One Year Limit to Assert Claim Sample Clauses

One Year Limit to Assert Claim. (A) The STATE shall not assert any claim for or seek the payment of or make any adjustment for any alleged overpayment made by the STATE to the MCO under section 4.1 more than one year after the date such payment was actually received by the MCO from the STATE. This one year limitation, along with the notice requirement described in section 4.11.1(C), does not apply to duplicate payments made because of multiple identification numbers for the same Enrollee, payments for full months for a Medical Assistance Enrollee while incarcerated in a facility, and payments for full months after the death of the Enrollee. (B) The MCO shall not assert any claim for or seek the payment of or make any adjustment for any alleged underpayment made by the STATE to the MCO more than one year after the date such payment was actually received by the MCO from the STATE. The MCO must have filed a timely appeal of risk factors under section 4.1.9 in order to assert any claims regarding risk adjusted payments.
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One Year Limit to Assert Claim. (A) The STATE shall in no event assert any claim for, seek the reimbursement of or make any adjustment for any alleged overpayment made by the STATE to the MCO under this Article more than one year after the date such payment was actually received by the MCO from the STATE. This one year limitation, along with the notice requirement described in section 4.20.2, does not apply to duplicate payments made because of multiple identification numbers for the same Enrollee, payments for full months for a Medical Assistance Enrollee who is incarcerated in a facility, and payments for full months after the death of the Enrollee. (B) The MCO shall in no event assert any claim for, seek the reimbursement of or make any adjustment for any alleged underpayment made by the STATE to the MCO more than one year after the date such payment was actually received by the MCO from the STATE.‌
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One Year Limit to Assert Claim. (1) The STATE shall not assert any claim for, seek the reimbursement of, or make any adjustment for any alleged overpayment made by the STATE to the MCO under section 4.1 more than one (1) year after the date such payment was actually received by the MCO from the STATE. This one year limitation, along with the notice requirement described in section 4.13.3.2(4), does not apply to duplicate payments made because of multiple identification numbers for the same Enrollee, payments for full months for an Enrollee while Incarcerated, and payments for full months after the death of the Enrollee and in the event that CMS or the state or federal Office of the Inspector General requires the STATE to recover payments. (2) The MCO shall not assert any claim for or seek the reimbursement of or make any adjustment for any alleged underpayment made by the STATE to the MCO more than one (1) year after the date such payment was actually received by the MCO from the STATE. (3) The parties shall notify each other in writing of any intent to assert a claim under this section. 4.14 PAYMENT FOR SKILLED NURSING FACILITY/NURSING FACILITY BENEFIT.‌ 4.14.1 180-Day SNF/NF Benefit Period for MSHO.‌ The MCO is responsible for services covered under the Medicare Advantage SNF benefit regardless of whether NF liability is indicated on the STATE’s Medical Assistance file. (1) For any Beneficiary who enrolls in MSHO while in a community setting (i.e. is assigned to Rate Cell category A or B), the MCO shall have financial responsibility for Nursing Facility services for one hundred eighty (180) days. The 180 days begin at the time of the Enrollee’s date of admission to a Skilled Nursing Facility (SNF) or Nursing Facility (NF) on or after the first effective date of enrollment. Both Medical Assistance and Medicare covered days shall be counted toward the 180-day benefit period, except that the MCO shall not pay for Nursing Facility services for new admits to a facility that occurs during Denial of Payment for New Admits (DOPNA) violation periods, since these days are not covered under the STATE’s fee-for-service program. The 180 days shall be counted cumulatively. The 180-day benefit period may be applied to an Enrollee more than once if the requirements of the one hundred and eighty (180) day Separation Period are met as specified in section 4.14.5. The MSHO MCO is responsible for services covered under the Medicare Advantage SNF benefit regardless of whether NF liability is indicated on t...
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One Year Limit to Assert Claim. (1) The STATE shall not assert any claim for, seek the reimbursement of, or make any adjustment for any alleged overpayment made by the STATE to the MCO under section 4.1 more than one (1) year after the date such payment was actually received by the MCO from the STATE. This one year limitation, along with the notice requirement described in section 4.13.4.1(3), does not apply to duplicate payments made because of multiple PMIs for the same Enrollee, payments for full months for an Enrollee while Incarcerated, payments for full months after the death of the Enrollee and in the event that CMS or the state or federal Office of the Inspector General requires the STATE to recover payments. (2) The MCO shall not assert any claim for, seek the payment of, or make any adjustment for any alleged underpayment made by the STATE to the MCO more than one (1) year after the date such payment was actually received by the MCO from the STATE. The MCO must have filed a timely appeal of risk factors under section 4.13 in order to assert any claims regarding risk adjusted payments.
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One Year Limit to Assert Claim. A. The STATE shall not assert any claim for or seek the payment of or make any adjustment for any alleged overpayment made by the STATE to the HEALTH PLAN under Section 4.6. more than one year after the date such payment was actually received by the HEALTH PLAN from the STATE, except for duplicate payments because of multiple identification numbers for the same Enrollee, and payments for months after the death of the Enrollee. B. The HEALTH PLAN shall not assert any claim for or seek the payment of or make any adjustment for any alleged underpayment made by the STATE to the HEALTH PLAN more than one year after the date such payment was actually received by the HEALTH PLAN from the STATE.
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