Common use of NON-CAPITATED SERVICES Clause in Contracts

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. 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 fee-for-service 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, Agency or its fiscal agent, agent shall also reimburse out-of-network providers on a FFS basis for authorized services.