Cost Projections; Subsequent Rate Determinations. The Provider, upon request by the PAYOR, shall provide the Payor with projected revenue and cost analyses (using formats acceptable to the parties) and all source documents for review in the subsequent determination by the Payor of the claims reimbursement methodology/rate(s) for authorized supports/services hereunder.
Cost Projections; Subsequent Rate Determinations. The Provider, upon request by the PAYOR, shall provide the Payor with projected revenue and cost analyses (using formats acceptable to the parties) and all source documents for review in the subsequent determination by the Payor of the claims reimbursement methodology/rate(s) for authorized supports/services hereunder. Coordination of Benefits: The PROVIDER shall submit itemized claims for coordination of benefits (COB) billing purposes detailing the daily revenue code and daily physician HCPC service code to fulfill PAYOR’S State of Michigan reporting and COB requirements. Any dual eligible CONSUMER with a deductible/coinsurance will be paid by the PAYOR in total up to the agreed upon payment amount for the billed service(s) identified in this agreement after all other payments, contractual adjustments, and any applicable co-payment, CONSUMER pay, or Medicaid Spend Down amounts have been deducted. The PAYOR shall only be responsible for and limit reimbursement to the PROVIDER for any amount less than the agreed upon amount for the billed service(s) identified in this agreement. In cases where third party coverage reimbursement exceeds the agreed upon amount for the billed service(s) identified in this agreement, no additional payment will be authorized the PAYOR. In all cases where the PAYOR is the secondary PAYOR, the PROVIDER shall submit an Explanation of Benefits (EOB) from the primary insurance coverage carrier along with the claim for service reimbursement to the PAYOR.
