Common use of Payment Suspension Clause in Contracts

Payment Suspension. BMS may suspend portions of capitation payments from the MCO as a remedy for non- performance. Whenever BMS determines that the MCO has failed to provide one (1) or more of the Medically Necessary covered Contract services, BMS may suspend an estimated portion of the MCO’s capitation payment in subsequent months. Such suspension amount will be equal to the amount of money BMS expected the MCO to pay for Medically Necessary covered Contract services, plus any administrative costs involved. The MCO may not deny any Medically Necessary covered Contract services in order to receive adjusted payment levels. The MCO will be given written notice at least ten (10) business days prior to the suspension of any capitation payment in accordance with Article II, Section 6.8. When it suspends payments under this section, BMS must submit to the MCO a list of the enrollees for whom payment is being suspended, the nature of service(s) denied, and payments BMS must make to provide Medically Necessary covered Contract services. When all payments have been made by BMS for the MCO Medically Necessary covered Contract services, BMS will reconcile the estimated suspension against actual enrollee payments. BMS may suspend MCO payments in accordance with 42 CFR §455.23 in case of a credible allegation of fraud against the MCO.

Payment Suspension. BMS may suspend portions of capitation payments from the MCO as a remedy for non- performance. Whenever BMS determines that the MCO has failed to provide one (1) or more of the Medically Necessary covered Contract services, BMS may suspend an estimated portion of the MCO’s capitation payment in subsequent months. Such suspension amount will be equal to the amount of money BMS expected the MCO to pay for Medically Necessary covered Contract services, plus any administrative costs involved. The MCO may not deny any Medically Necessary covered Contract services in order to receive adjusted payment levels. The MCO will be given written notice at least ten (10) business days prior to the suspension of any capitation payment in accordance with Article II, Section 6.8. When it suspends payments under this section, BMS must submit to the MCO a list of the enrollees for whom payment is being suspended, the nature of service(s) denied, and payments BMS must make to provide Medically Necessary covered Contract services. When all payments have been made by BMS for the MCO Medically Necessary covered Contract services, BMS will reconcile the estimated suspension against actual enrollee payments. BMS may suspend MCO payments in accordance with 42 CFR §455.23 in case of a credible allegation of fraud against the MCO.