Reconciliation of Eligibility. In the event of a retroactive cancellation or addition of an HMO Member, FHS shall adjust Capitation accordingly. In the event Contracted Services are provided to an individual who is not a Member, based on an erroneous or delayed enrollment list or confirmation of enrollment of said individual by FHS, FHS shall be financially responsible for all such services provided by PPG prior to the time PPG received notice of that person’s ineligibility, except when the individual is enrolled in another health care service plan or insurance program from whom PPG or Participating Provider has or may receive capitation or other payment for the individual. In the event FHS is financially responsible, FHS shall pay PPG at the fee-for-service rates in Addendum E when PPG supplies FHS with evidence that it has unsuccessfully sought payment through two billing cycles for all or a portion of such charges from the patient, or the person having legal responsibility for the patient or the entity having financial responsibility for such payment. In the event FHS pays PPG pursuant to this Section, PPG shall have no further right and shall not attempt to collect any additional payment from the patient for said services and PPG shall be deemed to have transferred all legal rights of collection and Coordination of Benefits for services to FHS.
Reconciliation of Eligibility. When Provider is compensated on ------------------------------ a Capitation Compensation basis, Foundation shall provide Provider with a monthly list of Beneficiaries for whom Provider is responsible for rendering Provider Risk Services during such month. Foundation will use its best efforts to discourage retroactive cancellation or addition of Beneficiaries to a Benefit Program. However, in the event Foundation allows such adjustments, Foundation shall retroactively adjust Provider's Capitation Compensation as necessary, provided that the retroactive addition or cancellation period shall not exceed 90 days (except for Medicare Risk Benefit Programs, which have no such limits). In cases where a Beneficiary has utilized a non-participating hospital, and an appeal of the denial of such utilization by Foundation or Provider has been approved in favor of the Beneficiary by a governmental agency or its agent, after such 90 day period, Foundation may disenroll such Beneficiary and retroactively adjust Provider's Capitation Compensation accordingly. In the event of allowable retroactive additions, Provider agrees to be responsible for all Provider Risk Services rendered to the Beneficiary from the beginning of the retroactive period. In the event of retroactive cancellations, Provider may xxxx the Beneficiary for all Provider Risk Services received by the Beneficiary from the date such Beneficiary was no longer covered under the applicable Benefit Program.
Reconciliation of Eligibility. Notwithstanding the ------------------------------- provisions contained in Section 3.4 of the Agreement, Foundation shall assume financial responsibility for care provided to an ineligible person due to retroactivity or otherwise erroneous, incomplete or late Eligibility List data Such care shall be provided at the lesser of the amount which the Medicare program would have paid plus any applicable deductible or copayment, or the compensation contained in Exhibit 1 to Addendum B. However, Foundation shall only be responsible for such payment in the event that no other payor, including Medicare, Medi-Cal, or other HMO or insurance plan, or other individual is responsible for such care, and when Provider has used Provider's best efforts to verify and confirm eligibility from Foundation for any patient whose eligibility is or should have been in question, or who required institutional or other high cost care.
Reconciliation of Eligibility. When RPO is compensated on a Capitation Compensation basis, Texas HealthSpring shall provide RPO with a monthly list of Members for whom RPO is responsible for rendering RPO Risk Services during such month. Texas HealthSpring shall provide RPO with an electronic date file reporting such Members for whom RPO is responsible for rendering RPO Risk Services by the tenth (10th) day of each month. Texas HealthSpring will discourage retroactive cancellation or addition of Members to a Benefit Program. However, in the event Texas HealthSpring allows such adjustments, Texas HealthSpring shall retroactively adjust RPO's Capitation Compensation as necessary, provided that the retroactive addition or cancellation period shall not exceed ninety (90) days (except for Benefit Programs under the Medicare+Choice Programs, which have no such limits). In cases where a Member has utilized a non-Participating Provider, and an appeal of the denial of such utilization by Texas HealthSpring or RPO has been determined in favor of the Member by the applicable Government Agency or its agent, after such ninety (90) day period, Texas Health Spring may disenroll such Member and retroactively adjust RPO's Capitation Compensation accordingly. In the event of allowable retroactive additions, RPO agrees to be responsible for all RPO Risk Services rendered to the Member from beginning of the retroactive period. In the event of retroactive cancellations, RPO may bill the putative Member for all RPO Risk Services receivex xx the putative Member from the date such putative Member was no longer covered under the applicable Benefit Program.
Reconciliation of Eligibility. In the event Contracted Services are provided to an individual who is not a Member, based on an erroneous or delayed confirmation of enrollment of said individual by HNI, HNI shall be financially responsible for all such services provided by PROVIDER prior to the time PROVIDER received notice of that person's ineligibility, except when the individual is enrolled in another health care service plan, or insurance program from whom PROVIDER has or may receive capitation or other payment from the individual. In the event HNI is financially responsible, HNI shall pay PROVIDER at the fee-for-service rates in Addendum D when PROVIDER supplies HNI with evidence that it has unsuccessfully sought payment through two (2) billing cycles for all or a portion of such charges from the patient, or the person having legal responsibility for the patient or the entity having financial responsibility for such payment. In the event HNI pays PROVIDER pursuant to this Section, PROVIDER shall have no further right and shall not attempt to collect any additional payment from the patient for said services and Coram Healthcare Amendment II Effective October 1, 2003 PROVIDER shall be deemed to have transferred all legal rights of collection and Coordination of Benefits for services to HNI. When PROVIDER is compensated on a Capitation basis, HNI shall provide PROVIDER with a monthly list of Members for whom PROVIDER is responsible for rendering Provider Risk Services during such month. HNI will use its best efforts to discourage retroactive cancellation or addition of Members to a Benefit Program. However, in the event HNI allows such adjustments, HNI shall retroactively adjust PROVIDER's Capitation Compensation as necessary, provided that the retroactive addition or cancellation period shall not exceed ninety (90) days. In the event of allowable retroactive cancellations, PROVIDER agrees to bill the responsible party for all Provider Risk Sexxxxes received by the Members from the date such Member was no longer covered under the applicable Benefit Program.
