Common use of Provider Refunds Of Claims Covered By Other Payments Clause in Contracts

Provider Refunds Of Claims Covered By Other Payments. 5 1. If CONTRACTOR, through its own efforts, identifies Medi-Cal coverage, third party 6 settlement, primary or other insurance coverage for services reimbursed through the Agreement, 7 CONTRACTOR shall, within thirty (30) calendar days of such identification, unless disputed in 8 accordance with subparagraph G.2. below, reimburse the Intermediary an amount equal to the MSN 9 payment. If Medi-Cal coverage, third party settlement, primary or other insurance coverage is identified 10 due to efforts of Intermediary’s Third Party Recovery Services (Recovery Services) specified in 11 subparagraph G.4. below, CONTRACTOR shall, within thirty (30) calendar days of notice from 12 Recovery Services, unless disputed in accordance with subparagraph G.2. below, reimburse the 13 Intermediary an amount equal to the MSN payment. Third-party settlement payments may be paid 14 directly to COUNTY or Intermediary, as directed by ADMINISTRATOR. 15 2. Should CONTRACTOR wish to dispute the reimbursement of a MSN payment as a result 16 of the identification of Medi-Cal coverage, third party settlement, primary or other insurance coverage 17 either by CONTRACTOR or through Recovery Services, CONTRACTOR shall give written notice, 18 within thirty (30) calendar days of notice of information, to ADMINISTRATOR’s MSN Program 19 Administrator or designee (MSN Administrator) setting forth in specific terms the existence and nature 20 of any dispute or concern related to the information provided through Recovery Services or the 21 reimbursement due MSN. MSN Administrator shall have fifteen (15) business days following such 22 notice to obtain resolution of any issue(s) identified in this manner, provided, however, by mutual 23 consent this period of time may be extended. If MSN Administrator determines that the recovery 24 information is accurate and appropriate, CONTRACTOR shall, within thirty (30) calendar days of 25 receipt, reimburse an amount equal to the MSN payment. 26 3. For purposes of computing the amount of reimbursement due from CONTRACTOR, after 27 Final Settlement, the services provided an Enrollee shall be valued at the percentage of reimbursement 28 for the applicable contract period, less any co-payments or other fees. 29 4. COUNTY has contracted for Third Party Recovery Services (Recovery Services) for the 30 purpose of actively pursuing reimbursement of claims paid for MSN Enrollees later determined to be 31 eligible for Medi-Cal or third party, primary or other insurance. CONTRACTOR shall reasonably 32 cooperate in recovering these costs. 33 5. If any reimbursement due is not paid by CONTRACTOR in accordance with subparagraphs 34 G.1., G.2., or G.4. above, the Intermediary shall reduce any payment due CONTRACTOR by an amount 35 not to exceed the amount to be reimbursed. 36 // 37 //

Provider Refunds Of Claims Covered By Other Payments. 5 10 1. If CONTRACTORCLINICCONTRACTOR, through its own efforts, identifies Medi-Cal coverage, third 11 party 6 settlement, primary or other insurance coverage for services reimbursed through the Agreement, 7 CONTRACTOR 12 CLINICCONTRACTOR shall, within thirty (30) calendar days of such identification, unless disputed in 8 13 accordance with 14 subparagraph G.2. below, reimburse the Intermediary an amount equal to the MSN 9 MSIMSN payment. If 15 Medi-Cal coverage, third party settlement, primary or other insurance coverage is identified 10 due to 16 efforts of Intermediary’s Third Party Recovery Services (Recovery Services) specified in 11 subparagraph G.4. below, CONTRACTOR shall, within thirty (30) calendar days of notice from 12 Recovery 18 Services, unless disputed in accordance with subparagraph G.2. below, reimburse the 13 Intermediary an 19 amount equal to the MSN MSIMSN payment. Third-party settlement payments may be paid 14 directly to 20 COUNTY or Intermediary, as directed by ADMINISTRATOR. 15 21 2. Should CONTRACTOR CLINICCONTRACTOR wish to dispute the reimbursement of a MSIa MSN payment 22 as a result 16 of the identification of Medi-Cal coverage, third party settlement, primary or other insurance 23 coverage 17 either by CONTRACTOR CLINICCONTRACTOR or through Recovery Services, CONTRACTOR CLINICCONTRACTOR 24 shall give written notice, 18 within thirty (30) calendar days of notice of information, to 25 ADMINISTRATOR’s MSN MSIMSN Program 19 Administrator Manager (MSI ManagerAdministrator or designee (MSN 26 Administrator) setting forth in specific terms the existence and nature 20 of any dispute or concern related 27 to the information provided through Recovery Services or the 21 reimbursement due MSNMSI. MSI 28 ManagerMSN. MSN Administrator shall have fifteen (15) business workingbusiness days following such 22 notice 29 to obtain resolution of any issue(s) identified in this manner, provided, however, by mutual 23 consent this 30 period of time may be extended. If MSN MSI ManagerMSN Administrator determines that the recovery 24 31 information is accurate and appropriate, CONTRACTOR CLINICCONTRACTOR shall, within thirty (30) calendar days 32 of 25 receipt, reimburse an amount equal to the MSN MSIMSN payment. 26 3. For purposes of computing the amount of reimbursement due from CONTRACTOR, after 27 Final Settlement, the services provided an Enrollee shall be valued at the percentage of reimbursement 28 for the applicable contract period, less any co-payments or other fees. 29 4. COUNTY has contracted for Third Party Recovery Services (Recovery Services) for the 30 purpose of actively pursuing reimbursement of claims paid for MSN Enrollees later determined to be 31 eligible for Medi-Cal or third party, primary or other insurance. CONTRACTOR shall reasonably 32 cooperate in recovering these costs. 33 5. If any reimbursement due is not paid by CONTRACTOR in accordance with subparagraphs 34 G.1., G.2., or G.4. above, the Intermediary shall reduce any payment due CONTRACTOR by an amount 35 not to exceed the amount to be reimbursed. 36 // 37 //

Provider Refunds Of Claims Covered By Other Payments. 5 8 1. If CONTRACTOR, through its own efforts, identifies Medi-Cal coverage, third party 6 9 settlement, primary or other insurance coverage for services reimbursed through the Agreement, 7 10 CONTRACTOR shall, within thirty (30) calendar days of such identification, unless disputed in 8 11 accordance with subparagraph G.2. below, reimburse the Intermediary an amount equal to the MSN 9 12 payment. If Medi-Cal coverage, third party settlement, primary or other insurance coverage is identified 10 13 due to efforts of Intermediary’s Third Party Recovery Services (Recovery Services) specified in 11 14 subparagraph G.4. below, CONTRACTOR shall, within thirty (30) calendar days of notice from 12 15 Recovery Services, unless disputed in accordance with subparagraph G.2. below, reimburse the 13 16 Intermediary an amount equal to the MSN payment. Third-party settlement payments may be paid 14 17 directly to COUNTY or Intermediary, as directed by ADMINISTRATOR. 15 18 2. Should CONTRACTOR wish to dispute the reimbursement of a MSN payment as a result 16 of 19 the identification of Medi-Cal coverage, third party settlement, primary or other insurance coverage 17 20 either by CONTRACTOR or through Recovery Services, CONTRACTOR shall give written notice, 18 21 within thirty (30) calendar days of notice of information, to ADMINISTRATOR’s MSN Program 19 Administrator 22 Administrator, or designee (MSN Administrator) setting forth in specific terms the existence and nature 20 23 of any dispute or concern related to the information provided through Recovery Services or the 21 24 reimbursement due MSN. MSN Administrator shall have fifteen (15) business days following such 22 25 notice to obtain resolution of any issue(s) identified in this manner, provided, however, by mutual 23 26 consent this period of time may be extended. If MSN Administrator determines that the recovery 24 27 information is accurate and appropriate, CONTRACTOR shall, within thirty (30) calendar days of 25 28 receipt, reimburse an amount equal to the MSN payment. 26 29 3. For purposes of computing the amount of reimbursement due from CONTRACTOR, after 27 30 Final Settlement, the services provided an Enrollee shall be valued at the percentage of reimbursement 28 31 for the applicable contract period, less any co-payments or other fees. 29 32 4. COUNTY has contracted for Third Party Recovery Services (Recovery Services) for the 30 33 purpose of actively pursuing reimbursement of claims paid for MSN Enrollees later determined to be 31 34 eligible for Medi-Cal or third party, primary or other insurance. CONTRACTOR shall reasonably 32 35 cooperate in recovering these costs.. 36 // 37 // 33 1 5. If any reimbursement due is not paid by CONTRACTOR in accordance with subparagraphs 34 2 G.1., G.2., or G.4. above, the Intermediary shall reduce any payment due CONTRACTOR by an amount 35 3 not to exceed the amount to be reimbursed. 36 // 37 //4