Common use of Payment Suspension Clause in Contracts

Payment Suspension. The Department may suspend portions of capitation payments from the MCO as a remedy for non-performance. Whenever the Department determines that the MCO has failed to provide one or more of the Medically Necessary covered Contract services, the Department 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 the Department 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 at least ten working days written notice prior to the suspension of any capitation payment in accordance with Section 6.8. When it suspends payments under this section, the Department must submit to the MCO a list of the members for whom payment is being suspended, the nature of service(s) denied, and payments the Department must make to provide Medically Necessary covered Contract services. When all payments have been made by the Department for the MCO Medically Necessary covered Contract services, the Department will reconcile the estimated suspension against actual member payments. The Department may suspend MCO payments in accordance with 42 CFR 455.23 in case of a credible allegation of fraud against the MCO.

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