Shadow Claims Reporting Sample Clauses

Shadow Claims Reporting. 62 3.6.13.3.1 Shadow Claims Requirements and Submission Standards..................................... 63 3.6.13.4 Third-Party Liability Reporting............................................................. 64 3.6.13.4.1 MCO TPL Responsibilities - Cost Avoidance............................................... 65 3.6.13.4.2
Sample 1
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Shadow Claims Reporting. It is OMPP's goal to improve the quality of, and access to, Hoosier Healthwise services. In order to ensure that these goals are being met in Hoosier Healthwise, OMPP must track expenditures and service utilization on an ongoing and regular basis. The State must collect information that is sufficient to calculate future capitation rates. Information must also be collected that enables the calculation of reimbursement rates for the fee-for-service reimbursement system. This information is gathered in the form of shadow claims (or encounter data). Shadow claims are reports of individual patient encounters with an MCO's healthcare network. These claims contain fee-for-service equivalent detail as to procedures, diagnoses, place of service, billed amounts, and rendering/billing providers, as well as detailed claims data for utilization analysis, quality improvement program analysis, and future capitation rate adjustments. The MCO must collect shadow claims/encounter data in standard formats and verify that the data is accurate, complete and timely. The MCO is responsible for ensuring the timely receipt of shadow claims from its capitated providers. The MCO is also responsible for the timely provision of shadow claims to OMPP. The MCO must have policies for using incentives, sanctions, or other sanction-like programs to ensure timely receipt of shadow claims from its capitated providers. 3.1 below for the specifics of what is expected for each of these named elements. The State will assess liquidated damages, in accordance with Section 3.16 of this BAA, for failure to comply with these requirements.
Sample 1
Shadow Claims Reporting. The MCO must have policies and procedures and mechanisms in place to support the shadow claims reporting process described below. The MCO Technical Meeting provides a forum for MCO technical support staff to ask questions related to data exchange issues, including shadow claims transmission and reporting issues. The MCO must report any problems it is experiencing with shadow claims submissions and reporting at this monthly meeting. The Electronic Claim Capture Shadow Claim Submission Technical Reference Manual and the Companion Guides-837 Institutional and Professional Claim and Encounter Transaction provide detailed instructions to guide the MCO in reporting shadow claims data.
Sample 1

Related to Shadow Claims Reporting

  • Administrative Claims Requirements and Procedures No suit or arbitration shall be brought arising out of this Agreement against City unless a claim has first been presented in writing and filed with City and acted upon by City in accordance with the procedures set forth in Chapter 1.34 of the Chula Vista Municipal Code, as same may be amended, the provisions of which, including such policies and procedures used by City in the implementation of same, are incorporated herein by this reference. Upon request by City, Consultant shall meet and confer in good faith with City for the purpose of resolving any dispute over the terms of this Agreement.

  • Claims Review The IRO shall perform the Claims Review annually to cover each of the five Reporting Periods. The IRO shall perform all components of each Claims Review.

  • Claims Review Population A description of the Population subject to the Claims Review.

  • Claims Released Subject only to the exceptions just noted, I am releasing all known and unknown claims, promises, causes of action, or similar rights of any type that I may have ("Claims") with respect to any Released Party listed in Section 2(d). I understand that the Claims I am releasing might arise under many different laws (including statutes, regulations, other administrative guidance, and common law doctrines), such as the following: Anti-discrimination statutes, such as the Age Discrimination in ---------------------------- Employment Act and Executive Order 11,141, which prohibit age discrimination in employment; Title VII of the Civil Rights Act of 1964, Sections 1981 and 1983 of the Civil Rights Act of 1866, and Executive Order 11,246, which prohibit discrimination based on race, color, national origin, religion, or sex; the Equal Pay Act, which prohibits paying men and women unequal pay for equal work; the Americans With Disabilities Act and Sections 503 and 504 of the Rehabilitation Act of 1973, which prohibit discrimination based on disability; and any other federal, state, or local laws prohibiting employment discrimination, such as the California Fair Employment and Housing Act, which prohibits discrimination in employment based on race, color, national origin, ancestry, physical or mental disability, medical condition, marital status, sex, or age. Federal employment statutes, such as the WARN Act, which requires --------------------------- that advance notice be given of certain work force reductions; the Employee Retirement Income Security Act of 1974, which, among other things, protects employee benefits; the Fair Labor Standards Act of 1938, which regulates wage and hour matters; the Family and Medical Leave Act of 1993, which requires employers to provide leaves of absence under certain circumstances; and any other federal laws relating to employment, such as veterans' reemployment rights laws. Other laws, such as any federal, state, or local laws providing ---------- workers' compensation benefits, restricting an employer's right to terminate employees, or otherwise regulating employment; any federal, state, or local law enforcing express or implied employment contracts or requiring an employer to deal with employees fairly or in good faith; any other federal, state, or local laws providing recourse for alleged wrongful discharge, tort, physical or personal injury, emotional distress, fraud, negligent misrepresentation, defamation, and similar or related claims, such as California Labor Code Section 200 et seq., relating to salary, commission, compensation, benefits, and other matters; the California Workers' Compensation Act; or any applicable California Industrial Welfare Commission order. Examples of released Claims include, but are not limited to: (i) --------------------------- Claims that in any way relate to my employment with the Company, or the termination of that employment, such as Claims for compensation, bonuses, commissions, lost wages, or unused accrued vacation or sick pay; (ii) Claims that in any way relate to the design or administration of any employee benefit program; (iii) Claims that I have irrevocable or vested rights to severance or similar benefits or to post-employment health or group insurance benefits; or (iv) any Claims to attorneys' fees or other indemnities with respect to Claims I am releasing.

  • Claims Review Methodology ‌‌ a. C laims Review Population. A description of the Population subject‌‌ to the Quarterly Claims Review.

  • Claims Review Report The IRO shall prepare a Claims Review Report as described in this Appendix for each Claims Review performed. The following information shall be included in the Claims Review Report for each Discovery Sample and Full Sample (if applicable).

  • Adverse Event Reporting Both Parties acknowledge the obligation to comply with the Protocol and / or applicable regulations governing the collection and reporting of adverse events of which they may become aware during the course of the Clinical Trial. Both Parties agree to fulfil and ensure that their Agents fulfil regulatory requirements with respect to the reporting of adverse events.

  • Litigation Reporting If Contractor is served with a pleading or other document in connection with an action before a court or other administrative decision making body, and such pleading or document relates to this Participating Addendum or may affect Contractor’s ability to perform its obligations under this Participating Addendum, Contractor shall, within 10 days after being served, notify the State of such action and deliver copies of such pleading or document to the State’s primary contact identified in §5 of the Participating Addendum .

  • Claims Submission Unless otherwise prohibited by federal or state law, Provider will submit Clean Claims for all Covered Services to BCBSM within one hundred eighty (180) days of the date of service.

  • Submitting False Claims; Monetary Penalties The AOC shall be entitled to remedy any false claims, as defined in California Government Code section 12650 et seq., made to the AOC by the Contractor or any Subcontractor under the standards set forth in Government Code section 12650 et seq. Any Contractor or Subcontractor who submits a false claim shall be liable to the AOC for three times the amount of damages that the AOC sustains because of the false claim. A Contractor or Subcontractor who submits a false claim shall also be liable to the AOC for (a) the costs, including attorney fees, of a civil action brought to recover any of those penalties or damages, and (b) a civil penalty of up to $10,000 for each false claim.

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