Common use of Third Party Reimbursement Clause in Contracts

Third Party Reimbursement. a. Provider shall comply with N.C.G.S. § 122C-146, which requires the Provider and Alliance to make every reasonable effort to collect payments from third party payers. Each time a Member receives services Provider shall determine if the Member has third party coverage that covers the service provided. Provider shall report any third party coverage to the appropriate county Department of Social Services (DSS) within five (5) days of obtaining the information from a source other than DSS. Provider shall report any change in county of residence to Alliance. b. Provider is required to bill all applicable third party payers prior to billing Alliance. i. Medicaid benefits payable through Alliance are secondary to benefits payable by a primary payer, including Medicare, even if the primary payer states that its benefits are secondary to Medicaid benefits or otherwise limits its payments to Medicaid beneficiaries. ii. Alliance makes secondary payments to supplement the primary payment if the primary payment is less than the lesser of the usual and customary charges for the service or the rate established by Alliance. iii. Alliance does not make a secondary payment if the Provider is either obligated to accept, or voluntarily accepts, as full payment, a primary payment that is less than its charges. iv. If Provider or Member receives a reduced primary payment because of failure to file a proper claim with the primary payer, Alliance’s secondary payment may not exceed the amount that would have been payable if the primary payer had paid on the basis of a proper claim. v. Provider must inform Alliance that a reduced payment was made, and the amount that would have been paid if a proper claim had been filed. c. Provider shall bill Alliance for third party co-pays and/or deductibles only as permitted by Controlling Authority.

Third Party Reimbursement. a. Provider shall comply with N.C.G.S. § 122C-146, which requires the Provider and Alliance to make every reasonable effort to collect payments from third party payers. Each time a Member Recipient receives services Provider shall determine if the Member Recipient has third party coverage that covers the service provided. Provider shall report any third party coverage to the appropriate county Department of Social Services (DSS) within five (5) days of obtaining the information from a source other than DSS. Provider shall report any change in county of residence to Alliance. b. Provider is required to bill all applicable third party payers prior to billing Alliance. i. Medicaid benefits payable through Alliance are secondary to benefits payable by a primary payer, including Medicare, even if the primary payer states that its benefits are secondary to Medicaid benefits or otherwise limits its payments to Medicaid beneficiaries. ii. Alliance makes secondary payments to supplement the primary payment if the primary payment is less than the lesser of the usual and customary charges for the service or the rate established by Alliance. iii. Alliance does not make a secondary payment if the Provider is either obligated to accept, or voluntarily accepts, as full payment, a primary payment that is less than its charges. iv. If Provider or Member Recipient receives a reduced primary payment because of failure to file a proper claim with the primary payer, Alliance’s secondary payment may not exceed the amount that would have been payable if the primary payer had paid on the basis of a proper claim. v. Provider must inform Alliance that a reduced payment was made, and the amount that would have been paid if a proper claim had been filed. c. Provider shall bill Alliance for third party co-pays and/or deductibles only as permitted by Controlling Authority.