Common use of HEALTH PLAN AND SUBCONTRACTOR REQUIREMENTS Clause in Contracts

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.