PACIFICARE STANDARDS FOR CLAIMS PROCESSING Sample Clauses

PACIFICARE STANDARDS FOR CLAIMS PROCESSING. Medical Group represents and warrants that Medical Group's Claim Processing Program shall be administered in accordance with PacifiCare's Claims Processing Program standards and procedures established in accordance with State and Federal law standards and shall include, but is not limited to, the following: A. All claims shall be processed within the earlier of the following time periods: (i) the time specified in the applicable agreement between Medical Group and its Participating Provider; (ii) forty five (45) working days of Medical Group's or any of its Participating Providers receipt of an uncontested claims for services provided to Commercial Medical Group Members; or (iii) the time period required by State and Federal Law for payment of claims. B. Medical Group shall notify Member of any contested claim(s) within the time periods identified above which states the portion of the claim that is contested and the specific reasons for contesting the claim. C. Medical Group shall have sufficient administrative capacity to carry out the requirements of this delegated function D. Medical Group shall have written procedures available to staff for review, including work flow charts and inventory data. E. Medical Group shall have an appropriate medical review process in place to review claims when necessary. Medical Group must participate, cooperate, and comply with PacifiCare for accessing medical records.
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