Emergency Services Denials. If the MCO has a pattern of inappropriately denying payments for emergency services as defined in Part II, Definitions, the MCO may be subject to suspension of new enrollments, withholding of capitation payments, contract termination, or refusal to contract in a future time period. This applies not only to cases where the DEPARTMENT has ordered payment after appeal, but also to cases where no appeal has been made (i.e., the DEPARTMENT is knowledgeable about documented abuse from other sources.)
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Samples: Wellcare Health Plans, Inc., Wellcare Health Plans, Inc.
Emergency Services Denials. If the MCO has a pattern of inappropriately denying payments for emergency services as defined in Part II, Definitions, the MCO it may be subject to suspension of new enrollments, withholding of capitation payments, contract termination, or refusal to contract in a future time period. This applies not only to cases where the DEPARTMENT has ordered payment after appeal, but also to cases where no appeal has been made (i.e., the DEPARTMENT is knowledgeable about documented abuse from other sources.)
Appears in 1 contract
Samples: Wellcare Health Plans, Inc.
Emergency Services Denials. If the MCO has MCOs that have a pattern of inappropriately denying payments for emergency emergency-related services as defined in Part II, Definitions, the MCO may be subject to suspension of new enrollments, withholding of a portion of capitation paymentspayments subject to Section 6.2, Sanctions, Section 6.6, Withholding of Payments, and Section 6.7, Disputes and Appeals of this contract, contract termination, or refusal to contract in a future time period. This applies not only MCOs have the right to cases where the DEPARTMENT has ordered payment after appeal, but also to cases where no appeal has been made (i.e., the DEPARTMENT is knowledgeable about documented abuse from other sources.)as specified under Section 6.7
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