Claims Payment. The Reinsurer will be liable to the Company for the benefits reinsured and the reinsurance will not exceed the Company's contractual liability under the terms of its policies. The payment of death claims by the Reinsurer will be in one lump sum regardless of the mode of settlement under the original policy. The Reinsurer's share of interest, which is based on the death proceeds paid by the Company, will be payable in addition to the death claim settlement. The Reinsurer will pay to the Company premiums at the rate applicable to the original policy on any policy approved for a waiver of premium claim, provided always that the waiver of premium benefit applicable to such benefits has been reinsured under this Agreement.
Claims Payment. If the Contractor fails to pay or deny at least ninety-eight percent (98%) of electronically filed clean claims in a given month within thirty (30) days of receipt, and/or at least ninety-eight percent (98%) clean paper claims in a given month within forty-five (45) calendar days of receipt, the Division shall deem this to be an instance of unsatisfactory claims performance and the Contractor will pay a fine of fifteen thousand dollars ($15,000.00) for each month that such determination is made. Should the Contractor have two (2) consecutive months of unsatisfactory claims performance, the Division shall immediately suspend enrollment of MississippiCAN members with the contractor, until such time as the Contractor successfully demonstrates that all past due clean claims have been paid or denied. Continued violations of this section may result in termination of the contract by the Division. Complaints. As used herein, the term “Medicaid Investigated Complaint” refers to a written member or provider complaint to the Division (or to another State agency or official and which is director to the Division) where (a) Division staff are assigned to investigate and address the issues raised by the complaint, and (b) the Division concludes that the complaint is valid even if the disposition of the complaint is not resolved in favor of the complaining party. If the contractor is subject to more than three (3) Medicaid Investigated Complaints in any one month, the Contractor will pay civil monetary penalties of ten thousand dollars ($10,000.00) for each such Medicaid Investigated Complaint above three (3) per month. Continued violations of this section may result in termination of the contract by the Division. EPSDT Screening and Immunization. Achievement of <85% screening and 90% immunization rate (the lowest rate shall be considered to be the rate for both screenings and immunizations) will require a refund of one hundred ($100) per Enrollee for all Enrollees under age 12 months. Continued violations of this section may result in termination of the contract by the Division. If the Contractor fails to fulfill its duties and obligations pursuant to this contract, the Division may issue a written notice to the Contractor indicating the violation(s) and advising the Contractor that failure to cure the violation(s) within a defined time span, to the satisfaction of the Division, may lead to the imposition of all or some of the sanctions listed below:
Claims Payment. If HEBP determines that a claim for benefits is a Valid Claim, or if Plan Administrator directs HEBP, in writing, to honor a claim for benefits, HEBP will arrange for the payment of the claim pursuant to the terms of this Agreement and Addendum A: Transfer Payment and Other Financial Responsibilities.
Claims Payment. Consistent with C.4.6(2)of its proposal, the Contractor shall develop and implement a system for processing and paying covered health claims on behalf of the high risk pool program.
Claims Payment. If Contractor fails to pay or deny ninety-eight per cent (98%) or more of any type of clean claims within the required timeframe, Contractor shall pay liquidated damages in the amount of five thousand, seven hundred dollars ($5,700) for each deficient claims type. For the purposes of this section, there are six claims types: professional paper claims, professional electronic claims, facility paper claims, facility electronic claims, pharmacy paper claims, and pharmacy electronic claims.
Claims Payment. All Contract claims services, with the exception of the adjudication of death claims not paid out as a lump sum, shall be performed by LMG on behalf of IIC. Notwithstanding, all such claims in the amount of $100,000 or greater shall be forwarded to IIC for review and approval prior to LMG's payment of the claim. All Contract claims shall be investigated, processed, and paid in accordance with the policies and procedures mutually agreed to by both parties. IIC will make its claims personnel and legal department available at IIC's expense to answer any questions that might arise from LMG's claims personnel relating to claims investigation, processing, and payment of Contract claims. In addition to the foregoing, in the case of a decision by LMG that a Contract claim should be denied, LMG shall communicate its proposed action to appropriate IIC personnel who must agree and approve the proposed claim denial before the claims decision is communicated to the policyholder or beneficiary. LMG will communicate appropriate details of any proposed claim denial in accordance with notification procedures to be jointly developed by the parties, which shall be in sufficient time to allow for a response by IIC and discussion with LMG to avoid violation of laws with respect to claims practices. If no response is received within five (5) business days of transmission, LMG shall have the right to proceed on the basis that IIC is in agreement with the decision to deny the claim. All claims paid by LMG from funds collected on behalf of, or for, IIC shall be paid only on drafts or checks of, and as authorized by, IIC. All monies received by LMG to pay claims on behalf of IIC shall be held in a fiduciary capacity. No deposits will be made into, nor disbursements made from, this fiduciary account, with the exception of claims and claims adjustment expenses. This fiduciary account will at all times have a balance equal to the amount deposited less claims and claims adjustment expenses paid. LMG is responsible for all correspondence with the claimant and preparation of the claim checks. Notwithstanding the foregoing, IIC shall provide legal support to LMG. For those claims referred to IIC by LMG, LMG will provide IIC with copies of the following:
Claims Payment. A claims payment is a payment made in full or in part to a service provider for the provision of medically necessary treatment and services to an eligible beneficiary that is a PASSE member (see enrolled member). Claims types include hospital inpatient, outpatient, professional payments, clinic, ancillary, pharmacy, support service, behavioral health services, services for intellectual and developmental disabilities and other institutional payments.
Claims Payment. 1. The Health Plan shall reimburse providers for the delivery of authorized services pursuant to Section 641.3155 F.S., including, but not limited to:
Claims Payment. Provided there is no existing material breach of this Agreement by the Company, the Reinsurer will be liable to the Company for the benefits reinsured and the reinsurance will not exceed the Company's contractual liability under the terms of its policies less the amount retained. The payment of death claims by the Reinsurer will be in one lump sum regardless of the mode of settlement under the original policy. If the Company pays interest from a specified date, such as the date of death of the insured, on the contractual benefit of a policy reinsured under this agreement, the Reinsurer shall indemnify the Company for the Reinsurer's share of such interest. Interest paid by the Reinsurer under this paragraph shall be computed at the same rate and commencing on the same date as that paid by the Company. The computation of interest paid by the Reinsurer under this paragraph shall cease the earlier of (1) the date of payment of the Reinsurer's share of reinsurance liability and (2) the date of the termination of the period for which the Company has paid interest.
Claims Payment. The Fund will process, investigate and pay valid and appropriate workers’ compensation claims made by Employers’ covered employees during the term of this Agreement subject to the terms of the Alabama Workers’ Compensation Law and applicable rules and regulations of the Department of Industrial Relations.