Common use of Third Party Resources Clause in Contracts

Third Party Resources. If an Enrollee has resources available for payment of expenses associated with the provision of Covered Services, other than those which are exempt under Title XIX of the Act, such resources are primary to the coverage provided by the Division and must be exhausted prior to payment by the Division. The capitation rates set forth in this Contract have been adjusted to account for the primary liability of third parties to pay such expenses. The Contractor shall be responsible for making every reasonable effort to determine the legal liability of third parties to pay for services rendered to Enrollees pursuant to this Contract. All funds recovered by the Contractor from third party resources shall be treated as income to the Contractor. The Contractor may delay payment of a subcontractor or Outside Provider for up to sixty (60) days following the date of receipt of the claims by the Contractor in the event that a third party resource is identified from which the subcontractor or Outside Provider is obligated to collect payment. If payment is made by the third party directly to a subcontractor or Outside Provider within sixty (60) days following the date of service, the Contractor may pay the subcontractor or Outside Provider only the amount, if any, by which the allowable claim exceeds the amount of the third party liability. If payment is not made by the third party within such sixty (60) day period, the Contractor must pay the subcontractor or Outside Provider and obtain a refund of any subsequent payments made by the third party. The Contractor may not withhold payment from a subcontractor or Outside Provider for services provided to an Enrollee due to the existence of third party resources, because the liability of a third party resource cannot be determined, or because payment will not be available within sixty (60) days. The exception to the sixty (60) day delayed payment rule is for prescribed drugs which are paid pursuant to an approved waiver described in 42 CFR § 433.139(b)(2)(i) and for medical services provided to pregnant women and children as specified in 42 CFR § 433.139 (b)(2)(ii) and (3). These services must be paid to the subcontractor or Outside Provider and the Contractor must pursue recovery from the liable third party source. The Contractor shall submit a report to the Division within thirty (30) days from discovery by the Contractor or subcontractor of any unknown third party resource or of the termination of a known resource. This report shall include Enrollee name, Medicaid ID number, dates of coverage, and third party resource.

Third Party Resources. If an Enrollee has resources available for payment of expenses associated with the provision of Covered Services, other than those which are exempt under Title XIX of the Act, such resources are primary to the coverage provided by the Division and must be exhausted prior to payment by the Division. The capitation rates set forth in this Contract have been adjusted to account for the primary liability of third parties to pay such expenses. The Contractor shall be responsible for making every reasonable effort to determine the legal liability of third parties to pay for services rendered to Enrollees pursuant to this Contract. All funds recovered by the Contractor from third party resources shall be treated as income to the Contractor. The Contractor may delay payment of a subcontractor or Outside Provider for up to sixty (60) days following the date of receipt of the claims by the Contractor in the event that a third party resource is identified from which the subcontractor or Outside Provider is obligated to collect payment. If payment is made by the third party directly to a subcontractor or Outside Provider within sixty (60) days following the date of service, the Contractor may pay the subcontractor or Outside Provider only the amount, if any, by which the allowable claim exceeds the amount of the third party liability. If payment is not made by the third party within such sixty (60) day period, the Contractor must pay the subcontractor or Outside Provider and obtain a refund of any subsequent payments made by the third party. The Contractor may not withhold payment from a subcontractor or Outside Provider for services provided to an Enrollee due to the existence of third party resources, because the liability of a third party resource cannot be determined, or because payment will not be available within sixty (60) days. The exception to the sixty (60) 60 day delayed payment rule is for prescribed drugs which are paid pursuant to an approved waiver described in 42 CFR § 433.139(b)(2)(i) and for medical services provided to pregnant women and children as specified in 42 CFR § 433.139 (b)(2)(ii) and (3). These services must be paid to the subcontractor or Outside Provider and the Contractor must pursue recovery from the liable third party source. The Contractor shall submit a report to the Division within thirty (30) days from discovery by the Contractor or subcontractor of any unknown third party resource or of the termination of a known resource. This report shall include Enrollee name, Medicaid ID number, dates of coverage, and third party resource.