Provider Billing. This agreement between you and us may prohibit you from billing an enrollee for unnecessary care if a physician or practitioner panel has determined the care was unnecessary. However, you shall not be required to pay hospital, institutional, laboratory, x-ray or like charges resulting from the provision of services lawfully ordered by you, even though such service may be determined to be unnecessary.
Provider Billing. This Agreement prohibits Provider from billing the Customer for unnecessary care if a physician or practitioner panel has determined the care was unnecessary. However, Provider shall not be required to pay hospital, institutional, laboratory, x-ray or like charges resulting from the provision of services lawfully ordered by Provider, even though such service may be determined to be unnecessary.
Provider Billing. Errors Claims Administrator’s post-payment editing programs and investigators and auditors perform additional screens and tests where billing information is inconsistent with age/services rendered or where there appears to be up-coding or unbundling of services. A recovery Post Payment Recovery Category Explanation of Services process is then employed to request and recover verified overpayments. Credit Balance This service requires an on-site review of the provider’s financial records and discussions with their staff. Credit balances are verified as owed to Plan Sponsor and the source of the credit is determined. The credit is reviewed with the provider and approved for payment back to Claims Administrator or the Plan Sponsor. Hospital Billing and Chart Review This service requires an on-site review of the Member’s medical charts and interviews with provider staff by registered nurses. Calypso out- sources the on-site review work to an independent vendor who ensures that: • Service is consistent with diagnosis and billing is consistent with services. • There has been no unbundling of services, diagnosis up-coding or billing maximization. • Services rendered were prescribed by the physician and the doctor’s notes were signed. • Standardized billing and payment policies were used. Calypso provides support for this vendor’s efforts as well as processes all recoveries.
Provider Billing. Errors Claims Administrator’s post-payment editing programs and investigators and auditors perform additional screens and tests where billing information is inconsistent with age/services rendered or where there appears to be up-coding or unbundling of services. A recovery Post Payment Recovery Category Explanation of Services process is then employed to request and recover verified overpayments. Credit Balance This service requires an on-site review of the provider’s financial records and discussions with their staff. Credit balances are verified as owed to Plan Sponsor and the source of the credit is determined. The credit is reviewed with the provider and approved for payment back to Claims Administrator or the Plan Sponsor. Hospital Billing and Chart Review This service requires an on-site review of the Member’s medical charts and interviews with provider staff by registered nurses. Calypso out- sources the on-site review work to an independent vendor who ensures that: • Service is consistent with diagnosis and billing is consistent with services. • There has been no unbundling of services, diagnosis up-coding or billing maximization. • Services rendered were prescribed by the physician and the doctor’s notes were signed. • Standardized billing and payment policies were used. Xxxxxxx provides support for this vendor’s efforts as well as processes all recoveries.
