Common use of Third Party Payors Clause in Contracts

Third Party Payors. 1. Not seek reimbursement from System Agency if the individual is covered by a third-party payor. 2. Demonstrate the capacity to bill insurance, Medicaid, and/or Medicare for individuals with health insurance coverage. i. Contract with Medicaid and the identified Managed Care Organizations in service delivery Region ii. Contract with Medicare in the service delivery Region. 3. Refer individuals to a treatment Program that is approved by the individual’s third-party payor if Grantee is not eligible for reimbursement. i. If the approved treatment Program refuses treatment services to the Client and documents that refusal, Grantee may provide treatment services and bill System Agency; ii. The refusal, including third-party payor and approved treatment Program, is documented in the Client file; (1) The Client meets the diagnostic criteria for substance use disorder; and (2) If Client’s third-party payor would cover or approves partial or full payment for treatment services, Grantee may bill System Agency for the non-reimbursed costs, including the deductible, provided: a. The Client’s parent/guardian refuses to file a claim with the third party payor, or refuses to pay either the deductible or the non-reimbursed portion of the cost of treatment, and Respondent has obtained a signed statement from the parent/guardian of refusal to pay, and Xxxxxxx has received written approval from the System Agency substance use disorder treatment Program services clinical coordinator to bill for the deductible or non-reimbursed portion of the cost; b. The Client or parent/guardian cannot afford to pay the deductible or the non- reimbursed portion of the cost of treatment; or c. The Client or parent/guardian has an adjusted income at or below200% of the Federal poverty guidelines. iii. If a Client has exhausted all insurance coverage and requires continued treatment, Grantee may provide the continued treatment services and bill System Agency if the Client meets Section II (C) 1-3.

Third Party Payors. 1. Not seek reimbursement from System Agency if the individual is covered by a third-party payor. 2. Demonstrate the capacity to bill insurance, Medicaid, and/or Medicare for individuals with health insurance coverage. i. Contract with Medicaid and the identified Managed Care Organizations in service delivery Region ii. Contract with Medicare in the service delivery Region. 3. Refer individuals to a treatment Program that is approved by the individual’s third-party payor if Grantee is not eligible for reimbursement. i. If the approved treatment Program refuses treatment services to the Client and documents that refusal, Grantee may provide treatment services and bill System Agency; ii. The refusal, including third-party payor and approved treatment Program, is documented in the Client file; (1) The Client meets the diagnostic criteria for substance use disorder; and (2) If Client’s third-party payor would cover or approves partial or full payment for treatment services, Grantee may bill System Agency for the non-reimbursed costs, including the deductible, provided: a. The Client’s parent/guardian refuses to file a claim with the third party payor, or refuses to pay either the deductible or the non-reimbursed portion of the cost of treatment, and Respondent has obtained a signed statement from the parent/guardian of refusal to pay, and Xxxxxxx has received written approval from the System Agency substance use disorder treatment Program services clinical coordinator to bill for the deductible or non-reimbursed portion of the cost; b. The Client or parent/guardian cannot afford to pay the deductible or the non- reimbursed portion of the cost of treatment; or c. The Client or parent/guardian has an adjusted income at or below200below 200% of the Federal poverty guidelines. iii. If a Client has exhausted all insurance coverage and requires continued treatment, Grantee may provide the continued treatment services and bill System Agency if the Client meets Section II (C) 1-3.