Common use of Cost Avoidance Activities Clause in Contracts

Cost Avoidance Activities. i. The Contractor will have primary responsibility for cost avoidance through the Coordination of Benefits (COB) relative to federal and private health insurance-type resources including, but not limited to, Medicare, private health insurance, Employees Retirement Income Security Act of 1974 (ERISA), 29 U.S.C.A. 1396a(a)(25) plans, and workers compensation. The Contractor must attempt to avoid initial payment of Claims, whenever possible, where federal or private health insurance-type resources are available. All cost-avoided funds must be reported to the Commonwealth via encounter data submissions and financial report 8A-D. The use of the COB flag, Medicare fields, and the Other Insurance Paid (OIP) field shall indicate that TPL has been pursued and the amount which has been cost-avoided. The Contractor shall not be held responsible for any TPL errors in the Department's Eligibility Verification System (EVS) or the Department's TPL file. 119 ii. The Contractor agrees to pay, and to require that its subcontractors pay, all Clean Claims for prenatal or preventive pediatric care (including EPSDT services to children), and services to children having medical coverage under a Title IV-D child support order to the extent the Contractor is notified by the Department of such support orders or to the extent the Contractor becomes aware of such orders, and then seek reimbursement from liable third parties. The Contractor recognizes that cost avoidance of these Claims is prohibited with the exception of hospital delivery Claims, which may be cost-avoided. iii. The Contractor may not deny or delay approval of otherwise covered treatment or services based upon third party liability considerations. The Contractor may neither unreasonably delay payment nor deny payment of Claims unless the probable existence of third party liability is established at the time the Claim is filed.

Cost Avoidance Activities. i. The Contractor will have primary responsibility for cost avoidance through the Coordination of Benefits (COB) relative to federal and private health insurance-type resources including, but not limited to, Medicare, private health insurance, Employees Retirement Income Security Act of 1974 (ERISA), 29 U.S.C.A. 1396a(a)(25) plans, and workers compensation. The Contractor must attempt to avoid initial payment of Claimsclaims, whenever possible, where federal or private health insurance-type resources are available. All cost-avoided funds must be reported to the 116 Commonwealth via encounter data submissions and financial report 8A-D. The use of the COB flag, Medicare fields, and the Other Insurance Paid (OIP) field shall indicate that TPL has been pursued and the amount which has been cost-avoided. The Contractor shall not be held responsible for any TPL errors in the Department's Eligibility Verification System (EVS) or the Department's TPL file. 119. ii. The Contractor agrees to pay, and to require that its subcontractors pay, all Clean Claims for prenatal or preventive pediatric care (including EPSDT services to children), and services to children having medical coverage under a Title IV-D child support order to the extent the Contractor is notified by the Department of such support orders or to the extent the Contractor becomes aware of such orders, and then seek reimbursement from liable third parties. The Contractor recognizes that cost avoidance of these Claims claims is prohibited with the exception of hospital delivery Claimsclaims, which may be cost-avoided. iii. The Contractor may not deny or delay approval of otherwise covered treatment or services based upon third party liability considerations. The Contractor may neither unreasonably delay payment nor deny payment of Claims claims unless the probable existence of third party liability is established at the time the Claim claim is filed.

Cost Avoidance Activities. i. ‌ a. The Contractor PH-MCO will have primary responsibility for cost avoidance through the Coordination of Benefits (COB) COB relative to federal and private health insurance-type resources including, but not limited to, Medicare, private health insurance, Employees Retirement Income Security Act of 1974 (ERISA), 29 U.S.C.A. 1396a(a)(25) ERISA plans, and workers compensationWorkers Compensation. The Contractor Except as provided in subparagraph b., the PH-MCO must attempt to avoid initial payment of Claims, whenever possible, where federal or private health insurance-type resources are available. All cost-The number of claims cost avoided funds must by the MCO's claims system should be reported to the Commonwealth via encounter data submissions and financial report in Financial Report #8A, “Claims Cost Avoided.” The PH-D. The use of the COB flag, Medicare fields, and the Other Insurance Paid (OIP) field shall indicate that TPL has been pursued and the amount which has been cost-avoided. The Contractor MCO shall not be held responsible for any TPL errors in the Department's Eligibility Verification System (EVS) or the Department's TPL file. 119. ii. b. The Contractor agrees to PH-MCO and its Subcontractors must pay, and to require that its subcontractors pay, then chase all Clean Claims for prenatal or preventive pediatric care (including EPSDT services to children), and services to children having medical coverage under a Title IV-D child support order to the extent the Contractor PH-MCO is notified by the Department of such support orders or to the extent the Contractor PH­ MCO becomes aware of such orders, and then seek reimbursement from liable third parties. The Contractor PH-MCO recognizes that cost avoidance of these Claims claims is prohibited with the exception of hospital delivery Claimsclaims, which may be cost-avoided. iii. c. The Contractor PH-MCO may not deny or delay approval of otherwise covered treatment or services based upon third party liability TPL considerations. The Contractor PH-MCO may neither unreasonably delay payment nor deny payment of Claims claims unless the probable existence of third party liability TPL is established at the time the Claim claim is filedadjudicated.