Common use of Review of Claims Clause in Contracts

Review of Claims. 21 A. INTERMEDIARYCONTRACTOR shall review all claims to determine whether the services 22 for which reimbursement is sought are Medical Services, reimbursable pursuant to the STCs, the LIHP 23 Agreement and the Agreement, and whether such services were rendered to an MSI EligibleMSN 24 Enrollee. 25 B. INTERMEDIARYCONTRACTOR shall review claims, and provide a medical utilization 26 review, in accordance with its Operations Manual. 27 C. INTERMEDIARYCONTRACTOR shall deny all claims that do not meet the conditions and 28 requirements of the Agreement for claim submission, processing, and reimbursement, including, but not 29 limited to obligations pursuant to Paragraph VIVII., Third Party, Primary, or Other Insurance Covered 30 Claims, as specified in this Exhibit B to the Agreement. 31 D. INTERMEDIARYCONTRACTOR shall use its best efforts to collect any monies paid, in any 32 form, for non-reimbursable services, for services to persons who are not Eligible PersonEnrollees, or for 33 payment to any Provider or other entity not entitled under the Agreement to such payment if the result of 34 inaccurate or inappropriate billing by any Provider or other entity. INTERMEDIARYCONTRACTOR 35 shall not be subject to disallowances for said payments. 00 X. XXXXXXXXXXXXXXXXXXXXXX shall use its best efforts to collect any monies paid, in any 37 form, for non-reimbursable services, for services to persons who are not Eligible PersonEnrollees, or for 1 payment to any Provider or other entity not entitled under the Agreement to such payment if the result of 2 inaccurate or inappropriate processing by INTERMEDIARYCONTRACTOR. Upon becoming aware (CAP).. 3 of such uncollectible payments, INTERMEDIARYCONTRACTOR shall submit to 4 ADMINISTRATOR a corrective action plan Upon review by ADMINISTRATOR, V. CONDITIONS OF REIMBURSEMENT 5 INTERMEDIARYCONTRACTOR may be subject to disallowances for said payments. 6 8 F. INTERMEDIARY shall process claims submitted by Long Beach Memorial Medical Center 9 (Medical Center), and affiliated physicians, for only those MSI Eligibles brought by Orange County 10 Paramedics to Medical Center for trauma services or other services specifically negotiated by 11 ADMINISTRATOR in accordance with the MSI Hospital Agreement. For the purposes of the 12 Agreement, Long Beach Memorial Medical Center and its affiliated physicians shall not be considered 13 Out-of-Network Providers. 14

Review of Claims. 21 29 A. INTERMEDIARYCONTRACTOR INTERMEDIARY shall review all claims to determine whether the services 22 for which 30 reimbursement is sought are Medical Services, reimbursable pursuant to the STCs, the LIHP 23 Agreement and the Exhibit C to this Agreement, 31 and whether such services were rendered to an MSI EligibleMSN 24 EnrolleeEligible. 25 32 B. INTERMEDIARYCONTRACTOR INTERMEDIARY shall review claims, and provide a medical utilization 26 review, in accordance 33 with its Operations Manual. 27 34 C. INTERMEDIARYCONTRACTOR INTERMEDIARY shall deny all claims that do not meet the conditions and 28 requirements of the 35 this Agreement for claim submission, processing, and reimbursement, including, but not 29 limited to 36 37 4 of 22 EXHIBIT E 1 obligations pursuant to Paragraph VIVIIVII., Third Party, Primary, or Other Insurance Covered 30 Claims, as 2 specified in this Exhibit B E to the Agreement. 31 3 D. INTERMEDIARYCONTRACTOR INTERMEDIARY shall use its best efforts to collect any monies paid, in any 32 form, for non-non- 4 reimbursable services, for services to persons who are not Eligible PersonEnrolleesPerson, or for 33 payment to any Provider 5 provider or other entity not entitled under the this Agreement to such payment if the result of 34 inaccurate or 6 inappropriate billing by any Provider provider or other entity. INTERMEDIARYCONTRACTOR 35 INTERMEDIARY shall not be subject to 7 disallowances for said payments. 00 X. XXXXXXXXXXXXXXXXXXXXXX 8 E. INTERMEDIARY shall use its best efforts to collect any monies paid, in any 37 form, for non-non- 9 reimbursable services, for services to persons who are not Eligible PersonEnrolleesPerson, or for 1 payment to any Provider 10 provider or other entity not entitled under the this Agreement to such payment if the result of 2 inaccurate or 11 inappropriate processing by INTERMEDIARYCONTRACTORINTERMEDIARY. Upon becoming aware (CAP).. 3 of such uncollectible payments, INTERMEDIARYCONTRACTOR 12 INTERMEDIARY shall submit to 4 ADMINISTRATOR a plan of corrective action plan action. Upon review by 13 ADMINISTRATOR, V. CONDITIONS OF REIMBURSEMENT 5 INTERMEDIARYCONTRACTOR INTERMEDIARY may be subject to disallowances for said payments. 6. 8 14 F. INTERMEDIARY shall process claims submitted by Long Beach Memorial Medical Center 9 15 (Medical Center), and affiliated physicians, for only those MSI Eligibles brought by Orange County 10 16 Paramedics to Medical Center for trauma services or other services specifically negotiated by 11 17 ADMINISTRATOR in accordance with the MSI Hospital Agreement. For the purposes of the 12 Agreement, Long Beach Memorial Medical Center and its affiliated physicians shall not be considered 13 Out-of-Network Providers. 1418

Review of Claims. 21 2 A. INTERMEDIARYCONTRACTOR INTERMEDIARY shall review all claims to determine whether the services 22 for which 3 reimbursement is sought are Medical Services, reimbursable pursuant to the STCs, the LIHP 23 Agreement and the Exhibit C to this Agreement, 4 and whether such services were rendered to an MSI EligibleMSN 24 EnrolleeEligible. 25 5 B. INTERMEDIARYCONTRACTOR INTERMEDIARY shall review claims, and provide a medical utilization 26 review, in accordance 6 with its Operations Manual. 27 7 C. INTERMEDIARYCONTRACTOR INTERMEDIARY shall deny all claims that do not meet the conditions and 28 requirements of the 8 this Agreement for claim submission, processing, and reimbursement, including, but not 29 limited to 9 obligations pursuant to Paragraph VIVIIVII., Third Party, Primary, or Other Insurance Covered 30 Claims, as 10 specified in this Exhibit B E to the Agreement. 31 11 D. INTERMEDIARYCONTRACTOR INTERMEDIARY shall use its best efforts to collect any monies paid, in any 32 form, for non-non- 12 reimbursable services, for services to persons who are not Eligible PersonEnrolleesPerson, or for 33 payment to any Provider 13 provider or other entity not entitled under the this Agreement to such payment if the result of 34 inaccurate or 14 inappropriate billing by any Provider provider or other entity. INTERMEDIARYCONTRACTOR 35 INTERMEDIARY shall not be subject to 15 disallowances for said payments. 00 X. XXXXXXXXXXXXXXXXXXXXXX 16 E. INTERMEDIARY shall use its best efforts to collect any monies paid, in any 37 form, for non-non- 17 reimbursable services, for services to persons who are not Eligible PersonEnrolleesPerson, or for 1 payment to any Provider 18 provider or other entity not entitled under the this Agreement to such payment if the result of 2 inaccurate or 19 inappropriate processing by INTERMEDIARYCONTRACTORINTERMEDIARY. Upon becoming aware (CAP).. 3 of such uncollectible payments, INTERMEDIARYCONTRACTOR 20 INTERMEDIARY shall submit to 4 ADMINISTRATOR a plan of corrective action plan action. Upon review by 21 ADMINISTRATOR, V. CONDITIONS OF REIMBURSEMENT 5 INTERMEDIARYCONTRACTOR INTERMEDIARY may be subject to disallowances for said payments. 6. 8 22 F. INTERMEDIARY shall process claims submitted by Long Beach Memorial Medical Center 9 23 (Medical Center), and affiliated physicians, for only those MSI Eligibles brought by Orange County 10 24 Paramedics to Medical Center for trauma services or other services specifically negotiated by 11 25 ADMINISTRATOR in accordance with the MSI Hospital Agreement. For the purposes of the 12 Agreement, Long Beach Memorial Medical Center and its affiliated physicians . 26 G. Claims submitted by a podiatrist or home health provider shall not be considered 13 Out-of-Network Providersdeemed received until the 27 first business day following review by the MRC. 1428

Review of Claims. 21 17 A. INTERMEDIARYCONTRACTOR INTERMEDIARY shall review all claims to determine whether the services 22 for which 18 reimbursement is sought are Medical Services, reimbursable pursuant to the STCs, the LIHP 23 Agreement 19 and the Agreement, and whether such services were rendered to an MSI EligibleMSN 24 EnrolleeEligible. 25 20 B. INTERMEDIARYCONTRACTOR INTERMEDIARY shall review claims, and provide a medical utilization 26 review, in accordance 21 with its Operations Manual. 27 22 C. INTERMEDIARYCONTRACTOR INTERMEDIARY shall deny all claims that do not meet the conditions and 28 requirements of the 23 Agreement for claim submission, processing, and reimbursement, including, but not 29 limited to 24 obligations pursuant to Paragraph VIVIIVI., Third Party, Primary, or Other Insurance Covered 30 Claims, as 25 specified in this Exhibit B to the Agreement. 31 26 D. INTERMEDIARYCONTRACTOR INTERMEDIARY shall use its best efforts to collect any monies paid, in any 32 form, for non-non- 27 reimbursable services, for services to persons who are not Eligible PersonEnrolleesPerson, or for 33 payment to any 28 Provider or other entity not entitled under the Agreement to such payment if the result of 34 inaccurate or 29 inappropriate billing by any Provider or other entity. INTERMEDIARYCONTRACTOR 35 INTERMEDIARY shall not be subject to 30 disallowances for said payments. 00 X. XXXXXXXXXXXXXXXXXXXXXX 31 E. INTERMEDIARY shall use its best efforts to collect any monies paid, in any 37 form, for non-non- 32 reimbursable services, for services to persons who are not Eligible PersonEnrolleesPerson, or for 1 payment to any 33 Provider or other entity not entitled under the Agreement to such payment if the result of 2 inaccurate or 34 inappropriate processing by INTERMEDIARYCONTRACTORINTERMEDIARY. Upon becoming aware (CAP).. 3 of such uncollectible payments, INTERMEDIARYCONTRACTOR 35 INTERMEDIARY shall submit to 4 ADMINISTRATOR a corrective action plan (CAP). Upon review by 36 ADMINISTRATOR, V. CONDITIONS OF REIMBURSEMENT 5 INTERMEDIARYCONTRACTOR INTERMEDIARY may be subject to disallowances for said payments. 6. 8 37 F. INTERMEDIARY shall process claims submitted by Long Beach Memorial Medical Center 9 (Center 1 ( Medical Center), and affiliated physicians, for only those MSI Eligibles brought by Orange County 10 2 Paramedics to Medical Center for trauma services or other services specifically negotiated by 11 3 ADMINISTRATOR in accordance with the MSI Hospital Agreement. For the purposes of the 12 4 Agreement, Long Beach Memorial Medical Center and its affiliated physicians shall not be considered 13 5 Out-of-Network Providers. 146

Review of Claims. 21 17 A. INTERMEDIARYCONTRACTOR INTERMEDIARY shall review all claims to determine whether the services 22 for which 18 reimbursement is sought are Medical Services, reimbursable pursuant to the STCs, the LIHP 23 Agreement 19 and the Agreement, and whether such services were rendered to an MSI EligibleMSN 24 EnrolleeEligible. 25 20 B. INTERMEDIARYCONTRACTOR INTERMEDIARY shall review claims, and provide a medical utilization 26 review, in accordance 21 with its Operations Manual. 27 22 C. INTERMEDIARYCONTRACTOR INTERMEDIARY shall deny all claims that do not meet the conditions and 28 requirements of the 23 Agreement for claim submission, processing, and reimbursement, including, but not 29 limited to 24 obligations pursuant to Paragraph VIVIIVI., Third Party, Primary, or Other Insurance Covered 30 Claims, as 25 specified in this Exhibit B to the Agreement. 31 26 D. INTERMEDIARYCONTRACTOR INTERMEDIARY shall use its best efforts to collect any monies paid, in any 32 form, for non-non- 27 reimbursable services, for services to persons who are not Eligible PersonEnrolleesPerson, or for 33 payment to any 28 Provider or other entity not entitled under the Agreement to such payment if the result of 34 inaccurate or 29 inappropriate billing by any Provider or other entity. INTERMEDIARYCONTRACTOR 35 INTERMEDIARY shall not be subject to 30 disallowances for said payments. 00 X. XXXXXXXXXXXXXXXXXXXXXX 31 E. INTERMEDIARY shall use its best efforts to collect any monies paid, in any 37 form, for non-non- 32 reimbursable services, for services to persons who are not Eligible PersonEnrolleesPerson, or for 1 payment to any 33 Provider or other entity not entitled under the Agreement to such payment if the result of 2 inaccurate or 34 inappropriate processing by INTERMEDIARYCONTRACTORINTERMEDIARY. Upon becoming aware (CAP).. 3 of such uncollectible payments, INTERMEDIARYCONTRACTOR 35 INTERMEDIARY shall submit to 4 ADMINISTRATOR a corrective action plan (CAP). Upon review by 36 ADMINISTRATOR, V. CONDITIONS OF REIMBURSEMENT 5 INTERMEDIARYCONTRACTOR INTERMEDIARY may be subject to disallowances for said payments. 6. 8 37 F. INTERMEDIARY shall process claims submitted by Long Beach Memorial Medical Center 9 1 (Medical Center), and affiliated physicians, for only those MSI Eligibles brought by Orange County 10 2 Paramedics to Medical Center for trauma services or other services specifically negotiated by 11 3 ADMINISTRATOR in accordance with the MSI Hospital Agreement. For the purposes of the 12 4 Agreement, Long Beach Memorial Medical Center and its affiliated physicians shall not be considered 13 5 Out-of-Network Providers. 146

Review of Claims. 21 2 A. INTERMEDIARYCONTRACTOR CONTRACTOR shall review all claims to determine whether the services 22 for which 3 reimbursement is sought are Medical Services, reimbursable pursuant to the STCs, the LIHP 23 Agreement and the Agreement, and whether 4 such services were rendered to an MSI EligibleMSN 24 MSN Enrollee. 25 5 B. INTERMEDIARYCONTRACTOR CONTRACTOR shall review claims, and provide a medical utilization 26 review, in accordance 6 with its Operations Manual. 27 7 C. INTERMEDIARYCONTRACTOR CONTRACTOR shall deny all claims that do not meet the conditions and 28 requirements of the 8 Agreement for claim submission, processing, and reimbursement, including, but not 29 limited to 9 obligations pursuant to Paragraph VIVIIVII., Third Party, Primary, or Other Insurance Covered 30 Claims, as 10 specified in this Exhibit B to the Agreement. 31 11 D. INTERMEDIARYCONTRACTOR CONTRACTOR shall use its best efforts to collect any monies paid, in any 32 form, for non-non- 12 reimbursable services, for services to persons who are not Eligible PersonEnrolleesEnrollees, or for 33 payment to any Provider or 13 other entity not entitled under the Agreement to such payment if the result of 34 inaccurate or inappropriate 14 billing by any Provider or other entity. INTERMEDIARYCONTRACTOR 35 CONTRACTOR shall not be subject to disallowances for said 15 payments. 00 X. XXXXXXXXXXXXXXXXXXXXXX 16 E. CONTRACTOR shall use its best efforts to collect any monies paid, in any 37 form, for non-non- 17 reimbursable services, for services to persons who are not Eligible PersonEnrolleesEnrollees, or for 1 payment to any Provider or 18 other entity not entitled under the Agreement to such payment if the result of 2 inaccurate or inappropriate 19 processing by INTERMEDIARYCONTRACTORCONTRACTOR. Upon becoming aware (CAP).. 3 of such uncollectible payments, INTERMEDIARYCONTRACTOR 20 CONTRACTOR shall submit to 4 ADMINISTRATOR a corrective action plan plan. Upon review by 21 ADMINISTRATOR, V. CONDITIONS OF REIMBURSEMENT 5 INTERMEDIARYCONTRACTOR CONTRACTOR may be subject to disallowances for said payments. 6. 8 22 F. INTERMEDIARY shall process claims submitted by Long Beach Memorial Medical Center 9 (Medical Center)CONTRACTOR and ADMINISTRATOR may mutually agree, and affiliated physiciansin writing, for only those MSI Eligibles brought by Orange County 10 Paramedics to Medical Center for trauma services or other services specifically negotiated by 11 ADMINISTRATOR in accordance with modify the MSI Hospital 23 Review of Claims Paragraph of this Exhibit B to the Agreement. For the purposes of the 12 Agreement, Long Beach Memorial Medical Center and its affiliated physicians shall not be considered 13 Out-of-Network Providers. 1424