Common use of Company Obligation to Pay for Covered Services Clause in Contracts

Company Obligation to Pay for Covered Services. Company shall make payments to Group for Covered Services on a timely basis consistent with the claims payment procedure described at 42 U.S.C. § 1396a(a)(37)(A). Company agrees to pay Group for non-capitated Covered Services rendered to Members according to the lesser of (i) Group’s actual billed charges or (ii) the rates set forth in the Services and Compensation Schedule, attached hereto and made a part hereof. Company must pay ninety percent (90%) of all such Clean Claims from Group within thirty (30) days following actual receipt; provided, further, Company must pay ninety-nine percent (99%) of all Clean Claims from Group within ninety (90) days following actual receipt. Group and Participating Group Physicians will make best commercial efforts to utilize online explanation of benefits or electronic remittance of advice (or combination thereof) and electronic funds transfer in lieu of receiving paper equivalents to the extent such services are available from Company. Company reserves the right to recoup any overpayment or payment made in error (e.g., a duplicate payment or payment for services rendered by Group to a patient who was not a Member and amounts identified through routine investigative reviews of records or audits) against any other monies due to Group under this Agreement. In the event that Group identifies any overpayments by Company, Group shall, as required under Section 6402(a) of the Patient Protection and Affordable Care Act, report and return any and all such overpayments to Company within sixty (60) days of Group’s identification of any and all such overpayments. In addition, when reporting and returning any such overpayments by Company, Group must provide Company with a written reason for the overpayment (e.g., excess payment under coordination of benefits, etc.). To the extent, if any, that the compensation under certain Plans is in the form of capitation payments or a case- based rate methodology, Group acknowledges the financial risks to Group of this arrangement and has made an independent analysis of the adequacy of this arrangement. Group, therefore, agrees and covenants not to bring any action asserting the inadequacy of these arrangements or that Group was in any way improperly induced by Company to accept the rate of payment, including, but not limited to, causes of actions for damages, rescission or termination alleging fraud or negligent misrepresentation or improper inducement. Furthermore, to the extent that the compensation under certain Plans is in the form of capitation payments or a case-based methodology and Participating Group Physician utilizes the services of a Covering Physician, Group agrees to hold Company, Government Sponsor, Affiliates, and Members harmless against any and all claims by such Covering Physician related to or arising out of payment for Covered Services rendered to Members. Group understands that if Company makes payment to such Covering Physician under the circumstances described above, Company may recoup against future payments the amount paid to such Covering Physician. Complaints or disputes concerning payments for the provision of services as described in this Agreement shall be subject to the Company’s grievance resolution system.

Company Obligation to Pay for Covered Services. Company shall make payments to Group Provider for Covered Services on a timely basis consistent with the claims payment procedure described at 42 U.S.C. § 1396a(a)(37)(A). Company agrees to pay Group Provider for non-capitated Covered Services rendered to Members according to the lesser of (i) GroupProvider’s actual billed charges or (ii) the rates set forth in the Services and Compensation Schedule, attached hereto and made a part hereof. Company must pay ninety percent (90%) of all such Clean Claims from Group Provider within thirty (30) days following actual receipt; provided, further, Company must pay ninety-nine percent (99%) of all Clean Claims from Group Provider within ninety (90) days following actual receipt. Group and Participating Group Physicians Provider will make best commercial efforts to utilize online explanation of benefits or electronic remittance of advice (or combination thereof) and electronic funds transfer in lieu of receiving paper equivalents to the extent such services are available from Company. Company reserves the right to recoup any overpayment or payment made in error (e.g., a duplicate payment or payment for services rendered by Group Provider to a patient who was not a Member and amounts identified through routine investigative reviews of records or audits) against any other monies due to Group Provider under this Agreement. In the event that Group Provider identifies any overpayments by Company, Group Provider shall, as required under Section 6402(a) of the Patient Protection and Affordable Care Act, report and return any and all such overpayments to Company within sixty (60) days of GroupProvider’s identification of any and all such overpayments. In addition, when reporting and returning any such overpayments by Company, Group Provider must provide Company with a written reason for the overpayment (e.g., excess payment under coordination of benefits, etc.). To the extent, if any, that the compensation under certain Plans is in the form of capitation payments or a case- case-based rate methodology, Group Provider acknowledges the financial risks to Group Provider of this arrangement and has made an independent analysis of the adequacy of this arrangement. GroupProvider, therefore, agrees and covenants not to bring any action asserting the inadequacy of these arrangements or that Group Provider was in any way improperly induced by Company to accept the rate of payment, including, but not limited to, causes of actions for damages, rescission or termination alleging fraud or negligent misrepresentation or improper inducement. Furthermore, Notwithstanding anything in this Agreement to the extent that the contrary, subcontractors agree to seek compensation under certain Plans solely from Provider for those Covered Services provided to Members and for which Provider is compensated by Company. Subcontractor shall in the form of capitation payments or a case-based methodology and Participating Group Physician utilizes the services of a Covering Physicianno event xxxx Company, Group agrees to hold Companyits Affiliates, Government Sponsor, Affiliatesor Members for any such Covered Services. Provider will provide Company with a Designation of Payment Schedule from all subcontractors, which will indemnify and hold harmless Company, Government Sponsor and its Members harmless against any and for payment of all claims by such Covering Physician related to or arising out of payment for Covered Services rendered to Members. Group understands that if Company makes payment to such Covering Physician compensation owed subcontractor under the circumstances described above, Company may recoup against future payments the amount paid to such Covering Physiciansubcontractor’s arrangement with Provider. Complaints or disputes concerning payments for the provision of services as described in this Agreement shall be subject to the Company’s grievance resolution system.

Company Obligation to Pay for Covered Services. Company shall make payments to Group Provider for Covered Services on a timely basis consistent with the claims payment procedure described at 42 U.S.C. § 1396a(a)(37)(A). Company agrees to pay Group Provider for non-capitated Covered Services rendered to Members according to the lesser of (i) GroupProvider’s actual billed charges or (ii) the rates set forth in the Services and Compensation Schedule, attached hereto and made a part hereof. Company must pay ninety percent (90%) of all such Clean Claims from Group Provider within thirty (30) days following actual receipt; provided, further, Company must pay ninety-nine percent (99%) of all Clean Claims from Group Provider within ninety (90) days following actual receipt. Group and Participating Group Physicians Provider will make best commercial efforts to utilize online explanation of benefits or electronic remittance of advice (or combination thereof) and electronic funds transfer in lieu of receiving paper equivalents to the extent such services are available from Company. Company reserves the right to recoup any overpayment or payment made in error (e.g., a duplicate payment or payment for services rendered by Group Provider to a patient who was not a Member and amounts identified through routine investigative reviews of records or audits) against any other monies due to Group Provider under this AgreementAddendum. In the event that Group Provider identifies any overpayments by Company, Group Provider shall, as required under Section 6402(a) of the Patient Protection and Affordable Care Act, report and return any and all such overpayments to Company within sixty (60) days of GroupProvider’s identification of any and all such overpayments. In addition, when reporting and returning any such overpayments by Company, Group Provider must provide Company with a written reason for the overpayment (e.g., excess payment under coordination of benefits, etc.). To the extent, if any, that the compensation under certain Plans is in the form of capitation payments or a case- case-based rate methodology, Group Provider acknowledges the financial risks to Group Provider of this arrangement and has made an independent analysis of the adequacy of this arrangement. GroupProvider, therefore, agrees and covenants not to bring any action asserting the inadequacy of these arrangements or that Group Provider was in any way improperly induced by Company to accept the rate of payment, including, but not limited to, causes of actions for damages, rescission rescission, or termination alleging fraud or negligent misrepresentation or improper inducement. Furthermore, to the extent that the compensation under certain Plans is in the form of capitation payments or a case-based methodology and Participating Group Physician utilizes the services of a Covering Physician, Group agrees to hold Company, Government Sponsor, Affiliates, and Members harmless against any and all claims by such Covering Physician related to or arising out of payment for Covered Services rendered to Members. Group understands that if Company makes payment to such Covering Physician under the circumstances described above, Company may recoup against future payments the amount paid to such Covering Physician. Complaints or disputes concerning payments for the provision of services as described in this Agreement Addendum shall be subject to the Company’s grievance grievance-resolution system.

Company Obligation to Pay for Covered Services. Company shall make payments to Group Hospital for Covered Services on a timely basis consistent with the claims payment procedure described at 42 U.S.C. § 1396a(a)(37)(A). Company agrees to pay Group Hospital for non-capitated Covered Services rendered to Members according to the lesser of (i) GroupHospital’s actual billed charges or (ii) the rates set forth in the Services and Compensation Schedule, attached hereto and made a part hereof. Company must pay ninety percent (90%) of all such Clean Claims from Group Hospital within thirty (30) days following actual receipt; provided, further, Company must pay ninety-nine percent (99%) of all Clean Claims from Group Hospital within ninety (90) days following actual receipt. Group and Participating Group Physicians .. Hospital will make best commercial efforts to utilize online explanation of benefits or electronic remittance of advice (or combination thereof) and electronic funds transfer in lieu of receiving paper equivalents to the extent such services are available from Company. Company reserves the right to recoup any overpayment or payment made in error (e.g., a duplicate payment or payment for services rendered by Group Hospital to a patient who was not a Member and amounts identified through routine investigative reviews of records or audits) against any other monies due to Group Hospital under this Agreement. In the event that Group Hospital identifies any overpayments by Company, Group Hospital shall, as required under Section 6402(a) of the Patient Protection and Affordable Care Act, report and return any and all such overpayments to Company within sixty (60) days of GroupHospital’s identification of any and all such overpayments. In addition, when reporting and returning any such overpayments by Company, Group Hospital must provide Company with a written reason for the overpayment (e.g., excess payment under coordination of benefits, etc.). To the extent, if any, that the compensation under certain Plans is in the form of capitation payments or a case- based rate methodology, Group Hospital acknowledges the financial risks to Group Hospital of this arrangement and has made an independent analysis of the adequacy of this arrangement. GroupHospital, therefore, agrees and covenants not to bring any action asserting the inadequacy of these arrangements or that Group Hospital was in any way improperly induced by Company to accept the rate of payment, including, but not limited to, causes of actions for damages, rescission or termination alleging fraud or negligent misrepresentation or improper inducement. Furthermore, to the extent that the compensation under certain Plans is in the form of capitation payments or a case-based methodology and Participating Group Physician utilizes the services of a Covering Physician, Group agrees to hold Company, Government Sponsor, Affiliates, and Members harmless against any and all claims by such Covering Physician related to or arising out of payment for Covered Services rendered to Members. Group understands that if Company makes payment to such Covering Physician under the circumstances described above, Company may recoup against future payments the amount paid to such Covering Physician. Complaints or disputes concerning payments for the provision of services as described in this Agreement shall be subject to the Company’s grievance resolution system.