Responsibility of Health Care Facility Sample Clauses

Responsibility of Health Care Facility. With respect to hospital or other health care facility contracts, and in accordance with N.J.A.C. 11:24-15.2(d)1 – 4, it is the responsibility of the health care facility (hospital) to follow clear procedures when granting and attending privileges to physicians; notification must be provided by the Health Plan when such procedures are no longer appropriate. The admissions procedures for members will be done in accordance with New Jersey law as detailed below. The health care facility (hospital) agrees to admit Members to hospital: (i) upon orders of a participating Physician; or (ii) in the case of a Member requiring Emergency Care and subsequent inpatient services. The health care facility (hospital) agrees to notify Health Plan when members present at emergency rooms in a manner prescribed in Provider Manual. The health care facility (hospital) shall permit the Health Plan to conduct on-site inspections by the Health Plan’s utilization management staff with respect to admissions and continued stays, and must ensure compliance with utilization management policies. Billing and payment procedures, schedules and negotiated arrangements will be made consistent with the New Jersey HINT law and as set forth in the Provider Manual. The Payor assumes no financial responsibility for admissions of Members which do not constitute Covered Services or which are provided in a manner that is inconsistent with the Provider Manual. Clean claims and billing information will be submitted by the health care facility (hospital) within thirty (30) days (electronic submission), but not more than forty (40) days (written submission), from the date of Covered Service. The Health Plan reserves the right to deny payment to the health care facility (hospital) if clean claims have not been submitted to Health Plan within the above time frames. All Clean Claims must be submitted electronically or in writing to the HMO or Payor. The Payor will pay the health care facility (hospital) within the above time frame from receipt of Clean Claim from health care facility (hospital). The health care facility (hospital) will notify the Health Plan within 90 days of any prior implementation of increased charges. Any overpayment may be recouped in accordance with Section 5.3. Notwithstanding the forgoing, with respect to claims being submitted by the Provider on behalf of the Member without an assignment of benefits, the Provider shall file the claim within 60 days of the last date of service of t...