EGID shall determine the MS-DRG Allowable Fee for non- transfer cases according to the following formula: Skilled Nursing Facility Services, Day Treatment and Residential treatment will be reimbursed utilizing the per diem methodology. In no event shall a per diem qualify as an Outlier. These benefits shall be allowed when the Member has received Medically Necessary Covered Services subject to the following policy limitations and conditions:
a) EGID shall pay the appropriate percentage of the MS-DRG Allowable Fee and the Member shall pay the remainder of the MS-DRG Allowable Fee unless the Member has met the stop loss limitation, and then EGID shall pay one hundred percent (100%) of the MS-DRG Allowable Fee and the Member has no liability.
b) The MS-DRG shall be controlling, subject to EGID’s approval and Article X of the Contract.
c) The MS-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed Current Procedural Terminology code Allowable Fees.
d) EGID may reduce its payment by any deductibles, coinsurance and co- payments owed by the Member.
e) EGID shall include the day of admission but not the day of discharge when computing the number of facility days provided to a Member. Observation Facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits.
f) In the case of a transfer, the Transfer Allowable Fee for the transferring Facility shall be calculated as follows: Transfer Allowable Fee = (MS-DRG Allowable Fee/Geometric Mean Length of Stay) x (Length of Stay + 1 day) The total Transfer Allowable Fee paid to the transferring Facility shall be capped at the amount of the MS-DRG Allowable Fee for a non-transfer case. EGID shall allow payment to the receiving Facility, if it is also the final discharging Facility, at the MS- DRG Allowable Fee as if it were an original admission.
g) EGID shall use the current version of the CMS MS-DRG grouper right to categorize what shall constitute a procedure. XXXX’s DRS and the Memberbeneficiary’s financial liability shall be limited to the Allowable Fee procedures allowable as determined by XXXX.DRS, paid by applying appropriate coding methodology, whether the Provider has billed appropriately or not.
h) 6.3 The Facility Provider agrees to accept the payment from DRS as full and complete payment for services for recipients of public assistance. If the patient is a recipient of Medical Assistance, Rehabilitation Services only, payment from the Department shall represent payment in full except the Provider may collect an amount not to charge more exceed that shown on DRS Form DRS-C-100, Medical services Authorization.
6.4 MS-MA-r, Notification of Eligibility Status for Medical Services or DHS Form MS-S-4, Notification of Eligibility Status for Medical Services for Persons Under 21 Years of Age, or Medical Services Authorization, VR-A-302-A.
6.5 The Provider shall bill DRS on forms acceptable to Members than DRS within 1 year of providing the amount normally charged Medical services. The Provider shall use current CPT codes with appropriate modifiers and ICD or DSM diagnostic codes, when applicable. The Provider shall furnish, upon request at no cost, all information, including Medical records, reasonably required by DRS to verify and substantiate the provision of Medical services and the charges for such services if the beneficiary and the Provider are seeking reimbursement through DRS.
6.6 DRS shall reimburse the Provider within thirty (30) days of receipt of xxxxxxxx that are accurate, complete and otherwise in accordance with Article VI of this Contract. DRS will not be responsible for delay of reimbursement due to circumstances beyond DRS’ control.
6.7 The Provider agrees to release all Provider liens for which payment has been made for Title XIX by DRS and notify DRS. However, this provision does not affect the Provider’s entitlement to file a lien or liens for non-pre-authorized services.
6.8 DRS shall have the right at all reasonable times and, to the extent permitted by law, to inspect and duplicate all Medical and billing records relating to Medical services rendered to beneficiaries at no cost to DRS or the beneficiary.
6.9 The Provider shall refund within 30 days of discovery to the beneficiary any overpayments made by the Facility to other patients for similar services.
i) For Outlier cases, EGID shall base its payment to the Facility using an Outlier Allowable Fee plus the MS-DRG Allowable Fee. The following formula shall be utilized to calculate the Outlier Allowable Fee: Outlier Allowable Fee = [Billed Charges – (MS-DRG Allowable Fee + Outlier Threshold)] x Marginal Cost Factor
6.4 When processing Outpatient claims, XXXX agrees to pay the Facility the Allowable Fee based on appropriate billing according to the following:
a) If a procedure does not have an Allowable Fee, EGID will allow a percentage of the billed charges for Covered Services.
b) EGID shall pay the appropriate percentage of the Allowable Fee and the Member shall pay the remainder based on the Member’s plan of benefits unless the Member has met the stop loss limitation, and then EGID shall pay 100% of the Allowable Fee and the Member has no liability.beneficiary.
Appears in 2 contracts
Samples: Network Provider Contract, Network Provider Contract
Compensation and Billing. 6.1 1. The Facility IHO shall only seek payment from EGID for the provision of Covered ServicesMedical or Dental Services except as provided in sections VI (2), VI (6) and VI (11). The Facility agrees payment from the HealthChoice Plan shall be limited to accept the amount of amounts referred to in section VI (2).
2. XXXX shall reimburse the Allowable Fee set by EGID for Covered Services as payment in full and agrees to only request payment from each procedure or the Member for deductibleIHO’s billed charge, co-insurance and amounts for defined Non-Covered Services attributable to the Member’s Health Choice Planwhichever is less. The payment shall be calculated and limited to the methodologies defined by this Contract.
6.2 When the Allowable Fee exceeds billed charges, EGID shall pay the appropriate percentage of the Allowable Fee and Member shall pay the appropriate percentage of billed charges unless the Member has met the stop loss limitation and then EGID shall pay the Allowable Fee and the Member has no liability.
6.3 When processing inpatient claims, EGID shall determine the MS-DRG Allowable Fee for non- transfer cases according to the following formula: Skilled Nursing Facility Services, Day Treatment and Residential treatment will be reimbursed utilizing the per diem methodology. In no event shall a per diem qualify as an Outlier. These benefits This reimbursement shall be allowed when the Member has received Covered Medically Necessary Covered Services subject to the following policy limitations limitation and conditions:
a) EGID shall pay the appropriate percentage of the MS-DRG Allowable Fee and the Member shall pay the remainder of the MS-DRG Allowable Fee unless the Member has met the stop loss limitation, and then EGID shall pay one hundred percent (100%) of the MS-DRG Allowable Fee and the Member has no liability.
b) The MS-DRG shall be controlling, subject to EGID’s approval and Article X of the Contract.
c) The MS-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed Current Procedural Terminology code Allowable Fees.
d) a. EGID may reduce its the payment by any deductibles, coinsurance and co- payments owed by copayments according to the Member.Member’s HealthChoice plan in effect at the time charges are incurred. Complete descriptions of HealthChoice Plans are available on EGID’s website.
e) b. EGID shall include have the day of admission but not the day of discharge when computing the number of facility days provided to a Member. Observation Facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits.
f) In the case of a transfer, the Transfer Allowable Fee for the transferring Facility shall be calculated as follows: Transfer Allowable Fee = (MS-DRG Allowable Fee/Geometric Mean Length of Stay) x (Length of Stay + 1 day) The total Transfer Allowable Fee paid to the transferring Facility shall be capped at the amount of the MS-DRG Allowable Fee for a non-transfer case. EGID shall allow payment to the receiving Facility, if it is also the final discharging Facility, at the MS- DRG Allowable Fee as if it were an original admission.
g) EGID shall use the current version of the CMS MS-DRG grouper right to categorize what shall constitute a procedure. XXXX’s EGID and the Member’s financial liability shall be limited to the procedure’s Allowable Fee or billed charge, whichever is less, as determined by XXXX.EGID, paid by applying appropriate coding methodology, whether the IHO has billed appropriately or not.
h) c. The Facility IHO agrees not to charge more for Medical or Dental Services to Members than the amount normally charged by the Facility IHO to other patients for similar services.services. The IHO’s usual and customary charges may be requested by XXXX and verified through an audit.
i) For Outlier casesd. An IDTF and laboratory shall provide, at no additional charge, all supplies necessary for the collection, preparation and preservation of all specimens to be submitted to the IDTF for testing.
3. The IHO agrees that EGID utilizes a comprehensive claim editing system to assist in determining which charges for Covered Services to allow for payment and to assist in determining inappropriate billing and coding. Said system shall rely on CMS and other industry standards in the development of its mutually exclusive, incidental, re-bundling, age conflict, gender conflict, cosmetic, experimental and procedure editing.
4. EGID shall base its payment have the right to the Facility using an Outlier Allowable Fee plus the MS-DRG Allowable Fee. The following formula shall be utilized to calculate the Outlier Allowable Fee: Outlier Allowable Fee = [Billed Charges – (MS-DRG Allowable Fee + Outlier Threshold)] x Marginal Cost Factor
6.4 When processing Outpatient claims, XXXX agrees to pay the Facility adjust the Allowable Fee based on appropriate billing according clinical editing and/or the use of modifiers as documented in the HealthChoice Provider Manual.
5. The IHO agrees that the only charges for which a Member may be liable and be billed by the IHO shall be for Medical or Dental Services not covered by a HealthChoice Plan, or as provided in sections VI (2), VI (6) and VI (11). The IHO shall not waive any deductibles, copayments and coinsurance required by EGID.
6. The IHO shall not collect amounts in excess of plan limits unless the Member has exceeded those established limits.
7. The IHO shall refund within 30 days of discovery to the following:Member any overpayments made by the Member.
a) If 8. In a procedure does not have an Allowable Feecase in which HealthChoice is primary under applicable coordination of benefit rules as defined in the HealthChoice Provider Manual, EGID will allow calculate the benefits to be paid without considering the other plan's benefits. In a percentage case in which HealthChoice is other than primary under the coordination of benefit rules, EGID will use the billed Standard Allowable Calculation methodology for Coordination of Benefits, up to EGID's maximum liability under the terms of this Contract.
9. The IHO shall bill EGID on forms acceptable to EGID within 365 days of providing the Medical or Dental Services. The IHO shall use the current revenue codes, ADA, CPT codes with appropriate modifiers, HCPCS codes, and ICD or DSM diagnosis codes, when applicable. The IHO shall furnish, upon request at no cost, all information, including Medical records and x-rays, reasonably required by EGID to verify and substantiate the provision of Medical or Dental Services and the charges for Covered Services.such services if the Member and the IHO are seeking reimbursement through EGID.
b) 10. EGID shall pay reimburse the appropriate percentage IHO within 45 days of receipt of xxxxxxxx that are accurate, complete, including all information requested by EGID reasonably required to verify and substantiate the billing, and otherwise in accordance with Article VI of this Contract. Refer to 74 O.S. § 1328. XXXX will not be responsible for delay of reimbursement due to circumstances beyond XXXX’s control.
11. The IHO shall not charge the Member for Medical or Dental Services denied during the Certification or Concurrent Review procedures described in Article VII, unless the IHO has obtained a written waiver from that Member. Such a waiver shall be obtained only upon the denial of admission, Certification or Concurrent Review and prior to the provision of those Medical or Dental Services. The waiver shall clearly state that the Member shall be responsible for payment of Medical or Dental Services denied by EGID.
12. EGID shall have the right at all reasonable times and, to the extent permitted by law, to inspect and duplicate all documentation or records relating to Medical or Dental Services rendered to Members at no cost to EGID or the Member.
13. The IHO agrees that XXXX’s subrogation rights or the existence of third-party liability does not affect the IHO’s agreement to accept the current Allowable Fee or billed charges, whichever is less, described in this Contract. Unrecorded alleged or recorded liens that are intended to secure charges for treatment rendered to, or on behalf of, a Member for amounts in excess of the Allowable Fee and the Member shall pay the remainder based on or billed charges, whichever is less, or which exceed the Member’s plan deductible and coinsurance liability as required by this Contract, are rendered invalid by the IHO’s submission of benefits unless a Member’s claims to EGID.
14. A list of the Member has met the stop loss limitation, CPT/HCPCS codes and then EGID shall pay 100% of the Allowable Fee for each can be found on the EGID website. EGID shall review and update the fee schedules quarterly or as needed
15. Implants are defined as material(s) inserted into the body, including living, inert, or biological material (e.g., screws, grafts, plates, or fixation devices) used for the purpose of creating stability (i.e., to correct, protect, or stabilize a deformity) where the majority of the product is left under the skin after surgery. EGID reimburses separately for implants found on the implant list at EGID Provider website. XXXX’s reimbursement of implants is subject to the following conditions:
a. Implants must be billed at invoice cost, plus 10% less any rebates and/or discounts received by the IHO. Implants shall be billed using the most descriptive CPT or HCPCS code and EGID will allow up to the net cost plus 10%, including shipping, handling, and tax. Shipping, handling and tax must be prorated for the billed implant for invoices including supplies other than the billed implant. If there is no CPT or HCPCS code available for a certain implant, EGID will accept the appropriate unlisted CPT or HCPCS code with an explanation of each item and the Member corresponding charge.
b. Upon request, EGID requires the actual invoice for the implant billed.
c. EGID may conduct quarterly retrospective audits of the IHO’s charges for implants.
d. Upon the occurrence of an audit, XXXX will request invoices for audited claims and any other documentation showing discounts that are not listed on the invoice. Invoices must identify which implants listed on the invoice apply to the claim being audited. Upon request, the IHO has 30 days to submit this information to EGID. During the audit, if XXXX finds that the IHO is billing more than acquisition costs, plus 10%, the IHO will be required to refund any overpayments made by EGID to the IHO and to provide copies of invoices for all subsequent claims submitted prior to payment. If the IHO continues to bill above the acquisition cost or does not provide copies of requested invoices with the required timeframe then, EGID will no liability.longer allow reimbursement to the IHO for implants as a separate reimbursable item.
Appears in 2 contracts
Samples: Independent Health Organization Contract, Independent Health Organization Contract
Compensation and Billing. 6.1
1. The Facility IHO shall only seek payment from EGID for the provision of Covered ServicesMedical or Dental Services except as provided in sections VI (2), VI (6) and VI (11). The Facility agrees payment from the HealthChoice Plan shall be limited to accept the amount of amounts referred to in section VI (2).
2. XXXX shall reimburse the Allowable Fee set by EGID for Covered Services as payment in full and agrees to only request payment from each procedure or the Member for deductibleIHO’s billed charge, co-insurance and amounts for defined Non-Covered Services attributable to the Member’s Health Choice Planwhichever is less. The payment shall be calculated and limited to the methodologies defined by this Contract.
6.2 When the Allowable Fee exceeds billed charges, EGID shall pay the appropriate percentage of the Allowable Fee and Member shall pay the appropriate percentage of billed charges unless the Member has met the stop loss limitation and then EGID shall pay the Allowable Fee and the Member has no liability.
6.3 When processing inpatient claims, EGID shall determine the MS-DRG Allowable Fee for non- transfer cases according to the following formula: Skilled Nursing Facility Services, Day Treatment and Residential treatment will be reimbursed utilizing the per diem methodology. In no event shall a per diem qualify as an Outlier. These benefits This reimbursement shall be allowed when the Member has received Covered Medically Necessary Covered Services subject to the following policy limitations limitation and conditions:
a) EGID shall pay the appropriate percentage of the MS-DRG Allowable Fee and the Member shall pay the remainder of the MS-DRG Allowable Fee unless the Member has met the stop loss limitation, and then EGID shall pay one hundred percent (100%) of the MS-DRG Allowable Fee and the Member has no liability.
b) The MS-DRG shall be controlling, subject to EGID’s approval and Article X of the Contract.
c) The MS-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed Current Procedural Terminology code Allowable Fees.
d) a. EGID may reduce its the payment by any deductibles, coinsurance and co- payments owed by copayments according to the Member.Member’s HealthChoice plan in effect at the time charges are incurred. Complete descriptions of HealthChoice Plans are available on EGID’s website.
e) b. EGID shall include have the day of admission but not the day of discharge when computing the number of facility days provided to a Member. Observation Facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits.
f) In the case of a transfer, the Transfer Allowable Fee for the transferring Facility shall be calculated as follows: Transfer Allowable Fee = (MS-DRG Allowable Fee/Geometric Mean Length of Stay) x (Length of Stay + 1 day) The total Transfer Allowable Fee paid to the transferring Facility shall be capped at the amount of the MS-DRG Allowable Fee for a non-transfer case. EGID shall allow payment to the receiving Facility, if it is also the final discharging Facility, at the MS- DRG Allowable Fee as if it were an original admission.
g) EGID shall use the current version of the CMS MS-DRG grouper right to categorize what shall constitute a procedure. XXXX’s EGID and the Member’s financial liability shall be limited to the procedure’s Allowable Fee or billed charge, whichever is less, as determined by XXXX.EGID, paid by applying appropriate coding methodology, whether the IHO has billed appropriately or not.
h) c. The Facility IHO agrees not to charge more for Medical or Dental Services to Members than the amount normally charged by the Facility IHO to other patients for similar services.services. The IHO’s usual and customary charges may be requested by XXXX and verified through an audit.
i) For Outlier casesd. An IDTF and laboratory shall provide, at no additional charge, all supplies necessary for the collection, preparation and preservation of all specimens to be submitted to the IDTF for testing.
3. The IHO agrees that EGID utilizes a comprehensive claim editing system to assist in determining which charges for Covered Services to allow for payment and to assist in determining inappropriate billing and coding. Said system shall rely on CMS and other industry standards in the development of its mutually exclusive, incidental, re-bundling, age conflict, gender conflict, cosmetic, experimental and procedure editing.
4. EGID shall base its payment have the right to the Facility using an Outlier Allowable Fee plus the MS-DRG Allowable Fee. The following formula shall be utilized to calculate the Outlier Allowable Fee: Outlier Allowable Fee = [Billed Charges – (MS-DRG Allowable Fee + Outlier Threshold)] x Marginal Cost Factor
6.4 When processing Outpatient claims, XXXX agrees to pay the Facility adjust the Allowable Fee based on appropriate billing according clinical editing and/or the use of modifiers as documented in the HealthChoice Provider Manual.
5. The IHO agrees that the only charges for which a Member may be liable and be billed by the IHO shall be for Medical or Dental Services not covered by a HealthChoice Plan, or as provided in sections VI (2), VI (6) and VI (11). The IHO shall not waive any deductibles, copayments and coinsurance required by EGID.
6. The IHO shall not collect amounts in excess of plan limits unless the Member has exceeded those established limits.
7. The IHO shall refund within 30 days of discovery to the following:Member any overpayments made by the Member.
a) If 8. In a procedure does not have an Allowable Feecase in which HealthChoice is primary under applicable coordination of benefit rules as defined in the HealthChoice Provider Manual, EGID will allow calculate the benefits to be paid without considering the other plan's benefits. In a percentage case in which HealthChoice is other than primary under the coordination of benefit rules, EGID will use the billed Standard Allowable Calculation methodology for Coordination of Benefits, up to EGID's maximum liability under the terms of this Contract.
9. The IHO shall bill EGID on forms acceptable to EGID within 180 days of providing the Medical or Dental Services. The IHO shall use the current revenue codes, ADA, CPT codes with appropriate modifiers, HCPCS codes, and ICD or DSM diagnosis codes, when applicable. The IHO shall furnish, upon request at no cost, all information, including Medical records and x-rays, reasonably required by EGID to verify and substantiate the provision of Medical or Dental Services and the charges for Covered Services.such services if the Member and the IHO are seeking reimbursement through EGID.
b) 10. EGID shall pay reimburse the appropriate percentage IHO within 45 days of receipt of xxxxxxxx that are accurate, complete, including all information requested by EGID reasonably required to verify and substantiate the billing, and otherwise in accordance with Article VI of this Contract. Refer to 74 O.S. § 1328. XXXX will not be responsible for delay of reimbursement due to circumstances beyond XXXX’s control.
11. The IHO shall not charge the Member for Medical or Dental Services denied during the Certification or Concurrent Review procedures described in Article VII, unless the IHO has obtained a written waiver from that Member. Such a waiver shall be obtained only upon the denial of admission, Certification or Concurrent Review and prior to the provision of those Medical or Dental Services. The waiver shall clearly state that the Member shall be responsible for payment of Medical or Dental Services denied by EGID.
12. EGID shall have the right at all reasonable times and, to the extent permitted by law, to inspect and duplicate all documentation or records relating to Medical or Dental Services rendered to Members at no cost to EGID or the Member.
13. The IHO agrees that XXXX’s subrogation rights or the existence of third-party liability does not affect the IHO’s agreement to accept the current Allowable Fee or billed charges, whichever is less, described in this Contract. Unrecorded alleged or recorded liens that are intended to secure charges for treatment rendered to, or on behalf of, a Member for amounts in excess of the Allowable Fee and the Member shall pay the remainder based on or billed charges, whichever is less, or which exceed the Member’s plan deductible and coinsurance liability as required by this Contract, are rendered invalid by the IHO’s submission of benefits unless a Member’s claims to EGID.
14. A list of the Member has met the stop loss limitation, CPT/HCPCS codes and then EGID shall pay 100% of the Allowable Fee for each can be found on the EGID website. EGID shall review and update the fee schedules quarterly or as needed
15. Implants are defined as material(s) inserted into the body, including living, inert, or biological material (e.g., screws, grafts, plates, or fixation devices) used for the purpose of creating stability (i.e., to correct, protect, or stabilize a deformity) where the majority of the product is left under the skin after surgery. EGID reimburses separately for implants found on the implant list at EGID Provider website. XXXX’s reimbursement of implants is subject to the following conditions:
a. Implants must be billed at invoice cost, plus 10% less any rebates and/or discounts received by the IHO. Implants shall be billed using the most descriptive CPT or HCPCS code and EGID will allow up to the net cost plus 10%, including shipping, handling, and tax. Shipping, handling and tax must be prorated for the billed implant for invoices including supplies other than the billed implant. If there is no CPT or HCPCS code available for a certain implant, EGID will accept the appropriate unlisted CPT or HCPCS code with an explanation of each item and the Member corresponding charge.
b. Upon request, EGID requires the actual invoice for the implant billed.
c. EGID may conduct quarterly retrospective audits of the IHO’s charges for implants.
d. Upon the occurrence of an audit, XXXX will request invoices for audited claims and any other documentation showing discounts that are not listed on the invoice. Invoices must identify which implants listed on the invoice apply to the claim being audited. Upon request, the IHO has 30 days to submit this information to EGID. During the audit, if XXXX finds that the IHO is billing more than acquisition costs, plus 10%, the IHO will be required to refund any overpayments made by EGID to the IHO and to provide copies of invoices for all subsequent claims submitted prior to payment. If the IHO continues to bill above the acquisition cost or does not provide copies of requested invoices with the required timeframe then, EGID will no liability.longer allow reimbursement to the IHO for implants as a separate reimbursable item.
Appears in 1 contract
Compensation and Billing. 6.1
1. The Facility shall only seek payment from EGID for the provision of Covered ServicesMedical and Dental Services except as provided in sections VI (2), VI (15) and VI (20). The Facility agrees to accept the amount of the Allowable Fee or billed charges, whichever is less, for Covered Services as payment in full and agrees to only request payment from the Member for deductible, co-insurance coinsurance and amounts for defined Non-Covered Services services attributable to the Member’s Health Choice HealthChoice Plan. The payment shall be calculated and limited to the methodologies defined by this Contract.
6.2 When 2. EGID shall reimburse the Allowable Fee exceeds set by EGID for each procedure or the Facility’s billed charge, whichever is less. This reimbursement shall be allowed when the Member has received Covered Medically Necessary Services subject to the following policy limitation and conditions:
a. EGID may reduce the payment by any deductibles, coinsurance and copayments according to the Member’s HealthChoice Plan in effect at the time charges are incurred. Complete descriptions of HealthChoice Plans are available on EGID’s website.
b. EGID shall have the right to categorize what shall constitute a procedure. EGID and the Member’s financial liability shall be limited to the procedure’s Allowable Fee or billed charges, EGID shall pay whichever is less, as determined by EGID, paid by applying appropriate coding methodology, whether the appropriate percentage of the Allowable Fee and Member shall pay the appropriate percentage of Facility has billed charges unless the Member has met the stop loss limitation and then EGID shall pay the Allowable Fee and the Member has no liabilityappropriately or not.
6.3 c. The Facility agrees not to charge more for Medical or Dental Services to Members than the amount normally charged by the Facility to other patients for similar services. The Facility’s usual and customary charges may be requested by EGID and verified through an audit.
3. Skilled Nursing Facility services, day treatment and Residential treatment will be reimbursed utilizing a per diem. In no event shall a per diem qualify as an Outlier.
4. The Facility agrees that XXXX utilizes a comprehensive claim editing system to assist in determining which charges for Covered Services to allow for payment and to assist in determining inappropriate billing and coding. Said system shall rely on CMS and other industry standards in the development of its mutually exclusive, incidental, re-bundling, age conflict, gender conflict, cosmetic, experimental and procedure editing.
5. When processing inpatient claims, EGID shall determine the MS-DRG Allowable Fee for non- non-transfer cases according to the following formula: Skilled Nursing Facility Services, Day Treatment and Residential treatment will be reimbursed utilizing the per diem methodology. In no event shall a per diem qualify as an Outlier. These benefits MS-DRG Allowable Fee = MS-DRG Relative Weight x Base Rate.
a. The reimbursement shall be allowed when the Member has received Medically Necessary Covered Services subject to the following policy limitations and conditions:
a) conditions: • EGID shall pay the appropriate percentage of the MS-DRG Allowable Fee or billed charges, whichever is less, and the Member shall pay the remainder of the MS-DRG Allowable Fee or billed charges, whichever is less, unless the Member has met the stop loss limitation, and then EGID shall pay one hundred percent (100%) % of the MS-DRG Allowable Fee or billed charge, whichever is less, and the Member has no liability.
b) liability. • The MS-DRG shall be controlling, subject to EGID’s approval and Article X of the Contract.
c) contract. • The MS-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed Current Procedural Terminology code Allowable Fees.
d) EGID may reduce its payment by any deductibles, coinsurance and co- payments owed by the Member.
e) CPT/HCPCS codes. • EGID shall include the day of admission but not the day of discharge when computing the the number of facility days provided to a Membermember. Observation Facility facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits.
f) benefits. • In the case of a transfer, the Transfer Allowable Fee for the transferring Facility shall be calculated as follows: follows: Transfer Allowable Fee = (MS-DRG Allowable Fee/Geometric Mean Length of Stay) x (Length of Stay + 1 day) ). • The total Transfer Allowable Fee paid to the transferring Facility shall be capped at the amount of the MS-DRG Allowable Fee or billed charges, whichever is less, for a non-transfer case. EGID shall allow payment to the receiving Facility, if it is also the final discharging Facility, at the MS- MS-DRG Allowable Fee or billed charges, whichever is less, as if it were an original admission.admission.
g) b. EGID shall use the current version of the CMS MS-DRG grouper to categorize what shall constitute a procedure. XXXX’s and the Member’s financial liability shall be limited to the Allowable Fee or billed charges, whichever is less, as determined by XXXX.EGID.
h) The Facility agrees not to charge more for Medical Services to Members than the amount normally charged by the Facility to other patients for similar services.
i) c. For Outlier cases, EGID shall base its payment to the Facility using an Outlier Allowable Fee plus the MS-DRG Allowable Fee. The following formula shall be utilized to calculate the Outlier Allowable Fee: Fee: Outlier Allowable Fee = [Billed Charges billed charges – (MS-DRG Allowable Fee + Outlier Threshold)] x Marginal Cost Factor.
6.4 6. When processing Outpatient inpatient LTCH claims, XXXX agrees to pay the LTCH Facility the Allowable Fee based on appropriate billing according to the following:
a) If a procedure does not have an Allowable Fee, EGID will allow a percentage of the billed charges for Covered Services.
b) a. EGID shall pay the appropriate percentage of the MS-LTC-DRG Allowable Fee and the Member shall pay the remainder based on of the Member’s plan of benefits MS-LTC-DRG Allowable Fee unless the Member has met the stop loss limitation, and then EGID shall pay 100% of the MS-LTC- DRG Allowable Fee and the Member has no liability.liability.
b. The MS-LTC-DRG shall be controlling, subject to EGID’s approval and Article X of the Contract.
c. The MS-LTC-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed CPT code Allowable Fees.
d. EGID may reduce its payment by any deductibles, coinsurance and co-payments owed by the Member.
e. EGID shall include the day of admission but not the day of discharge when computing the number of facility days provided to a Member. Observation Facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits.
f. EGID shall use the current version of the MS-LTC-DRG grouper to categorize what shall constitute a procedure. XXXX’s and the Member’s financial liability shall be limited to the Allowable Fee as determined by EGID.
g. The LTCH Facility agrees not to charge more for Medical Services to Members than the amount normally charged by the Facility to other patients for similar services.
7. EGID shall determine the Allowable Fee to an LTCH Facility for an unadjusted MS-LTC-DRG according to the following formula: MS-LTC-DRG Allowable Fee = MS-LTC-DRG Relative Weight x Base Rate
Appears in 1 contract
Samples: Facility Contract
Compensation and Billing. 6.1 1. The Facility shall only seek payment from EGID for the provision of Covered ServicesMedical and Dental Services except as provided in sections VI (2), VI (15) and VI (20). The Facility agrees to accept the amount of the Allowable Fee or billed charges, whichever is less, for Covered Services as payment in full and agrees to only request payment from the Member for deductible, co-insurance coinsurance and amounts for defined Non-Covered Services services attributable to the Member’s Health Choice HealthChoice Plan. The payment shall be calculated and limited to the methodologies defined by this Contract.
6.2 When 2. EGID shall reimburse the Allowable Fee exceeds set by EGID for each procedure or the Facility’s billed charge, whichever is less. This reimbursement shall be allowed when the Member has received Covered Medically Necessary Services subject to the following policy limitation and conditions:
a. EGID may reduce the payment by any deductibles, coinsurance and copayments according to the Member’s HealthChoice Plan in effect at the time charges are incurred. Complete descriptions of HealthChoice Plans are available on EGID’s website.
b. EGID shall have the right to categorize what shall constitute a procedure. EGID and the Member’s financial liability shall be limited to the procedure’s Allowable Fee or billed charges, EGID shall pay whichever is less, as determined by EGID, paid by applying appropriate coding methodology, whether the appropriate percentage of the Allowable Fee and Member shall pay the appropriate percentage of Facility has billed charges unless the Member has met the stop loss limitation and then EGID shall pay the Allowable Fee and the Member has no liabilityappropriately or not.
6.3 c. The Facility agrees not to charge more for Medical or Dental Services to Members than the amount normally charged by the Facility to other patients for similar services. The Facility’s usual and customary charges may be requested by EGID and verified through an audit.
3. Skilled Nursing Facility services, day treatment and Residential treatment will be reimbursed utilizing a per diem. In no event shall a per diem qualify as an Outlier.
4. The Facility agrees that XXXX utilizes a comprehensive claim editing system to assist in determining which charges for Covered Services to allow for payment and to assist in determining inappropriate billing and coding. Said system shall rely on CMS and other industry standards in the development of its mutually exclusive, incidental, re-bundling, age conflict, gender conflict, cosmetic, experimental and procedure editing.
5. When processing inpatient claims, EGID shall determine the MS-DRG Allowable Fee for non- non-transfer cases according to the following formula: Skilled Nursing Facility Services, Day Treatment and Residential treatment will be reimbursed utilizing the per diem methodology. In no event shall a per diem qualify as an Outlier. These benefits MS-DRG Allowable Fee = MS-DRG Relative Weight x Base Rate.
a. The reimbursement shall be allowed when the Member has received Medically Necessary Covered Services subject to the following policy limitations and conditions:
a) conditions: • EGID shall pay the appropriate percentage of the MS-DRG Allowable Fee or billed charges, whichever is less, and the Member shall pay the remainder of the MS-DRG Allowable Fee or billed charges, whichever is less, unless the Member has met the stop loss limitation, and then EGID shall pay one hundred percent (100%) % of the MS-DRG Allowable Fee or billed charge, whichever is less, and the Member has no liability.
b) liability. • The MS-DRG shall be controlling, subject to EGID’s approval and Article X of the Contract.
c) contract. • The MS-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed Current Procedural Terminology code Allowable Fees.
d) EGID may reduce its payment by any deductibles, coinsurance and co- payments owed by the Member.
e) CPT/HCPCS codes. • EGID shall include the day of admission but not the day of discharge when computing the the number of facility days provided to a Membermember. Observation Facility facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits.
f) benefits. • In the case of a transfer, the Transfer Allowable Fee for the transferring Facility shall be calculated as follows: follows: Transfer Allowable Fee = (MS-DRG Allowable Fee/Geometric Mean Length of Stay) x (Length of Stay + 1 day) ). • The total Transfer Allowable Fee paid to the transferring Facility shall be capped at the amount of the MS-DRG Allowable Fee or billed charges, whichever is less, for a non-transfer case. EGID shall allow payment to the receiving Facility, if it is also the final discharging Facility, at the MS- MS-DRG Allowable Fee or billed charges, whichever is less, as if it were an original admission.admission.
g) b. EGID shall use the current version of the CMS MS-DRG grouper to categorize what shall constitute a procedure. XXXX’s and the Member’s financial liability shall be limited to the Allowable Fee or billed charges, whichever is less, as determined by XXXX.EGID.
h) The Facility agrees not to charge more for Medical Services to Members than the amount normally charged by the Facility to other patients for similar services.
i) c. For Outlier cases, EGID shall base its payment to the Facility using an Outlier Allowable Fee plus the MS-DRG Allowable Fee. The following formula shall be utilized to calculate the Outlier Allowable Fee: Fee: Outlier Allowable Fee = [Billed Charges billed charges – (MS-DRG Allowable Fee + Outlier Threshold)] x Marginal Cost Factor.
6.4 6. When processing Outpatient inpatient LTCH claims, XXXX agrees to pay the LTCH Facility the Allowable Fee based on appropriate billing according to the following:
a) If a procedure does not have an Allowable Fee, EGID will allow a percentage of the billed charges for Covered Services.
b) a. EGID shall pay the appropriate percentage of the MS-LTC-DRG Allowable Fee and the Member shall pay the remainder based on of the Member’s plan of benefits MS-LTC-DRG Allowable Fee unless the Member has met the stop loss limitation, and then EGID shall pay 100% of the MS-LTC- DRG Allowable Fee and the Member has no liability.liability.
b. The MS-LTC-DRG shall be controlling, subject to EGID’s approval and Article X of the Contract.
c. The MS-LTC-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed CPT code Allowable Fees.
d. EGID may reduce its payment by any deductibles, coinsurance and co-payments owed by the Member.
e. EGID shall include the day of admission but not the day of discharge when computing the number of facility days provided to a Member. Observation Facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits.
f. EGID shall use the current version of the MS-LTC-DRG grouper to categorize what shall constitute a procedure. XXXX’s and the Member’s financial liability shall be limited to the Allowable Fee as determined by EGID.
g. The LTCH Facility agrees not to charge more for Medical Services to Members than the amount normally charged by the Facility to other patients for similar services.
7. EGID shall determine the Allowable Fee to an LTCH Facility for an unadjusted MS-LTC-DRG according to the following formula: MS-LTC-DRG Allowable Fee = MS-LTC-DRG Relative Weight x Base Rate
Appears in 1 contract
Samples: Facility Contract
Compensation and Billing. 6.1 1. The Facility Practitioner shall only seek payment from EGID for the provision of Covered Medical or Dental Services, except as provided in sections VI (5), VI (6) and VI (11). The Facility agrees payment from EGID shall be limited to accept the amount of amounts referred to in section VI (2).
2. XXXX shall reimburse the Allowable Fee set by EGID for Covered Services as payment in full and agrees to only request payment from each procedure or the Member for deductiblePractitioner’s billed charge, co-insurance and amounts for defined Non-Covered Services attributable to the Member’s Health Choice Planwhichever is less. The payment shall be calculated and limited to the methodologies defined by this Contract.
6.2 When the Allowable Fee exceeds billed charges, EGID shall pay the appropriate percentage of the Allowable Fee and Member shall pay the appropriate percentage of billed charges unless the Member has met the stop loss limitation and then EGID shall pay the Allowable Fee and the Member has no liability.
6.3 When processing inpatient claims, EGID shall determine the MS-DRG Allowable Fee for non- transfer cases according to the following formula: Skilled Nursing Facility Services, Day Treatment and Residential treatment will be reimbursed utilizing the per diem methodology. In no event shall a per diem qualify as an Outlier. These benefits This reimbursement shall be allowed when the Member has received Covered Medically Necessary Covered Services subject to the following policy limitations limitation and conditions:
a) EGID a. XXXX shall pay reimburse physician assistants, certified nurse practitioners, certified nurse midwives, and clinical nurse specialists, billing under their own NPIs within the appropriate percentage scope of their license. This reimbursement shall be 85% of the MS-DRG Allowable Fee and set by EGID for each procedure for professional services as defined on the Member HealthChoice fee schedules or the billed charge, whichever is less.
b. XXXX shall pay the remainder reimburse anesthesiology assistants 50% of the MS-DRG Allowable Fee unless set by EGID for each procedure or the Member has met the stop loss limitationbilled charge, and then EGID shall pay one hundred percent (100%) of the MS-DRG Allowable Fee and the Member has no liability.whichever is less.
b) The MS-DRG shall be controlling, subject to EGID’s approval and Article X of the Contract.
c) The MS-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed Current Procedural Terminology code Allowable Fees.
d) c. EGID may reduce its the payment by any deductibles, coinsurance and co- payments owed by copayments according to the Member.Member’s HealthChoice Plan in effect at the time charges are incurred. Complete descriptions of HealthChoice Plans are available on EGID’s website.
e) d. EGID shall include have the day of admission but not the day of discharge when computing the number of facility days provided to a Member. Observation Facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits.
f) In the case of a transfer, the Transfer Allowable Fee for the transferring Facility shall be calculated as follows: Transfer Allowable Fee = (MS-DRG Allowable Fee/Geometric Mean Length of Stay) x (Length of Stay + 1 day) The total Transfer Allowable Fee paid to the transferring Facility shall be capped at the amount of the MS-DRG Allowable Fee for a non-transfer case. EGID shall allow payment to the receiving Facility, if it is also the final discharging Facility, at the MS- DRG Allowable Fee as if it were an original admission.
g) EGID shall use the current version of the CMS MS-DRG grouper right to categorize what shall constitute a procedure. XXXX’s EGID and the Member’s financial liability shall be limited to the procedure’s Allowable Fee or billed charge, whichever is less, as determined by XXXX.EGID, paid by applying appropriate coding methodology, whether the Practitioner has billed appropriately or not.
h) e. The Facility Practitioner agrees not to charge more for Medical or Dental Services to Members than the amount normally charged by the Facility Practitioner to other patients for similar services.services. The Practitioner’s usual and customary charges may be requested by EGID and verified through an audit.
i) For Outlier cases3. The Practitioner agrees that XXXX utilizes a comprehensive claim editing system to assist in determining which charges for Covered Services to allow for payment and to assist in determining inappropriate billing and coding. Said system shall rely on CMS and other industry standards in the development of its mutually exclusive, incidental, re-bundling, age conflict, gender conflict, cosmetic, experimental and procedure editing.
4. EGID shall base its payment have the right to the Facility using an Outlier Allowable Fee plus the MS-DRG Allowable Fee. The following formula shall be utilized to calculate the Outlier Allowable Fee: Outlier Allowable Fee = [Billed Charges – (MS-DRG Allowable Fee + Outlier Threshold)] x Marginal Cost Factor
6.4 When processing Outpatient claims, XXXX agrees to pay the Facility adjust the Allowable Fee based on appropriate billing according clinical editing and/or the use of modifiers as documented in the HealthChoice Provider Manual.
5. The Practitioner agrees that the only charges for which a Member may be liable and be billed by the Practitioner shall be for Medical or Dental Services not covered by a HealthChoice Plan, or as provided in sections VI (2), VI (6) and VI (11). The Practitioner shall not waive any deductibles, copayments and coinsurance required by EGID.
6. The Practitioner shall not collect amounts in excess of the plan limits unless the Member has exceeded those established limits.
7. The Practitioner shall refund within 30 days of discovery to the following:Member any overpayments made by the Member.
a) If 8. In a procedure does not have an Allowable Feecase in which HealthChoice is primary under applicable coordination of benefit rules as defined in the HealthChoice Provider Manual, EGID will allow calculate the benefits to be paid without considering the other plan's benefits. In a percentage case in which HealthChoice is other than primary under the coordination of benefit rules, EGID will use the billed Standard Allowable Calculation methodology for Coordination of Benefits, up to EGID's maximum liability under the terms of this Contract.
9. The Practitioner shall bill EGID on forms acceptable to EGID within 365 days of providing the Medical or Dental Services. The Practitioner shall use the current ADA, CPT, HCPCS codes with appropriate modifiers and ICD or DSM diagnosis codes, when applicable. The Practitioner shall furnish, upon request at no cost, all information, including Medical records and X-rays, reasonably required by EGID to verify and substantiate the provision of Medical or Dental Services and the charges for Covered Services.such services if the Member and the Practitioner are seeking reimbursement through EGID.
b) 10. XXXX shall reimburse the Practitioner within 45 days of receipt of xxxxxxxx that are accurate, complete, including all information requested by EGID reasonably required to verify and substantiate the billing, and otherwise in accordance with Article VI of this Contract. Refer to 74 O.S. § 1328. XXXX will not be responsible for delay of reimbursement due to circumstances beyond XXXX's control.
11. The Practitioner shall not charge the Member for Medical or Dental Services or supplies denied during Certification or Concurrent Review procedures described in Article VII, unless the Practitioner has obtained a written waiver from that Member. Such a waiver shall be obtained only upon the denial of admission, Certification, or Concurrent Review and prior to the provision of those Medical or Dental Services. The waiver shall clearly state that the Member shall be responsible for payment of Medical or Dental Services denied by EGID.
12. EGID shall pay have the appropriate percentage right at all reasonable times and, to the extent permitted by law, to inspect and duplicate all documentation or records relating to Medical or Dental Services rendered to Members at no cost to EGID or the Member.
13. The Practitioner agrees that XXXX’s subrogation rights or the existence of third-party liability does not affect the Practitioner’s agreement to accept the current Allowable Fee or billed charges, whichever is less, described in this Contract. Unrecorded alleged or recorded liens that are intended to secure charges for treatment rendered to, or on behalf of, a Member for amounts in excess of the Allowable Fee and the Member shall pay the remainder based on or billed charges, whichever is less, or which exceed the Member’s plan deductible and coinsurance liability as required by this Contract, are rendered invalid by the Practitioner’s submission of benefits unless a Members’ claims to EGID.
14. A list of the Member has met the stop loss limitation, CPT/HCPCS codes and then EGID shall pay 100% of the Allowable Fee for each can be found on the EGID website. EGID shall review and update the Member has no liability.fee schedules quarterly or as needed.
Appears in 1 contract
Samples: Practitioner Contract
Compensation and Billing. 6.1 1. The Facility shall only seek payment from EGID for the provision of Covered ServicesMedical or Dental Services except as provided in sections VI (2), VI (10) and VI (15). The Facility agrees to accept the amount of the Allowable Fee or billed charges, whichever is less, for Covered Services as payment in full and agrees to only request payment from the Member for deductible, co-insurance coinsurance and amounts for defined Non-Covered Services services attributable to the Member’s Health Choice HealthChoice Plan. The payment shall be calculated and limited to the methodologies defined by this Contractcontract.
6.2 When 2. EGID shall reimburse the Allowable Fee exceeds set by EGID for each procedure or the Facility’s billed charge, whichever is less. This reimbursement shall be allowed when the Member has received Covered Medically Necessary Services subject to the following policy limitation and conditions:
a. EGID may reduce the payment by any deductibles, coinsurance and copayments according to the Member’s HealthChoice Plan in effect at the time charges are incurred. Complete descriptions of HealthChoice Plans are available on EGID’s website.
b. EGID shall have the right to categorize what shall constitute a procedure. EGID and the Member’s financial liability shall be limited to the procedure’s Allowable Fee or billed charges, EGID shall pay whichever is less, as determined by EGID, paid by applying appropriate coding methodology, whether the appropriate percentage of the Allowable Fee and Member shall pay the appropriate percentage of Facility has billed charges unless the Member has met the stop loss limitation and then EGID shall pay the Allowable Fee and the Member has no liabilityappropriately or not.
6.3 c. The Facility agrees not to charge more for Medical or Dental Services to Members than the amount normally charged by the Facility to other patients for similar services. The Facility’s usual and customary charges may be requested by EGID and verified through an audit.
3. Skilled Nursing Facility services, day treatment and Residential treatment will be reimbursed utilizing a per diem. In no event shall a per diem qualify as an Outlier.
4. The Facility agrees that XXXX utilizes a comprehensive claim editing system to assist in determining which charges for Covered Services to allow for payment and to assist in determining inappropriate billing and coding. Said system shall rely on CMS and other industry standards in the development of its mutually exclusive, incidental, re-bundling, age conflict, gender conflict, cosmetic, experimental and procedure editing.
5. When processing inpatient claims, EGID shall determine the MS-DRG Allowable Fee for non- non-transfer cases according to the following formula: Skilled Nursing Facility Services, Day Treatment and Residential treatment will be reimbursed utilizing the per diem methodology. In no event shall a per diem qualify as an Outlier. These benefits :
a. The reimbursement shall be allowed when the Member member has received Medically Necessary Covered Services subject to the following policy limitations and conditions:
a) : • EGID shall pay the appropriate percentage of the MS-DRG Allowable Fee or billed charges, whichever is less, and the Member shall pay the remainder of the MS-DRG Allowable Fee or billed charges, whichever is less, unless the Member has met the stop loss limitation, and then EGID shall pay one hundred percent (100%) % of the MS-DRG Allowable Fee or billed charge, whichever is less, and the Member has no liability.
b) liability. • The MS-DRG shall be controlling, subject to EGID’s approval and Article X of the Contract.
c) contract. • The MS-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed Current Procedural Terminology code Allowable Fees.
d) EGID may reduce its payment by any deductibles, coinsurance and co- payments owed by the Member.
e) CPT/HCPCS codes. • EGID shall include the day of admission but not the day of discharge when computing the the number of facility days provided to a Membermember. Observation Facility facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits.
f) benefits. • In the case of a transfer, the Transfer Allowable Fee for the transferring Facility facility shall be calculated as follows: follows: Transfer Allowable Fee = (MS-DRG Allowable Fee/Geometric Mean Length of Stay) x (Length of Stay + 1 day) ). • The total Transfer Allowable Fee paid to the transferring Facility shall be capped at the amount of the MS-DRG Allowable Fee or billed charges, whichever is less, for a non-transfer case. EGID shall allow payment to the receiving Facility, if it is also the final discharging Facility, at the MS- MS-DRG Allowable Fee or billed charges, whichever is less, as if it were an original admission.admission.
g) b. EGID shall use the current version of the CMS MS-DRG grouper to categorize what shall constitute a procedure. XXXX’s and the Member’s financial liability shall be limited to the Allowable Fee or billed charges, whichever is less, as determined by XXXX.EGID.
h) The Facility agrees not to charge more for Medical Services to Members than the amount normally charged by the Facility to other patients for similar services.
i) c. For Outlier cases, EGID shall base its payment to the Facility using an Outlier Allowable Fee plus the MS-DRG Allowable Fee. The following formula shall be utilized to calculate the Outlier Allowable Fee: Fee: Outlier Allowable Fee = [Billed Charges billed charges – (MS-DRG Allowable Fee + Outlier Threshold)] x Marginal Cost Factor.
6.4 6. When processing Outpatient outpatient claims, XXXX shall reimburse the Allowable Fee or the Facility’s billed charge for that procedure, whichever is less. The reimbursement shall be allowed when the Member has received Covered Medically Necessary Services.
7. A list of the CPT/HCPCS codes and the Allowable Fee for each can be found on the EGID website. EGID shall review and update the fee schedules quarterly or as needed.
8. A Facility’s urban/rural status is determined by EGID. Generally, counties which are designated by the U.S. Census Bureau as a part of a metropolitan core based statistical area (CBSA) are considered urban.
9. The Facility agrees to pay that the only charges for which a Member may be liable and be billed by the Facility shall be for Medical or Dental Services not covered by a HealthChoice Plan, or as provided in sections VI (2), VI (10) and VI (15). The Facility shall not waive any deductibles, copayments and coinsurance required by EGID.
10. The Facility shall not collect amounts in excess of plan limits unless the Member has exceeded those established limits.
11. The Facility shall refund to the Member within 30 days of discovery any overpayment made by the Member.
12. In a case in which HealthChoice is primary under applicable coordination of benefit rules as defined in the HealthChoice Provider Manual, EGID will calculate the benefits to be paid without considering the other plan's benefits. In a case in which HealthChoice is other than primary under the coordination of benefit rules, EGID will use the Standard Allowable Calculation methodology for Coordination of Benefits, up to EGID's maximum liability under the terms of this Contract.
13. The Facility shall bill EGID on forms acceptable to EGID within 365 days of providing the Medical or Dental Services. The Facility shall use the current revenue codes, ADA, CPT codes with appropriate modifiers, HCPCS codes, and ICD or DSM diagnosis codes, when applicable. The Facility shall furnish, upon request at no cost, all information, including Medical or Dental records and X-rays, reasonably required by EGID to verify and substantiate the provision of Medical or Dental Services and the charges for such services if the Member and the Facility are seeking reimbursement through EGID.
14. XXXX shall reimburse the Facility within 45 days of receipt of xxxxxxxx that are accurate, complete, including all information requested by EGID reasonably required to verify and substantiate the billing, and otherwise in accordance with Article VI of this Contract. See 74 O.S. § 1328. XXXX will not be responsible for delay of reimbursement due to circumstances beyond XXXX’s control.
15. The Facility shall not charge the Member for Medical and Dental Services denied by the Certification or Concurrent Review procedures described in Article VII, unless the Facility has obtained a written waiver from that Member. Such a waiver shall be obtained only upon the denial of Medical and Dental Services and prior to the provision of those Medical and Dental Services. The waiver shall clearly state that the Member shall be responsible for payment of Medical or Dental Services denied by EGID.
16. EGID shall have the right at all reasonable times and, to the extent permitted by law, to inspect and duplicate all documentation or records relating to Medical or Dental Services rendered to Members at no cost to EGID or the Member.
17. EGID shall have the right to adjust the Allowable Fee based on appropriate billing according to clinical editing and/or the following:use of modifiers as documented in the HealthChoice Provider Manual.
a) If a procedure 18. The Facility agrees that XXXX’s subrogation rights or the existence of third-party liability does not have an affect the Facility’s agreement to accept the current Allowable FeeFee or billed charges, EGID will allow a percentage of the billed whichever is less, described in this Contract. Unrecorded alleged or recorded liens that are intended to secure charges for Covered Services.
b) EGID shall pay the appropriate percentage treatment rendered to or on behalf of a Member for amounts in excess of the Allowable Fee and the Member shall pay the remainder based on or billed charges, whichever is less, or which exceed the Member’s plan deductible and coinsurance liability as required by the Contract, are rendered invalid by the Facility’s submission of benefits unless the Member has met the stop loss limitation, and then EGID shall pay 100% of the Allowable Fee and the Member has no liability.a Members’ claims to EGID.
Appears in 1 contract
Samples: Facility Contract
Compensation and Billing. 6.1
1. The Facility Practitioner shall only seek payment from EGID for the provision of Covered Medical or Dental Services, except as provided in sections VI (5), VI (6) and VI (11). The Facility agrees payment from EGID shall be limited to accept the amount of amounts referred to in section VI (2).
2. XXXX shall reimburse the Allowable Fee set by EGID for Covered Services as payment in full and agrees to only request payment from each procedure or the Member for deductiblePractitioner’s billed charge, co-insurance and amounts for defined Non-Covered Services attributable to the Member’s Health Choice Planwhichever is less. The payment shall be calculated and limited to the methodologies defined by this Contract.
6.2 When the Allowable Fee exceeds billed charges, EGID shall pay the appropriate percentage of the Allowable Fee and Member shall pay the appropriate percentage of billed charges unless the Member has met the stop loss limitation and then EGID shall pay the Allowable Fee and the Member has no liability.
6.3 When processing inpatient claims, EGID shall determine the MS-DRG Allowable Fee for non- transfer cases according to the following formula: Skilled Nursing Facility Services, Day Treatment and Residential treatment will be reimbursed utilizing the per diem methodology. In no event shall a per diem qualify as an Outlier. These benefits This reimbursement shall be allowed when the Member has received Covered Medically Necessary Covered Services subject to the following policy limitations limitation and conditions:
a) EGID a. XXXX shall pay reimburse physician assistants, certified nurse practitioners, certified nurse midwives, and clinical nurse specialists, billing under their own NPIs within the appropriate percentage scope of their license. This reimbursement shall be 85% of the MS-DRG Allowable Fee and set by EGID for each procedure for professional services as defined on the Member HealthChoice fee schedules or the billed charge, whichever is less.
b. XXXX shall pay the remainder reimburse anesthesiology assistants 50% of the MS-DRG Allowable Fee unless set by EGID for each procedure or the Member has met the stop loss limitationbilled charge, and then EGID shall pay one hundred percent (100%) of the MS-DRG Allowable Fee and the Member has no liability.whichever is less.
b) The MS-DRG shall be controlling, subject to EGID’s approval and Article X of the Contract.
c) The MS-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed Current Procedural Terminology code Allowable Fees.
d) c. EGID may reduce its the payment by any deductibles, coinsurance and co- payments owed by copayments according to the Member.Member’s HealthChoice Plan in effect at the time charges are incurred. Complete descriptions of HealthChoice Plans are available on EGID’s website.
e) d. EGID shall include have the day of admission but not the day of discharge when computing the number of facility days provided to a Member. Observation Facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits.
f) In the case of a transfer, the Transfer Allowable Fee for the transferring Facility shall be calculated as follows: Transfer Allowable Fee = (MS-DRG Allowable Fee/Geometric Mean Length of Stay) x (Length of Stay + 1 day) The total Transfer Allowable Fee paid to the transferring Facility shall be capped at the amount of the MS-DRG Allowable Fee for a non-transfer case. EGID shall allow payment to the receiving Facility, if it is also the final discharging Facility, at the MS- DRG Allowable Fee as if it were an original admission.
g) EGID shall use the current version of the CMS MS-DRG grouper right to categorize what shall constitute a procedure. XXXX’s EGID and the Member’s financial liability shall be limited to the procedure’s Allowable Fee or billed charge, whichever is less, as determined by XXXX.EGID, paid by applying appropriate coding methodology, whether the Practitioner has billed appropriately or not.
h) e. The Facility Practitioner agrees not to charge more for Medical or Dental Services to Members than the amount normally charged by the Facility Practitioner to other patients for similar services.services. The Practitioner’s usual and customary charges may be requested by EGID and verified through an audit.
i) For Outlier cases3. The Practitioner agrees that XXXX utilizes a comprehensive claim editing system to assist in determining which charges for Covered Services to allow for payment and to assist in determining inappropriate billing and coding. Said system shall rely on CMS and other industry standards in the development of its mutually exclusive, incidental, re-bundling, age conflict, gender conflict, cosmetic, experimental and procedure editing.
4. EGID shall base its payment have the right to the Facility using an Outlier Allowable Fee plus the MS-DRG Allowable Fee. The following formula shall be utilized to calculate the Outlier Allowable Fee: Outlier Allowable Fee = [Billed Charges – (MS-DRG Allowable Fee + Outlier Threshold)] x Marginal Cost Factor
6.4 When processing Outpatient claims, XXXX agrees to pay the Facility adjust the Allowable Fee based on appropriate billing according clinical editing and/or the use of modifiers as documented in the HealthChoice Provider Manual.
5. The Practitioner agrees that the only charges for which a Member may be liable and be billed by the Practitioner shall be for Medical or Dental Services not covered by a HealthChoice Plan, or as provided in sections VI (2), VI (6) and VI (11). The Practitioner shall not waive any deductibles, copayments and coinsurance required by EGID.
6. The Practitioner shall not collect amounts in excess of the plan limits unless the Member has exceeded those established limits.
7. The Practitioner shall refund within 30 days of discovery to the following:Member any overpayments made by the Member.
a) If 8. In a procedure does not have an Allowable Feecase in which HealthChoice is primary under applicable coordination of benefit rules as defined in the HealthChoice Provider Manual, EGID will allow calculate the benefits to be paid without considering the other plan's benefits. In a percentage case in which HealthChoice is other than primary under the coordination of benefit rules, EGID will use the billed Standard Allowable Calculation methodology for Coordination of Benefits, up to EGID's maximum liability under the terms of this Contract.
9. The Practitioner shall bill EGID on forms acceptable to EGID within 180 days of providing the Medical or Dental Services. The Practitioner shall use the current ADA, CPT, HCPCS codes with appropriate modifiers and ICD or DSM diagnosis codes, when applicable. The Practitioner shall furnish, upon request at no cost, all information, including Medical records and X-rays, reasonably required by EGID to verify and substantiate the provision of Medical or Dental Services and the charges for Covered Services.such services if the Member and the Practitioner are seeking reimbursement through EGID.
b) 10. XXXX shall reimburse the Practitioner within 45 days of receipt of xxxxxxxx that are accurate, complete, including all information requested by EGID reasonably required to verify and substantiate the billing, and otherwise in accordance with Article VI of this Contract. Refer to 74 O.S. § 1328. XXXX will not be responsible for delay of reimbursement due to circumstances beyond XXXX's control.
11. The Practitioner shall not charge the Member for Medical or Dental Services or supplies denied during Certification or Concurrent Review procedures described in Article VII, unless the Practitioner has obtained a written waiver from that Member. Such a waiver shall be obtained only upon the denial of admission, Certification, or Concurrent Review and prior to the provision of those Medical or Dental Services. The waiver shall clearly state that the Member shall be responsible for payment of Medical or Dental Services denied by EGID.
12. EGID shall pay have the appropriate percentage right at all reasonable times and, to the extent permitted by law, to inspect and duplicate all documentation or records relating to Medical or Dental Services rendered to Members at no cost to EGID or the Member.
13. The Practitioner agrees that XXXX’s subrogation rights or the existence of third-party liability does not affect the Practitioner’s agreement to accept the current Allowable Fee or billed charges, whichever is less, described in this Contract. Unrecorded alleged or recorded liens that are intended to secure charges for treatment rendered to, or on behalf of, a Member for amounts in excess of the Allowable Fee and the Member shall pay the remainder based on or billed charges, whichever is less, or which exceed the Member’s plan deductible and coinsurance liability as required by this Contract, are rendered invalid by the Practitioner’s submission of benefits unless a Members’ claims to EGID.
14. A list of the Member has met the stop loss limitation, CPT/HCPCS codes and then EGID shall pay 100% of the Allowable Fee for each can be found on the EGID website. EGID shall review and update the Member has no liability.fee schedules quarterly or as needed.
Appears in 1 contract
Samples: Practitioner Contract
Compensation and Billing. 6.1 1. The Facility shall only seek payment from EGID DOC for the provision of Covered Medical and Dental Services. The Facility agrees to accept the amount of the Allowable Fee or billed charges, whichever is less, for Covered Services as payment in full and agrees to only request payment from the Member for deductible, co-insurance and amounts for defined Non-Covered Services attributable to the Member’s Health Choice Planfull. The payment shall be calculated and limited to the methodologies defined by this Contract.
6.2 When 2. DOC shall reimburse the Allowable Fee exceeds set by DOC for each procedure or the Facility’s billed charge, whichever is less. This reimbursement shall be allowed when the Inmate has received Covered Medically Necessary Services subject to the following policy limitation and conditions:
a. DOC shall have the right to categorize what shall constitute a procedure. DOC’s financial liability shall be limited to the procedure’s Allowable Fee or billed charge, whichever is less, as determined by DOC, paid by applying appropriate coding methodology, whether the Facility has billed appropriately or not.
b. The Facility agrees not to charge more for Medical or Dental Services to Inmates than the amount normally charged by the Facility to other patients for similar services. The Facility’s usual and customary charges may be requested by DOC and verified through an audit.
c. Neither DOC nor the Inmate is responsible for charges above the Allowable Fee or billed charges, EGID shall pay the appropriate percentage of the Allowable Fee whichever is less, after all plan policies and Member shall pay the appropriate percentage of billed charges unless the Member has met the stop loss limitation and then EGID shall pay the Allowable Fee and the Member has no liabilityprovisions are applied.
6.3 When processing inpatient claims, EGID shall determine the MS-DRG Allowable Fee for non- transfer cases according to the following formula: 3. Skilled Nursing Facility Servicesservices, Day Treatment day treatment and Residential treatment will be reimbursed utilizing the a per diem methodologydiem. In no event shall a per diem qualify as an Outlier.
4. These benefits The Facility agrees that DOC utilizes a comprehensive claim editing system to assist in determining which charges for Covered Services to allow for payment and to assist in determining appropriate billing and coding. Said system shall rely on CMS and other industry standards in the development of its mutually exclusive, incidental, re-bundling, age conflict, gender conflict, cosmetic, experimental and procedure editing.
5. DOC shall have the right to adjust the Allowable Fee based on clinical editing and/or the use of modifiers as documented in the DOC Provider Manual.
6. When processing inpatient claims, DOC shall determine the MS-DRG Allowable Fee for non-transfer cases according to the following formula:
a. The reimbursement shall be allowed when the Member Inmate has received Medically Necessary Covered Services subject to the following policy limitations and conditions:
a) EGID : • DOC shall pay the appropriate percentage of the MS-DRG Allowable Fee or billed charges, whichever is less, and the Member shall pay the remainder of the MS-DRG Allowable Fee unless the Member has met the stop loss limitation, and then EGID shall pay one hundred percent (100%) of the MS-DRG Allowable Fee and the Member Inmate has no liability.
b) liability. • The MS-DRG shall be controlling, subject to EGIDDOC’s approval and Article X IX of the Contract.
c) Contract. • The MS-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed Current Procedural Terminology code Allowable Fees.
d) EGID may reduce its payment by any deductibles, coinsurance and co- payments owed by the Member.
e) EGID CPT/HCPCS codes. • DOC shall include the day of admission but not the day of discharge when computing the the number of facility days provided to a Memberan Inmate. Observation Facility facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits.
f) benefits. • In the case of a transfer, the Transfer Allowable Fee for the transferring Facility shall be calculated as follows: follows: Transfer Allowable Fee = (MS-DRG Allowable Fee/Geometric Mean Length of Stay) x (Length of Stay + 1 day) • The total Transfer Allowable Fee paid to the transferring Facility shall be capped at the amount of the MS-DRG Allowable Fee or billed charges, whichever is less, for a non-transfer case. EGID DOC shall allow payment to the receiving Facility, if it is also the final discharging Facility, at the MS- MS-DRG Allowable Fee or billed chares, whichever is less, as if it were an original admission.admission.
g) EGID b. DOC shall use the current version of the CMS MS-DRG grouper to categorize what shall constitute a procedure. XXXX’s and the MemberDOC’s financial liability shall be limited to the Allowable Fee or billed charges, whichever is less, as determined by XXXX.DOC.
h) The Facility agrees not to charge more for Medical Services to Members than the amount normally charged by the Facility to other patients for similar services.
i) c. For Outlier cases, EGID DOC shall base its payment to the Facility using an Outlier Allowable Fee plus the MS-DRG Allowable Fee. The following formula shall be utilized to calculate the Outlier Allowable Fee: Fee: Outlier Allowable Fee = [Billed Charges billed charges – (MS-DRG Allowable Fee + Outlier Threshold)] x Marginal Cost Factor
6.4 7. When processing Outpatient inpatient LTCH claims, XXXX agrees to pay the LTCH Facility the Allowable Fee based on appropriate billing according to the following:
a) If a procedure does not have an Allowable Fee, EGID will allow a percentage of the billed charges for Covered Services.
b) a. EGID shall pay the appropriate percentage of the MS-LTC-DRG Allowable Fee and the Member shall pay the remainder based on of the Member’s plan of benefits MS-LTC-DRG Allowable Fee unless the Member has met the stop loss limitation, and then EGID shall pay 100% of the MS-LTC- DRG Allowable Fee and the Member has no liability.liability.
b. The MS-LTC-DRG shall be controlling, subject to EGID’s approval and Article X of the Contract.
c. The MS-LTC-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed CPT code Allowable Fees.
d. EGID may reduce its payment by any deductibles, coinsurance and co-payments owed by the Member.
e. EGID shall include the day of admission but not the day of discharge when computing the number of facility days provided to a Member. Observation Facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits.
f. EGID shall use the current version of the MS-LTC-DRG grouper to categorize what shall constitute a procedure. XXXX’s and the Member’s financial liability shall be limited to the Allowable Fee as determined by EGID.
g. The LTCH Facility agrees not to charge more for Medical Services to Members than the amount normally charged by the Facility to other patients for similar services.
8. EGID shall determine the Allowable Fee to an LTCH Facility for an unadjusted MS-LTC-DRG according to the following formula: MS-LTC-DRG Allowable Fee = MS-LTC-DRG Relative Weight x Base Rate
Appears in 1 contract
Samples: Facility Contract
Compensation and Billing. 6.1 1. The Facility Practitioner shall only seek payment from EGID for the provision of Covered Medical or Dental Services, except as provided in sections VI (5), VI (6) and VI (11). The Facility agrees payment from EGID shall be limited to accept the amount of amounts referred to in section VI (2).
2. XXXX shall reimburse the Allowable Fee set by EGID for Covered Services as payment in full and agrees to only request payment from each procedure or the Member for deductiblePractitioner’s billed charge, co-insurance and amounts for defined Non-Covered Services attributable to the Member’s Health Choice Planwhichever is less. The payment shall be calculated and limited to the methodologies defined by this Contract.
6.2 When the Allowable Fee exceeds billed charges, EGID shall pay the appropriate percentage of the Allowable Fee and Member shall pay the appropriate percentage of billed charges unless the Member has met the stop loss limitation and then EGID shall pay the Allowable Fee and the Member has no liability.
6.3 When processing inpatient claims, EGID shall determine the MS-DRG Allowable Fee for non- transfer cases according to the following formula: Skilled Nursing Facility Services, Day Treatment and Residential treatment will be reimbursed utilizing the per diem methodology. In no event shall a per diem qualify as an Outlier. These benefits This reimbursement shall be allowed when the Member has received Covered Medically Necessary Covered Services subject to the following policy limitations limitation and conditions:
a) EGID a. XXXX shall pay reimburse physician assistants, certified nurse practitioners, certified nurse midwives, and clinical nurse specialists, billing under their own NPIs within the appropriate percentage scope of their license. This reimbursement shall be 85% of the MS-DRG Allowable Fee and set by EGID for each procedure for professional services as defined on the Member HealthChoice fee schedules or the billed charge, whichever is less.
b. XXXX shall pay the remainder reimburse anesthesiology assistants 50% of the MS-DRG Allowable Fee unless set by EGID for each procedure or the Member has met the stop loss limitationbilled charge, and then EGID shall pay one hundred percent (100%) of the MS-DRG Allowable Fee and the Member has no liability.whichever is less.
b) The MS-DRG shall be controlling, subject to EGID’s approval and Article X of the Contract.
c) The MS-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed Current Procedural Terminology code Allowable Fees.
d) c. EGID may reduce its the payment by any deductibles, coinsurance and co- payments owed by copayments according to the Member.Member’s HealthChoice Plan in effect at the time charges are incurred. Complete descriptions of HealthChoice Plans are available on EGID’s website.
e) d. EGID shall include have the day of admission but not the day of discharge when computing the number of facility days provided to a Member. Observation Facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits.
f) In the case of a transfer, the Transfer Allowable Fee for the transferring Facility shall be calculated as follows: Transfer Allowable Fee = (MS-DRG Allowable Fee/Geometric Mean Length of Stay) x (Length of Stay + 1 day) The total Transfer Allowable Fee paid to the transferring Facility shall be capped at the amount of the MS-DRG Allowable Fee for a non-transfer case. EGID shall allow payment to the receiving Facility, if it is also the final discharging Facility, at the MS- DRG Allowable Fee as if it were an original admission.
g) EGID shall use the current version of the CMS MS-DRG grouper right to categorize what shall constitute a procedure. XXXX’s EGID and the Member’s financial liability shall be limited to the procedure’s Allowable Fee or billed charge, whichever is less, as determined by XXXX.EGID, paid by applying appropriate coding methodology, whether the Practitioner has billed appropriately or not.
h) e. The Facility Practitioner agrees not to charge more for Medical or Dental Services to Members than the amount normally charged by the Facility Practitioner to other patients for similar services.services. The Practitioner’s usual and customary charges may be requested by EGID and verified through an audit.
i) For Outlier cases3. The Practitioner agrees that XXXX utilizes a comprehensive claim editing system to assist in determining which charges for Covered Services to allow for payment and to assist in determining inappropriate billing and coding. Said system shall rely on CMS and other industry standards in the development of its mutually exclusive, incidental, re-bundling, age conflict, gender conflict, cosmetic, experimental and procedure editing.
4. EGID shall base its payment have the right to the Facility using an Outlier Allowable Fee plus the MS-DRG Allowable Fee. The following formula shall be utilized to calculate the Outlier Allowable Fee: Outlier Allowable Fee = [Billed Charges – (MS-DRG Allowable Fee + Outlier Threshold)] x Marginal Cost Factor
6.4 When processing Outpatient claims, XXXX agrees to pay the Facility adjust the Allowable Fee based on appropriate billing according clinical editing and/or the use of modifiers as documented in the HealthChoice Provider Manual.
5. The Practitioner agrees that the only charges for which a Member may be liable and be billed by the Practitioner shall be for Medical or Dental Services not covered by a HealthChoice Plan, or as provided in sections VI (2), VI (6) and VI (11). The Practitioner shall not waive any deductibles, copayments and coinsurance required by EGID.
6. The Practitioner shall not collect amounts in excess of the plan limits unless the Member has exceeded those established limits.
7. The Practitioner shall refund within 30 days of discovery to the following:Member any overpayments made by the Member.
a) If 8. In a procedure does not have an Allowable Feecase in which HealthChoice is primary under applicable coordination of benefit rules as defined in the HealthChoice Provider Manual, EGID will allow calculate the benefits to be paid without considering the other plan's benefits. In a percentage case in which HealthChoice is other than primary under the coordination of benefit rules, EGID will use the billed Standard Allowable Calculation methodology for Coordination of Benefits, up to EGID's maximum liability under the terms of this Contract.
9. The Practitioner shall bill EGID on forms acceptable to EGID within 180 days of providing the Medical or Dental Services. The Practitioner shall use the current ADA, CPT, HCPCS codes with appropriate modifiers and ICD or DSM diagnosis codes, when applicable. The Practitioner shall furnish, upon request at no cost, all information, including Medical records and X-rays, reasonably required by EGID to verify and substantiate the provision of Medical or Dental Services and the charges for Covered Services.such services if the Member and the Practitioner are seeking reimbursement through EGID.
b) 10. XXXX shall reimburse the Practitioner within 45 days of receipt of xxxxxxxx that are accurate, complete, including all information requested by EGID reasonably required to verify and substantiate the billing, and otherwise in accordance with Article VI of this Contract. Refer to 74 O.S. § 1328. XXXX will not be responsible for delay of reimbursement due to circumstances beyond XXXX's control.
11. The Practitioner shall not charge the Member for Medical or Dental Services or supplies denied during Certification or Concurrent Review procedures described in Article VII, unless the Practitioner has obtained a written waiver from that Member. Such a waiver shall be obtained only upon the denial of admission, Certification, or Concurrent Review and prior to the provision of those Medical or Dental Services. The waiver shall clearly state that the Member shall be responsible for payment of Medical or Dental Services denied by EGID.
12. EGID shall pay have the appropriate percentage right at all reasonable times and, to the extent permitted by law, to inspect and duplicate all documentation or records relating to Medical or Dental Services rendered to Members at no cost to EGID or the Member.
13. The Practitioner agrees that XXXX’s subrogation rights or the existence of third-party liability does not affect the Practitioner’s agreement to accept the current Allowable Fee or billed charges, whichever is less, described in this Contract. Unrecorded alleged or recorded liens that are intended to secure charges for treatment rendered to, or on behalf of, a Member for amounts in excess of the Allowable Fee and the Member shall pay the remainder based on or billed charges, whichever is less, or which exceed the Member’s plan deductible and coinsurance liability as required by this Contract, are rendered invalid by the Practitioner’s submission of benefits unless a Members’ claims to EGID.
14. A list of the Member has met the stop loss limitation, CPT/HCPCS codes and then EGID shall pay 100% of the Allowable Fee for each can be found on the EGID website. EGID shall review and update the Member has no liability.fee schedules quarterly or as needed.
Appears in 1 contract
Samples: Practitioner Contract
Compensation and Billing. 6.1 1. The Facility IHO shall only seek payment from EGID for the provision of Covered ServicesMedical or Dental Services except as provided in sections VI (2), VI (6) and VI (11). The Facility agrees payment from the HealthChoice Plan shall be limited to accept the amount of amounts referred to in section VI (2).
2. XXXX shall reimburse the Allowable Fee set by EGID for Covered Services as payment in full and agrees to only request payment from each procedure or the Member for deductibleIHO’s billed charge, co-insurance and amounts for defined Non-Covered Services attributable to the Member’s Health Choice Planwhichever is less. The payment shall be calculated and limited to the methodologies defined by this Contract.
6.2 When the Allowable Fee exceeds billed charges, EGID shall pay the appropriate percentage of the Allowable Fee and Member shall pay the appropriate percentage of billed charges unless the Member has met the stop loss limitation and then EGID shall pay the Allowable Fee and the Member has no liability.
6.3 When processing inpatient claims, EGID shall determine the MS-DRG Allowable Fee for non- transfer cases according to the following formula: Skilled Nursing Facility Services, Day Treatment and Residential treatment will be reimbursed utilizing the per diem methodology. In no event shall a per diem qualify as an Outlier. These benefits This reimbursement shall be allowed when the Member has received Covered Medically Necessary Covered Services subject to the following policy limitations limitation and conditions:
a) EGID shall pay the appropriate percentage of the MS-DRG Allowable Fee and the Member shall pay the remainder of the MS-DRG Allowable Fee unless the Member has met the stop loss limitation, and then EGID shall pay one hundred percent (100%) of the MS-DRG Allowable Fee and the Member has no liability.
b) The MS-DRG shall be controlling, subject to EGID’s approval and Article X of the Contract.
c) The MS-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed Current Procedural Terminology code Allowable Fees.
d) a. EGID may reduce its the payment by any deductibles, coinsurance and co- payments owed by copayments according to the Member.Member’s HealthChoice plan in effect at the time charges are incurred. Complete descriptions of HealthChoice Plans are available on EGID’s website.
e) b. EGID shall include have the day of admission but not the day of discharge when computing the number of facility days provided to a Member. Observation Facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits.
f) In the case of a transfer, the Transfer Allowable Fee for the transferring Facility shall be calculated as follows: Transfer Allowable Fee = (MS-DRG Allowable Fee/Geometric Mean Length of Stay) x (Length of Stay + 1 day) The total Transfer Allowable Fee paid to the transferring Facility shall be capped at the amount of the MS-DRG Allowable Fee for a non-transfer case. EGID shall allow payment to the receiving Facility, if it is also the final discharging Facility, at the MS- DRG Allowable Fee as if it were an original admission.
g) EGID shall use the current version of the CMS MS-DRG grouper right to categorize what shall constitute a procedure. XXXX’s EGID and the Member’s financial liability shall be limited to the procedure’s Allowable Fee or billed charge, whichever is less, as determined by XXXX.EGID, paid by applying appropriate coding methodology, whether the IHO has billed appropriately or not.
h) c. The Facility IHO agrees not to charge more for Medical or Dental Services to Members than the amount normally charged by the Facility IHO to other patients for similar services.services. The IHO’s usual and customary charges may be requested by XXXX and verified through an audit.
i) For Outlier casesd. An IDTF and laboratory shall provide, at no additional charge, all supplies necessary for the collection, preparation and preservation of all specimens to be submitted to the IDTF for testing.
3. The IHO agrees that EGID utilizes a comprehensive claim editing system to assist in determining which charges for Covered Services to allow for payment and to assist in determining inappropriate billing and coding. Said system shall rely on CMS and other industry standards in the development of its mutually exclusive, incidental, re-bundling, age conflict, gender conflict, cosmetic, experimental and procedure editing.
4. EGID shall base its payment have the right to the Facility using an Outlier Allowable Fee plus the MS-DRG Allowable Fee. The following formula shall be utilized to calculate the Outlier Allowable Fee: Outlier Allowable Fee = [Billed Charges – (MS-DRG Allowable Fee + Outlier Threshold)] x Marginal Cost Factor
6.4 When processing Outpatient claims, XXXX agrees to pay the Facility adjust the Allowable Fee based on appropriate billing according clinical editing and/or the use of modifiers as documented in the HealthChoice Provider Manual.
5. The IHO agrees that the only charges for which a Member may be liable and be billed by the IHO shall be for Medical or Dental Services not covered by a HealthChoice Plan, or as provided in sections VI (2), VI (6) and VI (11). The IHO shall not waive any deductibles, copayments and coinsurance required by EGID.
6. The IHO shall not collect amounts in excess of plan limits unless the Member has exceeded those established limits.
7. The IHO shall refund within 30 days of discovery to the following:Member any overpayments made by the Member.
a) If 8. In a procedure does not have an Allowable Feecase in which HealthChoice is primary under applicable coordination of benefit rules as defined in the HealthChoice Provider Manual, EGID will allow calculate the benefits to be paid without considering the other plan's benefits. In a percentage case in which HealthChoice is other than primary under the coordination of benefit rules, EGID will use the billed Standard Allowable Calculation methodology for Coordination of Benefits, up to EGID's maximum liability under the terms of this Contract.
9. The IHO shall bill EGID on forms acceptable to EGID within 180 days of providing the Medical or Dental Services. The IHO shall use the current revenue codes, ADA, CPT codes with appropriate modifiers, HCPCS codes, and ICD or DSM diagnosis codes, when applicable. The IHO shall furnish, upon request at no cost, all information, including Medical records and x-rays, reasonably required by EGID to verify and substantiate the provision of Medical or Dental Services and the charges for Covered Services.such services if the Member and the IHO are seeking reimbursement through EGID.
b) 10. EGID shall pay reimburse the appropriate percentage IHO within 45 days of receipt of xxxxxxxx that are accurate, complete, including all information requested by EGID reasonably required to verify and substantiate the billing, and otherwise in accordance with Article VI of this Contract. Refer to 74 O.S. § 1328. XXXX will not be responsible for delay of reimbursement due to circumstances beyond XXXX’s control.
11. The IHO shall not charge the Member for Medical or Dental Services denied during the Certification or Concurrent Review procedures described in Article VII, unless the IHO has obtained a written waiver from that Member. Such a waiver shall be obtained only upon the denial of admission, Certification or Concurrent Review and prior to the provision of those Medical or Dental Services. The waiver shall clearly state that the Member shall be responsible for payment of Medical or Dental Services denied by EGID.
12. EGID shall have the right at all reasonable times and, to the extent permitted by law, to inspect and duplicate all documentation or records relating to Medical or Dental Services rendered to Members at no cost to EGID or the Member.
13. The IHO agrees that XXXX’s subrogation rights or the existence of third-party liability does not affect the IHO’s agreement to accept the current Allowable Fee or billed charges, whichever is less, described in this Contract. Unrecorded alleged or recorded liens that are intended to secure charges for treatment rendered to, or on behalf of, a Member for amounts in excess of the Allowable Fee and the Member shall pay the remainder based on or billed charges, whichever is less, or which exceed the Member’s plan deductible and coinsurance liability as required by this Contract, are rendered invalid by the IHO’s submission of benefits unless a Member’s claims to EGID.
14. A list of the Member has met the stop loss limitation, CPT/HCPCS codes and then EGID shall pay 100% of the Allowable Fee for each can be found on the EGID website. EGID shall review and update the fee schedules quarterly or as needed
15. Implants are defined as material(s) inserted into the body, including living, inert, or biological material (e.g., screws, grafts, plates, or fixation devices) used for the purpose of creating stability (i.e., to correct, protect, or stabilize a deformity) where the majority of the product is left under the skin after surgery. EGID reimburses separately for implants found on the implant list at EGID Provider website. XXXX’s reimbursement of implants is subject to the following conditions:
a. Implants must be billed at invoice cost, plus 10% less any rebates and/or discounts received by the IHO. Implants shall be billed using the most descriptive CPT or HCPCS code and EGID will allow up to the net cost plus 10%, including shipping, handling, and tax. Shipping, handling and tax must be prorated for the billed implant for invoices including supplies other than the billed implant. If there is no CPT or HCPCS code available for a certain implant, EGID will accept the appropriate unlisted CPT or HCPCS code with an explanation of each item and the Member corresponding charge.
b. Upon request, EGID requires the actual invoice for the implant billed.
c. EGID may conduct quarterly retrospective audits of the IHO’s charges for implants.
d. Upon the occurrence of an audit, XXXX will request invoices for audited claims and any other documentation showing discounts that are not listed on the invoice. Invoices must identify which implants listed on the invoice apply to the claim being audited. Upon request, the IHO has 30 days to submit this information to EGID. During the audit, if XXXX finds that the IHO is billing more than acquisition costs, plus 10%, the IHO will be required to refund any overpayments made by EGID to the IHO and to provide copies of invoices for all subsequent claims submitted prior to payment. If the IHO continues to bill above the acquisition cost or does not provide copies of requested invoices with the required timeframe then, EGID will no liability.longer allow reimbursement to the IHO for implants as a separate reimbursable item.
Appears in 1 contract
Compensation and Billing. 6.1 The Facility Provider shall only seek payment only from EGID DRS for the provision of Covered Services. The Facility agrees to accept the amount of the Allowable Fee for Covered Services Durable Medical Equipment services except as payment provided in full and agrees to only request payment from the Member for deductible, co-insurance and amounts for defined Non-Covered Services attributable to the Member’s Health Choice Planparagraph 6.3. The payment from DRS shall be calculated and limited to the methodologies defined by this Contractamounts referred to in paragraph 6.2.
6.2 When the Allowable Fee exceeds billed charges, EGID shall DRS agrees to pay the appropriate percentage of Provider’s billed charge for each procedure or the Allowable Fee and Member fee set by DRS for that procedure, whichever is less. DRS shall pay have the appropriate percentage of billed charges unless the Member has met the stop loss limitation and then EGID shall pay the Allowable Fee and the Member has no liability.
6.3 When processing inpatient claims, EGID shall determine the MS-DRG Allowable Fee for non- transfer cases according to the following formula: Skilled Nursing Facility Services, Day Treatment and Residential treatment will be reimbursed utilizing the per diem methodology. In no event shall a per diem qualify as an Outlier. These benefits shall be allowed when the Member has received Medically Necessary Covered Services subject to the following policy limitations and conditions:
a) EGID shall pay the appropriate percentage of the MS-DRG Allowable Fee and the Member shall pay the remainder of the MS-DRG Allowable Fee unless the Member has met the stop loss limitation, and then EGID shall pay one hundred percent (100%) of the MS-DRG Allowable Fee and the Member has no liability.
b) The MS-DRG shall be controlling, subject to EGID’s approval and Article X of the Contract.
c) The MS-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed Current Procedural Terminology code Allowable Fees.
d) EGID may reduce its payment by any deductibles, coinsurance and co- payments owed by the Member.
e) EGID shall include the day of admission but not the day of discharge when computing the number of facility days provided to a Member. Observation Facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits.
f) In the case of a transfer, the Transfer Allowable Fee for the transferring Facility shall be calculated as follows: Transfer Allowable Fee = (MS-DRG Allowable Fee/Geometric Mean Length of Stay) x (Length of Stay + 1 day) The total Transfer Allowable Fee paid to the transferring Facility shall be capped at the amount of the MS-DRG Allowable Fee for a non-transfer case. EGID shall allow payment to the receiving Facility, if it is also the final discharging Facility, at the MS- DRG Allowable Fee as if it were an original admission.
g) EGID shall use the current version of the CMS MS-DRG grouper right to categorize what shall constitute a procedure. XXXX’s DRS and the Memberbeneficiary’s financial liability shall be limited to the Allowable Fee procedures’ allowable as determined by XXXX.DRS, paid by applying appropriate coding methodology, whether the Provider has billed appropriately or not.
h) 6.3 The Facility Provider agrees to accept the payment from DRS as full and complete a payment for services for recipients of public assistance. If the patient is a recipient of Medical Assistance, Rehabilitation Services only, payment from the Department shall represent payment in full except the Provider may collect an amount not to charge more for exceed that shown on DRS form, DRS-C-100, Medical Services Authorization.
6.4 The Provider shall refund within 30 days of discovery to Members than DRS any overpayments made by DRS.
6.5 The Provider shall bill DRS on forms acceptable to DRS within 1 year of providing the amount normally charged medical services. The Provider shall use the current HCPCS codes and ICD codes, when applicable. The Provider shall furnish, upon request at no cost, all information, including medical records, reasonably required by DRS to verify and substantiate the Facility provision of medical services and the charges for such services if the beneficiary and the Provider are seeking reimbursement through DRS.
6.6 DRS shall reimburse the Provider within 30 days of receipt of xxxxxxxx that are accurate, complete and otherwise in accordance with Article VI of this Contract. DRS will not be responsible for delay of reimbursement due to other patients circumstances beyond DRS’ control.
6.7 The Provider agrees to release all Provider liens for similar services.which payment has been made for Title XIX by DRS and notify DRS. However, this provision does not affect the Provider’s entitlement to file a lien or liens for non-pre-authorized services.
i) For Outlier cases, EGID 6.8 DRS shall base its payment have the right at all reasonable times and to the Facility using an Outlier Allowable Fee plus extent permitted by law to inspect and duplicate all medical and billing records relating to medical services rendered to beneficiaries at no cost to DRS or the MS-DRG Allowable Fee. The following formula shall be utilized to calculate the Outlier Allowable Fee: Outlier Allowable Fee = [Billed Charges – (MS-DRG Allowable Fee + Outlier Threshold)] x Marginal Cost Factor
6.4 When processing Outpatient claims, XXXX agrees to pay the Facility the Allowable Fee based on appropriate billing according to the following:
a) If a procedure does not have an Allowable Fee, EGID will allow a percentage of the billed charges for Covered Services.
b) EGID shall pay the appropriate percentage of the Allowable Fee and the Member shall pay the remainder based on the Member’s plan of benefits unless the Member has met the stop loss limitation, and then EGID shall pay 100% of the Allowable Fee and the Member has no liability.beneficiary.
Appears in 1 contract
Samples: Durable Medical Equipment Contract
Compensation and Billing. 6.1 The Facility 1. MEDICAL PROVIDER shall only seek payment from EGID for the provision of Covered Services. The Facility agrees to accept the amount of the Allowable Fee receive payments for Covered Services as payment set forth in full the attachments to this Agreement. Compensation arrangements and agrees rates are set forth in applicable Attachments and may vary by payor. All Compensation arrangements and those arrangements that involve risk between the payor and the ACN or MEDICAL PROVIDER shall be approved by the ACN. Specific detail concerning risk sharing and distribution of deficit or excess fund balances shall be included in the specific payor attachment to only request payment from the Member this agreement.
2. MEDICAL PROVIDER's reimbursement for deductible, co-insurance and amounts for defined Non-Covered Services attributable to the Member’s Health Choice Plan. The payment shall be calculated the lesser of Health Care Professional's usual and limited customary charge for the service provided, or the ACN's negotiated fee as described in Attachments to the methodologies defined by this Contract.
6.2 When the Allowable Fee exceeds billed chargesAgreement, EGID less applicable Copayments, Deductibles and Coinsurance. MEDICAL PROVIDER shall pay the appropriate percentage of the Allowable Fee and Member shall pay the appropriate percentage of billed charges unless the Member has met the stop loss limitation and then EGID shall pay the Allowable Fee and the Member has no liability.
6.3 When processing inpatient claims, EGID shall determine the MS-DRG Allowable Fee xxxx for non- transfer cases according to the following formula: Skilled Nursing Facility Services, Day Treatment and Residential treatment will be reimbursed utilizing the per diem methodology. In no event shall a per diem qualify as an Outlier. These benefits shall be allowed when the Member has received Medically Necessary Covered Services subject to the following policy limitations and conditions:
a) EGID shall pay the appropriate percentage of the MS-DRG Allowable Fee and the Member shall pay the remainder of the MS-DRG Allowable Fee unless the Member has met the stop loss limitation, and then EGID shall pay one hundred percent (100%) of the MS-DRG Allowable Fee and the Member has no liability.
b) The MS-DRG shall be controlling, subject to EGID’s approval and Article X of the Contract.
c) The MS-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed Current Procedural Terminology code Allowable Fees.
d) EGID may reduce its payment by any deductibles, coinsurance and co- payments owed by the Member.
e) EGID shall include the day of admission but not the day of discharge when computing the number of facility days provided to a Member. Observation Facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits.
f) In the case of a transfer, the Transfer Allowable Fee for the transferring Facility shall be calculated as follows: Transfer Allowable Fee = (MS-DRG Allowable Fee/Geometric Mean Length of Stay) x (Length of Stay + 1 day) The total Transfer Allowable Fee paid to the transferring Facility shall be capped at the amount of the MS-DRG Allowable Fee for a non-transfer case. EGID shall allow payment to the receiving Facility, if it is also the final discharging Facility, at the MS- DRG Allowable Fee as if it were an original admission.
g) EGID shall use the current version of the CMS MS-DRG grouper to categorize what shall constitute a procedure. XXXX’s and the Member’s financial liability shall be limited to the Allowable Fee as determined by XXXX.
h) The Facility agrees not to charge more for Medical Services to Members than the amount normally charged by the Facility to other patients for similar services.
i) For Outlier cases, EGID shall base its payment to the Facility using an Outlier Allowable Fee plus the MS-DRG Allowable Fee. The following formula shall be utilized to calculate the Outlier Allowable Fee: Outlier Allowable Fee = [Billed Charges – (MS-DRG Allowable Fee + Outlier Threshold)] x Marginal Cost Factor
6.4 When processing Outpatient claims, XXXX agrees to pay the Facility the Allowable Fee based on appropriate billing according to the following:
a3. MEDICAL PROVIDER shall submit claims on the appropriate claim form for all Covered Services within sixty (60) If days of the date those services are rendered. Any amount owing under this Agreement shall be paid within thirty (30) days after the receipt of a procedure complete claim, unless additional required information is requested within the thirty (30) day period, or the claim involves coordination of benefits.
4. Payors shall agree to deduct any Copayments, Deductibles, or Coinsurance required by the Service Agreement from payment due to MEDICAL PROVIDER. Deduction of for the Copayment, Deductible or Coinsurance shall be determined on the basis of the lesser of MEDICAL PROVIDER's usual and customary charges and ACN's negotiated fee schedule.
5. MEDICAL PROVIDER shall not charge Beneficiary for services denied as not being Medically Necessary (defined herein), unless MEDICAL PROVIDER has obtained a written waiver from the Beneficiary. Such a waiver shall be obtained in advance of the provision of those services. The waiver shall clearly state that the Beneficiary acknowledges that such services are not Medically Necessary and that the Beneficiary shall be responsible for payment of charges for such services.
6. MEDICAL PROVIDER will look solely to designated Payor for compensation for Covered Services except for Copayments, Deductibles or Coinsurance. MEDICAL PROVIDER agrees that whether or not there is any unresolved dispute for payment, that under no circumstances will MEDICAL PROVIDER directly or indirectly make any charges or claims, other than for Copayments, Deductibles or Coinsurance against any Beneficiaries or their representatives for Covered Services and that this provision survives termination of this Agreement for services rendered prior to such termination. Except for the collection of Copayments, Deductibles or Coinsurance, only those services that are not Covered Services may be billed directly to Beneficiary, subject to limitations listed above. This paragraph is to be interpreted for the benefit of Beneficiary and does not have an Allowable Feediminish the obligation of Payor to make payments to MEDICAL PROVIDER according to the terms of this Agreement.
7. The following provisions apply regarding coordination of benefits:
a. When designated Payor is primary under applicable coordination of benefits rules, EGID ACN or Payor shall pay benefits as set forth in this Agreement without regard to the obligations of any secondary payor.
b. When designated Payor is determined to be secondary to any other payor, ACN or Payor will allow a percentage pay no greater amount than the difference between the amount payable to MEDICAL PROVIDER by the primary payor and the amount for Covered Services owing under this Agreement. Payor shall not be liable for any amount unless Payor has received MEDICAL PROVIDER's claim for such secondary payment within ninety (90) days of the billed charges for Covered Services.date when Payor is determined to be secondary.
b) EGID shall pay the appropriate percentage of the Allowable Fee and the Member shall pay the remainder based on the Member’s plan c. Where another payor is primary under coordination of benefits unless rules, MEDICAL PROVIDER shall follow that payor's billing rules.
8. MEDICAL PROVIDER may xxxx an individual directly for any services provided following the Member has met date the stop loss limitation, and then EGID shall pay 100% of the Allowable Fee and the Member individual ceases to be a Beneficiary. Designated Payor has no liability.obligation under this Agreement to pay for services rendered to individuals who no longer are Beneficiaries.
Appears in 1 contract
Compensation and Billing. 6.1 The Facility shall only seek payment only from EGID DRS for the provision of Covered Services. The Facility agrees to accept the amount of the Allowable Fee for Covered Services medical services except as payment provided in full and agrees to only request payment from the Member for deductible, co-insurance and amounts for defined Non-Covered Services attributable to the Member’s Health Choice Planparagraph 6.3. The payment from DRS shall be calculated and limited to the methodologies defined by this Contractamounts referred to in paragraph 6.2.
6.2 When the Allowable Fee exceeds billed charges, EGID shall DRS agrees to pay the appropriate percentage of Facility’s billed charge for each procedure or the Allowable Fee and Member shall pay the appropriate percentage of billed charges unless the Member has met the stop loss limitation and then EGID shall pay the Allowable Fee and the Member has no liability.
6.3 When processing inpatient claims, EGID shall determine the MS-DRG Allowable Fee for non- transfer cases according to the following formula: Skilled Nursing Facility Services, Day Treatment and Residential treatment will be reimbursed utilizing the per diem methodology. In no event shall a per diem qualify as an Outlier. These benefits shall be allowed when the Member has received Medically Necessary Covered Services subject to the following policy limitations and conditions:
a) EGID shall pay the appropriate percentage of the MS-DRG Allowable Fee and the Member shall pay the remainder of the MS-DRG Allowable Fee unless the Member has met the stop loss limitation, and then EGID shall pay one hundred percent (100%) of the MS-DRG Allowable Fee and the Member has no liability.
b) The MS-DRG shall be controlling, subject to EGID’s approval and Article X of the Contract.
c) The MS-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed Current Procedural Terminology code Allowable Fees.
d) EGID may reduce its payment fee set by any deductibles, coinsurance and co- payments owed by the Member.
e) EGID shall include the day of admission but not the day of discharge when computing the number of facility days provided to a Member. Observation Facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits.
f) In the case of a transfer, the Transfer Allowable Fee DRS for the transferring Facility provision of medical services, whichever is less. DRS shall be calculated as follows: Transfer Allowable Fee = (MS-DRG Allowable Fee/Geometric Mean Length of Stay) x (Length of Stay + 1 day) The total Transfer Allowable Fee paid to have the transferring Facility shall be capped at the amount of the MS-DRG Allowable Fee for a non-transfer case. EGID shall allow payment to the receiving Facility, if it is also the final discharging Facility, at the MS- DRG Allowable Fee as if it were an original admission.
g) EGID shall use the current version of the CMS MS-DRG grouper right to categorize what shall constitute a proceduremedical service. XXXX’s DRS and the Memberbeneficiary’s financial liability shall be limited to the Allowable Fee allowable for the medical service, as determined by XXXX.DRS, paid by applying appropriate coding methodology, whether the Facility has billed appropriately or not. Benefits will be allowed when the beneficiary has received medically necessary services pre-authorized by DRS.
h) 6.3 The Facility agrees to accept the payment from DRS as full and complete payment for services for recipients of public assistance. If the patient is a recipient of Medical Assistance, 5 DRSNFCv2.6 Rehabilitation Services only, payment from the Department shall represent payment in full except the Facility may collect an amount not to charge more for exceed that shown on DRS Form DRS-C- 100, Medical Services Authorization.
6.4 The Facility agrees to Members than release all liens for which payment has been made for Title XIX by DRS and notify DRS. However, this provision does not affect the amount normally charged by Facility’s entitlement to file a lien or liens for non-pre- authorized services.
6.5 The Facility shall bill DRS on form UB-04 in accordance with the UB-04 manual for the State of Practice and provide an itemized bill upon request. The Facility shall bill DRS within 1 year of the date of service or the date of discharge.
6.6 DRS shall reimburse the Facility within thirty (30) days of receipt of xxxxxxxx that are accurate, complete and otherwise in accordance with Article VI of this contract. DRS will not be responsible for the delay of reimbursement due to other patients for similar services.circumstances beyond DRS’ control.
i) For Outlier cases, EGID 6.7 DRS shall base its payment have the right at all reasonable times and to the Facility using an Outlier Allowable Fee plus extent permitted by law, to inspect and duplicate all medical and billing records relating to medical services rendered to pre- authorized beneficiaries at no cost to DRS or the MS-DRG Allowable Fee. The following formula shall be utilized to calculate the Outlier Allowable Fee: Outlier Allowable Fee = [Billed Charges – (MS-DRG Allowable Fee + Outlier Threshold)] x Marginal Cost Factor
6.4 When processing Outpatient claims, XXXX agrees to pay the Facility the Allowable Fee based on appropriate billing according to the following:
a) If a procedure does not have an Allowable Fee, EGID will allow a percentage of the billed charges for Covered Services.
b) EGID shall pay the appropriate percentage of the Allowable Fee and the Member shall pay the remainder based on the Member’s plan of benefits unless the Member has met the stop loss limitation, and then EGID shall pay 100% of the Allowable Fee and the Member has no liability.beneficiary.
Appears in 1 contract
Samples: Facility Contract
