NON-CAPITATED SERVICES. 9.01 Non-Capitated Services, as defined in this Article, shall include Covered Medical Services, as set forth in the applicable Benefit Agreement and as authorized or referred by PARTICIPATING MEDICAL GROUP. The Covered Medical Services encompassed in Non-Capitated Services are delineated in Exhibit A(1) and include, but are not limited to:
A. Inpatient Hospital Services (exclusive of professional charges).
B. Outpatient Hospital Services (exclusive of professional charges).
C. Hemodialysis Services (exclusive of professional charges).
D. In-Area Emergency Room Facility Services (exclusive of professional charges).
E. Related Hospital Services.
F. Skilled Nursing Facility Services. G. Ambulance Services.
NON-CAPITATED SERVICES a. For all electronically submitted claims for non-capitated services, the Health Plan shall:
(1) Within twenty-four (24) hours after the beginning of the next business day after receipt of the claim, provide electronic acknowledgment of the receipt of the claim to the electronic source submitting the claim.
(2) Within ten (10) business days after receipt of the claim, authorize and forward the claim to the Medicaid fiscal agent or notify the provider or designee that the claim is contested. The notification to the provider or designee of a contested claim shall include an itemized list of additional information or documents necessary to process the claim.
b. For all non-electronically submitted claims for non-capitated services, the Health Plan shall, within fifteen (15) business days after receipt of the claim, perform the following:
(1) Provide acknowledgment of receipt of the claim to the provider or designee or provide the provider or designee with access to the status of a submitted claim through such methods as, web portals, electronic reports, or provider services telephonic inquiries.
(2) Authorize and forward the claim to the Medicaid fiscal agent or notify the provider or designee that the claim is contested. The notification to the provider of a contested claim shall include an itemized list of additional information or documents necessary to process the claim.
c. The Agency, or its fiscal agent, shall reimburse FFS Health Plan providers for correct, authorized, clean claims according to the Florida Medicaid fee schedules for reimbursement for covered services provided to enrollees. The Agency, or its fiscal agent, shall also reimburse out-of-network providers on a FFS basis for authorized services.
NON-CAPITATED SERVICES. 9.01 Non-Capitated Services, as defined in this Article, shall include Covered Medical Services as set forth in the applicable Benefit Agreement and as authorized or referred by PARTICIPATING MEDICAL GROUP. The Covered Medical Services encompassed in Non-Capitated Services are delineated in Exhibit A(1) and include, but are not limited to. A Inpatient Hospital Services (exclusive of professional charges).
NON-CAPITATED SERVICES. The following Texas Medicaid program services have been excluded from the services included in the calculation of HMO capitation rate: THSteps Dental (including Orthodontia) Early Childhood Intervention Case Management/Service Coordination MHMR Targeted Case Management Mental Health Rehabilitation Pregnant Women and Infants Case Management THSteps Medical Case Management Texas School Health and Related Services Texas Commission for the Blind Case Management Tuberculosis Services Provided by TDH-approved providers (Directly Observed Therapy andContact Investigation) Vendor Drugs (out-of-office drugs) 1999 Renewal Contract Tarrant Service Area 42 August 9, 1999 43 Medical Transportation TDHS Hospice Services Refer to relevant chapters in the Provider Procedures Manual and the Texas Medicaid Bulletins for more information. Although HMO is not responsible for paying or reimbursing for these non-capitated services, HMO remains responsible for providing appropriate referrals for Members to obtain or access these services.
6.1.8.1 HMO is responsible for informing providers that all non-capitated services must be submitted to TDH for payment or reimbursement.
NON-CAPITATED SERVICES. The following Texas Medicaid program services have been excluded from the services included in the calculation of HMO capitation rate: THSteps Dental (including Orthodontia) Early Childhood Intervention Case Management/Service Coordination MHMR Targeted Case Management Mental Health Rehabilitation 34 Dallas Service Area Contract 41 Pregnant Women and Infants Case Management THSteps Medical Case Management Texas School Health and Related Services Texas Commission for the Blind Case Management Tuberculosis Services Provided by TDH-approved providers (Directly Observed Therapy and Contact Investigation) Vendor Drugs (out-of-office drugs) Medical Transportation TDHS Hospice Services Refer to relevant chapters in the Provider Procedures Manual and the Texas Medicaid Bulletins for more information. Although HMO is not responsible for paying or reimbursing for these non-capitated services, HMO remains responsible for providing appropriate referrals for Members to obtain or access these services.
6.1.8.1 HMO is responsible for informing providers that all non-capitated services must be submitted to TDH for payment or reimbursement.
NON-CAPITATED SERVICES. 9.01 Billing for Non-Capitated Services shall be as follows:
A. The provider of Non-Capitated Services may xxxx BLUE CROSS directly, in which case, BLUE CROSS shall reimburse said provider within forty-five (45) working days following receipt of a clean, undisputed claim accompanied by an authorization from PARTICIPATING MEDICAL GROUP; or
B. The provider of Non-Capitated Services may xxxx PARTICIPATING MEDICAL GROUP, in which case, PARTICIPATING MEDICAL GROUP shall xxxx BLUE CROSS for reimbursement. BLUE CROSS shall reimburse PARTICIPATING MEDICAL GROUP within forty-five (45) working days following BLUE CROSS’ receipt of a clean undisputed claim from PARTICIPATING MEDICAL GROUP, on the condition that such claim shall be submitted to BLUE CROSS no later than twelve (12) months after the date of service. This section shall only apply for the following Non-Capitated Services: mammography services, DME, prosthetics and injectable medications (including chemotherapy drugs and infused substances). In either case described above, BLUE CROSS shall pay contracting providers at the rate negotiated between BLUE CROSS and said provider. In the case of non-contracting providers, BLUE CROSS shall pay the lesser of: the actual billed charges, or the maximum allowable rate according to the BLUE CROSS Customary and Reasonable charges, or the rate arranged for by a CALIFORNIACARE Case Manager.
NON-CAPITATED SERVICES. The following Texas Medicaid program services have been excluded from the services included in the calculation of HMO capitation rate: - THSteps Dental (including Orthodontia); - Early Childhood Intervention Case Management/Service Coordination; - MHMR Targeted Case Management; - Mental Health Rehabilitation; - Pregnant Women and Infants Case Management; - THSteps Medical Case Management; - Texas School Health and Related Services; - Texas Commission for the Blind Case Management; - Tuberculosis Services Provided by HHSC-approved providers (Directly Observed Therapy and Contact Investigation); - Vendor Drugs (out-of-office drugs); - Medical Transportation; and - TDHS Hospice Services. Refer to relevant chapters in the Provider Procedures Manual and the Texas Medicaid Bulletins for more information. Although HMO is not responsible for paying or reimbursing for these noncapitated services, HMO remains responsible for providing appropriate referrals for Members to obtain or access these services.
6.1.8.1 HMO is responsible for informing providers that all non-capitated services must be submitted to HHSC for payment or reimbursement.
NON-CAPITATED SERVICES. The following Texas Medicaid program services have been excluded from the services included in the calculation of HMO capitation rate: THSteps Dental (including Orthodontia) Early Childhood Intervention Case Management/Service Coordination MHMR Targeted Case Management Mental Health Rehabilitation Pregnant Women and Infants Case Management THSteps Medical Case Management Texas School Health and Related Services Texas Commission for the Blind Case Management Tuberculosis Services Provided by TDH-approved providers (Directly Observed Therapy and Contact Investigation) Vendor Drugs (out of office drugs) Medical Transportation TDHS Hospice Services Refer to relevant chapters in the Provider Procedures Manual and the Texas Medicaid Bulletins for more information. TDHS/HMO CONTRACT August 11, 1999
NON-CAPITATED SERVICES. 9.01 Non-Capitated Services, as defined in this Article, shall include Covered Medical Services, as set forth in the applicable Benefit Agreement and as authorized or referred by PARTICIPATING MEDICAL GROUP. The Covered Medical Services encompassed in Non-Capitated Services are delineated in Exhibit A(1). For purposes of calculating the Non-Capitated Performance Settlement, these services include, but are not limited to the following:
A. Inpatient Hospital Services (exclusive of professional charges).
B. Outpatient Hospital Services (exclusive of professional charges).
C. Hemodialysis Services (exclusive of professional charges).
D. In-Area Emergency Room Facility Services (exclusive of professional charges).
E. Related Hospital Services.
F. Skilled Nursing Facility Services. G. Ambulance Services.
NON-CAPITATED SERVICES a. For all electronically submitted Claims for non-capitated services, the PSN shall:
(1) Within 24 hours after the beginning of the next Business Day after receipt of the Claim, provide electronic acknowledgment of the receipt of the Claim to the electronic source submitting the Claim.
(2) Within ten (10) Business Days after receipt of the Claim, authorize and forward the Claim to the Medicaid fiscal agent or notify the provider or designee that the Claim is contested. The notification to the provider or designee of a Contested Claim shall include an itemized list of additional information or documents necessary to process the Claim.
b. For all non-electronically submitted Claims for non-capitated services, the PSN shall, within fifteen (15) Business Days after receipt of the Claim, perform the following:
(1) Provide acknowledgment of receipt of the Claim to the provider or designee or provide the provider or designee with access to the status of a submitted Claim through such methods as, web portals, electronic reports, or provider services telephonic inquiries.
(2) Authorize and forward the Claim to the Medicaid fiscal agent or notify the provider or designee that the Claim is contested. The notification to the provider of a Contested Claim shall include an itemized list of additional information or documents necessary to process the Claim.
