Common use of Incurred Claims Clause in Contracts

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. •Pass through Payments •Increased payments for certain Medicaid primary care services provided by certain qualified primary care providers; •Supplemental payments included in MCO capitation rates intended for payment to providers and other entities. •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  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. •Pass through Payments •Increased payments for certain Medicaid primary care services provided by certain qualified primary care providers; •Supplemental payments included in rates intended for payment to providers and other entities. •Exclusions •Federal and State taxes and licensing and regulatory fees. Taxes, licensing and regulatory fees

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. •Pass through Payments •Increased payments for certain Medicaid primary care services provided by certain qualified primary care providers; •Supplemental payments included in MCO capitation rates intended for payment to providers and other entities. •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. •Pass through Payments •Increased payments for certain Medicaid primary care services provided by certain qualified primary care providers; •Supplemental payments included in rates intended for payment to providers and other entities. •Exclusions •Federal and State taxes and licensing and regulatory fees. Taxes, licensing and regulatory fees