Common use of Reimbursement/Claims/Rates Clause in Contracts

Reimbursement/Claims/Rates. (a) CMHSP shall reimburse Provider at the rates identified in Attachment B-1: Compensation Schedule (Non-Facility) or Attachment B-2: Compensation Schedule (Facility) for services rendered by Provider that have been authorized by CMHSP and or Administrator as the case may be. Actual payments are subject to Ability to Pay in accordance with Chapter 8 of the Mental Health Code and Chapter 8 of the Michigan Administrative Rules when applicable. (b) For claims payment, CMHSP shall adjudicate or arrange for adjudication and where appropriate make payment for Clean Claims for Covered Services submitted by Provider as follows: (1) 90% or higher for all Clean Claims from network subcontractors within Thirty (30) business days of receipt, and (2) at least 99% of all Clean Claims within Ninety (90) business days of receipt, except services rendered under a subcontract in which other timeliness standards have been specified and agreed upon by both parties (c) CMHSP and Provider shall be responsible for the coordination of public and private benefits for each Covered Person under this Agreement. Provider acknowledges that CMHSP is the payer of last resort. Provider shall be required to identify and seek recovery from all liable first and third parties. Third Party Liability refers to any health insurance or carrier, (e.g., individual, group, employer-related, self-insured, or self- funded plan or commercial carrier, automobile insurance and worker’s compensation) or program (e.g., Medicare) that has liability for all or part of a Covered Person’s covered benefit. (d) Provider may not xxxx Covered Person for the difference between Provider’s charges and CMHSP's or LRE’s rate for Services. Provider shall not seek nor accept additional supplemental payment from the Covered Person, his/her family, or representative in addition to the amount paid by CMHSP. Provider agrees not to maintain any action against a Covered Person to collect sums that are owed to Provider under the terms of this Agreement, even in the event CMHSP fails to pay, becomes insolvent, or otherwise breaches the terms and conditions of this Agreement. This section will survive the termination of this Agreement, regardless of the cause of termination and will be construed to be for the benefit of the Covered Person. (e) For services provided to all Medicaid/SUD Community Grant/PA2/General Fund beneficiaries, Provider’s maximum reimbursement (the sum of first Party, third Party, and CMHSP payments) shall not exceed the lesser of the third-Party payer’s maximum allowed amount, CMHSP’s or LRE’s contracted rate, or Provider’s reasonable and customary charge

Reimbursement/Claims/Rates. (a) CMHSP shall reimburse Provider at the rates identified in Attachment B-1: Compensation Schedule (Non-Facility) or Attachment B-2: Compensation Schedule (Facility) for services rendered by Provider that have been authorized by CMHSP and or Administrator as the case may be. Actual payments are subject to Ability to Pay in accordance with Chapter 8 of the Mental Health Code and Chapter 8 of the Michigan Administrative Rules when applicable. (b) For claims payment, CMHSP shall adjudicate or arrange for adjudication and where appropriate make payment for Clean Claims for Covered Services submitted by Provider as follows: (1) 90% or higher for all Clean Claims from network subcontractors within Thirty (30) business days of receipt, and (2) at least 99% of all Clean Claims within Ninety (90) business days of receipt, except services rendered under a subcontract in which other timeliness standards have been specified and agreed upon by both parties (c) CMHSP and Provider shall be responsible for the coordination of public and private benefits for each Covered Person under this Agreement. Provider acknowledges that CMHSP is the payer of last resort. Provider shall be required to identify and seek recovery from all liable first and third parties. Third Party Liability refers to any health insurance or carrier, (e.g., individual, group, employer-related, self-insured, or self- self-funded plan or commercial carrier, automobile insurance and worker’s compensation) or program (e.g., Medicare) that has liability for all or part of a Covered Person’s covered benefit. (d) Provider may not xxxx Covered Person for the difference between Provider’s charges and CMHSP's or LRE’s rate for Services. Provider shall not seek nor accept additional supplemental payment from the Covered Person, his/her family, or representative in addition to the amount paid by CMHSP. Provider agrees not to maintain any action against a Covered Person to collect sums that are owed to Provider under the terms of this Agreement, even in the event CMHSP fails to pay, becomes insolvent, or otherwise breaches the terms and conditions of this Agreement. This section will survive the termination of this Agreement, regardless of the cause of termination and will be construed to be for the benefit of the Covered Person. (e) For services provided to all Medicaid/SUD Community Grant/PA2/General Fund beneficiaries, Provider’s maximum reimbursement (the sum of first Party, third Party, and CMHSP payments) shall not exceed the lesser of the third-Party payer’s maximum allowed amount, CMHSP’s or LRE’s contracted rate, or Provider’s reasonable and customary charge

Reimbursement/Claims/Rates. (a) A. CMHSP shall reimburse Provider at the rates identified in Attachment B-1B: Compensation Schedule (Non-Facility) or Attachment B-2: Compensation Schedule (Facility) for services rendered by Provider that have been authorized by CMHSP and or Administrator as the case may be. Actual payments are subject to Ability to Pay in accordance with Chapter 8 of the Mental Health Code and Chapter 8 of the Michigan Administrative Rules when applicable. (b) B. For claims payment, CMHSP shall adjudicate or arrange for adjudication and where appropriate make payment for Clean Claims for Covered Services submitted by Provider as follows: (1) Ninety percent (90% %) or higher for all Clean Claims from network subcontractors within Thirty thirty (30) business days of receipt, and (2) at At least ninety-nine (99% %) of all Clean Claims within Ninety ninety (90) business days of receipt, except services rendered under a subcontract in which other timeliness standards have been specified and agreed upon by both parties. (c) C. CMHSP and Provider shall be responsible for the coordination of public and private benefits for each Covered Person under this Agreement. Provider acknowledges that CMHSP is the payer of last resort. Provider shall be required to identify and seek recovery from all liable first and third parties, except where Provider is furnishing Certified Community Behavioral Health Clinic (CCBHC) services as a Designated Collaborating Organization under the requirements of a CCBHC. Third Party Liability refers to any health insurance or carrier, (e.g., individual, group, employer-related, self-self- insured, or self- self-funded plan or commercial carrier, automobile insurance and worker’s compensation) or program (e.g., Medicare) that has liability for all or part of a Covered Person’s covered benefit. (d) D. In cases where Medicaid funds are used, Provider may not xxxx Covered Person for the difference between Provider’s charges and CMHSP's or LRE’s rate for Services. Provider shall not Services nor seek nor accept additional supplemental payment from the Covered Person, his/her family, or representative in addition to the amount paid by CMHSP. . E. In cases where non-Medicaid funds are used exclusively, Provider may not xxxx Covered Person for the difference between Provider’s charges and CMHSP's or LRE’s rate for Services nor seek nor accept additional supplemental payment from the Covered Person, his/her family, or representative in addition to the amount paid by CMHSP, without prior written authorization from CMHSP. F. Provider agrees not to maintain any action against a Covered Person to collect sums that are owed to Provider under the terms of this Agreement, even in the event CMHSP fails to pay, becomes insolvent, or otherwise breaches the terms and conditions of this Agreement. This section will survive the termination of this Agreement, regardless of the cause of termination and will be construed to be for the benefit of the Covered Person. (e) G. For services provided to all Medicaid/SUD Community Grant/PA2/General Fund beneficiaries, Provider’s maximum reimbursement (the sum of first Party, third Party, and CMHSP payments) shall not exceed the lesser of the third-Party payer’s maximum allowed amount, CMHSP’s or LRE’s contracted rate, or Provider’s reasonable and customary charge.

Reimbursement/Claims/Rates. (a) CMHSP shall reimburse Provider at the rates identified in Attachment B-1B: Compensation Schedule (Non-Facility) or Attachment B-2: Compensation Schedule (Facility) for services rendered by Provider that have been authorized by CMHSP and or Administrator as the case may be. Actual payments are subject to Ability to Pay in accordance with Chapter 8 of the Mental Health Code and Chapter 8 of the Michigan Administrative Rules when applicable. (b) For claims payment, CMHSP shall adjudicate or arrange for adjudication and where appropriate make payment for Clean Claims for Covered Services submitted by Provider as follows: (1) 90% or higher for all Clean Claims from network subcontractors within Thirty thirty (30) business days of receipt, and (2) at At least 99% of all Clean Claims within Ninety ninety (90) business days of receipt, except services rendered under a subcontract in which other timeliness standards have been specified and agreed upon by both parties. (c) CMHSP and Provider shall be responsible for the coordination of public and private benefits for each Covered Person under this Agreement. Provider acknowledges that CMHSP is the payer of last resort. Provider shall be required to identify and seek recovery from all liable first and third parties, except where Provider is furnishing Certified Community Behavioral Health Clinic (CCBHC) services as a Designated Collaborating Organization under the requirements of a CCBHC. Third Party Liability refers to any health insurance or carrier, (e.g., individual, group, employer-related, self-insured, or self- funded plan or commercial carrier, automobile insurance and worker’s compensation) or program (e.g., Medicare) that has liability for all or part of a Covered Person’s covered benefit. (d) In cases where Medicaid funds are used, Provider may not xxxx Covered Person for the difference between Provider’s charges and CMHSP's or LRE’s rate for Services. Provider shall not Services nor seek nor accept additional supplemental payment from the Covered Person, his/her family, or representative in addition to the amount paid by CMHSP. . (e) In cases where non-Medicaid funds are used exclusively, Provider may not xxxx Covered Person for the difference between Provider’s charges and CMHSP's or LRE’s rate for Services nor seek nor accept additional supplemental payment from the Covered Person, his/her family, or representative in addition to the amount paid by CMHSP, without prior written authorization from CMHSP. (f) Provider agrees not to maintain any action against a Covered Person to collect sums that are owed to Provider under the terms of this Agreement, even in the event CMHSP fails to pay, becomes insolvent, or otherwise breaches the terms and conditions of this Agreement. This section will survive the termination of this Agreement, regardless of the cause of termination and will be construed to be for the benefit of the Covered Person.fails (eg) For services provided to all Medicaid/SUD Community Grant/PA2/General Fund beneficiaries, Provider’s maximum reimbursement (the sum of first Party, third Party, and CMHSP payments) shall not exceed the lesser of the third-Party payer’s maximum allowed amount, CMHSP’s or LRE’s contracted rate, or Provider’s reasonable and customary charge.