Provider Reimbursement Sample Clauses

Provider Reimbursement. The MCO must pay for all Medically Necessary Covered Services provided to all Members for whom the MCO is paid a capitation. A STAR+PLUS MCO must also pay for all Functionally Necessary Covered Services provided to all Members for whom the MCO is paid a capitation. The MCO must ensure that claims payment is timely and accurate as described in Section 8.1.

Provider Reimbursement. The Department may define an alternative payment methodology to which Contractor must adhere to when reimbursing Providers for provided services. 5.7.7.1 For all FQHCs and RHCs that elect to use the Department’s alternative payment methodology, Contractor shall pay contracted FQHCs and RHCs at least the Department’s full cost‐based per‐ visit rate for Covered Services. 5.7.7.2 Provider agreements shall require that Network Providers submit benefit expense claim data, as defined in 7.11.6.2, for all Covered Services provided to Enrollees.

Provider Reimbursement. The MCO must pay for all Medically Necessary Covered Services provided to Members. A STAR+PLUS MCO must also pay for all Functionally Necessary Covered Services provided to Members. The MCO's Network Provider Agreement must include a complete description of the payment methodology or amount, as described in Uniform Managed Care Manual Chapter 8. 1. The MCO must ensure claims payment is timely and accurate as described in Section 8.1.18.5, "Claims Processing Requirements," and UMCM Chapters 2.0 through 2. 2. The MCO must require tax identification numbers from all participating Providers. The MCO is required to do back-up withholding from all payments to Providers who fail to give tax identification numbers or who give incorrect numbers. Provider payments must comply with all applicable state and federal laws, rules, and regulations, including the following sections of the Patient Protection and Affordable Care Act (PPACA) and, upon implementation, corresponding federal regulations: • Section 2702 of PPACA, entitled "Payment Adjustment for Health Care-Acquired Conditions;" • Section 6505 of PPACA, entitled "Prohibition on Payments to Institutions or Entities Located Outside of the United States;" and • Section 1202 of the Health Care and Education Reconciliation Act as amended by PPACA, entitled "Payments to Primary Care Physicians." As required by Texas Government Code § 533.005(a)(25), the MCO cannot implement across-the-board Provider reimbursement rate reductions unless: (1) it receives HHSC's prior approval, or (2) the reductions are based on changes to the Medicaid fee schedule or cost containment initiatives implemented by HHSC. For purposes of this requirement an across-the-board rate reduction is a reduction that applies to all similarly-situated providers or types of providers. The MCO must submit a request for an across-the-board rate reduction to HHSC's Director of Program Operations, if the reduction is not based on a change in the Medicaid fee schedule or cost containment initiative implemented by HHSC. The MCO must submit the request at least 90 days prior to the planned effective date of the reduction, and provide a copy to the Health Plan Manager. If HHSC does not issue a written statement of disapproval within 45 days of receipt, then the MCO may move forward with the reduction on the planned effective date.

Provider Reimbursement. 1. For the term of this Contract, the Program Administrator, pursuant to its agreement with Governing Board, shall reimburse providers at rates determined by Governing Board. Governing Board shall establish a Provider Rates Policy that sets forth the basis for provider payment rates which is subject to revision from time to time as determined by Governing Board. 2. The Program Administrator, pursuant to its agreement with Governing Board, shall use its reasonable best efforts to reimburse providers on a timely basis. 3. Reimbursement to providers made in error may be recovered by the Program Administrator, on behalf of Governing Board, or Governing Board or its designee.

Provider Reimbursement. Although not in the Agreement, BCBS stated in its March 2008 Aware Pro- vider Service Agreement Renewal letter that there will be three changes relating to reimbursement: 1) BCBS will use of the 2008 Medicare Relative Value Units (RVUs) in place of using the 2007 ▇▇▇▇- sitional Fully Implemented RVUs; 2) Unlisted Injectable Drugs will be paid at 82% of AWP (Average Wholesale Price); and 3) BCBS will be applying a site of service differential payment starting July 1, 2009.

Provider Reimbursement. 10.1 Applicants who are approved for HPE may receive medical services from any registered AHCCCS provider. 10.2 Hospitals or other registered Medicaid providers that provide medical care to HPE eligible applicants must submit claims to the AHCCCS Administration and will be reimbursed on a fee-for- service basis at the current AHCCCS rates for services rendered during the HPE period. 10.3 Applicants made presumptively eligible will be enrolled as AHCCCS Fee-for-Service members. 10.4 Hospitals may not charge applicants to apply for HPE or for assisting them with the submission of a full Medicaid/AHCCCS application. 10.5 AHCCCS will not reimburse the Hospital for completing a HPE determination or for submitting a full Medicaid application.

Provider Reimbursement. 1. The SE shall be responsible for reimbursing network and non-network providers in accordance with the requirements of this Contract (see Article 3.18 and Article 2. Except as otherwise provided in this Contract (see Article 6.15), for Medicaid services the SE shall negotiate the reimbursement methodology and rate with providers. The methodology may include but is not limited to fee-for-service, case rates, or subcapitation. If the SE changes an existing reimbursement methodology or rate, it shall take steps to transition the provider to the new methodology/rate and prevent adverse financial consequences to the provider. 3. For non-Medicaid services (to both Medicaid and non-Medicaid consumers), the SE shall use the providers and reimbursement methodology and rate specified by the Collaborative. 4. Regardless of a provider’s reimbursement methodology, the SE shall ensure that it receives required reports and data (e.g., encounter data) from network providers. 5. The SE shall develop and implement a plan, approved by the Collaborative, for moving toward a uniform system of service rates across Collaborative funding streams, specifically utilizing the Collaborative common service definitions. a. The plan shall be presented to the Collaborative for approval no later than that the date specified by the Collaborative. b. The SE shall work with Collaborative staff, as appropriate, in the implementation of its plan. c. The SE shall present any substantive changes to its plan to the Collaborative for review and approval prior to making those changes. d. The SE shall include in its plan: i. The changes it will need to make to its fiscal and claims payment systems to implement its plan; ii. How it will give providers the support and training that may be necessary in making the transition to the system; iii. How it will minimize impact on providers where more uniformity will result in a lower reimbursement rate for a particular provider, provider type, or geographic area; specifically, how it will phase in rate changes that will likely lower a high-volume or specialty provider’s overall revenue by more than ten percent (10%) in any six (6) month period; and iv. How its uniform rate structure will assist access in rural and frontier areas. e. The SE shall make progress toward the goals of more uniform rates through the implementation of this plan and shall submit a semi-annual report to the Collaborative on its progress. 6. The SE shall evaluate administrative costs ...

Provider Reimbursement