Claims Adjudication. The MCP shall have the capacity to electronically accept and adjudicate all claims to final status (payment or denial). Information on claims submission procedures shall be provided to non-contracting providers within 30 calendar days of a request. The MCP shall inform providers of its ability to electronically process and adjudicate claims and the process for submission. Such information shall be initiated by the MCP and not only in response to provider requests.
Claims Adjudication. The MCP must have the capacity to electronically accept and adjudicate all claims to final status (payment or denial). Information on claims submission procedures must be provided to non-contracting providers within thirty (30) days of a request. The MCP must inform providers of its ability to electronically process and adjudicate claims and the process for submission. Such information must be initiated by the MCP and not only in response to provider requests. The MCP must notify providers who have submitted claims of claims status [paid, denied, pended (suspended)] within one month of receipt by the MCP or its designee. Such notification may be in the form of a claim payment/remittance advice produced on a routine monthly, or more frequent, basis.
Claims Adjudication. Health Plan or its designee shall receive, process and pay in a timely manner claims for Covered Services rendered by Provider in accordance with the authorization procedures as set forth in the Provider Manual. Health Plan shall ensure that Clean Claims are adjudicated promptly in accordance with applicable statutory and regulatory requirements. Health Plan shall work diligently with Provider to resolve any perceived lack of timeliness with regard to claims payment under this Agreement.
Claims Adjudication. 1. Contractor shall adjudicate claims according to each and every element of the Plan Benefit Designs (not limited to those listed above) for the MSI Program and separately for the BHS Program.
Claims Adjudication. The Company agrees to act in good faith and in accordance with its standard claims practices applicable for all claims, regardless if reinsured, when enforcing the terms and conditions of the Policies in connection with the administration, negotiation, payment, denial or settlement of a claim.
Claims Adjudication. 6.3.1 HCT shall not be liable to make any payments for Covered Services for which Group fails to follow the prior authorization and eligibility verification procedures set forth in this Agreement, HCT’s Provider Manual and other applicable policies and procedures and under the applicable Certificate of Coverage. Further, all or a portion of payment due Group may be denied by HCT if such payment is specifically attributable to Group’s rendering or ordering: (i) services that are not Medically Necessary; (ii) services provided other than at an authorized level of care; or
Claims Adjudication. Administrator, directly or through a third party Claims Processor, shall adjudicate and process Prescription Claims for Covered Prescription Services in a POS environment in accordance with NCPDP guidelines, standards and guidelines established by the Pharmacy Plan Specifications and applicable Laws and Regulations. Administrator shall pay, on United’s behalf, only:
Claims Adjudication. 6.3.1 HCT shall not be liable to make any payments for Covered Services for which Provider fails to follow the prior authorization and eligibility verification procedures set forth in this Agreement, HCT’s Provider Manual and other applicable policies and procedures and under the applicable Certificate of Coverage. Further, all or a portion of payment due Provider may be denied by HCT if such payment is specifically attributable to Provider’s rendering or ordering: (i) services that are not Medically Necessary; (ii) services provided other than at an authorized level of care; or (iii) services that are not Covered Services.
Claims Adjudication. 4.1.1 Following receipt of a Claim, MHSAL shall adjudicate the Claim against the requirements of this Agreement, the applicable provisions of the Manual, any Policy, and any Procedure.
Claims Adjudication. In processing claims, Medical Group shall accept and adjudicate claims for health care service provided to PacifiCare Members in accordance with the provisions of Sections 1371, 1371.1, 1371.2, 1371.22, 1371.35, 1371.36, 1371.37, 1371.38, 1371.4, and 1371.8 of the California Health and Safety Code and Sections 1300.71, 1300.71.38, 1300.71.4, and 1300.77.4 of Title 28 of the California Code of Regulations.
