Common use of Processing of Claims Clause in Contracts

Processing of Claims. We agree to make reasonable efforts to process all claims for benefits for services and/or supplies provided to State Health Plan Members submitted by you, within thirty (30) days of our receipt of all necessary information. Except for retroactive adjustments to eligibility records pursuant to Section 4.6, we agree that we will not retroactively deny payment of properly submitted claims that have been pre-authorized through our utilization management processes, so long as our authorization was not based on a material misrepresentation knowingly provided by you, a State Health Plan Member, or other provider. Further, we represent that we have established billing, claim submission, and claim processing procedures to comply with the provisions of N.C.G.S. § 58-3-225, entitled “Prompt Claim Payments Under Health Benefit Plans.” You acknowledge and agree not to hold claims for processing by us at a later date unless specifically directed to do so by us.

Processing of Claims. We agree to make reasonable efforts to process all claims for benefits for services and/or supplies provided to State Health Plan Members submitted by you, within thirty (30) days of our receipt of all necessary information. Except for retroactive adjustments to eligibility records pursuant to Section 4.6, we agree that we will not retroactively deny payment of properly submitted claims that have been pre-authorized through our utilization management processes, so long as our authorization was not based on a material misrepresentation knowingly provided by you, a State Health Plan Member, or other provider. Further, we represent that we have established billing, claim submission, and claim processing procedures to comply with the provisions of N.C.G.S. § 58-3-3- 225, entitled “Prompt Claim Payments Under Health Benefit Plans.” You acknowledge and agree not to hold claims for processing by us at a later date unless specifically directed to do so by us.