Election of Third Party Billing Process. Contractor shall select an option for participating in serial billing of third- party payors for services provided through this Agreement through the completion of Attachment C – Election of Third Party Billing Process. The completed Attachment C shall be returned to the County with the signed Agreement. Based upon the option selected by the Contractor the appropriate following language shall be in effect for this Agreement.
a. Option One
1) Contractor shall xxxx all eligible third-party payors financially responsible for a beneficiary's health care services that Contractor provides through this Agreement. With every invoice submitted by Contractor to County, Contractor shall provide to County copies of the Explanation of Benefits or other remittance advice for every third-party payment and/or denial of such third- party payments for each such invoice. The County may withhold payment to Contractor for any and all services for which this required proof of third-party payments and/or denials of such payments is not provided. County may deduct from its payments to Contractor the amount of any such third-party payment. County accepts no financial responsibility for services provided to beneficiaries where there is a responsible third- party payor, and to the extent that County inadvertently makes payments to Contractor for such services rendered, County shall be entitled to recoup such reimbursement.
2) Contractor shall provide a copy of the completed Payor Financial Form (Attachment D) and in subsequent annual updates for all clients who receive services through this Agreement. For clients who begin to receive services during the term of this Agreement, completed Payor Financial Forms shall be provided to the County with client registration forms. For clients who were receiving services prior to the start date of this Agreement and who continue to receive services through this Agreement, completed Payor Financial Forms are due with the first invoice of the Agreement for services provided to said clients.
b. Option Two
1) Contractor shall provide information to County so that County may xxxx applicable other third-parties before billing Medi-Cal for services provided by Contractor through this Agreement. The County may withhold payment to Contractor for any and all services pending notification or receipt of such third-party payments or denials of such payments. County may deduct from its payments to Contractor the amount of any such third- party payment. To t...
Election of Third Party Billing Process. San Mateo County Health System is required to xxxx all other insurance (including Medicare) before billing Medi-Cal for beneficiaries who have other coverage in addition to Medi-Cal. This is called “serial billing.” All claims sent to Medi-Cal without evidence of other insurance having been billed first will be denied. In order to comply with the serial billing requirement you must elect which of the two following options to use in our contract with you. In either case, you will need to establish the eligibility of your clients through the completion of the standard form (Payor Financial Form) used to collect this information. Please select and complete one of the two options below: Our agency will xxxx other insurance, and provide San Mateo County Behavioral Health and Recovery Services (BHRS) with a copy of the Explanation of Benefits provided by that insurance plan before billing BHRS for the remainder. We Telecare Corporation elect option one. Signature of authorized agent Name of authorized agent Telephone number Our agency will provide information to San Mateo County Behavioral Health and Recovery Services (BHRS) so that BHRS may xxxx other insurance before billing Medi-Cal on our agency’s behalf. This will include completing the attached client Payor Financial Form and providing it to the BHRS Billing Office with the completed “assignment” that indicates the client’s permission for BHRS to xxxx their insurance. We Telecare Corporation elect option two. Signature of authorized agent Name of authorized agent Telephone number Please note if your agency already bills private insurance including Medicare for services you provide, then you must elect Option One. This is to prevent double billing. Please return this completed form to: Xxxxxx Xxxxx, Business Systems Manager Behavioral Health and Recovery Services 000 00xx Xxxxxx Xxx Xxxxx, XX 00000 (650) 573-2284 Client Date of Birth Undocumented? □ Yes □ No If no, Social Security Number (Required) 26.5 (AB3632) □ Yes □ No IEP (SELPA) start date Does Client have Medi-Cal? □ Yes □ No Share of Cost? □ Yes □ No Client’s Medi-Cal Number (BIC Number)? Please attach copy of MEDS Screen If client is Full scope Mcal, skip the remaining sections of this form and fax to MIS/Billing Unit – 573-2110 Is Client Potentially Eligible for Medi-Cal Benefits? □ Yes □ No Client Referred to Medi-Cal? □ Yes, give date: □ No Is this a Court-ordered Placement? □ Yes □ No Does Client have Medicare? □ Yes □ No If yes, please check a...
Election of Third Party Billing Process. Contractor shall select an option for participating in serial billing of third-party payors for services provided through this Agreement through the completion of Attachment C – Election of Third Party Billing Process. The completed Attachment C shall be returned to the County with the signed Agreement. Based upon the option selected by the Contractor the appropriate following language shall be in effect for this Agreement.
1. Option One
a. Contractor shall xxxx all eligible third-party payors financially responsible for a beneficiary's health care services that Contractor provides through this Agreement. Within ten (10) days of the end of each month, Contractor shall provide to County copies of the Explanation of Benefits or other remittance advice for every third-party payment and/or denial of such third- party payments for services provided by Contractor during such month. The amount of any such third-party payment shall be deducted from the total actual costs for all services rendered by Contractor as reflected on the Cost Report as defined in Paragraph M of this Exhibit B. County accepts no financial responsibility for services provided to beneficiaries where there is a responsible third-party payor, and to the extent that County inadvertently makes payments to Contractor for such services rendered, County shall be entitled to recoup such reimbursement, through the Cost Report reconciliation.
b. Contractor shall provide a copy of each completed Payor Financial Form (Attachment D) and subsequent annual updates for all clients who receive services through this Agreement. For clients who begin to receive services during the term of this Agreement, completed Payor Financial Forms shall be provided to the County with client registration forms. For clients who were receiving services prior to the start date of this Agreement and who continue to receive services through this Agreement, completed Payor Financial Forms are due within ten (10) days of the end of the first month of the Agreement.
2. Option Two
a. Contractor shall provide information to County so that County may xxxx applicable other third-parties before billing Medi-Cal for services provided by Contractor through this Agreement. The amount of any such third- party payment shall be deducted from the total actual costs for all services rendered by Contractor as reflected on the Cost Report as defined in Paragraph M of this Exhibit B. County accepts no financial responsibility for services provided...
