United Requirements. 4.1 Consistent with the exception language in N.Y. Ins. Law §3224-b, United shall retain the right to audit Provider’s claims for a two (2) year period from the date the care, services or supplies were provided or billed, or statutory requirement, whichever is later, and to recoup any overpayments discovered as a result of the audit. This two (2) year limitation does not apply to situations in which fraud may be involved or in which Provider or an agent of Provider prevents or obstructs United’s auditing. United shall provide Provider an opportunity to challenge an overpayment recovery in accordance with N.Y. Ins. Law §3224-b.
4.2 In addition to the requirements found in New York Public Health Law § 4406-d, United shall not terminate the Agreement unless United provides Provider with a written explanation of the reasons for the proposed termination and an opportunity for a review or hearing. These requirements will not apply in cases involving imminent harm to patient care, a determination of fraud, or a fiscal disciplinary action by a state licensing board or other governmental agency that impairs Provider’s ability to provide health care services.
(a) If United intends to terminate the Agreement, the notification of the proposed termination must include:
(i) The reasons for the proposed action;
(ii) Notice that Provider has the right to request a hearing or review, at Provider’s discretion, before a panel appointed by United;
(iii) A time limit of not less than thirty (30) days within which Provider may request a hearing; and
(iv) A time limit for a hearing date that must be held within thirty (30) days after the receipt of a request for a hearing.
(b) Except as provided in this Section, nothing in the Agreement or this Appendix shall supersede or impair Provider’s right to notice of reasons for termination and the opportunity for a hearing or review concerning such termination. The procedures for such hearing shall comply with the requirements set forth in the applicable State Contract and any applicable law. In no event shall termination be effective earlier than sixty (60) days from the receipt of the notice of termination.
4.3 United shall make payments to Provider for items and services covered under the State Contracts on a timely basis, consistent with the claims payment procedures described in N.Y. Ins. Law § 3224-a and 42 CFR 447.46, 42 CFR 447.45(d)(2), 42 CFR 447.45(d)(3), 42 CFR 447.45(d)(5) and 42 CFR 447.45(d)(6), as applicable and as may b...
United Requirements. 4.1 Prompt Payment. Subcontractor and/or Health Plan, as applicable, shall pay Provider pursuant to the State Contract and applicable State and federal law and regulations, including but not limited to 42 CFR 447.46, 42 CFR 447.45(d)(2), 42 CFR 447.45(d)(3), 42 CFR 447.45(d)(5) and 42 CFR 447.45(d)(6), as applicable and as may be amended from time to time. If a third party liability exists, payment of claims shall be determined in accordance with federal and/or State third party liability law and the terms of the State Contract. Unless Subcontractor and/or Health Plan otherwise requests assistance from Provider, Subcontractor and/or Health Plan will be responsible for third party collections in accordance with the terms of the State Contract.
United Requirements
