HEALTH PLAN AND SUBCONTRACTOR REQUIREMENTS. 5.1 Payments to Provider. Subcontractor or Health Plan (as applicable) shall pay Provider on a timely basis as set forth in the Agreement, the applicable State Contract and applicable State and federal law and regulations, including but not limited to 42 U.S.C. 1396u-2(f) and 42 CFR 447.46, 42 CFR 447.45(d)(2), 42 CFR 447.45(d)(3), 42 CFR 447.45(d)(5) and 42 CFR 447.45(d)(6), as applicable and as may be amended from time to time. Unless a different timeframe is set forth in the Agreement, Subcontractor or Health Plan (as applicable) will pay 90% of claims from physicians in an individual or group practice which can be processed without obtaining additional information from the physician or from a third party within ninety (90) days of the date of receipt of the claim. If a third party liability exists, payment of claims shall be determined in accordance with federal and/or State third party liability law and the terms of the applicable State Contract. Unless Subcontractor or Health Plan (as applicable) otherwise requests assistance from Provider, Subcontractor or Health Plan will be responsible for third party collections in accordance with the terms of the applicable State Contract.
HEALTH PLAN AND SUBCONTRACTOR REQUIREMENTS. 4.1 Prompt Payment. Subcontractor or Health Plan (as applicable) shall accept claims electronically by batch file upload or by direct data entry and pay Provider pursuant to the State Contract and applicable State and federal law and regulations, including but not limited to 42 CFR 447.46, 42 CFR 447.45(d)(2), 42 CFR 447.45(d)(3), 42 CFR 447.45(d)(5) and 42 CFR 447.45(d)(6), as applicable and as may be amended from time to time. If a third party liability exists, payment of claims shall be determined in accordance with federal and/or State third party liability law and the terms of the State Contract. Unless Subcontractor or Health Plan (as applicable) otherwise requests assistance from Provider, Subcontractor or Health Plan will be responsible for third party collections in accordance with the terms of the State Contract.
HEALTH PLAN AND SUBCONTRACTOR REQUIREMENTS. 5.1 Prompt Payment. Subcontractor or Health Plan (as applicable) shall pay Provider pursuant to the State Contract and applicable State and federal law and regulations, including but not limited to 42 CFR 447.46, 42 CFR 447.45(d)(2), 42 CFR 447.45(d)(3), 42 CFR 447.45(d)(5) and 42 CFR 447.45(d)(6), as applicable and as may be amended from time to time. If a third party liability exists, payment of claims shall be determined in accordance with federal and/or State third party liability law and the terms of the State Contract. Unless Subcontractor or Health Plan (as applicable) otherwise requests assistance from Provider, Subcontractor or Health Plan will be responsible for third party collections in accordance with the terms of the State Contract. Subcontractor or Health Plan shall not be responsible for any payments owed to Provider for services that were rendered prior to a Covered Person’s enrollment, even if such services fell within any applicable period of retroactive eligibility for Medicaid. Subcontractor or Health Plan shall not be financially liable for services rendered to treat a non-emergent condition in a hospital emergency room (except to assess whether a condition warrants treatment as Emergency Services, or as required elsewhere in law), unless the services were prior authorized or otherwise conformed to the terms of the Agreement. Subcontractor or Health Plan shall not be liable to pay claims to Provider if the validity of the claim is being challenged by Subcontractor or Health Plan through a grievance or appeal, unless Subcontractor or Health Plan is obligated to pay the claim or a portion of the claim through the Agreement.
HEALTH PLAN AND SUBCONTRACTOR REQUIREMENTS. 5.1. Prompt Payment. Health Plan or Subcontractor shall pay Provider pursuant to the applicable State Contract, applicable State law and regulations, and 42 CFR 447.46, 42 CFR 447.45(d)(2), 42 CFR 447.45(d)(3), 42 CFR 447.45(d)(5) and 42 CFR 447.45(d)(6), as applicable and as may be amended from time to time. If a third party liability exists, payment of claims shall be determined in accordance with federal and/or State third party liability law and the terms of the applicable State Contract. Unless Health Plan or Subcontractor otherwise requests assistance from Provider, Health Plan will be responsible for third party collections in accordance with the terms of the applicable State Contract.
HEALTH PLAN AND SUBCONTRACTOR REQUIREMENTS. 5.1 Prompt Payment. Subcontractor or Health Plan (as applicable) shall pay Provider on a timely basis as set forth in the Agreement, the State Contract and applicable State and federal law and regulations, including but not limited to 42 U.S.C. 1396u-2(f) and 42 CFR 447.46, 42 CFR 447.45(d)(2), 42 CFR 447.45(d)(3), 42 CFR 447.45(d)(5) and 42 CFR 447.45(d)(6), as applicable and as may be amended from time to time. Subcontractor or Health Plan (as applicable) shall adjudicate (finalize as paid or denied adjudicated) for: (1) healthcare services within thirty (30) days from the date it receives the Clean Claim from Provider; (2) pharmacy services no later than eighteen (18) days of receipt if submitted electronically or twenty-one (21) days if submitted non-electronically. Subcontractor or Health Plan (as applicable) shall pay Provider interest at a rate 18% per annum on all Clean Claims that are not adjudicated within thirty (30) days. If a third party liability exists, payment of claims shall be determined in accordance with federal and/or State third party liability law and the terms of the State Contract. Unless Subcontractor or Health Plan (as applicable) otherwise requests assistance from Provider, Subcontractor or Health Plan (as applicable) will be responsible for third party collections in accordance with the terms of the State Contract.
HEALTH PLAN AND SUBCONTRACTOR REQUIREMENTS. 4.1 In addition to Subcontractor’s termination rights under the Agreement, Health Plan shall have the right to revoke any functions or activities Subcontractor delegates to Provider under the Agreement or impose other sanctions consistent with the State Contract if in Health Plan’s reasonable judgment Provider’s performance under the Agreement is inadequate.
HEALTH PLAN AND SUBCONTRACTOR REQUIREMENTS. 4.1 Health Plan or Subcontractor shall pay Provider pursuant to the State Contract, applicable State law and regulations, and 42 CFR 447.46, 42 CFR 447.45(d)(2), 42 CFR 447.45(d)(3), 42 CFR 447.45(d)(5) and 42 CFR 447.45(d)(6), as applicable and as may be amended from time to time. Unless an alternative payment schedule is set forth in the Agreement, Health Plan or Subcontractor, as the case may be, shall pay 90% of all clean claims from Provider, within thirty (30) days of the date of receipt, and shall pay 99% of all clean claims from Provider within ninety (90) days of the date of receipt. The date of receipt is the date that Health Plan or Subcontractor, as the case may be, receives the claim, as indicated by its data stamp on the claim. The date of payment is the date of the check or other form of payment. If a third party liability exists, payment of claims shall be determined in accordance with federal and/or State third party liability law and the terms of the State Contract. Unless Health Plan or Subcontractor otherwise requests assistance from Provider, Health Plan will be responsible for third party collections in accordance with the terms of the State Contract.
HEALTH PLAN AND SUBCONTRACTOR REQUIREMENTS
