Common use of THIRD PARTY, PRIMARY OR OTHER INSURANCE CLAIMS Clause in Contracts

THIRD PARTY, PRIMARY OR OTHER INSURANCE CLAIMS. 32 A. Reimbursement provided through the Contract shall be payment of last resort. Prior to submitting 33 any claim to the Intermediary for reimbursement of Hospital Services provided to an Enrollee, 34 CONTRACTOR shall: 35 1. Use its reasonable best efforts to determine whether the claim is a third party, primary or 36 other insurance covered claim. 37 // 1 2. Bill and use its reasonable best efforts to collect third party, primary or other insurance 2 covered claims to the full extent of such coverage. 3 B. CONTRACTOR shall determine that a claim is not covered, in whole or in part, under any other 4 state or federal medical care program or under any other contractual or legal entitlement including, but 5 not limited to, coverage defined in W&I Section 10020. 6 C. With submission of a claim, CONTRACTOR shall provide proof of denial to the Intermediary, if 7 a third party, primary or other insurance denies coverage of the claim. 8 D. CONTRACTOR shall report to the Intermediary any payments received from a third party, primary 9 or other insurance covered claims. 10 E. The Contract shall not allow for reimbursement of deductibles or co-payments required by an 11 Enrollee’s third party, primary or other insurance coverage. ADMINISTRATOR shall also not reimburse 12 co-payments required by the MSN Program. 13 F. CONTRACTOR shall provide the Intermediary such records and other documentation as the 14 Intermediary may reasonably require to maintain centralized data collection and referral services in 15 support of third party revenue recovery activities. 16 G. Provider Refunds Of Claims Covered By Other Payments 17 1. If CONTRACTOR, through its own efforts, identifies Medi-Cal coverage, third party 18 settlement, primary or other insurance coverage for services reimbursed through the Contract, 19 CONTRACTOR shall, within thirty (30) calendar days of such identification, unless disputed in 20 accordance with subparagraph G.2. below, to reimburse the Intermediary an amount equal to the MSN 21 payment. If Medi-Cal coverage, third party settlement, primary or other insurance coverage is identified 22 due to efforts of Intermediary’s Third Party Recovery Services (Recovery Services) specified in 23 subparagraph G.4. below, CONTRACTOR shall, within thirty (30) calendar days of notice from Recovery 24 Services, unless disputed in accordance with subparagraph G.2. below, reimburse the Intermediary an 25 amount equal to the MSN payment. Third-party settlement payments may be paid directly to COUNTY 26 or Intermediary, as directed by ADMINISTRATOR. 27 2. Should CONTRACTOR wish to dispute the reimbursement of a MSN payment as a result of 28 the identification of Medi-Cal coverage, third party settlement, primary or other insurance coverage either 29 by CONTRACTOR or through Recovery Services, CONTRACTOR shall give written notice, 30 within thirty (30) calendar days of notice of information, to ADMINISTRATOR’s MSN Program 31 Administrator or designee (MSN Administrator) setting forth in specific terms the existence and nature 32 of any dispute or concern related to the information provided through Recovery Services or the 33 reimbursement due MSN. MSN Administrator shall have fifteen (15) business days following such notice 34 to obtain resolution of any issue(s) identified in this manner, provided, however, by mutual consent this 35 period of time may be extended. If MSN Administrator determines that the recovery information is 36 accurate and appropriate, CONTRACTOR shall, within thirty (30) calendar days of receipt, reimburse an 37 amount equal to the MSN payment. 1 3. For purposes of computing the amount of reimbursement due from CONTRACTOR, the 2 services provided an Enrollee shall be valued at the percentage of reimbursement for the applicable 3 contract period, less any co-payments or other fees. 4 4. COUNTY has contracted for Third Party Recovery Services (Recovery Services) for the 5 purpose of actively pursuing reimbursement of claims paid for MSN Enrollees later determined to be 6 eligible for Medi-Cal or third party, primary or other insurance. CONTRACTOR shall reasonably 7 cooperate in recovering these costs. 8 5. If any reimbursement due is not paid by CONTRACTOR in accordance with subparagraphs 9 G.1., G.2., or G.4. above, the Intermediary shall reduce any payment due CONTRACTOR by an amount 10 not to exceed the amount to be reimbursed. 11 H. CONTRACTOR and ADMINISTRATOR may mutually agree, in writing, to modify the Third 12 Party, Primary, or Other Insurance Claims Paragraph of this Exhibit B to the Contract. 13

THIRD PARTY, PRIMARY OR OTHER INSURANCE CLAIMS. 32 5 A. Reimbursement provided through the Contract thethis Agreement shall be payment of last resort. Prior to 6 submitting 33 any claim to the Intermediary for reimbursement of Hospital Services provided to an 7 Enrollee, 34 CONTRACTOR shall: 35 8 1. Use its reasonable best efforts to determine whether the claim is a third party, primary or 36 9 other insurance covered claim. 37 //. 1 10 2. Bill Xxxx and use its reasonable best efforts to collect third party, primary or other insurance 2 11 covered claims to the full extent of such coverage. 3 12 B. CONTRACTOR shall determine that a claim is not covered, in whole or in part, under any other 4 13 state or federal medical care program or under any other contractual or legal entitlement including, but 5 14 not limited to, coverage defined in W&I Section 10020. 6 15 C. With submission of a claim, CONTRACTOR shall provide proof of denial to the Intermediary, 16 if 7 a third party, primary or other insurance denies coverage of the claim. 8 17 D. CONTRACTOR shall report to the Intermediary any payments received from a third party, 18 primary 9 or other insurance covered claims. 10 19 E. The Contract ADMINISTRATOR shall not allow for reimbursement of reimburse deductibles or co-payments required by an 11 Enrollee’s 20 third party, primary or other insurance coverage. ADMINISTRATOR shall also not reimburse 12 co-co- 21 payments required by the MSN Program. 13 22 F. CONTRACTOR shall provide the Intermediary such records and other documentation as the 14 23 Intermediary may reasonably require to maintain centralized data collection and referral services in 15 24 support of third third-party revenue recovery activities. 16 25 G. Provider Refunds Of Ofof Claims Covered By Byby Other Payments 17 26 1. If CONTRACTOR, through its own efforts, identifies Medi-Cal coverage, third party 18 27 settlement, primary or other insurance coverage for services reimbursed through the Contractthethis Agreement, 19 28 CONTRACTOR shall, within thirty (30) calendar days of such identification, unless disputed in 20 29 accordance with subparagraph G.2. below, to reimburse the Intermediary an amount equal to the MSN 21 30 payment. If Medi-Cal coverage, third party settlement, primary or other insurance coverage is identified 22 31 due to efforts of Intermediary’s Third Party Recovery Services (Recovery Services) specified in 23 32 subparagraph G.4. below, CONTRACTOR shall, within thirty (30) calendar days of notice from 33 Recovery 24 Services, unless disputed in accordance with subparagraph G.2. below, reimburse the 34 Intermediary an 25 amount equal to the MSN payment. Third-party settlement payments may be paid 35 directly to COUNTY 26 or Intermediary, as directed by ADMINISTRATOR. 27 36 2. Should CONTRACTOR wish to dispute the reimbursement of a MSN payment as a result 37 of 28 the identification of Medi-Cal coverage, third party settlement, primary or other insurance coverage 4 of 89 EXHIBIT B 1 either 29 by CONTRACTOR or through Recovery Services, CONTRACTOR shall give written notice, 30 2 within thirty (30) calendar days of notice of information, to ADMINISTRATOR’s MSN Program 31 3 Administrator or designee (MSN Administrator) ), setting forth in specific terms the existence and nature 32 4 of any dispute or concern related to the information provided through Recovery Services or the 33 5 reimbursement due MSN. MSN Administrator shall have fifteen (15) business days following such 6 notice 34 to obtain resolution of any issue(s) identified in this manner, provided, however, by mutual 7 consent this 35 period of time may be extended. If MSN Administrator determines that the recovery 8 information is 36 accurate and appropriate, CONTRACTOR shall, within thirty (30) calendar days of 9 receipt, reimburse an 37 amount equal to the MSN payment. 1 10 3. For purposes of computing the amount of reimbursement due from CONTRACTOR, the 2 11 services provided an to Enrollee shall be valued at the percentage of reimbursement for the applicable 3 12 contract period, less any co-payments or other fees. 4 13 4. COUNTY has contracted for Third Party Recovery Services (Recovery Services) for the 5 14 purpose of actively pursuing reimbursement of claims paid for MSN Enrollees later determined to be 6 15 eligible for Medi-Cal or third party, primary or other insurance. CONTRACTOR shall reasonably 7 16 cooperate in recovering these costs. 8 17 5. If any reimbursement due is not paid by CONTRACTOR in accordance with subparagraphs 9 18 G.1., G.2., or G.4. above, the Intermediary shall reduce any payment due CONTRACTOR by an amount 10 19 not to exceed the amount to be reimbursed. 11 20 H. CONTRACTOR and ADMINISTRATOR may mutually agree, in writing, to modify the Third 12 21 Party, Primary, or Other Insurance Claims Paragraph of this Exhibit B to the ContractAgreement. 1322

THIRD PARTY, PRIMARY OR OTHER INSURANCE CLAIMS. 32 5 A. Reimbursement provided through the Contract this Agreement shall be payment of last resort. Prior to 6 submitting 33 any claim to the Intermediary for reimbursement of Hospital Services provided to an 7 Enrollee, 34 CONTRACTOR shall: 35 8 1. Use its reasonable best efforts to determine whether the claim is a third party, primary or 36 9 other insurance covered claim. 37 //. 1 10 2. Bill Xxxx and use its reasonable best efforts to collect third party, primary or other insurance 2 11 covered claims to the full extent of such coverage. 3 12 B. CONTRACTOR shall determine that a claim is not covered, in whole or in part, under any other 4 13 state or federal medical care program or under any other contractual or legal entitlement including, but 5 14 not limited to, coverage defined in W&I Section 10020. 6 15 C. With submission of a claim, CONTRACTOR shall provide proof of denial to the Intermediary, 16 if 7 a third party, primary or other insurance denies coverage of the claim. 8 17 D. CONTRACTOR shall report to the Intermediary any payments received from a third party, 18 primary 9 or other insurance covered claims. 10 19 E. The Contract ADMINISTRATOR shall not allow for reimbursement of reimburse deductibles or co-payments required by an 11 Enrollee’s 20 third party, primary or other insurance coverage. ADMINISTRATOR shall also not reimburse 12 co-co- 21 payments required by the MSN Program. 13 22 F. CONTRACTOR shall provide the Intermediary such records and other documentation as the 14 23 Intermediary may reasonably require to maintain centralized data collection and referral services in 15 24 support of third third-party revenue recovery activities. 16 25 G. Provider Refunds Of of Claims Covered By by Other Payments 17 26 1. If CONTRACTOR, through its own efforts, identifies Medi-Cal coverage, third party 18 27 settlement, primary or other insurance coverage for services reimbursed through the Contractthis Agreement, 19 28 CONTRACTOR shall, within thirty (30) calendar days of such identification, unless disputed in 20 29 accordance with subparagraph G.2. below, to reimburse the Intermediary an amount equal to the MSN 21 30 payment. If Medi-Cal coverage, third party settlement, primary or other insurance coverage is identified 22 31 due to efforts of Intermediary’s Third Party Recovery Services (Recovery Services) specified in 23 32 subparagraph G.4. below, CONTRACTOR shall, within thirty (30) calendar days of notice from 33 Recovery 24 Services, unless disputed in accordance with subparagraph G.2. below, reimburse the 34 Intermediary an 25 amount equal to the MSN payment. Third-party settlement payments may be paid 35 directly to COUNTY 26 or Intermediary, as directed by ADMINISTRATOR. 27 36 2. Should CONTRACTOR wish to dispute the reimbursement of a MSN payment as a result 37 of 28 the identification of Medi-Cal coverage, third party settlement, primary or other insurance coverage 1 either 29 by CONTRACTOR or through Recovery Services, CONTRACTOR shall give written notice, 30 2 within thirty (30) calendar days of notice of information, to ADMINISTRATOR’s MSN Program 31 3 Administrator or designee (MSN Administrator) ), setting forth in specific terms the existence and nature 32 4 of any dispute or concern related to the information provided through Recovery Services or the 33 5 reimbursement due MSN. MSN Administrator shall have fifteen (15) business days following such 6 notice 34 to obtain resolution of any issue(s) identified in this manner, provided, however, by mutual 7 consent this 35 period of time may be extended. If MSN Administrator determines that the recovery 8 information is 36 accurate and appropriate, CONTRACTOR shall, within thirty (30) calendar days of 9 receipt, reimburse an 37 amount equal to the MSN payment. 1 10 3. For purposes of computing the amount of reimbursement due from CONTRACTOR, the 2 11 services provided an to Enrollee shall be valued at the percentage of reimbursement for the applicable 3 12 contract period, less any co-payments or other fees. 4 13 4. COUNTY has contracted for Third Party Recovery Services (Recovery Services) for the 5 14 purpose of actively pursuing reimbursement of claims paid for MSN Enrollees later determined to be 6 15 eligible for Medi-Cal or third party, primary or other insurance. CONTRACTOR shall reasonably 7 16 cooperate in recovering these costs. 8 17 5. If any reimbursement due is not paid by CONTRACTOR in accordance with subparagraphs 9 18 G.1., G.2., or G.4. above, the Intermediary shall reduce any payment due CONTRACTOR by an amount 10 19 not to exceed the amount to be reimbursed. 11 20 H. CONTRACTOR and ADMINISTRATOR may mutually agree, in writing, to modify the Third 12 Party, Primary, or Other Insurance Claims Paragraph of this Exhibit B to the Contract. 13Third

THIRD PARTY, PRIMARY OR OTHER INSURANCE CLAIMS. 32 29 A. Reimbursement provided through the Contract shall be payment of last resort. Prior to submitting 33 30 any claim to the Intermediary for reimbursement of Hospital Clinic Services provided to an Enrollee, 34 31 CONTRACTOR shall: 35 32 1. Use its reasonable best efforts to determine whether the claim is a third party, primary or 36 33 other insurance covered claim. 37 //. 1 34 2. Bill and use its reasonable best efforts to collect third party, primary or other insurance 2 35 covered claims to the full extent of such coverage. 3 36 B. CONTRACTOR shall determine that a claim is not covered, in whole or in part, under any other 4 37 // 1 state or federal medical care program or under any other contractual or legal entitlement including, but 5 2 not limited to, coverage defined in W&I Section 10020. 6 3 C. With submission of a claim, CONTRACTOR shall provide proof of denial to the Intermediary, if 7 4 a third party, primary or other insurance denies coverage of the claim. 8 5 D. CONTRACTOR shall report to the Intermediary any payments received from a third party, primary 9 6 or other insurance covered claims. 10 7 E. The Contract shall not allow for reimbursement of deductibles or and co-payments required by an 11 8 Enrollee’s third party, primary or other insurance coverage. ADMINISTRATOR The Contract shall also not reimburse 12 allow for 9 reimbursement of co-payments required by the MSN Program. 13 10 F. CONTRACTOR shall provide the Intermediary such records and other documentation as the 14 11 Intermediary may reasonably require to maintain centralized data collection and referral services in 15 12 support of third party revenue recovery activities. 16 13 G. Provider Refunds Of Claims Covered By Other Payments 17 14 1. If CONTRACTOR, through its own efforts, identifies Medi-Cal coverage, third party 18 15 settlement, primary or other insurance coverage for services reimbursed through the Contract, 19 16 CONTRACTOR shall, within thirty (30) calendar days of such identification, unless disputed in 20 17 accordance with subparagraph G.2. below, to reimburse the Intermediary an amount equal to the MSN 21 18 payment. If Medi-Cal coverage, third party settlement, primary or other insurance coverage is identified 22 19 due to efforts of Intermediary’s Third Party Recovery Services (Recovery Services) specified in 23 20 subparagraph G.4. below, CONTRACTOR shall, within thirty (30) calendar days of notice from Recovery 24 21 Services, unless disputed in accordance with subparagraph G.2. below, reimburse the Intermediary an 25 22 amount equal to the MSN payment. Third-party settlement payments may be paid directly to COUNTY 26 23 or Intermediary, as directed by ADMINISTRATOR. 27 24 2. Should CONTRACTOR wish to dispute the reimbursement of a MSN payment as a result of 28 25 the identification of Medi-Cal coverage, third party settlement, primary or other insurance coverage either 29 26 by CONTRACTOR or through Recovery Services, CONTRACTOR shall give written notice, 30 27 within thirty (30) calendar days of notice of information, to ADMINISTRATOR’s MSN Program 31 28 Administrator or designee (MSN Administrator) setting forth in specific terms the existence and nature 32 29 of any dispute or concern related to the information provided through Recovery Services or the 33 30 reimbursement due MSN. MSN Administrator shall have fifteen (15) business days following such notice 34 31 to obtain resolution of any issue(s) identified in this manner, provided, however, by mutual consent this 35 32 period of time may be extended. If MSN Administrator determines that the recovery information is 36 33 accurate and appropriate, CONTRACTOR shall, within thirty (30) calendar days of receipt, reimburse an 37 34 amount equal to the MSN payment. 1 35 3. For purposes of computing the amount of reimbursement due from CONTRACTOR, the 2 36 services provided an Enrollee shall be valued at the percentage of reimbursement for the applicable 3 37 contract period, less any co-payments or other fees. 4 1 4. COUNTY has contracted for Third Party Recovery Services (Recovery Services) for the 5 2 purpose of actively pursuing reimbursement of claims paid for MSN Enrollees later determined to be 6 3 eligible for Medi-Cal or third party, primary or other insurance. CONTRACTOR shall reasonably 7 4 cooperate in recovering these costs. 8 5 5. If any reimbursement due is not paid by CONTRACTOR in accordance with subparagraphs 9 6 G.1., G.2., or G.4. above, the Intermediary shall reduce any payment due CONTRACTOR by an amount 10 7 not to exceed the amount to be reimbursed. 11 8 H. CONTRACTOR and ADMINISTRATOR may mutually agree, in writing, to modify the Third 12 Party, Primary, 9 Party Primary or Other Insurance Claims Paragraph of this Exhibit B to the Contract. 1310