Electronic Claims. Electronic Claims must be processed in adherence to information exchange and data management requirements specified in Section 4.17. As part of this Electronic Claims Management (ECM) function, the Contractor shall also provide on-line and phone-based capabilities to obtain Claims processing status information.
4.16.1.6 The Contractor shall generate Explanation of Benefits and Remittance Advices in accordance with State standards for formatting, content and timeliness.
4.16.1.7 The Contractor shall not pay any Claim submitted by a Provider who is excluded or suspended from the Medicare, Medicaid or SCHIP programs for Fraud, abuse or waste or otherwise included on the Department of Health and Human Services Office of Inspector General exclusions list, or employs someone on this list. The Contractor shall not pay any Claim submitted by a Provider that is on payment hold under the authority of DCH or its Agent(s).
4.16.1.8 Not later than the fifteenth (15th) business day after the receipt of a Provider Claim that does not meet Clean Claim requirements, the Contractor shall suspend the Claim and request in writing (notification via e-mail, the CMO plan Web Site/Provider Portal or an interim Explanation of Benefits satisfies this requirement) all outstanding information such that the Claim can be deemed clean. Upon receipt of all the requested information from the Provider, the CMO plan shall complete processing of the Claim within fifteen (15) Business Days.
4.16.1.9 Claims suspended for additional information must be closed (paid or denied) by the thirtieth (30th) Calendar Day following the date the Claim is suspended if all requested information is not received prior to the expiration of the 30-day period. The Contractor shall send Providers written notice (notification via e-mail, the CMO plan Web site/Provider Portal or an Explanation of Benefits satisfies this requirement) for each Claim that is denied, including the reason(s) for the denial, the date Contractor received the Claim, and a reiteration of the outstanding information required from the Provider to adjudicate the Claim.
4.16.1.10 The Contractor plan must process, and finalize, all appealed Claims to a paid or denied status within (30) Business Days of receipt of the Appealed Claim.
4.16.1.11 The Contractor shall finalize all Claims, including appealed Claims, within twenty-four (24) months of the date of service.
4.16.1.12 The Contractor may deny a Claim for failure to file timely if a Provider...
Electronic Claims. Provider shall prepare and submit to ILS Community Network or Managed Care Plan, according to the billing procedures established by ILS Community Network and Managed Care Plan, billing information for Enrollees who have received Covered Services from Provider. Provider shall use its best efforts to submit its claims for Covered Services electronically: (1) If a capitated Managed Care Plan, then to the capitated Managed Care Plan for compensation; (2) If a FFS, MMA or LTC Plan, then to the Agency or its Agent, unless the service is a transportation service for which the Managed Care Plan receives a capitation payment from the Agency. For such capitated Covered Services or transportation services, the Managed Care Plan shall require providers to look solely to the Managed Care Plan for payment.
Electronic Claims. Any Electronic Claim submitted by Provider shall be paid, denied or pended by Company within twenty-five (25) days from the date the Electronic Clean Claim is received by Company, unless (i) the claim is not payable under the terms of the Plan or (ii) just and reasonable grounds exist. Within five (5) working days of receipt of an Electronic Claim, Company shall review the entire claim and, if Company determines that the claim is not an accepted claim or Clean Claim, Company shall issue an exception report to Provider indicating all defects or reasons known at that time that the claim is not an accepted claim. If Provider submits a claim that is not an accepted claim, the claim shall be deemed to have been timely submitted for payment of Covered Services if Company fails to notify Provider, or the health care clearinghouse from which the claim was received, of all defects or reasons known at that time that the claim is not an accepted claim as required by state law. Company shall establish appropriate procedures, as approved by LDI, to assure that Provider receives a late payment adjustment equal to the amounts required by law if Provider is not paid within the statutory time frames. La. R.S. 22:1833.
Electronic Claims shall be treated as identical to paper-based Claims for the purposes of reporting.
Electronic Claims. Routing Process effective upon October 16, 2003. Amended June 13, 2002 EXHIBIT B ROYALTY FORMULA FOR SECTION 9 OF THE CONTROLLED AFFILIATE LICENSE AGREEMENT Controlled Affiliate will pay BCBSA a fee for this license in accordance with the following formula:
Electronic Claims. 3.1.13.1. Interface with clearing houses for all private claims (ETS, NEIC, IMS, and more)
3.1.13.2. Medicare: Blue Shield, Transamerica
3.1.13.3. Medicare National Standard, ANSI formats available
3.1.13.4. Medicaid 3.1.13.5. UB-92 Aetna
3.1.13.6. Online patient eligibility verification with NEIC access
3.1.13.7. Pre-transmit claims error check
Electronic Claims. Routing Process effective upon the mandated date for implementation of the HIPAA standard transaction. AMENDED NOVEMBER 15 2001 EXHIBIT B ROYALTY FORMULA FOR SECTION 9 OF THE CONTROLLED AFFILIATE LICENSE AGREEMENT Controlled Affiliate will pay BCBSA a fee for this license in accordance with the following formula:
Electronic Claims. Laboratory will make best commercial efforts to submit a minimum of eighty-five percent (85%) of its Member claims electronically to Xxxxxxx Xxxxx Plus. For claims Laboratory submits electronically, Laboratory shall not submit a claim to Xxxxxxx Xxxxx Plus in paper form unless it requests paper submissions or fails to pay or otherwise respond to electronic claims submission in accordance with the time frames required under this Agreement or applicable law or regulation.
Electronic Claims. The CLIENT will pay GATEWAY for the use of GATEWAY XXX’s clearinghouse to submit electronic claims to payers on the “Approved Payer List” based upon the following fee schedule:
Electronic Claims. Routing Process — A Plan shall fully participate in the Electronic Claims Routing Process through compliance with all Electronic Claims Routing Process Policies and Provisions and all applicable Inter-Plan Programs Policies and Provisions. Standard 5: Participation in National Programs
2.2.a Compliance determined by periodic reviews or audits and by reviews initiated by evidence of problems.
