Provider Billing Sample Clauses

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.
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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.
Sample 1Sample 2
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.
Sample 1

Related to Provider Billing

  • Provider Network The Panel of health service Providers with which the Contractor contracts for the provision of covered services to Members and Out-of-network Providers administering services to Members.

  • Provider Services Charges for the following Services when ordered by a Physician for the treatment of an Injury or Illness.

  • Provider If the Provider is a State Agency, the Provider acknowledges that it is responsible for its own acts and deeds and the acts and deeds of its agents and employees. If the Provider is not a State agency, then the Provider agrees to indemnify and save harmless the State and its officers and employees from all claims and liability due to activities of itself, its agents, or employees, performed under this contract and which are caused by or result from error, omission, or negligent act of the Provider or of any person employed by the Provider. The Provider shall also indemnify and save harmless the State from any and all expense, including, but not limited to, attorney fees which may be incurred by the State in litigation or otherwise resisting said claim or liabilities which may be imposed on the State as a result of such activities by the Provider or its employees. The Provider further agrees to indemnify and save harmless the State from and against all claims, demands, and causes of action of every kind and character brought by any employee of the Provider against the State due to personal injuries and/or death to such employee resulting from any alleged negligent act by either commission or omission on the part of the Provider.

  • Providers Services performed by a provider who has been excluded or debarred from participation in federal programs, such as Medicare and Medicaid. To determine whether a provider has been excluded from a federal program, visit the U.S. Department of Human Services Office of Inspector General website (xxxxx://xxxxxxxxxx.xxx.xxx.xxx/) or the Excluded Parties List System website maintained by the U.S. General Services Administration (xxxxx://xxx.xxx.gov/). • Services provided by facilities, dentists, physicians, surgeons, or other providers who are not legally qualified or licensed, according to relevant sections of Rhode Island Law or other governing bodies, or who have not met our credentialing requirements. • Services provided by a non-network provider, unless listed as covered in the Summary of Medical Benefits. • Services provided by naturopaths, homeopaths, or Christian Science practitioners.

  • Subcontracting for Medicaid Services Notwithstanding any permitted subcontracting of services to be performed under this Agreement, Party shall remain responsible for ensuring that this Agreement is fully performed according to its terms, that subcontractor remains in compliance with the terms hereof, and that subcontractor complies with all state and federal laws and regulations relating to the Medicaid program in Vermont. Subcontracts, and any service provider agreements entered into by Party in connection with the performance of this Agreement, must clearly specify in writing the responsibilities of the subcontractor or other service provider and Party must retain the authority to revoke its subcontract or service provider agreement or to impose other sanctions if the performance of the subcontractor or service provider is inadequate or if its performance deviates from any requirement of this Agreement. Party shall make available on request all contracts, subcontracts and service provider agreements between the Party, subcontractors and other service providers to the Agency of Human Services and any of its departments as well as to the Center for Medicare and Medicaid Services.

  • Billing Unless otherwise provided in the Grant Agreement, Grantee shall bill the System Agency in accordance with the Grant Agreement. Unless otherwise specified in the Grant Agreement, Grantee shall submit requests for reimbursement or payment monthly by the last business day of the month following the month in which expenses were incurred or services provided. Grantee shall maintain all documentation that substantiates invoices and make the documentation available to the System Agency upon request.

  • Medicaid If and when the Resident’s assets/funds have fallen below the Medicaid eligibility levels, and the Resident otherwise satisfies the Medicaid eligibility requirements and is not entitled to any other third party coverage, the Resident may be eligible for Medicaid (often referred to as the “payor of last resort”). THE RESIDENT, RESIDENT REPRESENTATIVE AND SPONSOR AGREE TO NOTIFY THE FACILITY AT LEAST THREE (3) MONTHS PRIOR TO THE EXHAUSTION OF THE RESIDENT’S FUNDS (APPROXIMATELY $50,000) AND/OR INSURANCE COVERAGE TO CONFIRM THAT A MEDICAID APPLICATION HAS OR WILL BE SUBMITTED TIMELY AND ENSURE THAT ALL ELIGIBILITY REQUIREMENTS HAVE BEEN MET. THE RESIDENT, RESIDENT REPRESENTATIVE AND/OR SPONSOR AGREE TO PREPARE AND FILE AN APPLICATION FOR MEDICAID BENEFITS PRIOR TO THE

  • Prices and Services Billing 8.1 SCHEDULE OF PRICES AND TERMS Competitive Supplier agrees to provide Firm Full-Requirements Power Supply and other related services as expressly set forth herein in accordance with the prices and terms included in EXHIBIT A to this ESA, which exhibit is hereby incorporated by reference into this ESA.

  • OGS Centralized Contract Terms and Conditions have been renumbered as depicted in the following chart: Current Amended Section Title 4.25 4.26 Severability 4.26 4.27 Entire Agreement

  • Provider Directory a. The Contractor shall make available in electronic form and, upon request, in paper form, the following information about its network providers: i. The provider’s name as well as any group affiliation; ii. Street address(es); iii. Telephone number(s); iv. Website URL, as appropriate; v. Specialty, as appropriate; vi. Whether the provider will accept new beneficiaries; vii. The provider’s cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or a skilled medical interpreter at the provider’s office, and whether the provider has completed cultural competence training; and viii. Whether the provider’s office/facility has accommodations for people with physical disabilities, including offices, exam room(s) and equipment. b. The Contractor shall include the following provider types covered under this Agreement in the provider directory: i. Physicians, including specialists ii. Hospitals

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