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.
Appears in 4 contracts
Samples: Medicaid Managed Care Contract, Medicaid Managed Care Contract, Medicaid Managed Care Contract
Processing Requirements. The Claims Pricing function for the those Fee for 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. 7.
Appears in 1 contract
Samples: Managed Care Contract (Wellcare Health Plans, Inc.)