Payment of Providers. The Contractor shall reimburse Providers as follows:
a. The Contractor shall reimburse Outside Providers for the following Covered Services:
i. Specialty care for which the Contractor has referred the Enrollee to an Outside Provider.
ii. Out-of-area services provided to an Enrollee in accordance with the Contractor's approved plan for out of area services.
b. Federally Qualified Health Centers (FQHC) - The Contractor shall reimburse FQHCs at the same encounter rate as paid by the Division.
c. Rural Health Centers (RHC) - The Contractor shall reimburse RHCs at the same encounter rate as paid by the Division. Within thirty (30) days following the date the claim is received by the Contractor from an Outside Provider, the Contractor shall process each clean claim, and for other claims the Contractor shall notify the provider of the status (pend, deny, or other reason) of the claim and if applicable, the reason the claim cannot be paid. Claims for Emergency Medical Services and Family Planning Services shall be paid at the applicable Medicaid fee-for-service rate in the absence of an agreement otherwise between the Contractor and the Outside Provider. The Contractor shall submit to the Division its criteria for authorization or denial of payment for services rendered by Outside Providers. The Division shall review all such criteria for conformity with Medicaid policy and must approve the criteria prior to implementation by the Contractor. The Contractor shall distribute its criteria for approval or denial of outside services to all Outside providers to whom Enrollees are referred and shall distribute its criteria for approval of outside Emergency Services to all facilities providing Emergency Medical Services known to the Contractor and located within a thirty (30) mile radius. All criteria shall be kept current. The Contractor shall have written policies and procedures, in form and content acceptable to the Division, providing a mechanism for Providers to appeal the denial of claims by the Contractor. If a claim is denied following completion of the Contractor's internal appeals procedure, the Contractor shall provide written notice of the denial to the Provider and the Division. Notice to the Provider shall include a statement that the Provider may appeal the determination to the Division; the procedure for submitting an appeal to the Division; and any forms required for an appeal. The Division shall make the final determination as to whether the Contractor i...
Payment of Providers. Payment of both contracted and non-participating providers shall, at a minimum, follow the same standards as those contained in 42 CFR 447.45 (d)(1)-(3), (5) and (6) as determined by SCDHHS. This includes the following: Providers must submit all claims no later than 12 months from the date of service. The Contractor shall pay 90% of all clean claims from practitioners, either in individual or group practice or who practice in shared health facilities, within thirty (30) days of the date of receipt. The Contractor shall pay 99% of all clean claims from practitioners, either in individual or group practice or who practice in shared health facilities, within ninety (90) days of the date of receipt. These provisions shall also apply to payments to hospitals. The date of receipt is the date the Contractor receives the claim, as indicated by its data stamp on the claim. The date of payment is the date of the check or other form of payment. The MCO and its providers may, by mutual agreement, establish an alternative payment schedule.
Payment of Providers. Blue Shield HMO-G contracts with groups of Physicians to provide Services to Members. A fixed, monthly fee is paid to the groups of Physicians for each Member whose Personal Physician is in the group. This payment system, capitation, includes incentives to the group of Physicians to manage all Services provided to Members in an appropriate manner consistent with this Agreement. Therefore, the Personal Physician is responsible for providing Services, referring the Member to Plan Specialists and Providers and authorizing Hospital, Skilled Nursing Facility or other Services. If you want to know more about this payment system, contact Member Services at the number listed in the back of this booklet or talk to your Plan Provider.
Payment of Providers. 1. Network Provider Reimbursement Personal Choice reimbursement programs for health care Providers are intended to encourage the provision of quality, cost-effective care for Personal Choice members. Set forth below is a general description of Personal Choice reimbursement programs, by type of Personal Choice Network health care Provider. Please note that these programs may change from time to time, and the arrangements with particular Providers may be modified as new contracts are negotiated. If you have any questions about how your health care Provider is compensated, please speak with your healthcare provider directly or contact the Carrier’s Member Services Department.
a. Physicians Personal Choice Network Physicians, including Primary Care Provider (PCPs) and specialists, are paid on a fee-for-service basis, meaning that payment is made according to the Carrier’s Personal Choice fee schedule for the specific medical services that the Physician performs.
