Common use of Payment Adjustments Clause in Contracts

Payment Adjustments. The Monthly Capitation Payments shall be adjusted for a period not to exceed twenty-four (24) months prior to the Monthly Capitation Payment to reflect corrections to the Enrollee Listing Report. Payments will be adjusted to reflect the automatic enrollment of eligible newborn infants. At such time that Kentucky HEALTH is live, a delivery payment will be paid on the eighth (8th) day of the month for the previous month’s claims. Claims for payment adjustments shall be deemed to have been waived by the Contractor if a payment request is not submitted in writing within twelve (12) months following the month for which an adjustment is requested. Waiver of a claim for payment shall not release the Contractor of its obligations to provide Covered Services pursuant to the Contract. In the event that an Enrollee is eligible and enrolled, but does not appear on the Enrollee Listing Report, the Contractor may submit a payment adjustment request. The Contractor shall submit the request in accordance with Appendix D “Reporting Requirements and Reporting Deliverables” for automated reporting requirements. In the event that an Enrollee is eligible and enrolled and the Contractor believes the Capitation Payment was in error due to underpayment, overpayment, or duplicate payment, the Contractor may submit a payment adjustment request. The Contractor shall submit the request in accordance with Appendix D “Reporting Requirements and Reporting Deliverables” for automated reporting requirements. In the event that an Enrollee does not appear on the Enrollee Listing Report, but the Department has paid the Contractor for an Enrollee, the Department may request and obtain a refund of, or it may recoup from subsequent payments, any payment previously made to the Contractor. In the event an Enrollee appears on the Enrollee Listing Report but is determined to be ineligible, the Department may request and obtain a refund of, or it may recoup from subsequent payments, any payment previously made to the Contractor. In such instances, for each Enrollee that is determined to be ineligible, the Contractor may recover payment from any Provider who rendered services to Enrollee during the period of ineligibility. The entity to which the Enrollee is retroactively added shall assume responsibility for payment of any services provided to Enrollees during the period of adjusted eligibility. For cases involving Enrollee ineligibility due to Fraud, Waste, and Abuse, the Department shall only recoup the Capitation amount and the Contractor shall establish procedures pursuant to Section

Payment Adjustments. The Effective starting with the January 2017 Monthly Capitation Payment, the Monthly Capitation Payments shall may be adjusted for a period not to exceed twenty-four (24) months prior to the Monthly Capitation Payment to reflect corrections to the Enrollee Member Listing Report. Payments will be adjusted to reflect the automatic enrollment of eligible newborn infants. At such time that Kentucky HEALTH is live, a delivery payment will be paid on the eighth (8th) day of the month for the previous month’s claims. Claims for payment adjustments shall be deemed to have been waived by the Contractor if a payment request is not submitted in writing within twelve (12) months following the month for which an adjustment is requested. Waiver of a claim for payment shall not release the Contractor of its obligations to provide Covered Services pursuant to the Contract. In the event that an Enrollee a Member is eligible and enrolled, but does not appear on the Enrollee Member Listing Report, the Contractor may submit a payment adjustment request. The Contractor shall submit the request is to be submitted in accordance with Appendix D “Reporting Requirements and Reporting Deliverables” for Report 230 automated reporting requirements. In the event that an Enrollee a Member is eligible and enrolled and the Contractor believes the Capitation Payment capitation payment was in error due to underpayment, overpayment, overpayment or duplicate payment, the Contractor may submit a payment adjustment request. The Contractor shall submit the request is to be submitted in accordance with Appendix D “Reporting Requirements and Reporting Deliverables” for Report 250 automated reporting requirements. In the event that an Enrollee a Member does not appear on the Enrollee Member Listing Report, but the Department has paid the Contractor for an Enrolleea Member, the Department may request and obtain a refund of, or it may recoup from subsequent payments, any payment previously made to the Contractor. In the event an Enrollee a Member appears on the Enrollee Member Listing Report but is determined to be ineligible, the Department may request and obtain a refund of, or it may recoup from subsequent payments, any payment previously made to the Contractor. In such instances, for each Enrollee Member that is determined to be ineligible, the Contractor may recover payment from any Provider who rendered services to Enrollee Member during the period of ineligibility. The entity to which the Enrollee Member is retroactively added shall will assume responsibility for payment of any services provided to Enrollees Members during the period of adjusted eligibility. For cases involving Enrollee member ineligibility due to Fraudfraud, Waste, waste and Abuseabuse, the Department shall will only recoup the Capitation capitation amount and the Contractor shall establish procedures pursuant to SectionSection 10.4 “Contractor Recoupment from Member for Fraud, Waste and Abuse” to recover paid Claims. Any adjustment by the Department hereunder for retroactive disenrollments of Enrollees shall not exceed twelve (12) months from the effective date of disenrollment.

Payment Adjustments. The Monthly Capitation Payments shall be adjusted for a period not to exceed twenty-four (24) months prior to the Monthly Capitation Payment to reflect corrections to the Enrollee Listing Report. Payments will be adjusted to reflect the automatic enrollment of eligible newborn infants. At such time that Kentucky HEALTH is live, a aA delivery payment will willmay be paid on the eighth (8th) day of the month for the previous month’s claims. Claims for payment adjustments shall be deemed to have been waived by the Contractor if a payment request is not submitted in writing within twelve (12) months following the month for which an adjustment is requested. Waiver of a claim for payment shall not release the Contractor of its obligations to provide Covered Services pursuant to the Contract. In the event that an Enrollee is eligible and enrolled, but does not appear on the Enrollee Listing Report, the Contractor may submit a payment adjustment request. The Contractor shall submit the request in accordance with Appendix D “Reporting Requirements and Reporting Deliverables” for automated reporting requirements. In the event that an Enrollee is eligible and enrolled and the Contractor believes the Capitation Payment was in error due to underpayment, overpayment, or duplicate payment, the Contractor may submit a payment adjustment request. The Contractor shall submit the request in accordance with Appendix D “Reporting Requirements and Reporting Deliverables” for automated reporting requirements. In the event that an Enrollee does not appear on the Enrollee Listing Report, but the Department has paid the Contractor for an Enrollee, the Department may request and obtain a refund of, or it may recoup from subsequent payments, any payment previously made to the ContractorCont ractor. In the event an Enrollee appears on the Enrollee Listing Report but is determined to be ineligible, the Department may request and obtain a refund of, or it may recoup from subsequent payments, any payment previously made to the Contractor. In such instances, for each Enrollee that is determined to be ineligible, the Contractor may recover payment from any Provider who rendered services to Enrollee during the period of ineligibility. The entity to which the Enrollee is retroactively added shall assume responsibility for payment of any services provided to Enrollees during the period of adjusted eligibility. For cases involving Enrollee ineligibility due to Fraud, Waste, and Abuse, the Department shall only recoup the Capitation amount and the Contractor shall establish procedures pursuant to Section

Payment Adjustments. The Monthly Capitation Payments shall Contractor may expend Funds for reimbursement that differ up to 25% from the amounts agreed upon with Agency Grant Manager each quarter in Payment table located in Section I, Exhibit A Statement of Work with the prior written approval of Agency’s Grant Manager, as long as the total amount expended for all Agreement activities paid for with Funds does not exceed the amount identified in Section 6 of this Agreement. Any adjustments that result in an increase above 25% from the amounts agreed up on with Agency Grant Manager each quarter in Payment table located in Section I, Exhibit A Statement of Work may not be adjusted for a period not done without an amendment to exceed twenty-four (24) months prior this Agreement. Any changes to Deliverables or SSEM Plan are subject to the Monthly Capitation Payment to reflect corrections agreement and acceptance of Agency Grant Manager. Any adjustments that result in an increase to the Enrollee Listing Reportamount identified in Section 6 of this Agreement may not be done without an amendment to this Agreement. Payments will be adjusted to reflect EXHIBIT B Contractor shall require its first-tier Subcontractor(s) (Subcontractor) that are not units of local government as defined in ORS 190.003, if any, to: i) obtain the automatic enrollment of eligible newborn infants. At such time that Kentucky HEALTH is liveinsurance specified under TYPES AND AMOUNTS and meet the requirements under ADDITIONAL INSURED, a delivery payment will be paid on CONTINUOUS CLAIMS MADE COVERAGE, NOTICE OF CANCELLATION OR CHANGE, and CERTIFICATES OF INSURANCE before the eighth Subcontractor(s) perform under contracts between Contractor and the Subcontractors (8ththe "Subcontracts"), and ii) day maintain the insurance in full force throughout the duration of the month for Subcontracts. The insurance must be provided by insurance companies or entities authorized to transact the previous month’s claimsbusiness of insurance and issue coverage in the State of Oregon and that are acceptable to Agency. Claims for payment adjustments Contractor shall be deemed not authorize Subcontractors to have been waived begin work under the Subcontracts until the insurance is in full force. Thereafter, Contractor shall monitor continued compliance with the insurance requirements on an annual or more frequent basis. Contractor shall incorporate appropriate provisions in the Subcontracts permitting it to enforce Subcontractor compliance with the insurance requirements and shall take all reasonable steps to enforce such compliance. Examples of "reasonable steps" include issuing stop work orders (or the equivalent) until the insurance is in full force, terminating the Subcontracts as permitted by the Contractor if a payment request is not submitted in writing within twelve (12) months following Subcontracts, or pursuing legal action to enforce the month for which an adjustment is requested. Waiver of a claim for payment shall not release the Contractor of its obligations to provide Covered Services pursuant to the Contract. In the event that an Enrollee is eligible and enrolled, but does not appear on the Enrollee Listing Report, the Contractor may submit a payment adjustment request. The Contractor shall submit the request in accordance with Appendix D “Reporting Requirements and Reporting Deliverables” for automated reporting insurance requirements. In the event that an Enrollee is eligible and enrolled and no event, shall Contractor permit a Subcontractor to work under a Subcontract when the Contractor believes is aware that the Capitation Payment was Subcontractor is not in error due to underpaymentcompliance with the insurance requirements. As used in this section, overpayment, or duplicate payment, a "first-tier" Subcontractor is a Subcontractor with which the Contractor may submit directly enters into a payment adjustment requestcontract. The Contractor It does not include a sub-subcontractor with which the Subcontractor enters into a contract. If Subcontractor maintains broader coverage and/or higher limits than the minimums shown in this insurance requirement exhibit, Agency requires and shall submit be entitled to the request broader coverage and/or higher limits maintained by Subcontractor. All employers, including Subcontractor, that employ subject workers, as defined in accordance ORS 656.027, shall comply with Appendix D “Reporting Requirements ORS 656.017 and Reporting Deliverables” shall provide Workers' Compensation Insurance coverage for automated reporting those workers, unless they meet the requirement for an exemption under ORS 656.126(2). Subcontractor shall require and ensure that each of its subcontractors complies with these requirements. In the event If Subcontractor is a subject employer, as defined in ORS 656.023, Subcontractor shall also obtain Employers' Liability Insurance coverage with limits not less than $500,000 each accident. If Subcontractor is an employer subject to any other state’s workers’ compensation law, Subcontractor shall provide Workers’ compensation Insurance coverage for its employees as required by applicable workers’ compensation laws including Employers’ Liability Insurance coverage with limits not less than $500,000 and shall require and ensure that an Enrollee does not appear on the Enrollee Listing Reporteach of its out-of-state subcontractors complies with these requirements. As applicable, but the Department has paid the Contractor for an Enrollee, the Department may request Subcontractor shall obtain coverage to discharge all responsibilities and obtain a refund of, liabilities that arise out of or it may recoup from subsequent payments, any payment previously made relate to the Contractor. In Xxxxx Act with limits of no less than $5,000,000 and/or the event an Enrollee appears on the Enrollee Listing Report but is determined to be ineligible, the Department may request Longshoremen’s and obtain a refund of, or it may recoup from subsequent payments, any payment previously made to the Contractor. In such instances, for each Enrollee that is determined to be ineligible, the Contractor may recover payment from any Provider who rendered services to Enrollee during the period of ineligibility. The entity to which the Enrollee is retroactively added shall assume responsibility for payment of any services provided to Enrollees during the period of adjusted eligibility. For cases involving Enrollee ineligibility due to Fraud, Waste, and Abuse, the Department shall only recoup the Capitation amount and the Contractor shall establish procedures pursuant to SectionHarbor Workers’ Compensation Act.

Payment Adjustments. The Monthly Capitation Payments shall be adjusted for a period not to exceed twenty-four (24) months prior to the Monthly Capitation Payment to reflect corrections to the Enrollee Listing Report. Payments will be adjusted to reflect the automatic enrollment of eligible newborn infants. At such time that Kentucky HEALTH is live, a A delivery payment will may be paid on the eighth (8th) day of the month for the previous month’s claims. Claims for payment adjustments shall be deemed to have been waived by the Contractor if a payment request is not submitted in writing within twelve (12) months following the month for which an adjustment is requested. Waiver of a claim for payment shall not release the Contractor of its obligations to provide Covered Services pursuant to the Contract. In the event that an Enrollee is eligible and enrolled, but does not appear on the Enrollee Listing Report, the Contractor may submit a payment adjustment request. The Contractor shall submit the request in accordance with Appendix D “Reporting Requirements and Reporting Deliverables” for automated reporting requirements. In the event that an Enrollee is eligible and enrolled and the Contractor believes the Capitation Payment was in error due to underpayment, overpayment, or duplicate payment, the Contractor may submit a payment adjustment request. The Contractor shall submit the request in accordance with Appendix D “Reporting Requirements and Reporting Deliverables” for automated reporting requirements. In the event that an Enrollee does not appear on the Enrollee Listing Report, but the Department has paid the Contractor for an Enrollee, the Department may request and obtain a refund of, or it may recoup from subsequent payments, any payment previously made to the Contractor. In the event an Enrollee appears on the Enrollee Listing Report but is determined to be ineligible, the Department may request and obtain a refund of, or it may recoup from subsequent payments, any payment previously made to the Contractor. In such instances, for each Enrollee that is determined to be ineligible, the Contractor may recover payment from any Provider who rendered services to Enrollee during the period of ineligibility. The entity to which the Enrollee is retroactively added shall assume responsibility for payment of any services provided to Enrollees during the period of adjusted eligibility. For cases involving Enrollee ineligibility due to Fraud, Waste, and Abuse, the Department shall only recoup the Capitation amount and the Contractor shall establish procedures pursuant to Section

Payment Adjustments. The (a) Buyer shall adjust each Monthly Capitation Payments shall be adjusted for a period not to exceed twenty-four (24) months prior to Contract Payment determined under the Monthly Capitation Payment to reflect corrections to the Enrollee Listing Report. Payments will be adjusted to reflect the automatic enrollment of eligible newborn infants. At such time that Kentucky HEALTH is live, a delivery payment will be paid on the eighth (8th) day of the month for the previous month’s claims. Claims for payment adjustments shall be deemed to have been waived by the Contractor if a payment request is not submitted in writing within twelve (12) months following the month for which an adjustment is requested. Waiver of a claim for payment shall not release the Contractor of its obligations to provide Covered Services pursuant to the Contract. In the event that an Enrollee is eligible and enrolled, but does not appear on the Enrollee Listing Report, the Contractor may submit a payment adjustment request. The Contractor shall submit the request QF 20MW Settlement Contract in accordance with Appendix D “Reporting Requirements and Reporting Deliverables” for automated reporting requirements. In the event that an Enrollee is eligible and enrolled and the Contractor believes the Capitation Applicable QF 20MW Settlement Contract Payment was in error due to underpaymentProvisions, overpaymentincluding, or duplicate paymentwithout limitation, the Contractor may submit terms of Section 4.02 of the QF 20MW Settlement Contract. Buyer shall adjust each Monthly Contract Payment determined under Exhibit C of this Agreement to Seller to account for: (i) Scheduling Fees owed by Seller to Buyer, as set forth in Exhibit E; (ii) Any SDD Energy Adjustment or SDD Administrative Charge, as set forth in Exhibit I; (iii) Any CAISO Charges owed by Seller to Buyer, as set forth in Exhibit H; (iv) Any payment adjustments (including adjustments to CAISO Charges) provided for under this Agreement; (v) Any Governmental Charges owed by either Party to the other Party, as set forth in Section 8.02; and (vi) The agreement of the Parties that Buyer shall have no liability to make any payments to Seller for any electricity deliveries from the Generating Facility in a payment adjustment request. The Contractor shall submit Term Year that exceed one hundred and twenty percent (120%) of Expected Term Year Energy Production. (b) During the request in accordance with Appendix D “Reporting Requirements and Reporting Deliverables” for automated reporting requirements. In the event that an Enrollee does not appear on the Enrollee Listing Report, but the Department has paid the Contractor for an Enrollee, the Department may request and obtain a refund of, or it may recoup from subsequent paymentsTerm, any payment previously adjustments will be added to or deducted from a subsequent regular Monthly Contract Payment that is made by Buyer to Seller after the Contractor. In expiration of a 30-day period which begins upon Buyer’s receipt of all of the event an Enrollee appears on information required in order to calculate the Enrollee Listing Report but is determined to payment adjustment, provided that during the QF Settlement Contract Payment Period this provision shall not be ineligibleapplicable and the Applicable QF 20MW Settlement Contract Payment Provisions shall apply. (c) After the Term End Date, the Department may request and obtain a refund of, or it may recoup from subsequent payments, Buyer shall invoice Seller for any payment previously made adjustments within sixty (60) days of Buyer’s receipt of all of the information required in order to calculate the Contractor. In such instancespayment adjustment, for each Enrollee provided that is determined to be ineligible, the Contractor may recover payment from any Provider who rendered services to Enrollee during the period of ineligibility. The entity to which the Enrollee is retroactively added QF Settlement Contract Payment Period this provision shall assume responsibility for payment of any services provided to Enrollees during the period of adjusted eligibility. For cases involving Enrollee ineligibility due to Fraud, Waste, and Abuse, the Department shall only recoup the Capitation amount not be applicable and the Contractor Applicable QF 20MW Settlement Contract Payment Provisions shall establish procedures pursuant to Sectionapply.

Payment Adjustments. The Monthly Capitation Payments shall will be adjusted for a period not to exceed twenty-four (24) months prior to the Monthly Capitation Payment to reflect corrections to the Enrollee Member Listing Report, provided corrections are received within forty-five days (45) of receipt of the Member Listing Report. Payments will be adjusted to reflect the automatic enrollment of eligible newborn infants. At such time that Kentucky HEALTH is live, a delivery payment will be paid on the eighth (8th) day of the month for the previous month’s claims. Claims for payment adjustments shall be deemed to have been waived by the Contractor if a payment request is not submitted in writing within twelve three (123) months following the month for which an adjustment is requested. Waiver of a claim for payment shall not release the Contractor of its obligations to provide Covered Services pursuant to the Contract. In the event that an Enrollee a Member is eligible and enrolled, but does not appear on the Enrollee Member Listing Report, the Contractor may submit a payment adjustment request. The Contractor shall submit Each request must contain the request in accordance with Appendix D “Reporting Requirements following Member information: A. Name (last, first, middle initial) and Reporting Deliverables” Medicaid identification number; B. Current address; C. Age and aid category; and D. Month for automated reporting requirementswhich payment is being requested. In the event that an Enrollee is eligible and enrolled and the Contractor believes the Capitation Payment was in error due to underpayment, overpayment, or duplicate payment, the Contractor may submit a payment adjustment request. The Contractor shall submit the request in accordance with Appendix D “Reporting Requirements and Reporting Deliverables” for automated reporting requirements. In the event that an Enrollee Member does not appear on the Enrollee Member Listing Report, but the Department has paid the Contractor for an Enrolleea Member, the Department may request and obtain a refund of, or it may recoup from subsequent payments, any payment previously made to the ContractorContractor for which the Contractor has not provided Covered Services to the Member or otherwise made payments on behalf of the Member. In the event an Enrollee a Member appears on the Enrollee Member Listing Report but is determined to be ineligible, the Department may request and obtain a refund of, or it may recoup from subsequent payments, any payment previously made to the ContractorContractor within the previous twelve (12) months. In such instances, for each Enrollee Member that is determined to be ineligible, the Contractor may recover payment from any Provider who rendered services to Enrollee Member during the period of ineligibility. The entity to which the Enrollee Member is retroactively added shall will assume responsibility for payment of any services provided to Enrollees Members during the period of adjusted eligibility. For cases involving Enrollee member ineligibility due to Fraudfraud, Waste, waste and Abuseabuse, the Department shall will only recoup the Capitation capitation amount and the Contractor shall establish procedures pursuant to SectionSection 10.4 “Contractor Recoupment from Member for Fraud, Waste and Abuse” to recover paid Claims. Any adjustment by the Department hereunder for retroactive disenrollments of Enrollees shall not exceed twelve (12) months from the effective date of disenrollment.