Prohibit Billing Member Sample Clauses

Prohibit Billing Member. Except as expressly provided in this Agreement in addition to the exception of cost sharing pursuant to the Hawaii Medicaid State Plan, Provider (and any Subcontractors) shall look solely to the responsible Payor for compensation for Covered Services rendered to Medicaid/QUEST Integration Members, and Provider agrees that in no event (including non-payment by Payor, insolvency of Payor or breach of the Agreement) shall Provider (or Subcontractor) bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against any Member, person acting on the Member’s behalf, Official, State or any Medicaid plans, for Covered Services provided under the Agreement. Without limiting the foregoing, Provider shall not seek payment from Members for reasons including (i) amounts denied by Payor because billed charges were not customary or reasonable, (ii) Provider’s failure to obtain Authorization for Services delivered, (iii) clinical data that was not submitted promptly, or (iv) Provider’s failure to submit a Claim in accordance with the appropriate billing procedures or within the appropriate time frame, or in accordance with commonly accepted standard coding practices. • • The provider will comply with all requirements regarding when billing a member or assessing charges is allowable, as described below: • • Health Plan may collect fees directly from members for non-covered services or for services from unauthorized non-health plan providers. • Health Plan may deny payment to the provider when a member self-refers to a specialist or other provider without following the Health Plan’s prior authorization procedures. • Health Plan has described the process for the provider on how to bill a member when non- covered or unauthorized services are provided as described below: ✓ If a member self-refers to a specialist or other provider within the network without following the Health Plan’s prior authorization procedures and the Health Plan does deny payment to the provider, the provider may bill the member if the provider provided the member with an Advance Beneficiary Notice of non-coverage; ✓ If a provider fails to follow Health Plan procedures which results in nonpayment, the provider may not bill the member; and • If a provider bills the member for non-covered services or for self-referrals, he or she shall inform the member and obtain prior agreement from the member regarding the cost of the procedure and the payment terms...