Common use of WITHHOLDING OF CAPITATION PAYMENTS AND ORDERS TO PROVIDE SERVICES Clause in Contracts

WITHHOLDING OF CAPITATION PAYMENTS AND ORDERS TO PROVIDE SERVICES. Notwithstanding the provisions of Article VI, the Department may withhold portions of capitation payments as liquidated damages or otherwise recover damages from the HMO on the following grounds: 1. Whenever the Department determines that the HMO has failed to provide one or more of the medically necessary Medicaid covered contract services required under Article III, the Department may either order the HMO to provide such service, or withhold a portion of the HMO’s capitation payments for the following month or subsequent months, such portion withheld to be equal to the amount of money the Department must pay to provide such services. If the Department orders the HMO to provide services under this section and the HMO fails to provide the services within the timeline specified by the Department, the Department may withhold from the HMO’s capitation payments an amount up to 150% of the FFS amount for such services. When it withholds payments under this section, the Department must submit to the HMO a list of the participants for whom payments are being withheld, the nature of the service(s) denied, and payments the Department must make to provide medically necessary services. If the Department acts under this section and subsequently determines that the services in question were not covered services: a. If the Department withheld payments, it will restore to the HMO the full capitation payment; or b. If the Department ordered the HMO to provide services under this section, it will pay the HMO the actual documented cost of providing the services. 2. If the HMO fails to submit required data and/or information to the Department or the Department’s authorized agents, or fails to submit such data or information in the required form or format, by the deadline specified by the Department, the Department may immediately impose HMO Contract for February 1, 2006 - December 31, 2007 liquidated damages in the amount of $1,500 per day for each day beyond the deadline that the HMO fails to submit the data or fails to submit the data in the required form or format, such liquidated damages to be deducted from the HMO’s capitation payments. 3. If the HMO fails to comply with state and federal compliance requirements for abortions, hysterectomies and sterilizations, the Department may impose liquidated damages in the amount of $10,000.

WITHHOLDING OF CAPITATION PAYMENTS AND ORDERS TO PROVIDE SERVICES. Notwithstanding the provisions of Article VIV, the Department may withhold portions of capitation payments as liquidated damages or otherwise recover damages from the HMO on the following grounds: 1. Whenever the Department determines that the HMO has failed to provide one or more of the medically necessary Medicaid covered contract services required under Article III, the Department may either order the HMO to provide such service, or withhold a portion of the HMO’s 's capitation payments for the following month or subsequent months, such portion withheld to be equal to the amount of money the Department must pay to provide such services. If the Department orders the HMO to provide services under this section and the HMO fails to provide the services within the timeline specified by the Department, the Department may withhold from the HMO’s capitation payments an amount up to 150% 150 percent of the FFS amount for such servicesservices from the HMO's capitation payments. When it withholds payments under this section, the Department must submit to the HMO a list of the participants for whom payments are being withheld, the nature of the service(s) denied, and payments the Department must make to provide medically necessary services. If the Department acts under this section and subsequently determines that the services in question were not covered services: a. If In the event the Department withheld payments, payments it will shall restore to the HMO the full capitation payment; , or b. If In the event the Department ordered the HMO to provide services under this section, it will shall pay the HMO the actual documented cost of providing the services. 2. If the HMO fails to submit required data and/or information to the Department or the Department’s 's authorized agents, or fails to submit such data or information in the required form or format, by the deadline HMO Contract for January 1, 2002 - December 31, 2003 -95- specified by the Department, the Department may immediately impose HMO Contract for February 1, 2006 - December 31, 2007 liquidated damages in the amount of $1,500 per day for each day beyond the deadline that the HMO fails to submit the data or fails to submit the data in the required form or format, such liquidated damages to be deducted from the HMO’s 's capitation payments. 3. If the HMO fails to comply with state submit State and federal Federal reporting and compliance requirements for abortions, hysterectomies and sterilizations, the Department may impose liquidated damages in the amount of $10,00010,000 per reporting period. 4. If the HMO fails to correct an error to the encounter record within the timeframe specified, the Department may assess liquidated damages of $5 per erred encounter record per month until the error has been corrected. The liquidated damage amount will be deducted from the HMO's capitation payment. When applied, these liquidated damages will be calculated and assessed on a monthly basis. If upon audit or review, the Department finds that the HMO has, without Department approval, removed an erred encounter record, the Department may assess liquidated damages for each day from the date of original error notification until the date of correction.

WITHHOLDING OF CAPITATION PAYMENTS AND ORDERS TO PROVIDE SERVICES. Notwithstanding the provisions of Article VIthis Contract, the Department may withhold portions of capitation payments as liquidated damages or otherwise recover damages from the HMO on the following grounds: 1. a. Whenever the Department determines that the HMO has failed to provide one or more of the medically necessary Medicaid covered contract services required under Article IIIthe Contract, the Department may either order the HMO to provide such service, or withhold a portion of the HMO’s capitation payments for the following month or subsequent months, such portion withheld to be equal to the amount of money the Department must pay to provide such services. If the Department orders the HMO to provide services under this section and the HMO fails to provide the services within the timeline specified by the Department, the Department may withhold from the HMO’s capitation payments an amount up to 150% of the FFS Fee for Service amount for such services. When it withholds payments under this section, the Department must submit to the HMO a list of the participants for whom payments are being withheld, the nature of the service(s) denied, and payments the Department must make to provide medically necessary services. If the Department acts under this section and subsequently determines that the services in question were not covered services: a. : • If the Department withheld payments, it will restore to the HMO the full capitation payment; or b. or • If the Department ordered the HMO to provide services under this section, it will pay the HMO the actual documented cost of providing the services. 2. b. If the HMO fails to submit required data and/or information to the Department or the Department’s authorized agents, or fails to submit such data or information in the required form or format, by the deadline specified by the Department, the Department may immediately impose HMO Contract for February 1, 2006 - December 31, 2007 liquidated damages in the amount of $1,500 per day for each day beyond the deadline that the HMO fails to submit the data or fails to submit the data in the required form or format, such liquidated damages to be deducted from the HMO’s capitation payments. Additionally, if it is found that the HMO failed to submit accurate and complete encounter data prior to the submission deadlines, the Department will be considered damaged. The HMO may be held responsible for reimbursing the Department for the staffing and out-of-pocket costs incurred by the Department and its contractors associated with reviewing the delayed data submission, and developing and publishing revised rates. 3. c. If the HMO fails to comply with state and federal compliance requirements for abortions, hysterectomies and sterilizations, the Department may impose liquidated damages in the amount of $10,000. d. The HMO must meet the Department’s aggregate standards for submitting encounter data as outlined in Article XII (D) or liquidated damages may apply based on “erred” data.

WITHHOLDING OF CAPITATION PAYMENTS AND ORDERS TO PROVIDE SERVICES. Notwithstanding the provisions of Article VI, the Department may withhold portions of capitation payments as liquidated damages or otherwise recover damages from the HMO on the following grounds: 1. Whenever the Department determines that the HMO has failed to provide one or more of the medically necessary Medicaid covered contract services required under Article III, the Department may either order the HMO to provide such service, or withhold a portion of the HMO’s capitation payments for the following month or subsequent months, such portion withheld to be equal to the amount of money the Department must pay to provide such services. If the Department orders the HMO to provide services under this section and the HMO fails to provide the services within the timeline specified by the Department, the Department may withhold from the HMO’s capitation payments an amount up to 150% of the FFS amount for such services. When it withholds payments under this section, the Department must submit to the HMO a list of the participants for whom payments are being withheld, the nature of the service(s) denied, and payments the Department must make to provide medically necessary services. If the Department acts under this section and subsequently determines that the services in question were not covered services: a. If the Department withheld payments, it will restore to the HMO the full capitation payment; or b. If the Department ordered the HMO to provide services under this section, it will pay the HMO the actual documented cost of providing the services. 2. If the HMO fails to submit required data and/or information to the Department or the Department’s authorized agents, or fails to submit such data or information in the required form or format, by the deadline specified by the Department, the Department may immediately impose HMO Contract for February 1, 2006 - December 31, 2007 liquidated damages in the amount of $1,500 per day for each day beyond the deadline that the HMO fails to submit the data or fails to submit the data in the required form or format, such liquidated damages to be deducted from the HMO’s capitation payments. 3. If the HMO fails to comply with submit state and federal reporting and compliance requirements for abortions, hysterectomies and sterilizations, the Department may impose liquidated damages in the amount of $10,00010,000 per reporting period.

WITHHOLDING OF CAPITATION PAYMENTS AND ORDERS TO PROVIDE SERVICES. Notwithstanding the provisions of Article VIV, the Department may withhold portions of capitation payments as liquidated damages or otherwise recover damages from the HMO on the following grounds: 1. Whenever the Department determines that the HMO has failed to provide one or more of the medically necessary Medicaid covered contract services required under Article III, the Department may either order the HMO to provide such service, or withhold a portion of the HMO’s 's capitation payments for the following month or subsequent months, such portion withheld to be equal to the amount of money the Department must pay to provide such services. If the Department orders the HMO to provide services under this section and the HMO fails to provide the services within the timeline specified by the Department, the Department may withhold from the HMO’s capitation payments an amount up to 150% 150 percent of the FFS fee-for-service amount for such servicesservices from the HMO's capitation payments. When it withholds payments under this section, the Department must submit to the HMO a list of the participants for whom payments are being withheld, the nature of the service(s) denied, and payments the Department must make to provide medically necessary services. If the Department acts under this section and subsequently determines that the services in question were not covered services: a. If In the event the Department withheld payments, payments it will shall restore to the HMO the full capitation payment; , or b. If In the event the Department ordered the HMO to provide services under this section, it will shall pay the HMO the actual documented cost of providing the services. 2. If the HMO fails to submit required data and/or information to the Department or the Department’s 's authorized agents, or fails to submit such data or information in the required form or format, by the deadline specified by the Department, the Department may immediately impose HMO Contract for February 1, 2006 - December 31, 2007 liquidated damages in the amount of $1,500 per day for each day beyond the deadline that the HMO fails to submit the data or fails to submit the data in the required form or format, such liquidated damages to be deducted from the HMO’s 's capitation payments.. HMO Contract for January 1, 2000 - December 31, 2001 3. If the HMO fails to comply with state submit State and federal Federal reporting and compliance requirements for abortions, hysterectomies and sterilizations, the Department may impose liquidated damages in the amount of $10,00010,000 per reporting period. 4. If the HMO fails to correct an error to the encounter record within the timeframe specified, the Department may assess liquidated damages of $5 per erred encounter record per month until the error has been corrected. The liquidated damage amount will be deducted from the HMO's capitation payment. When applied, these liquidated damages will be calculated and assessed on a monthly basis. If upon audit or review, the Department finds that the HMO has, without Department approval, removed an erred encounter record, the Department may assess liquidated damages for each day from the date of original error notification until the date of correction.

WITHHOLDING OF CAPITATION PAYMENTS AND ORDERS TO PROVIDE SERVICES. In any case under this Contract where the Department has the authority to withhold capitation payments, the Department also has the authority to use all other legal processes for the recovery of damages. Notwithstanding the provisions of Article VIthis Contract, the Department may withhold portions of capitation payments as liquidated damages or otherwise recover damages from the HMO on the following grounds: 1. a. Medically Necessary Covered Services Whenever the Department determines that the HMO has failed to provide one or more of the medically necessary Medicaid covered contract services required under Article IIIthe Contract, the Department may either order the HMO to provide such service, or withhold a portion of the HMO’s capitation payments for the following month or subsequent months, such portion withheld to be equal to the amount of money the Department must pay to provide such services. If the Department orders the HMO to provide services under this section and the HMO fails to provide the services within the timeline specified by the Department, the Department may withhold from the HMO’s capitation payments an amount up to 150% of the FFS Fee for Service amount for such services. When it withholds payments under this section, the Department must submit to the HMO a list of the participants for whom payments are being withheld, the nature of the service(s) denied, and payments the Department must make to provide medically necessary services. If the Department acts under this section and subsequently determines that the services in question were not covered services: a. :  If the Department withheld payments, it will restore to the HMO the full capitation payment; or b. or  If the Department ordered the HMO to provide services under this section, it will pay the HMO the actual documented cost of providing the services. b. Payment Denials for New Members Payments provided for under the contract will be denied for new members when, and for so long as, payment for those members is denied by CMS in accordance with the requirements in 42 CFR 438.730. Specifically, the State may recommend that CMS impose the denial of payment for new members to an HMO that has a contract to provide BadgerCare Plus and/or Medicaid SSI services if the State determines that the HMO acts or fails to act as pursuant to 42 CFR 438.700. The State’s determination becomes CMS’ determination for purposes of Section 1903(m)(5)(A) of the Act unless CMS reverses or modifies it within 15 days. When the State decides to recommend imposing the sanctions described in 42 CFR 438.730(e), this recommendation becomes CMS’ decision, for purposes of section 1903(m)(5)(B)(ii) of the Act, unless CMS rejects this (1) Give the HMO written notice of the nature and basis of the proposed sanction; (2) Allow the HMO 15 days from the date it receives the notice to provide evidence that it has not acted or failed to act in the manner that is the basis for the recommended sanction; (3) May extend the initial 15-day period for an additional 15 days if: (i) The HMO submits a written request that includes a credible explanation of why it needs additional time; (ii) The request is received by CMS before the end of the initial period; (iii) CMS has not determined that the HMO’s conduct poses a threat to an enrollee’s health or safety. If the HMO submits a timely response to the notice of sanction, the State: (i) Conducts an informal reconsideration that includes review of the evidence by a State agency official who did not participate in the original recommendation; (ii) Gives the HMO a concise written decision setting forth the factual and legal basis for the decision; (iii) Forwards the decision to CMS. The State’s decision will become CMS’ decision unless CMS reverses or modifies the decision within 15 days from date of receipt by CMS. If CMS reverses or modifies the State decision, the agency sends the HMO a copy of CMS’ decision. c. Required Reports and Data Submissions 1) Encounter Data If the HMO fails to submit required data and/or information to the Department or the Department’s authorized agents, or fails to submit such data or information in the required form or format, by the deadline specified by the Department, the Department may immediately impose HMO Contract for February 1, 2006 - December 31, 2007 liquidated damages in the amount of $1,500 per day for each day beyond the deadline that the HMO fails to submit the data or fails to submit the data in the required form or format, such liquidated damages to be deducted from the HMO’s capitation payments. 3. If Additionally, if it is found that the HMO fails failed to comply with state submit accurate and federal compliance requirements for abortions, hysterectomies and sterilizationscomplete encounter data prior to the submission deadlines, the Department will be considered damaged. The HMO may impose be held responsible for reimbursing the Department for the staffing and out-of-pocket costs incurred by the Department and its contractors associated with reviewing the delayed data submission, and developing and publishing revised rates. The HMO must meet the Department’s aggregate standards for submitting encounter data as outlined in Article XII(D) or liquidated damages in the amount of $10,000may apply based on “erred” data.