Enrollment and Monthly Capitation Reconciliation. The MCO must maintain the integrity of its membership data through processing and loading of data contained for each member in the HIPAA 834C daily enrollment files and reconciling the daily changes with the HIPAA 834F monthly enrollment file. The MCO must report discrepancies between the HIPAA 834C daily enrollment files and HIPAA 834F monthly enrollment file that have a negative impact on a member’s access to care to ODM within one business day. The MCO must submit reconciliation for any discrepancies of enrollments/disenrollments contained on the HIPAA 834 files, and HIPAA 820 monthly remittance advice for the associated HIPAA 834 files, to ODM no later than 60 calendar days after the issuance of the HIPAA 820 monthly remittance advice. The MCO must report discrepancies and reconciliation requests. The MCO must submit all reconciliation requests in the format specified by ODM. ODM may reject reconciliation requests submitted by the MCO after the initial 60 calendar day due date. ODM may process MCO reconciliation requests submitted after the initial 60 calendar day due date at ODM’s sole discretion. ODM will not accept MCO reconciliation requests for enrollment and/or payment beyond the last day of the 18th month after the capitation/enrollment month. ODM will always process reconciliations for ODM recoupment of capitation payments. ODM will not accept newborn reconciliations beyond the last day of the month in which the newborn turns 15 months of age where the MCO has not submitted a Medicaid billing ID as part of the reconciliation process.
Appears in 6 contracts
Samples: Baseline Provider Agreement, Baseline Provider Agreement, Baseline Provider Agreement
