CONTRACTOR shall also Clause Samples
CONTRACTOR shall also a. Ensure that all billing activity is maintained, controlled and exchanged as necessary in compliance with all current Federal requirements, as well as State regulatory requirements as set forth by DHCS;
b. Ensure that billing staff has a thorough knowledge and understanding of SDMC billing on an ongoing basis. It is the responsibility of CONTRACTOR to maintain this knowledge and train staff when changes in staffing and/or regulations occur. ADMINISTRATOR is available to be a consultant on fine points or details; but will not train CONTRACTOR’s new staff.
c. Ensure compliance on an ongoing basis with emerging and future Federal and State regulatory requirements within established deadlines;
d. Work cooperatively with ADMINISTRATOR during any system/application changes or enhancements to ensure continuity of compliant operations;
e. Ensure Federal HIPAA compliance;
f. Have ability to compile and electronically transmit Medi-Cal 837 claim files to ADMINISTRATOR for submission to and adjudication by the State of California;
g. Have ability to receive electronic transmissions of Medi-Cal 835 adjudicated claims files back from ADMINISTRATOR, if necessary, as received by the State of California;
h. Resolve any issues with errors in claim submissions within the established timeframes, and perform re-submissions as necessary;
i. Review all claims to see that the claims are billed within the twelve (12) months from DOS requirement. Any stale dated claims (those over twelve (12) months) shall be the responsibility of CONTRACTOR and not billed to ADMINISTRATOR. Any stale dated claims that may have been previously reported to and paid by ADMINISTRATOR shall be reimbursed to ADMINISTRATOR as indicated in the Services Paragraph of this Exhibit A to the Contract.
j. Report all stale dated costs to ADMINISTRATOR. These costs shall be reported on the monthly Expenditure and Revenue Report; as requested by ADMINISTRATOR.
k. Conduct reviews and audits to see that claims submissions by Outpatient and Inpatient Network Providers and payments for approved claims are accurate. If the review/audit reveals that money is payable from one Party to the other, that is, reimbursement by CONTRACTOR to COUNTY, or payment of sums due from COUNTY to CONTRACTOR, said funds shall be due and payable from one Party to the other within sixty (60) calendar days of receipt of the review/audit results.
1) If claims to be reimbursed are within the current fiscal period, the claims shall be settled...