Common use of SECONDARY PAYOR Clause in Contracts

SECONDARY PAYOR. 1. The INSURER shall be a secondary payor to any other party liable in any claim for services to a beneficiary, including but not limited to: the INSURER itself, Medicare, other insurers or health maintenance organizations, non-profit INSURER's operating under law 152 approved May 9, 1942 as amended, Asociacion de Maestros de Puerto Rico, medical plans sponsored by employee organizations, labor unions, and any other entity that results liable for the benefits claimed against the INSURER for coverage to beneficiaries. 2. It shall be the responsibility of the INSURER to ascertain that the aforementioned provisions of Law 72 of September 7, 1993 are enforced and that the INSURER acts as secondary payor to any other medical insurance. 3. The ADMINISTRATION and the INSURER will cooperate in the exchange of third parties health insurance benefits information. To this effect the INSURER will comply fully with the Carta Normativa Numero N-E-5-95-98 issued by the Office of the Insurance Commissioner of Puerto Rico and the HIPAA regulations provisions cited elsewhere in this contract. 4. The INSURER will make diligent efforts to determine if beneficiaries have third party coverage and will attempt to utilize such coverage when applicable. The INSURER, will be permitted to retain 100% of the collections from subrogation. The plan's experience will be credited with the amount collected from said primary payor. 5. The INSURER must report quarterly to the ADMINISTRATION the amounts collected from third parties for health services provided. Said reports must provide a detailed description of the beneficiary's name, contract number, third party payor name and address, date of service, diagnosis and provider's name and address and identification number. 6. The INSURER must report quarterly to the ADMINISTRATION the amounts collected from third parties for health services provided according with standard format to be adopted by the ADMINISTRATION. Said reports must provide a detailed description of the beneficiary's name, contract number, third party payor name and address, date of service, diagnosis and provider's name and address and identification number. 7. The INSURER shall develop specific procedures for the exchange of information, collections and reporting of other primary payor sources and is required to verify its own eligibility files for information on whether or not the beneficiary has private health insurance within the INSURER. 8. The INSURER must implement and execute, an effective and diligent mechanism in order to assure the collection from primary payors of all benefits covered under this contract. Said program, mechanisms and method of implementation shall be reported to the ADMINISTRATION as of the first date of the effectiveness of this contract. 9. Failure of the INSURER to comply with this Article may, at the discretion of the ADMINISTRATION, be cause for the application of the provisions under Article XXXIII.

SECONDARY PAYOR. 1. The INSURER shall be a secondary payor to any other party liable in any claim for services to a beneficiary, including but not limited to: the INSURER itself, Medicare, other insurers or managed care organizations, health maintenance organizations, non-profit INSURER's operating under law 152 approved May 9, 1942 as amended, "Asociacion de Maestros de Puerto Rico", medical plans sponsored by employee organizations, labor unions, and any other entity that results liable for the benefits claimed against the INSURER for coverage to beneficiaries. 2. It shall be the responsibility of the INSURER to ascertain that the aforementioned provisions of Law 72 of September 7, 1993 are enforced and that the INSURER acts as secondary payor to any other medical insurance. 3. The ADMINISTRATION and the INSURER will cooperate in the exchange of third parties health insurance benefits information. To this effect the INSURER will comply fully with the "Carta Normativa Numero N-E-5-95-98 98" issued by the Office of the Insurance Commissioner of Puerto Rico and the HIPAA regulations provisions cited elsewhere in this contract. 4. The INSURER will make the most diligent best efforts to determine if beneficiaries have third party coverage and will attempt to utilize such coverage when applicable. The INSURER, INSURER will be permitted to retain 100% of the collections from subrogation. The plan's experience will be credited with the amount collected from said primary payor, once payment is made and the INSURER recovers payments according to the corresponding transaction process established. If the provider detect that a beneficiary have other health plan coverage not identified in the beneficiary card, the provider will bill the primary payor and will provide the information to txx XNSURER. 5. The INSURER must report quarterly to the ADMINISTRATION the amounts collected from third parties for health services provided. Said reports must provide a detailed description of the beneficiary's name, contract number, third party payor name and address, date of service, diagnosis and provider's name and address and identification number. 6. The INSURER must report quarterly to the ADMINISTRATION the amounts collected from third parties for health services provided according with standard format to be adopted by the ADMINISTRATION. Said reports must provide a detailed description of the beneficiary's name, contract number, third party payor name and address, date of service, diagnosis and provider's name and address and identification number. 7. The INSURER shall develop specific procedures for the exchange of information, collections and reporting of other primary payor sources and is required to verify its own eligibility files for information on whether or not the beneficiary has private health insurance within the INSURER. 8. The INSURER must implement and execute, execute an effective and diligent mechanism in order to assure the collection from primary payors of all benefits covered under this contract. Said program, mechanisms and method of implementation shall be reported to the ADMINISTRATION as of the first date of the effectiveness of this contract. 9. Failure of the INSURER to comply with this Article may, at the discretion of the ADMINISTRATION, be cause for the application of the provisions under Article XXXIII.

SECONDARY PAYOR. 1. The INSURER MBHO shall be a secondary payor to any other party liable in any claim for services to a beneficiary, including but not limited to: the INSURER MBHO itself, Medicare, other insurers MANAGED BEHAVIORAL HEALTH ORGANIZATIONS or health maintenance organizationsHealth Maintenance Organizations (HMO's), non-profit INSURER's MANAGED BEHAVIORAL HEALTH ORGANIZATION operating under law Law 152 approved May 9, 1942 as amended, Asociacion de Maestros de Teachers Association of Puerto Rico, medical plans sponsored by employee organizations, labor unions, and any other entity that results liable for the benefits claimed against the INSURER MBHO for coverage to beneficiaries. 2. It shall be the responsibility of the INSURER MBHO to ascertain that the aforementioned provisions of Law 72 of September 7, 1993 are enforced and that the INSURER MBHO acts as secondary payor to any other medical insurance. 3. The ADMINISTRATION and the INSURER will cooperate in the exchange of third parties health insurance benefits information. To this effect the INSURER will comply fully with the Carta Normativa Numero N-E-5-95-98 issued by the Office of the Insurance Commissioner of Puerto Rico and the HIPAA regulations provisions cited elsewhere in this contract. 4. The INSURER MBHO will make diligent efforts to determine if beneficiaries have third party coverage and will attempt to utilize such coverage when applicable. The INSURERMBHO, will be permitted to retain 100% of the collections from subrogation. The plan's experience will be credited with the amount collected from said primary payor. 54. The INSURER MBHO must report quarterly to the ADMINISTRATION the amounts collected from third parties for health services provided. Said reports must provide a detailed description of the beneficiary's name, contract number, third party payor name and address, date of service, diagnosis and provider's name and address and identification number. 65. The INSURER MBHO must report quarterly to the ADMINISTRATION the amounts collected from third parties for health services provided according with standard format to be adopted by the ADMINISTRATION. Said reports must provide a detailed description of the beneficiary's name, contract number, third party payor name and address, date of service, diagnosis and provider's name and address and identification number. 76. The INSURER MBHO shall develop specific procedures for the exchange of information, collections and reporting of other primary payor sources and is required to verify its own eligibility files for information on whether or not the beneficiary has private health insurance within the INSURERinsurance. 87. The INSURER MBHO must implement and execute, an effective and diligent mechanism in order to assure the collection from primary payors of all benefits covered under this contract. Said program, mechanisms and method of implementation shall be reported to the ADMINISTRATION as of the first date of the effectiveness of this contract. 98. Failure of the INSURER MBHO to comply with this Article may, at the discretion of the ADMINISTRATION, be cause for the application of the provisions under Article XXXIIIXXXII.

SECONDARY PAYOR. 1. The INSURER shall be a secondary payor to any other party liable in any claim for services to a beneficiary, including but not limited to: the INSURER itself, Medicare, other insurers or health maintenance organizations, non-profit INSURER's operating under law 152 approved May 9, 1942 as amended, Asociacion de Maestros de Puerto Rico, medical plans sponsored by employee organizations, labor unions, and any other entity that results liable for the benefits claimed against the INSURER for coverage to beneficiaries. 2. It shall be the responsibility of the INSURER to ascertain that the aforementioned provisions of Law 72 of September 7, 1993 are enforced and that the INSURER acts .acts as secondary payor to any other medical insurance. 3. The ADMINISTRATION and the INSURER will cooperate in the exchange of third parties health insurance benefits information. To this effect the INSURER will comply fully with the Carta Normativa Numero N-E-5-95-98 issued by the Office of the Insurance Commissioner of Puerto Rico and the HIPAA regulations provisions cited elsewhere in this contract. 4. The INSURER will make diligent efforts to determine if beneficiaries have third party coverage and will attempt to utilize such coverage when applicable. The INSURER, will be permitted to retain 100% of the collections from subrogation. The plan's experience will be credited with the amount collected from said primary payor. 5. The INSURER must report quarterly to the ADMINISTRATION the amounts collected from third parties for health services provided. Said reports must provide a detailed description of the beneficiary's name, contract number, third party payor name and address, date of service, diagnosis and provider's name and address and identification number. 6. The INSURER must report quarterly to the ADMINISTRATION the amounts collected from third parties for health services provided according with standard format to be adopted by the ADMINISTRATION. Said reports must provide a detailed description of the beneficiary's name, contract number, third party payor name and address, date of service, diagnosis and provider's name and address and identification number. 7. The INSURER shall develop specific procedures for the exchange of information, collections and reporting of other primary payor sources and is required to verify its own eligibility files for information on whether or not the beneficiary has private health insurance within the INSURER. 8. The INSURER must implement and execute, an effective and diligent mechanism in order to assure the collection from primary payors of all benefits covered under this contract. Said program, mechanisms and method of implementation shall be reported to the ADMINISTRATION as of the first date of the effectiveness of this contract. 9. Failure of the INSURER to comply with this Article may, at the discretion of the ADMINISTRATION, be cause because for the application of the provisions under Article XXXIII.

SECONDARY PAYOR. 1. The INSURER shall be a secondary payor to any other party liable in any claim for services to a beneficiary, including but not limited to: the INSURER itself, Medicare, other insurers or managed care organizations, health maintenance organizations, non-profit INSURER's operating under law 152 approved May 9, 1942 as amended, "Asociacion de Maestros de Puerto Rico", medical plans sponsored by employee organizations, labor unions, and any other entity that results liable for the benefits claimed against the INSURER for coverage to beneficiaries. 2. It shall be the responsibility of the INSURER to ascertain that the aforementioned provisions of Law 72 of September 7, 1993 are enforced and that the INSURER acts as secondary payor to any other medical insurance. 3. The ADMINISTRATION and the INSURER will cooperate in the exchange of third parties health insurance benefits information. To this effect the INSURER will comply fully with the "Carta Normativa Numero N-E-5-95-98 98" issued by the Office of the Insurance Commissioner of Puerto Rico and the HIPAA regulations provisions cited elsewhere in this contract. 4. The INSURER will make the most diligent best efforts to determine if beneficiaries have third party coverage and will attempt to utilize such coverage when applicable. The INSURER, INSURER will be permitted to retain 100% of the collections from subrogation. The plan's experience will be credited with the amount collected from said primary payor, once payment is made and the INSURER recovers payments according to the corresponding transaction process established. If the provider detect that a beneficiary have other health plan coverage not identified in the beneficiary card, the provider will xxxx the primary payor and will provide the information to the INSURER. 5. The INSURER must report quarterly to the ADMINISTRATION the amounts collected from third parties for health services provided. Said reports must provide a detailed description of the beneficiary's name, contract number, third party payor name and address, date of service, diagnosis and provider's name and address and identification number. 6. The INSURER must report quarterly to the ADMINISTRATION the amounts collected from third parties for health services provided according with standard format to be adopted by the ADMINISTRATION. Said reports must provide a detailed description of the beneficiary's name, contract number, third party payor name and address, date of service, diagnosis and provider's name and address and identification number. 7. The INSURER shall develop specific procedures for the exchange of information, collections and reporting of other primary payor sources and is required to verify its own eligibility files for information on whether or not the beneficiary has private health insurance within the INSURER. 8. The INSURER must implement and execute, execute an effective and diligent mechanism in order to assure the collection from primary payors of all benefits covered under this contract. Said program, mechanisms and method of implementation shall be reported to the ADMINISTRATION as of the first date of the effectiveness of this contract. 9. Failure of the INSURER to comply with this Article may, at the discretion of the ADMINISTRATION, be cause for the application of the provisions under Article XXXIII.

SECONDARY PAYOR. 1. The INSURER shall be a secondary payor to any other party liable in any claim for services to a beneficiary, including but not limited to: the INSURER itself, Medicare, other insurers or managed care organizations, health maintenance organizations, non-profit INSURER's ’s operating under law Law 152 approved May 9, 1942 as amended, Asociacion “Asociación de Maestros de Puerto Rico”, medical plans sponsored by employee organizations, labor unions, and any other entity that results liable for the benefits claimed against the INSURER for coverage to beneficiaries. 2. It shall be the responsibility of the INSURER to ascertain that the aforementioned provisions of Law 72 of September 7, 1993 are enforced and that the INSURER acts as secondary payor to any other medical insurance. 3. The ADMINISTRATION and the INSURER will cooperate in the exchange of third parties health insurance benefits information. To this effect the INSURER will comply fully with the “Carta Normativa Numero NNxxxxx X-E-5X-0-9500-98 00” issued by the Office of the Insurance Commissioner of Puerto Rico and the HIPAA regulations provisions cited elsewhere in this contract. 4. The INSURER will make diligent efforts to determine if beneficiaries have third party coverage and will attempt to utilize such coverage when applicable. The INSURER, INSURER will be permitted to retain a 100% of the collections obtained from subrogation, to the extent of the risk assumed by the INSURER and that of the participating providers at risk. The INSURER shall share with at-risk providers the collections obtained, which respect to the commensurate risk borne by said party and in proportion of the reimbursement collected. The plan's ’s experience will be credited with the amount collected from said primary payorpayer. 5. The INSURER must report quarterly to the ADMINISTRATION the amounts collected from third parties for health services provided. Said reports must provide a detailed description of the beneficiary's beneficiary ‘s name, contract number, third party payor payer name and address, date of service, diagnosis and diagnosis, provider's ’s name and address and identification number; according with a standard format adopted by the Administration. 6. The INSURER must report quarterly to the ADMINISTRATION the amounts collected from third parties for health services provided according with standard format to be adopted by the ADMINISTRATION. Said reports must provide a detailed description of the beneficiary's name, contract number, third party payor name and address, date of service, diagnosis and provider's name and address and identification number. 7. The INSURER shall develop specific procedures for the exchange of information, collections and reporting of other primary payor payer sources and is required to verify its own eligibility files for information on whether or not the beneficiary has private health insurance within the INSURER. 87. The INSURER must implement and execute, execute an effective and diligent mechanism in order to assure the collection from primary payors payers of all benefits covered under this contract. Said program, mechanisms and method of implementation shall be reported to the ADMINISTRATION as of the first date of the effectiveness of this contract. 98. Failure of the INSURER to comply with this Article may, at the discretion of the ADMINISTRATION, shall be cause for the application of the penalties provisions and sanctions under Article XXXIIIArticles XXXVIII and XXXIX.