Common use of Submission and Payment of Claims Clause in Contracts

Submission and Payment of Claims. Provider shall not submit claim or encounter data for services covered by the Alliance Tailored Plan directly to the Department. Provider shall submit all claims for processing and Alliance shall process and pay claims in accordance with the following terms and conditions. a. If Alliance denies payment of a claim, Alliance shall provide Provider the ability to electronically access the specific denial reason. b. Status of a claim shall be available within five to seven (5-7) days of Alliance’s receipt of the claim. c. Alliance is not limited to approving a claim in full or requesting additional information for the entire claim. Rather, as appropriate, Alliance may approve a claim in part, deny a claim in part, and/or request additional information for only a part of the claim. d. Alliance will not reimburse Provider for services provided by staff not meeting licensure, certification or accreditation requirements. e. Provider agrees to send 837 HIPAA compliant transactions and to receive 835 Remittances or to participate in Alliance's web based billing process. f. Claims must be submitted electronically either through HIPAA Compliant Transaction Sets 820 – Premium Payment, 834 – Member Enrollment and Eligibility Maintenance, 835 – Remittance Advice, 837P – Professional claims, 837I – Institutional claims, or Alliance’s secure web based billing system. Provider will notify Alliance if electronic submission is not possible for a particular claim, and the Parties will work cooperatively to facilitate manual submission of the claim if necessary. g. Provider’s claims shall be compliant with the National Correct Coding Initiative effective on the date of service. h. Both Parties shall be compliant with the requirements of the National Uniform Billing Committee. i. Provider may submit claims beyond one-hundred-eighty (180) days in instances where the Recipient has been retroactively enrolled in the NC Medicaid Program or in the BH I/DD Tailored Plan, or where the Recipient has primary insurance which has not yet paid or denied its claim. In such instances, Provider should bill Alliance within thirty (30) days of receipt of notice by the Provider of the Recipient’s eligibility, or within ninety (90) days of final action (including payment or denial) by the primary insurance or Medicare or the date of service or discharge (whichever is later). j. If Provider delays submission of the claims due to the coordination of benefits, subrogation of benefits or the determination of eligibility for benefits for the Recipient, Provider should submit such claims within thirty (30) days of the date of the notice of determination of coverage or payment by the third party. k. If a claim is denied, and the Provider wishes to resubmit the denied claim with additional information, Provider must resubmit the claim within ninety (90) days after Provider’s receipt of the denial. If the Provider needs more than ninety (90) days to resubmit a denied claim, Provider must request and receive an extension from Alliance before the expiration of the ninety (90) day deadline, such extension not to be unreasonably withheld. l. All claims shall be adjudicated as outlined in the Alliance Provider Manual. m. Diagnosis submitted on claims must be consistent with the service provided. n. If a specific service (as denominated by specific identifying codes such as CPT or HCPCS) is rendered multiple times in a single day to the same Recipient, the specific service may be billed as the aggregate of the units delivered rather than as separate line items. o. Alliance shall not reimburse Provider for “never events” as that term is defined by the Centers for Medicare and Medicaid Services (CMS). p. Provider shall not require co-pays, deductibles, or other forms of cost sharing for Covered Services under the Contract or charge Recipients or bill Alliance for missed appointments. q. Provider shall comply with the requirements of 42 C.F.R. §438.3(g) including, but not limited to, the identification of provider-preventable conditions as a condition of payment, and appropriate reporting to Alliance. r. Provider shall have policies and procedures that recognize and accept Medicaid as the payer of last resort.

Submission and Payment of Claims. Provider shall not submit claim or encounter data for services covered by the Alliance Tailored Plan directly to the Department. The Provider shall submit all claims for processing and Alliance shall process and pay claims in accordance with the following terms set forth in Attachment B , which are attached hereto and conditionsincorporated herein. Participating Providers shall not submit claim or encounter data for services covered by Alliance directly to the Department. a. If Alliance denies payment of a claim, Alliance shall provide Provider the ability to electronically access the specific denial reason. b. Status of a claim shall be available within five to seven (5-7) days of Alliance’s receipt of the claim. c. Alliance is not limited to approving a claim in full or requesting additional information for the entire claim. Rather, as appropriate, Alliance may approve a claim in part, deny a claim in part, and/or request additional information for only a part of the claim. d. Alliance will not reimburse Provider for services provided by staff not meeting licensure, certification or accreditation requirements. e. Provider agrees to send 837 HIPAA compliant transactions and to receive 835 Remittances or to participate in Alliance's web based billing process. f. Claims must be submitted electronically either through HIPAA Compliant Transaction Sets 820 – Premium Payment, 834 – Member Enrollment and Eligibility Maintenance, 835 – Remittance Advice, 837P – Professional claims, 837I – Institutional claims, or Alliance’s secure web based billing system. Provider will notify Alliance if electronic submission is not possible for a particular claim, and the Parties will work cooperatively to facilitate manual submission of the claim if necessary. g. Provider’s claims shall be compliant with the National Correct Coding Initiative effective on the date of service. h. Both Parties shall be compliant with the requirements of the National Uniform Billing Committee. i. Provider may submit claims beyond one-hundred-eighty (180) days in instances where the Recipient Member has been retroactively enrolled in the NC Medicaid Program or in the BH I/DD Tailored Alliance Medicaid Direct Plan, or where the Recipient Member has primary insurance which has not yet paid or denied its claim. In such instances, Provider should bill Alliance within thirty (30) days of receipt of notice by the Provider of the RecipientMember’s eligibility, or within ninety (90) days of final action (including payment or denial) by the primary insurance or Medicare or the date of service or discharge (whichever is later). j. If Provider delays submission of the claims due to the coordination of benefits, subrogation of benefits or the determination of eligibility for benefits for the RecipientMember, Provider should submit such claims within thirty (30) days of the date of the notice of determination of coverage or payment by the third party. k. If a claim is denied, and the Provider wishes to resubmit the denied claim with additional information, Provider must resubmit the claim within ninety (90) days after Provider’s receipt of the denial. If the Provider needs more than ninety (90) days to resubmit a denied claim, Provider must request and receive an extension from Alliance before the expiration of the ninety (90) day deadline, such extension not to be unreasonably withheld. l. All claims shall be adjudicated as outlined in the Alliance Provider Manual. m. Diagnosis submitted on claims must be consistent with the service provided. n. If a specific service (as denominated by specific identifying codes such as CPT or HCPCS) is rendered multiple times in a single day to the same RecipientMember, the specific service may be billed as the aggregate of the units delivered rather than as separate line items. o. Alliance shall not reimburse Provider for “never events” as that term is defined by the Centers for Medicare and Medicaid Services (CMS). p. Provider shall not require cobill any member for covered services, except for specified coinsurance, copayments, and applicable deductibles established by the Department. This provision shall not prohibit a Provider and Member from agreeing to continue non-payscovered services at the Member's own expense, as long as the Provider has notified the Member in advance that the PIHP may not cover or continue to cover specific services and the member to receive the service. If a Member deductibles, or other forms of cost sharing copayments, coinsurance is identified, Provider is responsible for Covered Services under collecting the Contract or charge Recipients or bill Alliance for missed appointmentspayment from the Member. q. Provider shall comply with the requirements of 42 C.F.R. §438.3(g) including, but not limited to, the identification of provider-preventable conditions as a condition of payment, and appropriate reporting to Alliance. r. Provider shall have policies and procedures that recognize and accept Medicaid as the payer of last resort. s. PIHP shall accept delivery of any requested clinical documentation through a mutually agreed to solution via electronic means available to the Provider and shall not require that the documentation be transmitted via facsimile.

Submission and Payment of Claims. Provider shall not submit claim or encounter data for services covered by the Alliance Tailored Plan directly to the Department. The Provider shall submit all claims for processing and Alliance shall process and pay claims in accordance with the following terms set forth in Attachment J, which are attached hereto and conditionsincorporated herein. Participating Providers shall not submit claim or encounter data for services covered by Alliance directly to the Department. a. If Alliance denies payment of a claim, Alliance shall provide Provider the ability to electronically access the specific denial reason. b. Status of a claim shall be available within five to seven (5-7) days of Alliance’s receipt of the claim. c. Alliance is not limited to approving a claim in full or requesting additional information for the entire claim. Rather, as appropriate, Alliance may approve a claim in part, deny a claim in part, and/or request additional information for only a part of the claim. d. Alliance will not reimburse Provider for services provided by staff not meeting licensure, certification or accreditation requirements. e. Provider agrees to send 837 HIPAA compliant transactions and to receive 835 Remittances or to participate in Alliance's web based billing process. f. Claims must be submitted electronically either through HIPAA Compliant Transaction Sets 820 – Premium Payment, 834 – Member Enrollment and Eligibility Maintenance, 835 – Remittance Advice, 837P – Professional claims, 837I – Institutional claims, or Alliance’s secure web based billing system. Provider will notify Alliance if electronic submission is not possible for a particular claim, and the Parties will work cooperatively to facilitate manual submission of the claim if necessary. g. Provider’s claims shall be compliant with the National Correct Coding Initiative effective on the date of service. h. Both Parties shall be compliant with the requirements of the National Uniform Billing Committee. i. Provider may submit claims beyond one-hundred-eighty (180) days in instances where the Recipient Member has been retroactively enrolled in the NC Medicaid Program or in the BH I/DD Tailored Alliance Medicaid Direct Plan, or where the Recipient Member has primary insurance which has not yet paid or denied its claim. In such instances, Provider should bill Alliance within thirty (30) days of receipt of notice by the Provider of the RecipientMember’s eligibility, or within ninety (90) days of final action (including payment or denial) by the primary insurance or Medicare or the date of service or discharge (whichever is later). j. If Provider delays submission of the claims due to the coordination of benefits, subrogation of benefits or the determination of eligibility for benefits for the RecipientMember, Provider should submit such claims within thirty (30) days of the date of the notice of determination of coverage or payment by the third party. k. If a claim is denied, and the Provider wishes to resubmit the denied claim with additional information, Provider must resubmit the claim within ninety (90) days after Provider’s receipt of the denial. If the Provider needs more than ninety (90) days to resubmit a denied claim, Provider must request and receive an extension from Alliance before the expiration of the ninety (90) day deadline, such extension not to be unreasonably withheld. l. All claims shall be adjudicated as outlined in the Alliance Provider Manual. m. Diagnosis submitted on claims must be consistent with the service provided. n. If a specific service (as denominated by specific identifying codes such as CPT or HCPCS) is rendered multiple times in a single day to the same RecipientMember, the specific service may be billed as the aggregate of the units delivered rather than as separate line items. o. Alliance shall not reimburse Provider for “never events” as that term is defined by the Centers for Medicare and Medicaid Services (CMS). p. Provider shall not require cobill any member for covered services, except for specified coinsurance, copayments, and applicable deductibles established by the Department. This provision shall not prohibit a Provider and Member from agreeing to continue non-payscovered services at the Member's own expense, as long as the Provider has notified the Member in advance that the PIHP may not cover or continue to cover specific services and the member to receive the service. If a Member deductibles, or other forms of cost sharing copayments, coinsurance is identified, Provider is responsible for Covered Services under collecting the Contract or charge Recipients or bill Alliance for missed appointmentspayment from the Member. q. Provider shall comply with the requirements of 42 C.F.R. §438.3(g) including, but not limited to, the identification of provider-preventable conditions as a condition of payment, and appropriate reporting to Alliance. r. Provider shall have policies and procedures that recognize and accept Medicaid as the payer of last resort. s. PIHP shall accept delivery of any requested clinical documentation through a mutually agreed to solution via electronic means available to the Provider and shall not require that the documentation be transmitted via facsimile.