Incurred Claims. Direct claims that the MCO pays to providers (including under capitation contracts with health care professionals) for services or supplies covered under the managed care contract with DMS, provided to enrollees; •Incurred but not reported and unpaid claims reserves for the MLR Reporting year, including claims reported in the process of adjustment; •Percentage withholds from payments made to contracted providers; •Claims that are recoverable for anticipated coordination of benefits; •Claims payments recoveries received as a result of subrogation; •Changes in other claims-related reserves; •Claims payments recoveries as a result of fraud reductions efforts, not to exceed the amount of fraud reduction expenses; •Reserves for contingent benefits and the medical claim portion of lawsuits; and •The amount of incentive and bonus payments made to providers. •Deductions from Claims •Overpayment recoveries received from providers; •Prescription drug rebates received by the MCO or PIHP; and •State subsidies based on a stop-loss payment methodology. •Solvency Funds •Payments made by an MCO to mandated solvency funds. •Health Care Quality Activities May be included in numerator •Any MCO expenditure that is related to Health Information Technology and meaningful use, and is not considered incurred claims. •Excluded from Claims •Amounts paid to third party vendors for secondary network savings; •Amounts paid to third party vendors for network development, administrative fees, claims processing, and utilization management; and •Amounts paid, including amounts paid to a provider, for professional or administrative services that do not represent compensation or reimbursement for State plan services, provided to an enrollee. •Amounts paid to the State as remittance •Pass-through Payments made under 42 CFR 438.6(d) Denominator •Revenue •State capitation payments to the MCO for all enrollees under a risk contract less any unreturned withholds •State-developed one time payments, for specific life events; •Payments to the MCO for incentive arrangements or payments for the amount of a withhold the MCO earns in accordance with conditions in the contract •Unpaid cost sharing amounts that the MCO could have collected from enrollees under the contract •All changes to unearned premium reserves. •Exclusions •Federal and State taxes and licensing and regulatory fees. Taxes, licensing and regulatory fees
Incurred Claims. 6 2.40 INCURRED PREMIUM REFUNDS . . . . . . . . . . . . . . . . . . . 6 2.41
Incurred Claims. For purposes of this Section 6.2(a), an “Incurred Claim” is deemed to be incurred (A) with respect to medical, dental, vision and/or prescription drug benefits, upon the rendering of health services giving rise to such claim or liability; (B) with respect to life insurance, accidental death and dismemberment and business travel accident insurance, upon the occurrence of the event giving rise to such claim or liability; and (C) with respect to long-term disability benefits, upon the date of an individual’s disability, as determined by the disability benefit insurance carrier, giving rise to such claim or liability.
Incurred Claims. For purposes of this Section 6.2(a), an “Incurred Claim” is deemed to be incurred (A) with respect to medical, dental, vision and/or prescription drug benefits, upon the rendering of health services giving rise to such claim or liability; (B) with respect to life insurance, accidental death and dismemberment and business travel accident insurance, upon the occurrence of the event giving rise to such claim or liability; (C) with respect to long-term disability benefits, upon the date of an individual’s disability, as determined by the disability benefit insurance carrier, giving rise to such claim or liability; and (D) with respect to a period of continuous hospitalization, upon the date of admission to the hospital, unless otherwise provided under the terms of the applicable Greatbatch Welfare Plan.
Incurred Claims. Incurred claims are as defined in 42 CFR § 438.8 (e) (2).
Incurred Claims. Incurred claims are as defined in 42 CFR § 438.8. Also known as the Arkansas Independent Assessment (ARIA). A functional assessment conducted by qualified individual who does not work for DHS, a PASSE, or a provider of services using an assessment instrument approved by DHS. Services that are provided in lieu of a required covered benefit. These services are not part of the PASSE covered benefit, but because of special circumstances, it is deemed more cost effective to provide a non-covered service in lieu of more expensive care which is covered under the PASSE program. For services provided in an Institution for Mental Diseases, the PASSE must ensure compliance with 42 CFR § 438.6(e).
Incurred Claims. Incurred claims must include the following:
a) Direct claims that the Contractor paid to Providers (including under capitated contracts with network Providers) for services or supplies covered under the contract and services meeting the requirements of 42 C.F.R. § 438.3(e) provided to members.
b) Unpaid claims liabilities for the MLR reporting year, including claims reported that are in the process of being adjusted or claims incurred but not reported.
c) Withholds from payments made to network providers to the extent that such withholds have been finalized to be paid or have been paid.
d) Claims that are recoverable for anticipated coordination of benefits.
e) Claims payments recoveries received as a result of subrogation.
f) Incurred but not reported claims based on past experience, and modified to reflect current conditions, such as changes in exposure or claim frequency or severity.
g) Changes in other claims-related reserves.
h) Reserves for contingent benefits and the medical claim portion of lawsuits. Amounts that must be deducted from incurred claims include the following:
a) Premiums and overpayment recoveries received from network providers.
b) Prescription drug rebates received and accrued. Expenditures that must be included in incurred claims include the following:
Incurred Claims. Merck shall retain all responsibilities, obligations and liabilities for claims arising or incurred on or before the Transfer Date relating to any Merck Transferee under any medical, dental, vision, life insurance, hospitalization, prescription drug, behavioral health or short-term disability plan of Merck. For purposes of this Section 9(e), a claim shall be deemed to have arisen or to have been incurred upon the incurrence of a qualified expense for which reimbursement or payment is sought.
Incurred Claims direct claims paid to providers including all costs of CMHSP capitated contracts (excluding PIHP delegated Managed care administrative costs), 2) Unpaid claims for dates of service falling within the reporting year (accounts payable), 3) Estimate of claims incurred but not reported based on past experience, 4) payments to the ISF, and 5) incentives/bonuses paid to providers. Reduce claims by 6) Overpayment recoveries from providers, 7) prescription drug rebates, 8) claims recovered through fraud reduction efforts up to the amount of fraud reduction expense included in the numerator, 9) Hospital Rate Adjuster payments and 10) contribution to ISF fund.
Incurred Claims. “Incurred Claims” for the 2021-2022 Policy Year will be defined as follows: total paid claims to date for the 2021-2022 Policy Year completed to ultimate by means of the appropriate completion factor.
