PAYMENT AND FINANCIAL PROVISIONS. Section 5.1 Limited Incorporation of Section 4 of the MCO Contract
PAYMENT AND FINANCIAL PROVISIONS. 137 Section 5. Additional Terms and Conditions 160 Section 6. Signatures 188 Section 7. Appendices 197
PAYMENT AND FINANCIAL PROVISIONS. 1General Financial Provisions A.Capitation Payments EOHHS will make monthly capitation payments to the Contractor in accordance with the rates of payment and payment provisions set forth herein for all Covered Services actually and properly delivered to eligible Enrollees in accordance with and subject to all applicable federal and State laws, regulations, rules, billing instructions, and bulletins, as amended. The Contractor will receive two monthly capitation payments for each Dual Eligible Enrollee: one amount from Medicare and a second amount from MassHealth. Medicare and MassHealth each produce different Rate Cells (RCs) according to the individual Enrollee’s clinical and demographic status and setting of care. For those Enrollees who are eligible for MassHealth only, the Contractor will receive one monthly capitation payment from MassHealth.
PAYMENT AND FINANCIAL PROVISIONS. A.2 is hereby amended by deleting it in its entirety and replacing it with the following:
PAYMENT AND FINANCIAL PROVISIONS. 1. Section 10.5.B.1 is hereby amended by deleting it in its entirety and replacing it with the following:-
1. Each month EOHHS shall issue monthly payments to the Contractor for PCC Plan Management Support Services, in accordance with the following methodology. EOHHS shall:
a. Determine the number of PCC Enrollees for the month using the monthly enrollment file used to generate prospective capitation.
b. Multiply the number of Enrollees for the month, as determined by EOHHS, by the PMPM Plan management support rate; this payment will be the final Monthly PCC Plan Management Support Services Payment Amount.”
2. Section 10.5.C is hereby amended by deleting it in its entirety and replacing it with the following:-
PAYMENT AND FINANCIAL PROVISIONS. 150
4.1. General Financial Provisions 150 4.2. Payment Terms 158 4.3. Transitions between Rating Categories and Risk Score Changes 166 4.4. Reconciliation 166 4.5. Payment in Full 167 5.1. Administration 167 5.2. Confidentiality 174 5.3. General Terms and Conditions 176 5.4. Record Retention, Inspection, and Audits 186 5.5. Termination of Contract 186 5.6. Order of Precedence 189 5.7. Contract Term 190 5.8. Amendments 190 5.9. Written Notices 190 This Contract, made on December 20, 2013, is between the Department of Health and Human Services, acting by and through the Centers for Medicare & Medicaid Services (CMS), the Commonwealth of Virginia, acting by and through the Department of Medical Assistance Services (DMAS) and < Insert Contractor Name> (the Contractor). The Contractor's principal place of business is Enter principal place of business.
PAYMENT AND FINANCIAL PROVISIONS. For services provided pursuant to this Agreement, MBHP shall pay Provider in accordance with the terms set forth in Exhibit C attached hereto. In the event that MBHP reviews the ESP Services provided by Provider and determines that such services were not provided pursuant to this agreement, MBHP may retroactively deny payment and recoup or offset those amounts that should not have been paid. Any such action by MBHP shall be subject to your rights of appeal set forth in the Administrative Operations section of the Provider Manual.
PAYMENT AND FINANCIAL PROVISIONS.
4.1 General Financial Provisions
PAYMENT AND FINANCIAL PROVISIONS. 1. Section 4.4.B of the Contract is hereby amended by striking the following language:
PAYMENT AND FINANCIAL PROVISIONS. Section 6.5- Special Payment Requirements, Paragraphs A through E; Section 6.6, Funding and Approval, Paragraph B4; Section 6.9, Expenditures Incurred But Not Reported (IBNR); and Section 6.10, Payment for Services – Non-Medicaid, Paragraph F, are amended to update the date and fiscal year references and shall read as follows:
