Processing Requirements.
1. BCRC receives external files from a data sharing partner through a dedicated T-1 line (AT&T Global Network Services [AGNS]), HTTPS, or Secure File Transfer Protocol (SFTP).
2. The input files are checked to ensure they are in the correct format.
3. A check is performed to detect and bypass duplicate files.
4. Records are edited for required fields and data format.
5. Records received are matched to the exiting BCRC tables.
6. Transactions are created to add new records that were received, update existing records or delete records that were not received on the input file.
7. Transactions are sent to the Medicare Beneficiary Part D Database (MBD).
8. Results from MBD are used to create the response files.
9. Beneficiary Part D eligibility/enrollment information will be retrieved and added to the response files.
10. Response files are transmitted to the DSA partner.
Processing Requirements. You agree to submit only any transactions for processing which represent a bona fide, permissible transaction free of liens, claims, and encumbrances other than ordinary sales taxes; as outlined in this Agreement and in the Card Company Rules, or which accurately describes the product or services being sold or the charitable donations being made. You authorize PayPal to submit transactions to and receive settlement from American Express and to disclose transaction and merchant information to American Express to perform analytics and create reports, and for any other lawful business purposes, including commercial marketing communications purposes and important transactional or relationship communications. You also agree to ensure data quality and that any Data is processed promptly, accurately and completely, and complies with the Card Companies’ technical specifications. You agree not to process transactions or receive payments on behalf of any other party or redirect payments to any other party. You agree not to bill or collect from any cardholder for any purchase or payment on the card unless you have the right to do so under the Card Company Rules.
Processing Requirements. On the effective date, the Company will process Purchase Payments and requested transfers or withdrawals received in the Home Office in good order. Good order means complete and accurate instructions are provided by the Owner in accordance with the Company’s then current procedures. The Company also reserves the right to require a Contract Owner or other persons providing a signature in connection with a disbursement of proceeds or a change in ownership or beneficial rights under this Contract to provide a signature guarantee, unless expressly prohibited by applicable law, whenever required by the Company’s then-effective procedures.
Processing Requirements. The Claims Pricing function for the Fee for Service contracts the vendor has with providers of the MIS must have the capabilities to:
1. Calculate payment amounts according to the fee schedules, per diems, rates, formulas, and rules established by the Contractor.
2. Maintain access to pricing and reimbursement methodologies to appropriately price claims at the Contractor’s allowable amount.
3. Maintain flexibility to accommodate future changes and expanded implementation of co pays.
4. Deduct Member liability amounts from payment amounts as defined by the Department.
5. Deduct TPL amounts from payments amounts.
6. Provide adjustment processing capabilities.
Processing Requirements. The MIS must perform three types of financial processing: 1) payment processing; 2) adjustment processing;
Processing Requirements. The Provider Data Maintenance function must have the capabilities to:
1. Transmit a provider enrollment file to the Department in a specified format;
2. Maintain current and historical provider enrollment applications from receipt to final disposition (approval only);
3. Maintain on-line access to all current and historical provider information, including Provider rates and effective dates, Provider program and status codes, and summary payment data;
4. Maintain on-line access to Provider information with inquiry by Provider name, partial name characters, provider number, NPI, SSN, FEIN, CLIA number, Provider type and specialty, County, Zip Code, and electronic billing status;
5. Edit all update data for presence, format, and consistency with other data in the update transaction;
6. Edits to prevent duplicate Provider enrollment during an update transaction;
7. Accept and maintain the National Provider Identification (NPI);
8. Provide a Geographic Information System (GIS) to identify Member populations, service utilization, and corresponding Provider coverage to support the Provider recruitment, enrollment, and participation;
9. Maintain on-line audit trail of Provider names, Provider numbers (including old and new numbers, NPI), locations, and status changes by program;
10. Identify by Provider any applicable type code, NPI/TAXONOMY code, location code, practice type code, category of service code, and medical specialty and sub-specialty code which is used in the Kentucky Medicaid program, and which affects Provider billing, claim pricing, or other processing activities;
11. Maintain effective dates for Provider membership, Enrollment status, restriction and on-review data, certification(s), specialty, sub-specialty, claim types, and other user-specified Provider status codes and indicators;
12. Accept group provider numbers, and relate individual Providers to their groups, as well as a group to its individual member Providers, with effective date ranges/spans. A single group provider record must be able to identify an unlimited number of individuals who are associated with the group;
13. Maintain multiple, provider-specific reimbursement rates, including, but not necessarily limited to, per diems, case mix, rates based on licensed levels of care, specific provider agreements, volume purchase contracts, and capitation, with beginning and ending effective dates for a minimum of sixty (60) months.
14. Maintain provider-specific rates by program, type of cap...
Processing Requirements. The primary processes of Claims Operations Management are to maintain sufficient on-line claims information, provide on-line access to this information, and produce claims processing reports. The claims operations management function of the MIS must:
1. Maintain Claim history at the level of service line detail.
2. Maintain all adjudicated (paid and denied) claims history. Claims history must include at a minimum: All submitted diagnosis codes (including service line detail, if applicable); Line item procedure codes, including modifiers; Member ID and medical coverage group identifier; Billing, performing, referring, and attending provider Ids and corresponding provider types; All error codes associated with service line detail, if applicable; Billed, allowed, and paid amounts; TPL and Member liability amounts, if any; Prior Authorization number; Procedure, drug, or other service codes; Place of service; Date of service, date of entry, date of adjudication, date of payment, date of adjustment, if applicable.
3. Maintain non-claim-specific financial transactions as a logical component of Claims history.
4. Provide access to the adjudicated and Claims in process, showing service line detail and the edit/audits applied to the Claim.
5. Maintain accurate inventory control status on all Claims.
Processing Requirements. As a Data Processor, OpenAI agrees to:
a. process Customer Data only (i) on Customer’s behalf for the purpose of providing and supporting OpenAI’s Services (including to provide insights, reporting, analytics and platform abuse, trust and safety monitoring); (ii) in compliance with the written instructions received from Customer; and (iii) in a manner that provides no less than the level of privacy protection required of it by Data Protection Laws;
b. promptly inform Customer in writing if OpenAI cannot comply with the requirements of this DPA;
c. not provide Customer with remuneration in exchange for Customer Data from Customer. The parties acknowledge and agree that Customer has not “sold” (as such term is defined by the CCPA) Customer Data to OpenAI; d. not “sell” (as such term is defined by U.S. Privacy Laws) or “share” (as such term is defined by the CCPA) Personal Data;
e. inform Customer promptly if, in OpenAI’s opinion, an instruction from Customer violates applicable Data Protection Laws;
f. require (i) persons employed by it and (ii) other persons engaged to perform on OpenAI’s behalf to be subject to a duty of confidentiality with respect to the Customer Data and to comply with the data protection obligations applicable to OpenAI under the Agreement and this DPA;
g. engage the organizations or persons listed at xxxxx://xxxxxxxx.xxxxxx.xxx/subprocessors to process Customer Data (each a “Subprocessor,” and the list at the foregoing URL, the “Subprocessor List”) to help OpenAI satisfy its obligations in accordance with this DPA or to delegate all or part of the processing activities to such Subprocessors. Customer hereby consents to the use of such Subprocessors. If Customer subscribes to email notifications as provided on the Subprocessor List website, then OpenAI will notify Customer of any changes OpenAI intends to make to the Subprocessor List at least 15 days before the changes take effect (which may be via email, a posting, or notification on an online portal for our services or other reasonable means). In the event that Customer does not wish to consent to the use of such additional Subprocessor, Customer may notify OpenAI that Customer does not consent within fifteen (15) days on reasonable grounds relating to the protection of Customer Data by following the instructions set forth in the Subprocessor List or contacting xxxxxxx@xxxxxx.xxx. In such case, OpenAI shall have the right to cure the objection through one of the following options: (...
Processing Requirements. The Company will process requested transactions, payments, and changes under this Policy only after receipt in the Home Office of all requirements in good order according to the Company’s then current procedures. These requirements, which the Company may change from time to time, may include proper completion of forms, valid instructions and authorizations, or other administrative or evidentiary requirements of the Company. The Company reserves the right to require the Owner or other persons providing a signature in connection with a disbursement of any amounts under this Policy, or a change in ownership or beneficial rights under this Policy, to provide a signature guarantee to protect against fraud.
Processing Requirements. The Utilization/Quality Improvement function must include the following capabilities:
1. Maintain Provider credentialing and recredentialing activities.
2. Maintain Contractor’s processes to monitor and identify deviations in patterns of treatment from established standards or norms. Provide feedback information for monitoring progress toward goals, identifying optimal practices, and promoting continuous improvement.
3. Maintain development of cost and utilization data by Provider and services.
4. Provide aggregate performance and outcome measures using standardized quality indicators similar to Medicaid HEDIS as specified by the Department.
5. Support focused quality of care studies.
6. Support the management of referral/utilization control processes and procedures.
7. Monitor PCP referral patterns.
8. Support functions of reviewing access, use and coordination of services (i.e. actions of peer review and alert/flag for review and/or follow-up; laboratory, x-ray and other ancillary service utilization per visit).
9. Store and report Member satisfaction data through use of Member surveys, Grievance/Appeals processes, etc.
10. Provide Fraud, Waste and Abuse detection, monitoring and reporting.
