Common use of Payment of Providers Clause in Contracts

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 is obligated to pay a claim pursuant to the section and shall provide written notice to the Contractor and the Provider setting forth its determination. The Contractor shall pay each claim within thirty (30) calendar days following the date of each notice by the Division indicating that it has made a final determination requiring payment of the claim by the Contractor.

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 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 is obligated to pay a claim pursuant to the section and shall provide written notice to the Contractor and the Provider setting forth its determination. The Contractor shall pay each claim within thirty (30) calendar days following the date of each notice by the Division indicating that it has made a final determination requiring payment of the claim by the Contractor.

Payment of Providers. The Contractor shall reimburse Providers as follows: a. The Contractor shall reimburse Outside Providers for the following Covered Services: i. (1) Specialty care for which the Contractor has referred the Enrollee to an Outside Provider.; ii. (2) 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 a rate negotiated between the same encounter rate as Contractor and the FQHC. These reimbursements shall be no less than the Division would pay to FQHC providers. Therefore, within thirty (30) days after the end of each quarter, the Contractor must submit to the Division an individual report for each FQHC which details claims processed (broken down by paid, pended and denied) during that respective quarter. These reports must include Enrollee name, Medicaid ID number, dates of service, procedure billed, billed amount and paid by the Divisionamount. c. Rural Health Centers (RHC) - The Contractor shall reimburse RHCs at a rate negotiated between the same encounter rate as Contractor and the RHC. These reimbursements shall be no less than the Division would pay to RHC providers. Therefore, within thirty (30) days after the end of each quarter, the Contractor must submit to the Division an individual report for each RHC which details claims processed (broken down by paid, pended and denied) during that respective quarter. These reports must include Enrollee name, Medicaid ID number, dates of service, procedure billed, billed amount and paid by the Divisionamount. 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 is obligated to pay a claim pursuant to the section and shall provide written notice to the Contractor and the Provider setting forth its determination. The Contractor shall pay each claim within thirty (30) calendar days following the date of each notice by the Division indicating that it has made a final determination requiring payment of the claim by the Contractor.